Exploring the views and experiences of people recovering from a stroke about a new text message intervention to promote physical activity after rehabilitation-Keeping Active with Texting After Stroke: A qualitative study.

BACKGROUND: Participating in exercise following a stroke is essential for recovery. When community-based rehabilitation services end, some people struggle to remain active. We codesigned Keeping Active with Texting After Stroke (KATS), a text message intervention to support home-based, self-directed plans to continue exercising. KATS delivers a series of automated text messages over a 12-week period from the point of discharge from National Health Service-funded therapy. The aim of this study was to explore the views and experiences of the first cohort of participants to complete the KATS intervention about the meaning, engagement, workability and worth of the intervention. METHODS: We undertook a qualitative study, theoretically informed by Normalisation Process Theory. We conducted semi-structured telephone interviews with people with stroke from two Health Boards in Scotland. Data collection took place over two phases, with each participant being interviewed twice: first, halfway through intervention delivery (Week 6) and then again at the end of the intervention (Week 12). All interviews were audio-recorded, transcribed and analysed thematically. RESULTS: A total of 24 interviews were conducted with 12 participants. Our findings were organised around four overarching analytical themes: (1) making sense of KATS: timing and complementarity in the rehabilitation journey; (2) engaging with KATS: connection and identification with others; (3) making KATS work: flexibility and tailorable guidance; (4) appraising the worth of KATS: encouragement and friendliness. Participants differentiated KATS from current rehabilitation practice, finding it relevant, fitting and worthwhile. Variations were reported in engagement with behaviour change techniques, but participants were able to tailor KATS use, making it work for them in different ways. CONCLUSIONS: Perceived benefits went beyond promoting physical activity, including feeling supported and connected. Future research will test the effectiveness of KATS in promoting physical activity and explore any associations with relevant social and emotional secondary outcomes. PATIENT OR PUBLIC CONTRIBUTION: A research funding proposal was developed in collaboration with five people with stroke and three spouses. After securing funding, six people with stroke were invited to join the project's Collaborative Working Group, alongside health professionals and stroke rehabilitation experts, to codevelop the intervention and support the feasibility study.

Keeping Active with Texting after Stroke (KATS): development of a text message intervention to promote physical activity and exercise after stroke.

BACKGROUND: Post-stroke physical activity reduces disability and risk of further stroke. When stroke rehabilitation ends, some people feel abandoned by services and struggle to undertake physical activities that support recovery and health. The aim of this study was to codesign a novel text message intervention to promote physical activity among people with stroke and provide support when formal rehabilitation ends. This manuscript describes the intervention development processes that will inform future pilot and feasibility studies. METHODS: The planned intervention was a series of text messages to be sent in a predetermined sequence to people with stroke at the end of rehabilitation. The intervention, underpinned by behaviour change theory and using salient behaviour change techniques, would provide daily messages offering encouragement and support for the uptake and maintenance of physical activity following stroke. The intervention was codesigned by a Collaborative Working Group, comprised of people with stroke, rehabilitation therapists, representatives from stroke charities and academics. A four-step framework was used to design the intervention: formative research on physical activity post-stroke, creation of the behaviour change text message intervention, pre-testing and refinement. Formative research included a review of the scientific evidence and interviews with community-dwelling people with stroke. Data generated were used by the Collaborative Working Group to identify topics to be addressed in the intervention. These were mapped to constructs of the Health Action Process Approach, and salient behaviour change techniques to deliver the intervention were identified. The intervention was rendered into a series of text messages to be delivered over 12 weeks. The draft intervention was revised and refined through an iterative process including review by people with stroke, their spouses, rehabilitation therapists and experts in the field of stroke. The messages encourage regular physical activity but do not prescribe exercise or provide reminders to exercise at specific times. They use conversational language to encourage engagement, and some are personalised for participants. Quotes from people with stroke provide encouragement and support and model key behaviour change techniques such as goal setting and coping planning. DISCUSSION: Co-design processes were critical in systematically developing this theory and evidence-based intervention. People with stroke and rehabilitation therapists provided insights into perceived barriers post-rehabilitation and identified strategies to overcome them. The structured multistep approach highlighted areas for improvement through successive rounds of review. The intervention will be tested for acceptability, feasibility and effectiveness in future studies. This co-design approach could be used for interventions for other heath behaviours and with different populations.

Supported self-management in community stroke rehabilitation: what is it and how does it work? A protocol for a realist evaluation study.

INTRODUCTION: A growing evidence base demonstrates the effectiveness of supported self-management in stroke for stroke survivors and their families. However, there is significant variation in its implementation in community stroke care and little understanding about how supported self-management works and is delivered across different settings, models used and contexts of community stroke rehabilitation. METHODS AND ANALYSIS: Using a mixed method, realist approach across two phases, this protocol describes a study on community-based supported self-management. The aim is to identify the mechanisms and outcomes of supported self-management in stroke and to understand how supported self-management is implemented in different contexts of community stroke rehabilitation. Phase 1 involves (1) a realist synthesis, (2) a scoping and mapping of current community rehabilitation settings and (3) a Q-methodology study to develop initial programme theories about how community-based supported self-management works, for whom and in what contexts. Phase 2 involves realist informed interviews/focus groups with stroke survivors, community rehabilitation practitioners and team managers from across Scotland to test and refine programme theories and an explanatory model for how supported self-management works across different contexts of community-based stroke rehabilitation. ETHICS AND DISSEMINATION: Ethical approval and R&D approvals have been granted from East of Scotland Research Ethics Committee (REC reference number: 19/ES/0055) and participating NHS boards. An understanding of how, for whom and in what contexts community-based supported self-management works will help to strengthen its delivery in practice. Such an understanding will enable the design of context-specific recommendations for policy and practice that genuinely reflect the challenges in implementing supported self-management in community stroke care. Results will be disseminated to clinical partners working in community stroke rehabilitation, stroke survivors and families and to policymakers and third sector partners involved in the provision of long-term support for people affected by stroke. PROSPERO REGISTRATION NUMBER: CRD42020166208.