3.1 Participant characteristics and workshop attendance
Forty-three people participated in the co-production workshops including 17 staff, 14 stroke survivors, six caregivers, and six researchers (workshop facilitators; JH, SM, CF, DJC, RL, LB). At least three researchers were present at each workshop to facilitate the small-group discussions and activities. See Table 3.0 for an overview of attendance at each workshop in each location.
Table 3.0
Co-production workshop attendance in West Yorkshire and Edinburgh
| | West Yorkshire | Edinburgh |
Workshop 1 – October 2018 | Stroke survivor | 5 | 4 |
Caregiver | 3 | 1 |
Staff | 6 | 7 |
Workshop 2 – November 2018 | Stroke survivor | 5 | 6 |
Caregiver | 2 | 3 |
Staff | 5 | 3 |
Workshop 3 – December 2018 | Stroke survivor | 6 | 7 |
Caregiver | 2 | 2 |
Staff | 5 | 6 |
Workshop 4 – January 2019 | Stroke survivor | 4 | 6 |
Caregiver | 3 | 2 |
Staff | 5 | 6 |
Workshop 5 – February 2019 | Stroke survivor | 6 | 6 |
Caregiver | 3 | 2 |
Staff | 5 | 5 |
At the time of the first workshop, the average age of the stroke survivor participants was 72 years (range of 56 to 83 years) and the average time since the event of their stroke was 10 months (range of 4 to 15 months). The average age of caregivers was 68 years (range of 54 to 83 years). Other stroke survivor and caregiver participant characteristics are detailed in Table 4.0. Staff participants included physiotherapists, therapy assistants, occupational therapists, registered nurses, healthcare support workers, exercise instructors, and volunteers. Aside from the exercise instructors, all staff worked at an inpatient stroke unit or for a linked community stroke service, and varied in seniority. Ten staff participants had more than five years’ experience in stroke care and the majority (15) were female.
Table 4.0
Stroke survivor and caregiver participant characteristics
| Number (percentage) |
| Stroke survivors | Caregivers |
Female | 6 (43%) | 4 (67%) |
Presence of aphasia | 3 (21%) | - |
Capability to stand independently | 13 (93%) | - |
Retired | 11(79%) | 4 (67%) |
Full-time employed | 2 (14%) | 1 (17%) |
Unemployed | 1 (7%) | 0 (0%) |
Stroke survivors’ spouse | - | 5(83%) |
Stroke survivors’ daughter | - | 1 (17%) |
3.3 Intervention development: Increasing standing and moving after stroke
This section describes the process of intervention development. The BCW steps are presented sequentially for clarity however in reality the activities fluid and non-linear. Co-produced intervention strategies were coded to the BCTs and intervention functions, rather than being used to structure the workshop tasks. Figure 2.0 outlines the key outputs from each co-production workshop in relation to intervention development.
Figure 2.0. Examples of how data from each workshop contributed to intervention development
BCW stage 1: Understanding of the behaviour
Researchers’ work to understand the behaviour took place prior to the workshops, and during workshops one and two. Data from workshop two was analysed to specify the target behaviour and complete behavioural analyses for the three target behaviours.
Step 1: Defining the problem. The intervention aims to address the ‘problem’ of high levels of sedentary behaviour in people after stroke. This was defined by the research team as part of the process of acquiring funding for the research and was communicated to the participants involved in the workshops as part of recruitment for the workshops and reiterated during workshop one.
Step 2: Identifying the target behaviour. Target behaviours were identified for each user group: to increase standing and moving (stroke survivors), and to support stroke survivors to increase standing and moving (staff and caregivers). Whilst the target behaviour was identified prior to the co-production work, participants’ preferred terminology was discussed and agreed during the second co-production workshop. There was a consensus to avoid the word ‘sedentary’ in the target behaviours and in intervention materials targeted at stroke survivors and caregivers due to a perception that the word is complex, technical, ambiguous, and can have negative connotations, for example ‘lazy’. Prior to engaging in the workshops some participants misunderstood sedentary behaviour and associated this with a lack of physical, cognitive or social activity. Participants agreed that ‘increase standing and moving’ is simple and understandable, and reframes the issue in a positive way, i.e. it is a goal to work towards.
