Promoting physical activity and physical function in people with long-term conditions in primary care: the Function First realist synthesis with co-design

Article history

The research reported in this issue of the journal was funded by the HS&DR programme or one of its preceding programmes as project number 17/45/22. The contractual start date was in September 2018. The final report began editorial review in March 2020 and was accepted for publication in November 2020. The authors have been wholly responsible for all data collection, analysis and interpretation, and for writing up their work. The HS&DR editors and production house have tried to ensure the accuracy of the authors’ report and would like to thank the reviewers for their constructive comments on the final report document. However, they do not accept liability for damages or losses arising from material published in this report.

Copyright statement

Copyright © 2021 Law et al. This work was produced by Law et al. under the terms of a commissioning contract issued by the Secretary of State for Health and Social Care. This is an Open Access publication distributed under the terms of the Creative Commons Attribution CC BY 4.0 licence, which permits unrestricted use, distribution, reproduction and adaption in any medium and for any purpose provided that it is properly attributed. See: https://creativecommons.org/licenses/by/4.0/. For attribution the title, original author(s), the publication source – NIHR Journals Library, and the DOI of the publication must be cited.

2021 Law et al.

Physical functioning

Physical capability, a concept also referred to as ‘physical functioning’, is a term used to describe an individual’s capacity to undertake the physical tasks of everyday living. 13 Poor physical functioning is associated with negative outcomes, including higher risk of 30-day hospital re-admission,14 increased morbidity and mortality15,16 and long-term disability. 12,17 Multimorbidity predicts future functional decline, which is more marked with increasing numbers of conditions and with condition severity. 18 Worsening physical function also affects older adults with long-term conditions in terms of health and independence, and may have an impact on how they perceive their overall health and symptom management. 19 Thus, physical function is one of the most important factors in quality of life among older adults,19,20 and optimising and preserving physical functioning should be a central goal for all people with long-term conditions. Increasing awareness about the important relationship between physical function and overall health status is likely to lead to improvement in care for people with long-term conditions. 21,22

Physical activity

A different, but related, concept is physical activity, defined as ‘any bodily movement produced by skeletal muscles that results in energy expenditure’. 23 ‘Physical activity’ refers to what one actually does (i.e. a behaviour), rather than just the capacity to do something. Habitual performance of at least minimal levels of recommended physical activity is important for preventing and managing long-term conditions, with positive effects comparable to those from optimal medication. 24 Previous studies of middle-aged and older adults show that more physically active people have better levels of physical functioning. 13,25–28 Indeed, physical inactivity, or sedentarism, is one of the strongest predictors of physical disability in older people. 29,30 The proposed process behind this association is that physical activity helps to maintain muscle and cardiac function, improves gait, balance and mood, and subsequently prevents functional decline. 31–34 Moreover, regular physical activity prevents or improves conditions that underlie disability in older adults, including falls,35 hip fracture,36 cardiovascular disease,37 diabetes,38 obesity39 and frailty,40 with longitudinal studies suggesting that regular physical activity is associated with reduced mortality. 41 Several studies have also demonstrated the benefits of physical activity for psychosocial functional outcomes in older adults. 42–44

There are known benefits of physical activity for the management of long-term conditions and particularly for improving physical function. 40,45–50 Despite this evidence, the proportion of the adult population in England and Wales reporting moderate levels of physical activity (i.e. participating in moderate physical activity for at least 30 minutes, five times per week) was 66% in 2017/18,51 22% were classified as inactive (i.e. participating in < 30 minutes of physical activity per week), and increasing age associated with less physical activity. However, individuals overestimate the amount of physical activity they do in self-reported surveys and so the true situation is likely to be worse. For example, objective measurements of physical activity collected using accelerometery have demonstrated that only 6% of men and 4% of women meet the recommended activity guidelines, suggesting considerably lower levels of participation. 52

Levels of physical activity in people with long-term conditions are even lower, and an inverse association has been found between physical activity and multimorbidity. 53,54 The worldwide economic burden of physical inactivity has been estimated to be at least £51.5B per year55 and the estimated annual direct cost of physical inactivity to the NHS across the UK is £1.06B. 56 This is not just a UK issue, as the World Health Organization has the target of achieving a 10% reduction in physical inactivity by 2025. 57

Public Health England launched ‘One You’, the first nationwide campaign to address preventable disease in adults. This aimed to encourage people, particularly adults in middle age, to take control of their health by ‘moving more’ to enjoy significant benefits now and in later life. 58 In addition, the importance of physical activity and physical function was emphasised in the ‘Start Active, Stay Active’ report from the four home countries’ Chief Medical Officers on physical activity for health. 59 The variation in physical function that exists among people as they age was acknowledged and the report gave recommendations for groups of older adults with different functional status and activity needs, including the following:

• People who are already active, through daily walking, an active job or engaging in regular recreational or sporting activity. This group may benefit from sustaining their current activity levels and potentially by increasing their general activity or introducing an additional activity to improve specific aspects of fitness or function.

• People whose function is declining owing to low levels of activity and excessive sedentary time, who may have lost muscle strength, or are overweight but otherwise remain reasonably healthy. This is the largest group with a great deal to gain from changing behaviour, restoring function and preventing disease.

• People who are frail or have very low physical or cognitive function, perhaps as a result of old age or long-term conditions such as arthritis and dementia. This group requires a therapeutic approach (e.g. falls prevention programmes) and many will be in residential care.

In Wales, the Well-being of Future Generations (Wales) Act 201560 put in place seven well-being goals, including ‘a heathier Wales’. A strategic aim of this policy is ‘to encourage more adults to be more active, more often, throughout life’.

The important role of primary care

In total, 90% of patient interaction with the NHS occurs in primary care and people with long-term conditions are in regular contact with primary care services. 7 The management of these conditions has been strongly influenced by the Quality and Outcomes Framework,61 which emphasises disease-centred outcomes and the recording of risk factors, such as blood pressure and body weight, rather than the assessment of physical activity and physical function. Although managing disease remains important, placing more emphasis on functional limitations, such as whether or not people can perform ADLs, has the potential to improve care for people with long-term conditions. Organisational interventions targeted on patient-specific difficulties (e.g. functional ability) appear to be more effective than generic interventions,62 especially when the intervention is more comprehensive and integrated into routine care. 63

Physical activity could be promoted in primary care by making physical activity an explicit element of regular behavioural risk factor screening, patient education and referral, as well as developing and maintaining strong links between primary care settings and local community-based opportunities. Patients can be referred from primary care to exercise referral schemes. 64 However, the effectiveness of these schemes is limited by low rates of recruitment and retention. 65 There are several possible reasons for this. First, the benefits of physical activity and fitness are poorly taught in medical education. 66 Second, referral to these schemes is not routine in primary care management of long-term conditions. Third, these gym-based schemes may appear irrelevant to people’s day-to-day lives. A different approach is warranted. Interventions could also be widened to include community care, as primary and community care are increasingly integrated. Further examples of areas for integration include social care, leisure services and the third sector.

