Planning Active Brains
Reviewing relevant literature
Given the wealth of existing reviews on the topics of interest, the findings were not formally synthesised for write-up. However, key findings pertinent to our research aims are summarised in Table 1, which also illustrates how they informed intervention guiding principles. Key findings included there being no substantial evidence that the intervention’s physical activity recommendations should differ for older adults with MCI/AACD compared to a general older-adult population. The cognitive training intervention evidence suggested training multiple cognitive-domains to be the optimum choice for both cognitively-healthy older adults and those with cognitive impairment (e.g. 44, 45). Regarding physical activity interventions, those with and without cognitive impairment shared similar attitudes towards physical activity, and recognised similar barriers (e.g. remembering, social isolation), facilitators (e.g. accessibility of activity options, simple activities) and preferred activities (e.g. walking) (46, 47). There was only a small amount of evidence about intervention features that may be acceptable and engaging for both groups. Acceptable intervention features amongst those with cognitive impairment often overlapped with those frequently used in interventions for older adults in general (e.g. planning features; 48). Otherwise, there was little evidence about whether engagement with intervention features was likely to differ between groups, so we aimed to explore this within our primary qualitative work.
Development of Guiding Principles
The finalised Active Brains guiding principles (Table 1) were: minimizing cognitive load and dependence on technology; positive framing and promoting immediate-term quality of life benefits; and catering for heterogeneous preferences and capabilities. These guiding principles underpinned and informed the development of all intervention materials both in terms of the content, and also the presentation style, format and functionality.
Developing Active Brains programme theory
Behavioural Analysis
The full behavioural analysis is presented in Additional Table 4. Active Brains targeted nine behaviours: initial engagement with the online intervention; increasing physical activity; reducing sedentary behaviour; uptake of strength and balance activities; uptake of brain training; healthy changes to eating behaviours; reviewing behaviours and revising goals; integration of recommended activities into daily routines, and; maintaining engagement with the online intervention. These behaviours were further broken down into 19 sub-behaviours required to enact each behaviour. Mapping these behaviours, their determinants, and intervention features onto the BCW and TDF illustrates that Active Brains employs 36 BCTs to deliver seven intervention functions (modelling, education, persuasion, training, enablement, environmental restructuring, incentivisation) to target thirteen behavioural domains (intentions, optimism, emotion, knowledge, skills, beliefs about consequences, beliefs about capabilities, goals, social influences, environmental context and resources, reinforcement, memory, attention and decision processes and behavioural regulation). This analysis provided an in-depth understanding of the behaviours for Active Brains to target and the mechanisms through which it is anticipated that these could be changed. These understandings informed the development of the intervention’s logic model.
The Active Brains intervention logic model
A summary version of the Active Brains logic model is shown in Figure 2. Additional Figure 1 shows the full version with intervention processes mapped on to BCW, TDF and BCTs. The culmination of the planning phase in preliminary guiding principles and a logic model provided the underpinning framework for Active Brains. The Active Brains digital intervention comprises three online modules that become available sequentially: ‘Active Lives’ (physical activity) is available immediately; ‘Brain Training’ (cognitive training) is available after 4 weeks; and ‘Eat for Health’ (healthy eating) is available after 8 weeks. ‘Active Lives’ is further divided into three sub-modules: ‘Getting Active’, ‘Strength and Balance’ and ‘Breaks from Sitting’ with recommendations about which to start with tailored to users’ baseline activity and capability. Within each module, users can access: information addressing common concerns, instruction about recommended activities, goal setting and review for chosen activities, and tailored motivational feedback on progress. Reminder emails are sent to motivate users to continue with their activities and to encourage them to revisit online content. Additional support from a central facilitator (for one arm of Active Brains trial) comprises up to three 10-minute phone calls at two-week intervals, plus additional email support if required. This can be used to discuss behavioural changes participants are attempting, and to support them with use of the online intervention content. The facilitator employs the CARE (Congratulate, Ask, Reassure, Encourage) approach to provide support in a broadly standardised format (49). After seven months, the Active Brains ‘booster section’ allows users access to additional resources for embedding recommended activities into daily life. It also introduces the brain training ‘boosters’ to maintain the benefits of the initial intensive training period.
Optimising Active Brains
The findings of the qualitative work are described below. These fed back into ongoing iteration of the guiding principles, and behavioural analysis and also informed required intervention changes.
Think-aloud interviews
Feedback on the Active Brains prototype was encouraging with largely positive feedback from participants’ indicating that they found the content easy to understand, persuasive and interesting. Users were particularly positive about what they considered to be more novel activities including strength and balance training, and brain training games.
“I thought it was actually really helpful, and I thought it offered a really wide range of ways for people, starting from different levels of activity, to think about doing more. I also thought the parts that are the little sections that said things like 'I'm concerned about overdoing it', you know the sections about people's concerns? I thought that the content of all of those parts addressed the issues really clearly.” (J0105, female, 65, higher cognitive performance)
“I thought it was very good actually. I thought it was excellent in fact. If only for the fact that it did, it related to me one hundred percent. It was completely informative and helpful, you know, giving… giving me the impetus to move on.” (P0122, male, 73, lower cognitive performance)
Less positive feedback included sections where users found navigation confusing, a lack of specificity surrounding physical activity goals, and a desire to address health-related concerns earlier. We analysed feedback for differences between those with lower and higher cognitive performance scores to determine whether different intervention features or characteristics may be more engaging or desirable for those with lower cognitive performance. There was no evidence of any substantive differences. Table 2 summarises key feedback that required addressing and the resulting changes implemented.