Step 3: Specifying the target behaviour. During the second co-production workshop, participants discussed the target behaviour for each user group of the intervention, including considering where and when the target behaviour should be performed. Following the workshop in each location, data from the discussion was coded and summarised by the research team, to inform the specification of each target behaviour. As an example, the stroke survivor target behaviour is aimed at all stroke survivors admitted to an inpatient stroke unit who are safe and able to stand either independently or with the assistance of one person. Stroke survivors should aim to stand and move for three minutes every thirty minutes throughout the day however this will be tailored to individual stroke survivors’ capability, safety, and circumstances.
Step 4: Identifying what needs to change. A ‘behavioural diagnosis’ activity was completed during workshop two, which involved identifying barriers and facilitators to achieving the target behaviour for two different stroke survivor, caregiver and staff member ‘personas’, which were developed based on the evidence and insight generated during earlier work streams. Following workshop two researchers coded the data from this activity into capability, opportunity, motivation and the TDF domain categories. The behavioural diagnosis facilitated the identification of which COM-B and TDF domains the intervention should target for each user group, based on the absence or presence of barriers pertaining to each domain; see Table 6.0.
Table 6.0
TDF domains that are targeted within the ‘Get Set, Go’ intervention
TDF domain | Targeted | Targeting which user groups |
Physical skills | Yes | Staff, caregivers |
Knowledge | Yes | Stroke survivors, staff, caregivers |
Cognitive and interpersonal skills | Yes | Stroke survivors, staff caregivers |
Memory, attention and decision processes | Yes | Stroke survivors, staff |
Behavioural regulation | Yes | Stroke survivors, staff, caregivers |
Environmental context and resources | Yes | Stroke survivors, staff, caregivers |
Social influences | Yes | Stroke survivors, caregivers |
Professional/social role and identity | Yes | Stroke survivors, staff, caregivers |
Beliefs about capabilities | Yes | Stroke survivors, staff, caregivers |
Optimism | No | - |
Beliefs about consequences | Yes | Stroke survivors, staff, caregivers |
Intentions | Yes | Stroke survivors |
Goals | Yes | Stroke survivors, staff, caregivers |
Reinforcement | Yes | Caregivers |
Emotions | Yes | Stroke survivors, staff, caregivers |
As an example, barriers to caregivers achieving the target behaviour across the COM-B domains included a limited understanding of how to support stroke survivors to increase standing and moving (capability), caregivers having other responsibilities which limit the time they have available to support the stroke survivor (opportunity), and a perception that there are risks to supporting the stroke survivor to increase standing and movement, such as an increased falls risk, that outweigh the potential benefits (motivation). An example of a completed behavioural diagnosis is presented in additional file 5.0. The research team developed summaries of the main barriers to achieving the target behaviour for each user group; see additional file 2.0 for the stroke survivor example.
BCW stage 2: Intervention options During workshop three, participants utilised the summaries of the main barriers to achieving the target behaviour to identify, and then appraise, ‘solutions’ to the barriers, including delivery methods. Following the workshop, the research team reviewed the data and applied the APEASE criteria to co-produced intervention components to develop a prototype intervention. All intervention components were based on solutions and delivery methods favoured during the workshops and were ‘coded’ to TDF domains to ensure that the prototype intervention addressed the domains identified as being important to target following the behavioural diagnosis (workshop two). During workshop four participants appraised the draft intervention components via a validation activity. Prior to the workshop, the researchers agreed that any proposed intervention component that had more ‘no’ than ‘yes’ responses across all participants would be removed from the proposed intervention. The proposed intervention was iteratively refined based on a review of workshop four and five data. The developed intervention was then retrospectively coded for intervention functions and policy categories.
Step 5: Identify intervention functions. The intervention strategies co-produced in workshop three and refined in workshop four were subsequently coded to five of the nine intervention functions included within the BCW (19). The ‘Get Set, Go’ intervention functions are detailed in Table 7.0 with examples of intervention strategies that align with the function.