International examples of importance include the ‘Exercise is Medicine’67 movement in the USA and the Canadian Chronic Care model, which takes the perspective that function is the ‘sixth vital sign’. 22 A multicomponent rehabilitation intervention including function-based individual assessment and action planning, rehabilitation self-management workshops, online self-assessment of function, and organisational capacity-building has been explored in a Canadian primary health-care setting. 21 This functional approach is different from the medical model of illness that focuses on the diagnosis, categorisation and medication of disease. 68 Rather, it concentrates on functional limitations, such as whether or not people can perform ADLs. 69 In addition, to improve care for people with long-term conditions, it has been suggested that there is a need to shift away from a reactive, disease-focused, fragmented model of care towards one that is proactive, holistic and preventative. 63 Similarly, the chronic care model, which has influenced health policy around the world, also stresses the need to transform health care for people with long-term conditions from a system that is largely reactive in responding mainly when a person is sick to one that is much more proactive and focuses on supporting patients to self-manage. 70

Systematic reviews and guidelines

Previous systematic reviews and guidelines have explored the effects of physical activity interventions in sedentary adults and people with multimorbidity, osteoarthritis, obesity and chronic pain in the primary care setting. 45,71,72 They have also explored barriers to and facilitators of physical activity and the effectiveness of different intervention ‘deliverers’. 73,74 However, although the links between physical activity and physical function are evident and the benefits of physical activity are clear, the best way for primary care to help people with long-term conditions increase physical activity is unclear.

The National Institute for Health and Care Excellence (NICE) guidelines for the clinical assessment and management of multimorbidity recommend that functional assessments, such as objective measurement of gait speed and grip strength and subjective patient self-reported health status, should be used in primary care to assess frailty. 71 NICE has also issued guidelines for the prevention of frailty, disability and dementia in mid-life by increasing habitual physical activity. 75 NICE recommends that campaigns should promote the message that it is not inevitable for older people to experience sustained ill health, it is possible to reduce the risk and severity of dementia, disability and frailty, and, although it is better to make changes earlier in life, even changing behaviours in mid-life can bring about health gains. Moreover, NICE recommends that future research should focus on determining the most effective and cost-effective mid-life services and interventions, including how these can be delivered in a consistent and sustainable manner.

In summary, insufficient habitual physical activity levels are most apparent in those with long-term conditions. However, despite the benefits of physical activity for physical (and psychosocial) functioning and the regular contact with primary care for long-term condition management, primary care interventions to increase physical activity for people with long-term conditions are used in only a limited way in the UK NHS. Therefore, a better way for primary care to help reduce functional decline and promote physical activity is needed. 76 This includes a consideration of changes in the culture of primary care and an understanding that physical activity promotion is an important health promotion activity and long-term condition management, as well as having the tools available to assist the workforce and change behaviour.

Rationale for a realist approach

Optimising physical function and physical activity is likely to involve a complex intervention, drawing on a range of resources that activate different participant responses. 77 Therefore, a methodology that focuses on this complexity is required. A realist approach recognises how ‘patterning of social activities are brought about by the underlying mechanisms constituted by people’s reasoning, and the resources they are able to summon in a particular context’ (p. 220). 78

Realist methods examine the interplay between different contexts and mechanisms that underpin interventions in primary care to improve physical activity and physical function for people with long-term conditions, and how these different contexts and mechanisms lead to different outcomes.

The rationale for using realist synthesis, as opposed to a systematic non-realist review, is that through the identification of context, mechanism and outcome (CMO) configurations it provides a contextualised explanation of ‘what works, for whom, in what circumstances, in what respects and why’. 79 It has also been recommended that the research community should shift from designing and testing small-scale interventions to change individual behaviour towards expanding the evidence on strategies for translating, disseminating, implementing and scaling up effective policy and practice for physical activity promotion worldwide. 80 As increasing habitual physical activity plays an important role in maintaining and improving physical function, this synthesis considers these issues. It also explores the potential for a ‘culture shift’ in the focus of NHS general practice from a disease-centred approach, emphasising diagnosis, categorisation and medication, to one that promotes overall function and well-being.

A key part of realist synthesis is the interrogation of relevant theory-rich literature. However, realist evidence syntheses are also participatory in nature, drawing on the lived experiences of service users and professionals providing services to identify ‘nascent’ theories based on individual experiences. 78 To enable this, creative methods from the field of co-design were used to ensure that the views of all stakeholders were included and embedded in the review process. The co-produced theory and ideas from these stakeholders were fed back into the literature searches, refining the search criteria, adding an interpretative frame to interrogate the literature, and corroborating and refuting the evidence. The resulting theories then informed a co-design stage, during which they were refined and prioritised before being used to generate implications for service innovation and implementation. 1

Aims and objectives

• To identify and produce a taxonomy of physical activity interventions that aim to reduce functional decline in people with long-term conditions managed in primary care.

• To work with patients, health professionals and researchers to uncover the complexity associated with the range of physical activity interventions in primary care, and how they directly or indirectly affect the physical functioning of people with long-term conditions.

• To identify the mechanisms through which interventions bring about functional improvements in people with long-term conditions, and the circumstances associated with the organisation and operation of the interventions in different primary care contexts.

• To understand the potential impacts of these interventions across primary care and other settings, such as secondary health care and social care, paying attention to the conditions that influence how they operate.

• To co-produce an evidence-based, theory-driven explanatory account in the form of refined programme theory to underpin and develop a new intervention through a co-design process with patients, health professionals and researchers. 1

Co-production of the short title and acronym

Members of the study management group, including public research partners, worked together to develop the short title of the study ‘Function First’ and the strapline ‘Be Active, Stay Independent’. We first discussed project keywords and gathered suggestions to develop 11 options. The final version was chosen following a vote and subsequent discussion.

Summary of the overall methods

We used Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) methodological guidance and standards to inform our application of realist methods. 81

The first stage of the synthesis developed initial theories about how and why primary care interventions aiming to improve physical function and physical activity among patients with long-term conditions work (or may not work), for whom, and in which circumstances. These theories were developed through two theory-building stakeholder workshops and an early scoping search of published and grey literature. This phase informed theory development and literature searches by helping to develop a shared understanding of the key topic areas and stimulate initial ideas.

Following the theory-building workshops, a list of ‘if . . . then’ statements were created, and the search strategy and inclusion and exclusion criteria were developed and refined. The ‘if . . . then’ statements also formed part of the activities included in the first co-design workshop, where stakeholders took part in activities and games to familiarise themselves with the emerging ideas and match different statements.

After an initial sift of titles and abstracts, we refined our inclusion and exclusion criteria a second time and identified relevant systematic reviews. We created an evidence table to capture relevant realist critique from the systematic reviews. This evidence table and the ‘if . . . then’ statements were then used to develop eight emerging ‘theory areas’. To explore these theory areas, we then conducted 10 individual ‘theory-refining’ interviews with stakeholders. These theory areas were explored during the second co-design workshop, with stakeholders considering how particular intervention assets related to the theory areas.

Data were extracted from papers that were identified as rich and relevant to the eight theory areas, including individual qualitative and quantitative studies, guidelines and the grey literature. Through this process, and iterative discussion, we developed initial ‘candidate’ CMO statements. These were further refined and tested through the organisation of extracted information into evidence tables representing the different sources of evidence, including the individual stakeholder interviews. This enabled exploration of confirming or refuting evidence. We also developed a taxonomy of primary care physical activity interventions for people with long-term conditions.

The CMOs formed part of the final co-design and knowledge mobilisation workshops, where participants considered the emerging CMOs and how they were embodied within the co-designed resources. The ‘final’ five CMO statements were then defined, alongside the co-designed ‘Function First’ product.

As this was an iterative process, there were some changes to the original protocol, and these changes are outlined in more detail below.

Changes to the original proposal

Figure 2 shows the original schematic of project progression.

FIGURE 2.

