Systematic development of a behavioural intervention to target an increase in daily physical activity levels of people living with heart failure

Student thesis: Doctoral Thesis


Background: Heart failure (HF) effects approximately 1 million adults in the United Kingdom (UK), and the prevalence is increasing due to an ageing population. Guidelines recommend that adults with HF are referred to cardiac rehabilitation and engage in regular physical activity to achieve health and wellbeing benefits, including improved HF symptoms, quality of life, and physical functioning. However, physical activity levels and cardiac rehabilitation referral and attendance rates in adults with HF are suboptimal. The aim of this thesis was to co-design a behavioural intervention to target physical activity behaviour and uptake of cardiac rehabilitation in adults with HF.
Methods: A mixed methods approach was used to systematically develop a theory and evidence-informed behavioural intervention with participants (adults with HF) recruited from three NHS Trusts. The intervention was designed to (1) increase physical activity levels; and (2) increase uptake of cardiac rehabilitation. The intervention was developed with reference to the Behaviour Change Wheel and a corresponding four-stage development process: (1) the conduct of a systematic review and meta-analysis to quantify habitual physical activity levels of adults with HF; (2) a qualitative study with adults with HF using the COM-B Self Evaluation Questionnaire version 1 (COM-B-SEQv1) and Theoretical Domains Framework (TDF) informed semi-structured interviews to identify the behavioural determinants, barriers and facilitators to increasing physical activity; (3) co-design workshops conducted with adults with HF to inform content, mode of delivery, and design of the intervention; and (4) a study to determine the daily physical activity levels of adults with HF assessed over nine consecutive days using a Yamax Series CW-700 pedometer. Data were descriptively analysed and the trend between steps per day and continuous variables were explored with a simple linear regression.
Results: Seventy-five studies were included in the systematic review (N=7,775 HF patients). Meta-analysis was restricted to mean steps per day (n=27-studies; n=1,720 HF patients), and pooled mean steps per day was 5,040 (tau ± 1,796). Sixteen participants with HF completed the COM-B-SEQv1 and a semi-structured interview. COM-B-SEQv1 findings highlighted ‘capability’ as the most frequently populated component in terms of increasing physical activity behaviour. Interviews identified eight theoretical domains linked to specific barriers and enablers to increasing levels of physical activity and engaging in cardiac rehabilitation (e.g., ‘knowledge’, ‘social influences’, ‘beliefs about consequences’). Co-design workshop findings (n=9 participants) and three one-to-one interviews (n=3) indicated that participants had a preference for the intervention being delivered and supported by healthcare professionals, that it was tailored to their individual needs and circumstances, that intervention components are available as leaflets and workbooks, and that information about the benefits of physical activity should be provided. Interview and workshop findings facilitated selection of 22 behaviour change techniques (BCTs) for inclusion in the prototype intervention (named ‘BeActive-HF’). Finally, steps per day of adults with HF from three participating hospital trusts from the Northeast of England (N=30) indicated that participants were low-active (i.e., mean steps per day 4,668) and these findings corresponded to those reported by the meta-analysis.
Conclusion: The findings of the systematic review and physical activity assessment study provide evidence that adults with HF exhibit low levels of physical activity, less than one-third of the guideline recommended physical activity levels. Therefore, the need to develop an intervention to target an increase in physical activity behaviour was evident. The systematic development process reported within this thesis to develop the ‘BeActive-HF’ intervention represents, to the best of my knowledge, the first intervention that targets both free-living physical activity levels and uptake of cardiac rehabilitation within routine clinical care. Unlike other previously developed interventions that target physical activity behaviour within the HF population, the BeActive-HF intervention followed a systematic, theory and evidence-informed development process that helps to facilitate replication and robust evaluation. In conclusion, should this intervention demonstrate to be acceptable and feasible for use in routine care, it holds the potential to increase uptake of cardiac rehabilitation and physical activity levels of adults with HF that could improve their quality of life and longevity.
Date of Award16 Feb 2024
Original languageEnglish
Awarding Institution
  • Teesside University
SupervisorLeah Avery (Supervisor), Alan Batterham (Supervisor) & Darren Flynn (Supervisor)

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