DEVELOPMENT OF A COMPLEX THEORY-INFORMED INTERVENTION FOR IMPROVING PHYSICAL ACTIVITY AFTER STROKE IN SINGAPORE: A CO-DESIGN APPROACH

S. Thilarajah¹, K. Doshi², D. De Silva³, E. Wai⁴, L.K. Kwah⁵

¹Singapore General Hospital, Physiotherapy, Singapore, Singapore, ²National University of Singapore, Department of Psychology, Singapore, Singapore, ³Singapore General Hospital Campus, National Neuroscience Institute, Neurology, Singapore, Singapore, ⁴Singapore National Stroke Association, Singapore, Singapore, ⁵Singapore Institute of Technology, Health and Social Sciences Cluster, Singapore, Singapore

Background: Stroke survivors face many barriers to physical activity (PA) in Singapore. Prior studies have indicated that the problem of physical inactivity not only requires solutions at the personal level but also at the wider organizational and community levels. For example, the availability of wheelchair access, adaptive equipment and skilled help at public fitness spaces influenced whether stroke survivors would engage in regular PA. Interventions targeted at improving PA after stroke need to consider context-specific barriers and enablers in order to optimise the success of the intervention in clinical trials, and accelerate uptake in clinical practice.

Purpose: We aimed to document the development process of a complex theory-informed behaviour change intervention targeted at improving PA after stroke.

Methods: We conducted two co-design workshops (each of two hours in duration) in August 2022 to develop and refine elements of the intervention. The findings from prior work by the authors consisting of a survey (Barriers to Physical Activity Questionnaire-Mobility Impairments) and interviews guided by the Theoretical Domains Framework (TDF), to understand the barriers and facilitators to PA after stroke, were presented at the workshops. The relevant TDF domains were mapped to the Behaviour Change Wheel (BCW) to identify intervention functions that are likely to improve PA after stroke. Workshop activities included small breakout group discussions on TDF themes with conflicting statements, brainstorming of solutions, big group discussion on details of the program (guided by the Template for Intervention Description and Replication (TIDieR) checklist), and sharing of solution prototypes. The workshops were held at the office of the Singapore National Stroke Association (SNSA) and were facilitated by two physiotherapists, one neuropsychologist, one user experience designer, and an executive committee member of the SNSA.

Results: Three members of the study team (2 physiotherapists and 1 neuropsychologist) trained in implementation science facilitated the small group discussions. The workshops were attended by 11 stroke survivors and 3 caregivers. Small group discussions centered around the TDF themes of environmental context and resources, knowledge and skills, and reinforcements and reminders. The knowledge units of “Who”, “What”, “When”, "Where", "How" and "How Much", as per the TIDieR checklist, were established via facilitated discussions. The workshop facilitators iteratively summarised discussions to ensure an accurate interpretation of participants’ input. Key elements of what stroke survivors want in a PA program included: resources to guide them on the selection and adaptation of exercises and equipment, adaptive equipment (e.g., arm and leg straps), information and access to neighbourhood PA opportunities, advice from skilled individuals (namely physiotherapist), medical clearance to engage in moderate-intensity PA and a personalised program that considers the stroke survivor’s deficits, exercise preferences and social circumstances.

Conclusions: Key elements to a successful PA program were identified by stroke survivors and caregivers in Singapore. These matched the BCW intervention functions of education, training, modeling, enablement, environment, persuasion and incentivisation.

Implications: These results form the basis of a theory-informed and co-designed complex behaviour change intervention that will be tested in a hybrid type 1 randomised controlled trial.

Funding acknowledgements: Singapore Institute of Technology Ignition Grant (2021104)

Keywords:
Stroke
Physical activity
Implementation science

Topics:
Neurology: stroke
Research methodology, knowledge translation & implementation science
Health promotion & wellbeing/healthy ageing/physical activity

Did this work require ethics approval? Yes

Institution: Singapore Institute of Technology

Committee: Singapore Institute of Technology

Ethics number: 2021104