The original schematic of project stages. See Figure 1 for the actual process of project progression.

All elements of the protocol were completed as planned. However, there was more overlap in the stages than originally anticipated because of the large evidence base in the areas of physical activity, physical function and primary care for people with long-term conditions. This meant that:

1. We discussed emerging ‘theory areas’ with stakeholders in the theory-refining interviews, rather than conjectured CMO statements.

This was necessary to enable refinement of the key emerging theories and to avoid artificially ‘jumping ahead’ to CMO development. It allowed for a deeper understanding of the areas involved, strengthening the eventual theories developed.

1. The CMOs were not finalised before the first co-design workshops began and developed further as we progressed through the workshops.

The integration of CMO development with the co-design workshops was an unanticipated strength of the research process and meant that the refinement of the final CMOs benefited greatly from further stakeholder input, including suggestions for additional literature searches. In addition, the co-design process was not limited by a final set of CMO statements and was more authentic as a result. Chapter 6 discusses this further.

Data sources, analysis and synthesis

The data sources and how they were analysed and synthesised are described in the following sections. The realist synthesis of literature including stakeholder interviews, co-design workshops and knowledge mobilisation event are described in the Chapters 3 and 4.

Early scoping exercise of published and grey literature

To gain familiarity with the literature and aid with the identification of keywords, we carried out a preliminary scoping of the literature to retrieve reports, theses, key articles, systematic reviews and any relevant websites to help inform our formal search strategy. This scoping exercise was informed by previous work in this area,82–84 proposal work-up, early study management, and Project Advisory Group meetings and discussions with patient and public representatives.

Theoretical landscape

As part of the above scoping exercise and to stimulate early thinking about important areas, we identified the overarching theories and frameworks that we determined as likely to inform the realist synthesis. We drew from theories that address a wide social context including theories and models relating to physical function (e.g. International Classification of Functioning, Disability and Health69); environmental factors and individual compensation strategies;85 psychological theories of motivation, behaviour and behaviour change relevant to patients and health professionals (e.g. self-efficacy and self-determination theory,86,87 intention and behaviour,88 health beliefs, planned behaviour);89,90 interventions based around Capability, Opportunity, Motivation – Behaviour (COM-B) principles;91,92 and the self-regulation of illness,93,94 sociological theory (e.g. governmentality,95 habitus,96 social and peer support97,98); implementation theories (e.g. diffusion,99 knowledge to action100); and organisational theories relevant to how interventions fit into different ways of delivering services and pathways. 1,101,102

Stakeholder analysis

An initial stakeholder analysis helped us to identify and target the most relevant groups for the different stages of the synthesis. 103 It included representation from people with long-term conditions, primary care professionals working in general medical practices, allied health professionals, third-sector organisations, council-funded initiatives, social care, policy-makers and commissioners of services (Figure 3). The stakeholder analysis was used to ensure that no particularly important groups were missed. The stakeholder analysis took place across two or three study management meetings and one external Project Advisory Group meeting, and involved a process of feedback and iteration. This was consistently monitored, and care was taken to incorporate any missing perspectives. Researchers with knowledge and experience relevant to the syntheses were also identified as stakeholders as the project progressed.

FIGURE 3.

Summary of the stakeholder analysis. LTC, long-term condition; OT, occupational therapy.

Theory-building workshops

Data collection using LEGO^® Serious Play^®

Creative methods, borrowed from the field of co-design, were employed to structure the two theory-building workshops and elicit the views and experiences of all stakeholder representatives, including a facilitated session using LEGO^® Serious Play^® (LEGO, Billund, Denmark). This method has been used previously in service improvement work, training of health professionals, and research. 104–108 The specific choice to use LEGO Serious Play as opposed to other participatory approaches was because of the tangibility of working with LEGO. LEGO Serious Play enabled a move from ‘research’ activity into ‘co-design’ activity through making tangible outputs. By using these tangible forms, it set some expectations early on in the programme of work about the transition from intangible to tangible (i.e. from evidence to actionable tools). Participants who attended these two workshops are detailed in Report Supplementary Material 1.

Following a series of skills-building activities, each individual created and described LEGO models (physical metaphors) in response to the following questions: ‘What does physical function mean to you?’ and ‘What are your experiences of maintaining physical function?’.

Participants were encouraged to play with the LEGO as they considered the questions, connecting bricks while they thought. This gave the participants’ hands, and part of their mind, an occupation while they pondered the topic in question. What is built by the end of the reflective period then becomes a physical ‘tool’ that can be used to enhance the expression of those thoughts back to the wider group. We also asked participants to summarise their thoughts in three words written on a Post-it Note (Post-it^® Brand; 3M, Cynthiana, KY, USA). As shown in Figure 4a, some participants chose to augment this communication further by using illustrations as well as their LEGO model. This demonstrates one of the core values behind the LEGO Serious Play methods; these media give people a greater opportunity for self-expression (using LEGO model plus verbal description) than the sole use of speech or writing.

FIGURE 4.

Example models built by participants in the theory-building workshops to reflect on and describe their interpretation of (a) what physical function meant to them; (b) how they maintained physical function; and (c) an example of a ‘shared landscape’.

This process helped to develop a shared understanding of the key topic areas and stimulate initial ideas and thoughts for theory development. It exposed researchers involved in the workshop to first-hand lived experiences of people with long-term conditions and professionals working in primary care. These LEGO models were then incorporated into a shared ‘landscape’ to explore which aspects of these experiences helped or hindered the maintenance of physical function (see Figure 4b).

As shown in Figure 4, photographics of the models were captured. Participant descriptions were audio-recorded and then transcribed for analysis and interpretation, and were used to shape emerging theories.

Literature searching

We reviewed the existing literature to look for evidence that suggested how and for whom physical activity interventions work to optimise physical function in the primary care setting. As interventions or services based in other areas of literature (e.g. secondary care, social services, the voluntary sector, exercise science) also hold relevant insight for the development of the initial programme theories, searches were not restricted. A systematic search strategy was developed and amended for use with the following databases: Cochrane Library, MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycInfo^® (American Psychological Association, Washington, DC, USA), Sociological Abstracts, Web of Science™ (Clarivate Analytics, Philadelphia, PA, USA), Applied Social Sciences Index and Abstracts (ASSIA; ProQuest^®, ProQuest LLC, Ann Arbor, MI, USA), Social Care Online and Social Care Institute for Excellence (see Report Supplementary Material 4). 1 Keywords were developed from the early scoping exercise and the key themes underpinning the initial programme theories were adapted for each information source as necessary. The searches were run in March 2019 and updated in 2020.

Our searches included adults of all ages and socioeconomic backgrounds. We translated non-English-language papers where relevant and practical. We did not limit our searches by publication date and there was no restriction on the type of publication or study type. We examined published and unpublished literature including research articles, systematic reviews and documents detailing policy and local and national initiatives. We did not search for, or include, studies that had limited transferability to NHS primary care, such as interventions involving pharmacological agents or very technical, high-cost equipment.

Literature initially was screened for relevance to the initial programme theories and cross-checked by two members of the research team. To assist with this, articles were uploaded to Covidence (Melbourne, VIC, Australia) to complete the initial sift. This software enabled multiple members of the team to participate in the sifting out of irrelevant articles.