Table 7.0
‘Get Set, Go’ intervention functions
Intervention function | Definition | Example intervention strategy |
Education | Increasing knowledge or understanding | Providing information to staff, stroke survivors and caregivers about the benefits of standing and moving |
Persuasion | Using communication to induce positive or negative feelings or stimulate action | Deliver messages via authoritative source |
Training | Imparting skills | Upskilling staff in how to support stroke survivors to increase standing and moving |
Environmental changes | Changing the physical or social context | Suggestions provided with regards to how to adapt the home environment to encourage movement |
Enablement | Increasing means / reducing barriers to increase capability or opportunity | Encouraging patients to monitor and record their standing and moving |
Step 6: Identify policy categories. The intervention is intended to be delivered at a service level, and thus incorporates the policy category ‘guidelines’ as this involves creating documents that recommend or mandate practice including all changes to service provision. None of the other BCW policy categories were applicable to the developed intervention.
BCW stage 3: Content and implementation options
As with the BCW intervention functions and policy categories (stage two), the co-produced intervention based on the behavioural diagnosis was retrospectively coded for behaviour change techniques and delivery modes.
Step 7: Identify behaviour change techniques. Following the co-production of the intervention components, three researchers collaboratively coded BCTs evident within each intervention component. For example, caregivers completing an action planning activity which involves considering challenges to achieving the target behaviour and how to overcome them was coded as problem solving. Other intervention components were further specified to include additional BCTs, for example, information about others’ approval (BCT 6.3) was applied to staff training. The intervention incorporates 34 BCTs from the Behaviour Change technique Taxonomy v1 (20). The included BCTs were from 11 of the 16 categories: goals and planning, feedback and monitoring, social support, shaping knowledge, natural consequences, comparison of behaviour, associations, repetition and substitution, comparison of outcomes, antecedents, identity, and self-belief. No BCTs were included from the categories: reward and threat, regulation, scheduled consequences, and covert learning. See Table 8.0 for an example of a BCT from each category, including which TDF domains it is targeting and how it is operationalised in the intervention.
Step 8: Identify mode of delivery. Modes of delivery were initially discussed during workshop three and iteratively refined alongside the intervention components based on data from workshops four and five. Most of the intervention is delivered face-to-face: some takes place at a group level (e.g. staff training) whereas other components are delivered at an individual level. The intervention also includes written materials, which are also available online.
Table 8.0
Selected BCTs and examples of how operationalised in the intervention
Example BCT | TDF domains | Example operationalisation |
1.2 Problem solving (goals and planning) | Skills, intentions, goals, behavioural regulation | Caregivers consider challenges to achieving target behaviour in ‘action planning’ activity |
2.3 Self-monitoring of behaviour (feedback and monitoring) | Intentions, goals, behavioural regulation | Monitoring sheets provided for patients to record standing and moving activity |
3.2 Social support – practical (social support) | Social influences | Providing examples of how caregivers can provide practical help to stroke survivors, e.g. physically supporting standing and moving |
4.1 Instruction on how to perform a behaviour (shaping knowledge) | Knowledge, skills, memory / attention / decision making processes | Advise staff on how to deliver intervention components during training session |
5.1 Information about health consequences (natural consequences) | Knowledge, beliefs about consequences | Inform staff and stroke survivors about the health benefits of standing and moving after stroke via posters |
6.3 Information about others’ approval (comparison of behaviour) | Social / professional identity and role, beliefs about capabilities, beliefs about consequences | Informing staff that senior colleagues approve of supporting patient to increase standing and moving |
7.1 Prompts / cues (association) | Environmental context and resources | Providing a fridge magnet prompt to stroke survivors to increase standing and moving |
8.7 Graded tasks (repetition and substitution) | Behavioural regulation | Increasing stroke survivors’ standing and moving target over time, dependent on ability |
9.1 Credible source (comparison of outcomes) | Social / professional role and identity, beliefs about consequences | Advice relating to standing and moving provided to patients and caregivers by professionals |
12.5 Adding objects to the environment (antecedents) | Environmental context and resources | Posters displayed on stroke wards |
13.2 Framing / reframing (Identity) | Knowledge, skills, social / professional role and identity, beliefs about consequences | Suggesting that staff think about existing activities in relation to whether they restrict or facilitate patient standing and movement |
15.1 Verbal persuasion about capability (self-belief) | Beliefs about capabilities, behavioural regulation | Informing stroke survivors of their ability to stand and move |