scope & purpose of the toolkit
Overall Objective
To support health professionals working with survivors of stroke to promote improved and ongoing physical activity and exercise; to ‘move more for life’.The toolkit is designed for health professionals who are developing physical activity programs for survivors of stroke. This could include recommendations regarding being physically active, whether in recreational and household activities, formal physical activity programs or completing exercise programs developed by the health professional.
Potential users of the toolkit
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Health professionals who work with survivors of stroke to promote physical activity and exercise, including, but not limited to, physiotherapists, exercise physiologists, allied health assistants, and occupational therapists.
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In the community, inpatient and outpatient settings.
Whilst the ACT now toolkit has been developed with a focus on physical activity and exercise adherence, many of the included resources could be adapted for use when addressing other areas of lifestyle behaviour change in survivors of stroke, such as dietary changes or ceasing smoking.
toolkit development process
This toolkit resource has been developed according to World Health Organisation (WHO) recommendations. In 2003, the WHO conducted the ‘Adherence to Long-Term Therapies Project’, a global initiative aiming to improve global rates of adherence to therapies, including physical activity programs, in people with chronic health conditions.
Adherence was defined as “the extent to which a person’s behaviour – taking medication, following a diet and/or executing lifestyle changes, corresponds with agreed recommendations from a healthcare provider.”
The report concluded that increasing the effectiveness of adherence to interventions may have a far greater impact on the health of the population than any improvement in specific medical treatments.
To enhance adherence and empower health professionals, it was recommended that an ‘adherence counselling toolkit’ should be developed and implemented for specific chronic conditions, incorporating information on adherence, a clinically useful way of using this information, and behavioural tools for maintaining habits.
This toolkit has been developed over four phases to best determine the needs and preferences of health professionals, survivors of stroke, and their carers/significant others. The phases are outlined below.
A systematic review was conducted to identify and evaluate existing toolkits developed to promote adherence to physical activity in people with chronic health conditions (Levy et al 2023).
A member of the research team completed the University College of London Centre for Behaviour Change International Training Programme: Principles and Practice course.
Phase 1
REVIEW OF THE LITERATURE
An online survey exploring attitudes, experiences and beliefs about exercise adherence was developed and disseminated to health professionals, survivors of stroke and their carers. Focus groups were conducted to fully explore survey findings.
Phase 2
SURVEYS AND FOCUS GROUPS
A ‘Stakeholder Working Group’ was convened to review the survey and focus group findings and plan the development of an ‘Adherence Counselling Toolkit’ (ACT now).
Phase 3
STAKEHOLDER
WORKING GROUP
MEETINGS AND
CONSULTATION
Members of the Stakeholder Working Group were consulted to ensure that the content and format recommendations were appropriately addressed. Pilot work was conducted with health professionals and survivors of stroke.
Phase 4
DEVELOPMENT AND EVALUATION
bACKGROUND
Why is the ACT Now Toolkit needed?
What the World Health Organisation says
In 2003, the WHO recommended that adherence counselling toolkits should be developed and implemented for specific chronic conditions and should address three topics simultaneously.
The toolkits should:
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Incorporate information on adherence
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Encompass tools and strategies and a clinically useful way of using this information
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Include behavioural tools for maintaining habits.
has this happened?
The short answer is NO! We have conducted a systematic review (Levy et al 2023) titled ‘Physical activity for people with chronic conditions: a systematic review of toolkits to promote adherence’, and based on the findings of this review a recommended toolkit design could not be identified. Furthermore, none of the included toolkits were specific to survivors of stroke.
What we know about adherence in survivors of stroke
Rates of adherence to physical activity and exercise in survivors of stroke have been explored in many studies. It has been reported that many survivors of stroke do not adhere to recommendations or participate in long-term physical activity or exercise. Research suggests this figure may be as low as 50%. But we know this is important for health and well-being! In fact a lot of research links degree of exercise adherence to functional outcomes in survivors of stroke (Gunnes 2019).Long-term, a complex combination of factors seems to influence adherence to exercise in survivors of stroke, some of which are modifiable (Morris, 2016). These include intention to engage, self-motivation, levels of confidence, previous adherence patterns, social support, knowledge and rate of physical recovery. The role of the health professional, especially via goal setting and monitoring of progress, has been identified as important in determining adherence to home-based exercise programs (Moore, Holden, Foster & Jinks, 2020).
Why we should use a 'behavioural' approach
Adherence requires behaviour change and it is recognised that health professionals should apply relevant behaviour change theory and techniques to enhance adherence to physical activity and exercise (Hay-Smith 2016). Using a theoretical base in the design of interventions allows health professionals to identify key constructs influencing behaviour – and this will lead to well developed, theory-based exercise/physical activity programs that are more likely to lead to long-term adherence.
Many behavioural strategies have been explored. Interventions based on motivational strategies, via individualised tailored counselling, have been shown to be effective in increasing physical activity (Van der Ploeg et al., 2006), and the use of motivational strategies in stroke rehabilitation has been shown to enhance adherence to programs and improve outcomes (Cheng et al., 2015; McGrane et al., 2015). Reduced self-efficacy, or a lack of confidence in their ability to continue with their physical activity program has been identified as a key barrier for many survivors of stroke. Programs that incorporate strategies to enhance self-efficacy and encourage problem-solving and decision-making have therefore been recommended (Caetano et al., 2020).
Why the COM-B Model?
There is a strong theoretical base to the COM-B model (Michie 2011). It sits at the core of the Behaviour Change Wheel (BCW) (Michie 2014) which is a practical tool that can be applied to move from identification of barriers to selecting relevant interventions or strategies to support change. The BCW was developed by a group of expert implementation scientists, led by Professor Susan Michie. It is supported by very strong evidence as it was a synthesis of 19 behaviour change frameworks.The COM-B states that for a behaviour to change at least one of 3 components must change – capability, opportunity, or motivation.The COM-B model has been used extensively in the adherence literature. But as well as being a good research tool it is widely considered an easy-to-use model for health professionals who want to get a good understanding of their clients.
The Behaviour Change Wheel
Michie, S., van Stralen, M.M., & West, R. (2011). The behavior change wheel: A new method for characterizing and designing behavior change interventions. Implementation Science, 6(1), 42. Retrieved from https://doi.org/10.1186/1748-5908-6-42