The review team then followed predefined inclusion and exclusion criteria to remove irrelevant articles (see Report Supplementary Material 5). Thirty per cent of articles were reviewed by two members of the review team, with conflicts resolved through discussion between the two main reviewers and other members of the review team as necessary. As part of these discussions, study team meetings and following the initial theory-building workshops, we iteratively refined the inclusion and exclusion criteria. After this initial phase of double reviewing, the criteria were deemed sufficiently robust, and the remaining articles were reviewed by a single member of the review team. This resulted in a library of 2083 relevant papers. From that library, a purposive sample of 170 papers were selected for data extraction, chosen on the basis that they were the most relevant to the developing theory areas and gave the clearest and richest examples of evidence of interventions aimed at functional improvements in people with long-term conditions, and evidence of how these interventions are organised and operate with different primary care contexts. We supplemented the systematic search with forwards and backwards citation tracking of key articles. We also drew on the expertise of the project team, external Project Advisory Group, patient and public representatives, and other key researchers (nationally and internationally) and organisations to ensure that we did not miss any relevant evidence that may not have been retrieved by our traditional systematic searching methods.

We also carried out a grey literature search by targeting relevant organisations and programmes:

• organisational websites of professional bodies (i.e. Royal College of General Practitioners, Royal College of Physicians, Royal College of Nursing, Chartered Society of Physiotherapy, Royal College of Occupational Therapists, Academy of Medical Royal Colleges, Royal College of Surgeons, British Association of Sport and Exercise Sciences and Royal College of Psychiatrists)

• government departments and national centres (i.e. Public Health Wales, Public Health England, National Centre for Sport and Exercise Medicine, UK Faculty of Sport and Exercise Medicine, Sport England, Sport Wales and The King’s Fund)

• specific organisations and charities for people with long-term conditions

• Natural Resources Wales and National Parks England.

We also searched the Evidence for Policy and Practice Information and Co-ordinating Centre, NHS Evidence, Social Care Online and OpenGrey. In addition, we conducted an open web search for any grey literature (including from commercial leisure services). We used the grey literature sources to ensure that we had captured information about specific campaigns around physical activity for people with long-term conditions.

As previously described,109 unlike a traditional systematic review, a realist synthesis requires an iterative process for identifying literature. In addition to the systematic review of the literature, we also performed additional purposive searches enabling the initial programme theories developed in stage 1 to be expanded. The purposive searches were as follows:

• Guidelines: MEDLINE was searched using specific physical function keywords (physical function* OR physical activity OR physical fitness or exercise) with guideline keywords (exp guideline/ OR Guideline$.ti OR (guideline or practice guideline).pt. We also manually checked the websites of major guideline producers: NICE, Centre for Reviews and Dissemination, professional organisations, World Health Organization, Scottish Intercollegiate Guidelines Network and the National Guideline Clearinghouse.

• Social prescribing: we carried out a MEDLINE search using the phrase ‘social prescribing’ and filtered for recent reviews. We followed up with forwards and backwards citation searching on those reviews and consulted with the project team for additional references.

• Physical literacy: we carried out a MEDLINE search using the phrase ‘physical literacy’ and filtering for adults only. We also followed up with forwards and backwards citation searching on the papers identified and consulted with the project team.

Data extraction

Consistent with the realist synthesis approach,110 the test for inclusion was whether or not the evidence was ‘good and relevant enough’ to be included. 79 Relevance was defined as the ability of the data to contribute to the programme theory. 81 Assessment of relevance involved seeking any ‘trustworthy nuggets of information to contribute to the overall synthesis’ (p. 90). 111 For example, evidence-rich papers included detailed and reflective descriptions of what it was about interventions that worked (or not) (e.g. papers including qualitative or service evaluation elements), whereas less-rich papers provided limited in-depth description of the intervention and the factors influencing whether or not it worked (e.g. randomised controlled trials with mainly objective outcomes). Rigour or whether or not the quality of the evidence is ‘good enough’ was the research team’s judgement of the credibility of the data, including fidelity, trustworthiness and value. 82

Owing to the large data set, we adopted the following approach to data extraction:

• We identified all of the systematic reviews and conducted a ‘realist critique’ of all those which were relevant to gather an overview of the evidence available. The realist critique consisted of brief notes describing what information the paper provided about what was working or what was not working to improve physical activity or physical function and why, for whom and in what settings. It enabled us to identify the rich systematic reviews and also increased our awareness of broader patterns in the emerging contexts, mechanisms and outcomes.

• Using the information from this process and from the stakeholder work, we then developed eight theory areas.

• To facilitate data extraction, we designed a bespoke data extraction form to ensure that we captured data informing the developing theory areas, including intervention details and any differences in implementation.

• We then identified literature that was specific to primary care and used the bespoke data extraction form to capture relevant data (see Report Supplementary Material 6).

When discrepancies were encountered, the project team discussed whether or not the evidence provided met the criteria to be included.

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram depicts the flow of information through the different phases of the synthesis, and details the number and type of papers identified, included and excluded (Figure 5). The list of final included papers is included in Report Supplementary Material 7.

FIGURE 5.

The PRISMA flow diagram detailing the flow of information through the different phases of the review and the purposive searches.

Theory-refining interviews

As part of the iterative process of refining final programme theories, we explored the developing theory areas with stakeholders through 10 qualitative telephone interviews. Purposive sampling of the stakeholders was informed by the stakeholder analysis to provide a range of perspectives, which included three people with long-term conditions, three GPs, two practice nurses, one health-care assistant and one researcher with a background in pedagogy. One of the people with a long-term condition and one of the GPs were also participants in a theory-building workshop. The researcher with a background in pedagogy also participated in a later co-design and knowledge mobilisation workshop.

A semistructured interview topic guide was used to elicit the views of stakeholders on their resonance with the developing theory areas. The approach used in the interviews was a ‘teacher–learner cycle’ whereby the researcher presented the developing theory areas to the stakeholder (‘teaching’) and then verified with the stakeholder where they needed adjusting (‘learning’) to create an improved, refined version and a ‘mutual understanding’ of the developing theories. 1,112

With permission, the telephone interviews were audio-recorded and transcribed verbatim for descriptive analysis of the key themes, which contributed to refinement of the theories. 1 NVivo version 12 (QSR International, Warrington, UK) was used to organise the data. Coding linked the themes with the developing theories.

Taxonomy

Alongside the evidence synthesis process, we developed a taxonomy of primary care physical activity interventions for people with long-term conditions, which categorised and provided examples of interventions in the following categories:

• brief interventions

• telephone interventions

• online/‘eHealth’ interventions

• exercise referral schemes

• community navigators

• referral to exercise specialists

• intervention delivery by existing primary care staff

• physical activity pathways

• practice-wide initiatives

• community initiatives

• whole-system approaches to embed physical activity promotion in clinical practice

• multifaceted interventions.

Participants

The participants at each workshop were key ‘data sources’ (see Report Supplementary Material 1). Public contributors had a range of long-term conditions including hypertension, previous stroke, cancer and chronic obstructive pulmonary disease. Some professional contributors also described their own experiences of living with a long-term condition as well as providing care for someone with a long-term condition.

Workshop 1 (immersion)

The first activities in this workshop were card games designed to enable participants (in three small mixed groups) to immerse themselves in the evidence and apply it to the context of their own experiences and beliefs, and those of their group peers. This was about developing a nascent, shared understanding based on the evidence available to the whole co-design group both from the literature review and from their own experience.

