What is the role of primary care in reducing the decline in physical function and physical activity in people with long-term conditions? Findings from a realist evidence synthesis with intervention co-design.
Problem
Approximately 25% of people with one long-term condition report ‘problems performing usual activities’, rising to over 60% with three or more long-term conditions. As people age and accumulate more long-term conditions, physical activity typically declines, contributing further to disability and reduced independence. Primary care is well placed to empower individuals and communities to address this problem; however, the best approach is uncertain. This study aims to develop a primary care intervention to promote physical activity and physical function for people with long-term conditions.
Approach
A realist synthesis was conducted, incorporating systematic and purposive searches of relevant literature, two theory-building workshops (n=25) and ten theory-refining interviews with stakeholders. The emerging evidence-based programme theories informed three co-design workshops (n=23) and a knowledge mobilisation event (n=14) to develop a primary care service innovation.
Findings
Five context (C), mechanism (M), and outcome (O) statements were developed:1. Primary care settings are characterised by competing demands, and improving physical activity and physical function is not prioritised in a busy practice (C). If the practice team culture is aligned to promote and support the elements of physical literacy (M), then physical activity promotion will become more routine and embedded in usual care (O). 2. Physical activity promotion in primary care is inconsistent and uncoordinated (C). If specific resources are allocated to physical activity promotion (in combination with an aligned practice culture) (M), then this will improve opportunities to change behaviour (O).3. People with long-term conditions have varying levels of physical function and physical activity, different attitudes to physical activity and differing access to local resources that enable physical activity (C). If physical activity promotion is adapted to individual needs, priorities and preferences, and considers local resource availability (M), then this will facilitate a sustained improvement in physical activity (O).4. Many primary care practice staff have a lack of knowledge and confidence to promote physical activity (C). If staff develop an improved sense of capability through education and training (M), then they will increase their engagement in physical activity promotion (O).5. There have been many initiatives to encourage physical activity with varying degrees of success (C). If a programme is credible to patients and professionals, trust and confidence in the programme will develop (M) and more patients and professionals engage with the programme (O).A prototype intervention has been co-designed, embodying the emerging programme theories and developing resources to promote physical activity and physical function for people with long-term conditions.
Consequences
This work addresses the need to determine ways of promoting physical activity that can improve health and independence for people with long-term conditions, and are adaptable to varying and pressurised primary care contexts. A future research programme will develop further the intervention elements and assess acceptability.