Longitudinal qualitative feasibility study
Part one: Table of changes analysis
Collating feedback from this later round of interviews into a second table of changes confirmed that the amendments based on the initial think-aloud interviews were well received, with the original issues no longer being raised. Participants’ accounts of their experiences also revealed examples of ways in which they had engaged in the activities recommended by the intervention and confirmed they were happy with the digital delivery format.
“It did make me think about it in general, and reminded me that I'm not doing so much aerobic activity, and I'm not really measuring my activity. So I decided I would - there are about four flights of stairs when I go to work, and I always used to walk up them, and now I've got a bit lazy about it, so I decided I was going to go back to that, and also use an app to measure how much I walk, because I've got a dog and I walk a lot every day.” (P0129, female, 67, lower cognitive performance)
“I found the explanations on the type of foods you should eat to help your brain. I found all those very interesting. I don't think my diet is that bad, but it's nice to know that I have been eating the right things and things that I can add too, to what I'm doing. I like the recipes. I'm looking at the recipes, I did print those out.” (P0229, female, 68, higher cognitive performance)
“But I mean somebody who hadn’t got any [IT] skills and were just having to read and have just got a next or a back button, it is very easy to use. You don’t really need to do much, as long as they know where the click on and off, and move on. It’s like turning a page of the book, isn’t it? It’s as simple as that, isn’t it? Yes.” (P0104, female, 75, lower cognitive performance)
In general, there were a smaller number of negative comments about the intervention content, but a few remaining points were identified and addressed (Table 3). There were no substantial differences in the views expressed by individuals with higher and lower levels of cognitive performance.
Part two: inductive thematic analysis
The inductive thematic analysis generated three overarching themes, comprising several subthemes. These were: 1)‘knowledge and understanding of brain health’, including subthemes ‘the meaning of brain health’, ‘perceived availability of information about brain health’ and ‘knowledge of determinants of brain health’; 2) ‘motivators and barriers’, including the subthemes ‘motivations for achieving/maintaining good brain health’, ‘motivators for engaging in helpful behaviours’, and ‘barriers to engaging in helpful behaviours’; and finally 3) ‘the role of social support’ including subthemes ‘desirability of social support’ and ‘motivational mechanisms of social support’. Key findings from each theme are briefly summarised with illustrative quotes from the data. These findings helped to further refine the intervention guiding principles and behavioural analysis.
Knowledge and understanding of brain health
This theme suggests that, for older adults, ‘good brain health’ is largely about maintaining independence and remaining able to do the activities one wishes to do. More than half of participants also discussed retention of specific cognitive skills such as good memory and decision-making.
“If you've got good brain health, then you can carry on with your daily life: cooking, managing your finances, managing your social life - you know, day-to-day things, really.” (P0229, female, 68, higher cognitive performance)
A large proportion of individuals felt that, whilst information about cognitive health and how to protect it is available, it often requires one to actively look for it. Many also mentioned the availability of information about body health, but not necessarily about brain health.
“So you do need to know about it. But you have to make the effort to either read a newspaper or look at the news, or get your brain active yourself.” (P0265, female, 69, lower cognitive performance)
Despite this, nearly three-quarters of participants named typically promoted strategies for maintaining cognitive health, such as brain training activities and puzzles. Half of participants also acknowledged the role of health-related behaviours, such as physical activity, in maintaining cognitive health.
Motivators and barriers
Two different types of motivation were identified within participants’ accounts. The first were motivations to maintain good brain health in order to avoid cognitive decline and its anticipated negative consequences, such as loss of independence, poor quality of life, and interference with relationships. This was often accompanied by accounts of friends or family with dementia and their strong wish to avoid this.
“It's a tremendous thing, for me anyway, because I've seen other people go through it. I don't want to, […] It is frustrating for other people as well as for yourself. I think it's important not just for you, but it's also important for the rest of the family, and to be able to pass the memories on as well.” (P0225, female, 65, lower cognitive performance)
The second type of motivation related to factors that encouraged individuals to engage in behaviours important for maintaining cognitive health. The overwhelming sentiment was that enjoyment is the main motivator. Even when individuals acknowledged that behaviours were beneficial for brain health, this seemed an ‘added bonus’ rather than the primary motivator.
“…yeah, you know, I do a lot of things like maths games. And crosswords and stuff like that every day, so I don’t know if that actually helps but I just find them interesting.” (P0138, male, 70, higher cognitive performance)
Barriers to engaging in activities to support cognitive health were not discussed extensively, but the most common difficulty mentioned was managing other health conditions.
“I'm quite hampered with physical activity because I've got arthritis and am registered disabled so, to be honest, physical activity is so difficult for me. That's where these exercises come in, really and it's mostly what I can do.” (P0261, male, 62, higher cognitive performance)
The role of social support
Participants who discussed involving others in healthy lifestyle activities mentioned several mechanisms through which this provided motivation for beginning and maintaining activities. This included creation of action plans with others, being accountable to others and sharing encouragement and new ideas.
“I think, if you're going swimming or something once a week, it's nice if someone says, 'Are you ready to go?' 'Shall we go today?' rather than you think: Oh, do I really want to go today? If there's two of you or three of you wanting to go, you encourage each other.” (P0229, female, 68, higher cognitive performance)
However, it was widely acknowledged that individuals’ preferences and circumstances determine whether involvement of others is possible, or even desirable. More than half of participants expressed that they would be happy (or sometimes prefer) to do such activities alone.
“I'm quite happy with my own company. I mean, I enjoy doing things with other people, and I go to yoga and I get on with everybody there, and I've got quite a few friends that go, but I would go whether they went or not.” (P0129, female, 67, lower cognitive performance).