The two components of the ‘If . . . then’ statements were divided into two decks of cards. The three components of emergent CMOs were also divided into three decks of cards and the eight emergent theory areas were added as a separate deck of cards. The participants were divided into three groups, each containing a mix of project team members, people with long-term conditions, health-care professionals, service providers, managers and other researchers. The cards were shuffled and the participants in each group were challenged to find matching pairs or trios, and to critically reflect on the theory areas in the context of their own experiences. The format of this activity as a card game created an informal and equal environment. People took turns to draw cards, discuss them and then move on to the next ‘player’. This engaged everyone in the group without requiring reference to rules or formal facilitation by a leader. The cards themselves and the notion of this as a card game facilitated this process and supported the agency of all the participants, removing any perceived hierarchy in the group. The groups made their own notes, edited cards if they wished and added cards as they felt necessary (Figure 6).

FIGURE 6.

Illustration of the ‘If . . . then’ card game (a) and sample images of the cards edited by participants (b, c).

The important thing with these card games was that they represented the wider evidence base and playing the game elicited critical discussion among the smaller groups about the evidence, enabling participants to make sense of it in the context of their own experiences and those of the other group members. The groups then shared their discussions with all the participants by selecting one issue arising from the ‘If . . . then’ card game that had created the most discussion in their group, followed by a general point about the discussion emerging from the CMO card game. These discussions were ‘captured’ by the facilitators on paper using flip charts (Figure 7).

FIGURE 7.

Summary notes of the whole-group discussion about the evidence emerging from the literature, following the ‘If . . . then’ and CMO card games.

The next activity in this workshop was designed to get participants thinking about themselves and their individual experiences. They had to identify which CMOs would most support them to engage with physical activities, and which would discourage them. Figures 8a and 8b are examples of some of the personal profiles created by the participants. The ‘data’ from this activity was not essential for developing an intervention but helped the co-design participants to think about the practical application of this evidence to a wider variety of people and the challenges associated with this.

FIGURE 8.

Examples of the personal profiles created by the participants (a, b), an example of one of the personas (c) and suggested relevant CMOs for this ‘case’; and (d) a final group discussion presented the personas and the CMO combinations defined for each case.

To encourage participants to think about the practical application of this evidence to other people, they created archetype personas (two per subgroup). They constructed comprehensive, holistic ‘pictures’ of these people and then considered what might work, and what might not work (in terms of CMOs) for each individual to encourage them to maintain or improve their physical function. To do this, they created personas that were culturally, socially and geographically diverse (in urban and rural settings); built up comprehensive ‘pictures’ of the whole life of each persona; and considered what CMOs would be most relevant in enabling primary care services to support each persona to be active and maintain physical function. Figures 8c and 8d illustrate one persona and the suggested relevant CMOs for this ‘case’.

This was followed by a broad discussion reflecting on everything that had been considered in this first workshop. These discussions were captured on paper on wall and flip charts.

This final discussion opened up some important topics:

• Ubiquitous or positive pervasive messaging – it is the responsibility of every health-care professional to have an understanding of the importance of physical activity, which should be discussed with patients in a consistent manner.

• The stages or states of ‘readiness for change’ on the part of the patient. Different strategies or interventions may be required at different stages of readiness, which raised further points –

  • There was a need to think creatively about how to enable people to move from ‘not being ready to engage’ to ‘being ready to engage’.

  • How to identify that ‘key moment’ when someone is ready to change and receptive to help.

  • There was a pragmatic argument to invest more time, effort and resources into that moment.

  • There was a need to think very differently about how to sustain long-term engagement in any activity.

  • The need to personalise or tailor the intervention at a practice level for staff and also for patients.

It was acknowledged that the context varied for different workshop participants, so this workshop provided an opportunity for sense-checking as well as further refinement of the emerging theories. Giving everyone the same time and space to do this at the start respected and valued their history and personal narrative, enabling everyone to move towards the main purpose of the co-design process. The activities in these workshops did not contribute directly to the design and development of ‘an intervention’ per se, but were vital building blocks, creating a shared understanding of each other, and of the evidence, as well as raising awareness of potential challenges and opportunities for developing a practical set of resources.

Design activity 1

Between workshops 1 and 2 the designers created a visual summary of workshop 1 to add to the growing visual narrative of the whole research process (Figure 9). This visual summary was brought back to every workshop as a way of enabling participants to continually position the co-design activity in the context of the process and evidence of the research project to that point.

FIGURE 9.

Visual ‘storyboard’ of the function first co-design process. (See also Report Supplementary Material 8 for a larger version.)

The design researchers reflected on and categorised the data produced by the co-design partners in workshop 1, using this to refine and adapt the plan for the next workshop. They then designed and produced the templates, resources and visual wall displays for the next workshop. Some of these activities included an exploration of previous co-design work strategies for engaging co-design partners and a breadth of existing interventions and analogous practices for presentation at workshop 2 as provocations for new ideas. We also invited participants to bring examples of existing interventions or resources relating to existing interventions that they had experienced or had knowledge of.

Workshop 2 (ideation)

The ultimate goal of this workshop was to generate ideas of tangible things that might help primary care professionals enable people with long-term conditions to sustain and improve their function. Before being able to generate ideas, it was important to enable participants to consider the kinds of ‘assets’ that individuals, communities and primary care services might utilise to support this kind of work (e.g. people, places, services, media, knowledge or technology).

This began by drawing up a working list of potential assets that might be available to people (Figure 10a) and then thinking about how these assets might relate to the eight theory areas. The groups also considered how these assets may have greater (or lesser) utility at different stages of ‘readiness’ to engage in activities related to sustaining physical function (Figure 10b). The participants then returned to the personas that they had created in workshop 1 and listed all of the possible assets that may be relevant to each persona (Figure 10c), before developing a specific ‘package’ of assets that could be used for the persona over a period of time (Figure 10d).

FIGURE 10.

Images showing lists of (a) potential assets; (b) the potential utility of these assets at different stages of ‘readiness’; (c) application to different personas; and (d) development of a specific package of assets.

Following this, the participants physically mapped these persona-specific packages of assets onto geographic representations of rural and urban areas (Figure 11a) before considering ‘spanners’ (i.e. disruptions to people’s routines that made it challenging to sustain behaviours). Considering these possible disruptions was an important step to heighten awareness and consider ideas that might overcome these issues. The group also considered what might affect the scaling up of these assets from individual to group, local, regional and then national levels. Finally, the group were challenged to generate novel ideas (new assets, ways of connecting assets or new combinations of assets) that might augment or add value to the existing maps (Figure 11b).

FIGURE 11.

(a) The beginning of the mapping activity; and (b) novel ideas written onto ‘light bulbs’.

Workshop 3 (co-design)

In this workshop, the prototypes were refined and selected. This involved all participants testing and refining the ideas and models further and employing a shared prioritisation process to select the top four ideas. This involved a ‘Dragon’s Den’-style activity, where participants were split into groups. Each group took responsibility for one of the top four concepts (Figure 12a). The participants developed these concepts to a point where they could be shared with a panel of external people; people with expertise and experience in this area who had not been involved in the project to date (see Report Supplementary Material 1). This process provided useful critical feedback that helped the participants develop the four ideas further and begin to make stronger connections between them. The ideas began to coalesce into a cohesive single intervention with four different elements that embodied the evidence and refined CMO statements (Figure 12b).

FIGURE 12.

(a) The four top concepts for the intervention idea; and (b) how they connect together.

Design activity 3

Between workshop 3 and the knowledge mobilisation event the designers extended the visual summary to include workshop 2, adding to the growing visual narrative of the whole research process.

The design researchers reflected on and categorised the data produced by the co-design partners in workshop 3, using this to refine and adapt the plan for the next knowledge mobilisation workshop. They then designed and produced the templates, resources and visual wall displays for the next workshop along with early, rough prototypes based on the ideas and content generated in workshop 2. This conversion of ideas into material form was a key step in setting up workshop 3. These early forms had to be sufficiently vague and roughly finished to encourage participants to critique, change and deconstruct them. Yet they had to have sufficient form to bring the ideas to life and give people a strong sense of what this might or might not be, and how it might or might not work. Part of this process involved presenting a range of possibilities to avoid leading people down a specific route (Figure 13). The design team then made further adjustments based on feedback and developments from the co-design workshop.

FIGURE 13.

Physical variations, sample content detail and an image showing how the content was deconstructed and refined as part of the workshop.

Summary and storyboard

Evidence from the realist synthesis phases was integrated into the co-design process in an iterative way. Figure 9 shows a storyboard of the overall process (see also Report Supplementary Material 8 for the larger version). This was displayed at each workshop and added to as the process progressed.

The co-designed resources are discussed in full in Chapter 3.

The series of images are a visual representation of the whole research and co-design process. The storyboard was essential in the participatory work, being used as a visual update at each participatory event of the work done to date and as a way of ensuring that participants in the co-design process were continually mindful of the wider evidence and context. This helped to make the co-design work evidence-informed co-design; informed by the wider academic literature as well as personal experiences of those delivering and receiving health-care services or living with a long-term condition.

Patient and public involvement

Taxonomy

Table 1 describes the categories of interventions included in this review, with an accompanying example of each.

Programme theories

The theory development and refinement process, outlined in Chapters 2 and 3, led to the development of five CMO configurations that, collectively, provide an evidence-based theoretical account of what it is about physical activity interventions in primary care that work (or do not work) for people with long-term conditions, and in what circumstances. In this section, each CMO configuration is reviewed, including the evidence underpinning physical activity interventions in primary care and explaining how the contexts and mechanisms identified lead to outcomes relevant to improving physical activity in people with long-term conditions. Examples of evidence from the literature review and from the stakeholder interviews (see Chapter 3) are included in the explanatory account to highlight meaning and illustrate salient points. We also group all of the interventions that contributed evidence for each CMO (see Boxes 1–5).

The CMO configurations were developed and refined by a range of stakeholders, who considered all sources of evidence, and provided regular purposeful input into the co-design process. When considered together, they offer a programme theory about ‘what works, for whom, under what circumstance’.

The five configurations are summarised here and described in further detail in the following sections:

1. changing practice culture through alignment

2. providing resources

3. individual advice

4. improving capability of practice workforce

5. programme credibility.

Rather than presenting the CMO configuration as an addition equation (i.e. C + M = O), we have chosen to present outcomes (O) as a function (f) of the interactions between the context (C) and mechanism (M), because this better reflects the nature of the relationships observed in this synthesis. Therefore, in Figure 14 we present the visual representations of the CMO configurations by applying the following formula:

FIGURE 14.

Visual representation of the five CMO statements. From top to bottom: CMO 1 – ‘changing practice culture through alignment’; CMO 2 – ‘providing resources’; CMO 3 – ‘individual advice’; CMO 4 – ‘improving capability of practice workforce’; CMO 5 – ‘programme credibility’. C, context; M, mechanism; O, outcome; PA, physical activity.

Context–mechanism–outcome statement 1: changing practice culture through alignment

Context–mechanism–outcome statement 2: providing resources

Context–mechanism–outcome statement 3: individual advice

Context–mechanism–outcome statement 4: improving capability of practice workforce

Context–mechanism–outcome statement 5: programme credibility

Summary of final programme theory

Throughout the synthesis, five CMO configurations were developed and then refined to explain how physical activity could be promoted to enhance physical functioning (and also psychosocial functioning) in people with long-term conditions whose care is managed in primary care. Together, the configurations represent a final programme theory of what works, for whom, how and under which conditions. We suggest that this programme theory offers a more specific level of abstraction,245 which reflects the nature of the focus of this particular synthesis, and which could better guide the prototype intervention development. Ultimately, the aim in realist approaches is to generate mid-range (testable) theories by subjecting the programme theory to different contexts over time. For this study, our programme theory has resulted in an explanatory account which shows that:

• Primary care settings are characterised by competing demands, and improving physical activity and physical function are not prioritised in a busy practice (context). If the practice team culture is aligned to promote and support the elements of physical literacy (mechanism), then physical activity promotion will become routine and embedded in usual care (outcome).

• Physical activity promotion in primary care is inconsistent and unco-ordinated (context). If specific resources are allocated to physical activity promotion (in combination with an aligned practice culture) (mechanism), then this will improve opportunities to change behaviour (outcome).

• People with long-term conditions have varying levels of physical function and physical activity, varying attitudes to physical activity and differing access to local resources that enable physical activity (context). If physical activity promotion is adapted to individual needs, priorities and preferences, and considers local resource availability (mechanism), then this will facilitate a sustained improvement in physical activity (outcome).

• Many primary care practice staff have a lack of knowledge and confidence to promote physical activity (context). If staff develop an improved sense of capability through education and training (mechanism), then they will increase their engagement in physical activity promotion (outcome).

• If a programme is credible to patients and professionals (context), trust and confidence in the programme will develop (mechanism) and more patients and professionals engage with the programme (outcome).

Revisiting the theoretical landscape

At the start of the project, we considered the theoretical foundations relevant to promoting physical activity and physical function (see Chapter 2). Table 2 provides a summary of where and how we found resonance between the final programme theory and the theoretical landscape.

Co-designed prototype intervention

The Function First kit: a tool for primary care staff to support physical activity promotion

The design illustrated on the next few pages is not a ‘final’ design. It is a prototype or a concept that has been made into physical components using the methods described in Chapter 4. These would require far more detailed content if they were to be taken forward and subsequent co-design work may still add to, or change, some of these components. The participants involved in this co-design process felt that what is presented here embodies the features of the CMOs and represented their collective thinking about how best to realise this in a physical form.

The following pages illustrate the overall design concept, the various components are labelled to illustrate which of the five CMOs they represent and embody. This labelling is only for the purposes of this report and indicates how the research evidence manifests in a physical form. It is not proposed that these labels would be included in any end-product delivered to primary care.

The prototype is illustrated in the following way, using a combination of design images and written narrative:

• general presentation of the kit and its packaging (Figure 15)

• how box presentation could be branded to work with existing schemes (Figure 16)

• components of box 1 and their relation to the CMOs (Figure 17)

• components of box 2 and their relation to the CMOs (Figure 18)

• detailed descriptions of each component in the kit

• how a proposed web-based resource would complement the boxes.

The full design presentation file for the intervention, that could be used as part of the non-academic dissemination strategy for further development and potential future use, is shown in Report Supplementary Material 12.

FIGURE 15.

Design images showing the initial presentation of the Function First kit and its packaging, including how the CMOs are referenced.

FIGURE 16.

Design images showing how box presentation could be branded to work with existing schemes. ‘Move More’ logo reproduced with the permission of Sheffield Hallam University (March 2020) on behalf of the National Centre for Sport and Exercise Medicine in Sheffield.

FIGURE 17.

Design image showing the components of box 1 and their relation to the CMOs.

FIGURE 18.

Design image showing the components of box 2 and their relation to the CMOs.

Components of the Function First kit

The following sections provides a detailed description of each of the components of the kit.

The prototype itself is divided into two main parts, one aimed at the health-care service and the other at individuals, thus addressing two different sets of needs. However, both parts provide resources that enable people (primary care staff or people with long-term conditions) to ‘work out’ an optimal intervention for themselves rather than simply giving people a defined answer or a one-size fits all intervention. This addresses two fundamental and interlinked points emerging from the realist evidence: (1) tailored, individual solutions are more likely to be sustained and (2) involving people in working out a solution for themselves facilitates ‘buy in’ and gives people the tools and capabilities to make adaptations as needed. These are both important principles when considering the sustainability of an intervention.

For the health service users of this intervention, buy-in is essential; it must be worth their time and effort to engage with it. Therefore, the first thing they need to see as part of an intervention is the potential value to them and their practice. The remainder of the resources for the health professionals focuses on physical literacy, promoting dialogue between staff, promoting informed dialogue for all staff-patient interactions, and promoting visibility of the initiative within the practice.

For individuals, this buy-in is also important and so the resources aim to support a facilitated dialogue about personal circumstances, goals, resources and preferences, before following with the development of a personal plan, including addressing practical issues such as transport, access and scheduling to fit with other commitments. This holistic approach was deemed essential as it was often wider life issues that became ‘barriers’ to the uptake or sustainability of physical activity.

Box 1: resources for practice

Phase 1: opening the box

What is this box for? This box contains resources to help improve the practice culture around physical activity, by encouraging conversation and demonstrating the value of physical activity to staff and patients. There are four suggested steps:

1. Step 1 – ordering the Function First Kit.

   When the kit is ordered a private profile would be created online for the practice.

2. Step 2 – opening for the first time.

   From the moment the first box is opened, it needs to prove its value to the practice staff. The first thing staff would be prompted to do is to see how using the kit would benefit the surgery.

3. Step 3 – personalised interactive animations.

   Following the link would take the individual to an online profile where they can interact with a series of animated scenes. Using practice-specific data, either preloaded or entered by staff, these animations would visually demonstrate the effect of physical activity on variables such as number of appointments, cost to the practice, time saved, etc. This should be a quick and effective way of demonstrating the value of physical activity to encourage further engagement with the materials in the box.

4. Step 4 – introduction to the materials.

   The inside lid details the contents of the box as well as a recommended reading order. Initially the reader is presented with two documents: an introductory guidebook and a stack of card-based activities.

Phase 2: top-layer materials

Document 1: Function First introductory guidebook

This booklet summarises the goals and methods that would be used in the Function First kit, taking the reader step-by-step through each resource and explaining how it should be used. This would include a detailed strategy to find and recruit a ‘Physical Activity Advisor’ to be a part of the practice, delivering sessions to generate personalised recommendations for physical activity.

Phase 3: bottom-layer materials

Document 2: activity cards

These demonstrate a series of activities suggested by the participants in the co-design workshops. In this iteration they are represented as card-based resources. These could be used in a variety of settings, such as coffee breaks and team meetings, and include:

1. Conversation cards

These cue cards are designed to help reception staff initiate conversations with patients. This is to act as a kind of primer before the GP starts to raise these questions in the consultations.

1. Case study cards

A selection of real-life stories from patients and health-care professionals of the whole-body benefits of physical activity. To be read, shared and discussed as a group during a coffee break or team meeting.

1. ‘Why don’t you?’ cards

A reflective activity where staff can address why they may not currently recommend physical activity to patients and as a group acknowledge and resolve the reasons behind these decisions.

Document 3: non-prescription pads

Non-prescription pads are tools that help to communicate why a person has not received treatment in the form of medication, as might be expected. This method could be employed in this case, where physical activity would be recommended but not necessarily ‘prescribed’ in the traditional sense. An existing example is the non-prescription for ‘get well soon – without antibiotics’ that can be seen at www.wales.nhs.uk/sitesplus/866/page/75953 (accessed 13 March 2020). Figure 19 shows a prototype ‘non-prescription’ pad for physical activity.

FIGURE 19.

Design image of a ‘non-prescription’ pad for physical activity.

Evidence from the literature and from health professionals who have used physical activity prescriptions suggest that they have not worked in the past because a slip of paper is not seen as credible. However, it is proposed that this element would not be seen (or used) in isolation and would fit into the whole range of changes of culture, practice and behaviour for both patients and primary care professionals, giving it greater credibility.

Document 4: active practice poster and resources

This poster captures suggestions from co-design participants to make the GP practice more ‘activity friendly’ (Figure 20). Presented in the form of a blueprint, it provides inspiration and practical advice for creating more awareness and opportunity to engage in physical activity. The bottom half of the poster provides space to map out how a practice’s own space could be improved. Stationery would be provided to facilitate this.

FIGURE 20.

Design image detailing resources to facilitate the development of an ‘activity friendly’ practice.

Document 5: marketing campaign

To help communicate a clear and consistent message across all GP surgeries, as well as more widely, our co-design work suggests a marketing campaign relevant to the benefits of physical activity. We have not developed the content for this yet but would take inspiration from the bold and creative campaign recently launched called ‘HELP US HELP YOU’ (www.adsoftheworld.com/media/print/nhs_take_the_drama_out_of_minor_illnesses; accessed 12 March 2020). Working with a marketing company alongside designers and artists, provocative and eye-catching posters and films have been created, encouraging people to change their behaviour and see a pharmacist rather than their GP. These posters cut through the traditional formality of marketing material found in GP surgeries and it would be worth considering the value of these in terms of effectiveness. The digital files for this campaign would be included in the box on a Universal Serial Bus (USB) or available to download through the online portal described in Function First online. These could then be displayed on screens or monitors already installed in waiting rooms.

Box 2: resources for one-to-one/group consultations

Phase 1: opening the box

What is this box for? One of the evidence-informed implications arising from the co-design work was the potential for a ‘credible professional’ to run consultations where participants can explore a range of physical activity options, work to solve potential problems or barriers and set attainable goals that take into account their life situation. This box contains resources to help someone run such a consultation.

Step 1: opening the box for the first time

As this box is designed for more social situations, the inside lid acts as a session summary and list of guidelines that can be referred to throughout the session. The box could remain open and visible to patients as the consultation progresses.

Phase 2: top-layer materials

Document 1: facilitation guidebook

The guidebook would be a reference document for whoever is running the consultation. It would contain methods and materials needed to run a range of activities as well as offering advice and useful strategies on initiating behaviour change. This would not be a patient-facing book but should be the first thing that the credible professional reads when receiving the kit for the first time.

Document 2: activity summary

This flip chart would be a patient-facing document summarising the goals and methods of each of the activities. It is constructed to be free-standing so could be placed on a table as a constant visible reminder of the activity in progress.

Phase 3: bottom-layer materials

These materials include:

1. Multipurpose game boards

A supporting feature to help facilitate different activities with the same set of cards. The actual content of these could be refined and developed during future co-production sessions (Figure 21).

1. Adding more utility/dimension to the cards

It could be useful to arrange cards on a tabletop or gameboard. The cards could be given even more utility if there was a way to elevate or prioritise cards. Conversely, it may also be desirable to hide or discard cards from view (Figure 22).

1. Self-prescription

This ‘self-prescription’ could be the take-away result of the card-game. Reflections and goals can be distilled into this simple folding card. This would act as a visual reminder of the goals set during the workshop and could be referred to during follow-up consultations (Figure 22).

FIGURE 21.

Design image showing details of guided card games.

FIGURE 22.

Design image showing the multipurpose gameboards, methods of displaying cards and the resulting self-prescription.

Function First online

A key evidence-informed implication that emerged was the need for an online directory of community assets that would benefit different stakeholders. In the interest of clear communication, what we present here is a conceptual online resource. We envisage an account system ensuring that individuals or groups would see only the information that is relevant to them. Report Supplementary Material 13 shows some initial examples of what each account would allow access to.

Directory of local assets

As shown in Figure 23, from here users could view a range of activities, groups, events and transport options in their local area. Activities could be filtered based on personal preference, ability, location and other variables. The Physical Activity Advisor would help people navigate the site during consultations.

FIGURE 23.

Design image illustrating screenshots of a website showing a publicly accessible portal to search and filter physical and social activities within a specific filter.

Patient goals and activity record

General practice staff and the Physical Activity Advisor can access simple patient information such as goals and agreed activities during consultation (Figure 24).

FIGURE 24.

Design image illustrating screenshots of web pages showing (left) a possible way of visualising local value to a primary care practice and (right) enrolled patients, their goals and current activities.

Community activity description and contact

Each community activity scheme can have its own page populated by the team with a brief description of the service, photos of recent events, directions and contact information (Figure 25).

FIGURE 25.

Design image illustrating screenshots of web pages showing possible community transport links and ways that community activities could register on the directory to welcome new participants with long-term conditions.

Summary of co-designed prototype intervention

This section has presented the prototype Function First intervention; a whole system intervention aimed at addressing the individual needs of people with long-term conditions to maintain physical function, and the needs of the primary care practices supporting those individuals. Features of the intervention system that embody the CMOs defined by the evidence synthesis have been highlighted.

Individual elements of this intervention could work on their own and have some beneficial impact. Yet the basis and strength of this design, supported by the evidence from the realist synthesis, is that the sum of the parts is far greater than the individual elements; the impact of the whole will be greater than picking individual elements.

Throughout the co-design process, it was vital to provide continuous, accessible updates of the evolving CMOs to the co-design partners, highlighting how their input contributed to the evolution of the CMOs and ensuring that the CMOs were being directly addressed within specific features of the design concepts. This continuous attention to the flow of information between the realist synthesis and the co-design partners ensured a balance between research evidence and evidence from co-design partners in the creation of the prototype intervention, balancing the ideals of controlled academic studies with the lived realities of service providers and patients. Both realist syntheses and co-design are iterative approaches, and the natural synchronicity between iterations of both approaches in this project facilitated this two-way flow of information; it was a natural methodological fit.

For the wider research community, in the context of co-produced research, the approach we adopted can be used to overcome perceptions of tokenism in which non-academic contributors may feel undervalued or unable to contribute meaningfully.

Summary of findings

‘Function First’ aimed to determine the role of primary care in promoting physical activity and physical function for people with long-term conditions and developed programme theories, which describe what works, for whom and in what circumstances. This study is the first realist synthesis in this area, offering a theory-based consideration of the current literature, views and perspectives of the role of primary care in promoting physical activity and physical function for people with long-term conditions.

This realist evidence synthesis with embedded co-design has resulted in five CMO statements and a co-designed set of resources that embody these CMOs and are designed to facilitate improvements in physical activity and physical function for people with long-term conditions in primary care.

The five CMO statements are as follows:

1. Primary care settings are characterised by competing demands, and improving physical activity and physical function are not prioritised in a busy practice (context). If the practice team culture can be aligned to promote and support the elements of physical literacy (mechanism), then physical activity promotion will become routine and embedded in usual care (outcome).

2. Physical activity promotion in primary care is inconsistent and unco-ordinated (context). If specific resources are allocated to physical activity promotion (in combination with a practice culture that is supportive) (mechanism), then this will improve opportunities to change behaviour (outcome).

3. People with long-term conditions have varying levels of physical function and physical activity, varying attitudes to physical activity and differing access to local resources that enable physical activity (context). If physical activity promotion is adapted to individual needs, priorities and preferences, and considers local resource availability (mechanism), then this will facilitate a sustained improvement in physical activity (outcome).

4. Many primary care practice staff have a lack of knowledge and confidence to promote physical activity (context). If staff develop an improved sense of capability through education and training (mechanism), then they will increase their engagement in physical activity promotion (outcome).

5. If a programme is credible to patients and professionals (context), then trust and confidence in the programme will develop (mechanism) and more patients and professionals will engage with the programme (outcome).

We also co-designed a prototype multicomponent intervention with a range of stakeholders, embodying the emerging programme theories and developing resources to promote physical activity and physical function for people with long-term conditions. These consisted of resources designed to help nurture physical literacy among practice staff and complement existing schemes promoting physical activity. Suggestions for changing the layout of the practice and other promotional materials are included and would aim to create an environment encouraging physical activity. Although it is important that all members of staff promote physical activity during routine consultations, resources have been developed for a credible professional who can concentrate on physical activity behaviour change with individual people with long-term conditions. We developed prototype materials to facilitate this behaviour change, as well as resources to signpost to local community assets and to address barriers to the uptake of physical activity, such as community transport schemes. People would be directed to local exercise opportunities, clubs and groups following the adaptation of existing electronic social prescribing directories. These resources would need further development and refinement before being ready for use in practice (see Chapter 7).

Findings in the context of previous research and guidance

This realist synthesis of evidence has drawn from a wide variety of evidence sources and has identified many interventions designed for use by primary care professionals to promote physical activity to people with long-term conditions (e.g. LGM; Movement as Medicine for Type 2 diabetes). These have had varying levels of success in implementation. There are also a growing number of initiatives that provide additional education and resources for GPs and primary care staff on physical activity promotion for different long-term conditions (e.g. Motivate2Move, Moving Healthcare Professionals Programme, Moving Medicine). There is also the ‘Active Practice Charter’ developed by the Royal College of General Practitioners, which is designed to encourage practices to become ‘Active Practices’ by adopting ways of working to encourage physical activity in both patients and professionals. As described as part of this synthesis, research within the area of physical activity promotion interventions in primary care is rapidly developing; for example, the number of PubMed-referenced articles about physical activity within primary care has doubled between 2012 and 2014. 153

Recent Public Health England guidance246 on the prevention and management of long-term conditions summarises health and social benefits of physical activity, discusses the scale of physical inactivity and the barriers that people with long-term conditions experience. It then sets out available physical activity resources, programmes and campaigns for the public, physical activity training for health-care professionals, digital toolkits for clinicians, and initiatives in general medical practices such as the ‘Active Practice Charter’ and the parkrun practice initiative. There is a call for action for health-care professionals, local authorities and NHS organisations. What ‘Function First’ adds is:

• a set of evidence-based theoretical statements of what works, for whom and in what circumstances when promoting physical activity and physical function for people with long-term conditions, and how this could be embedded in routine practice

• a prototype multicomponent intervention of how this could be implemented, which involves practice alignment, a set of resources that sit alongside existing interventions and initiatives and makes a credible intervention for people with long-term conditions and their treating clinicians.

To our knowledge, this realist synthesis is the first to explore the role of primary care in promoting physical activity and physical function for people with long-term conditions. There are a limited number of existing realist evidence syntheses in the area of physical activity promotion for people with long-term conditions. In the primary care setting, a realist review has explored what works, and why, in the identification and referral of adults with comorbid obesity to weight management services. Similar mechanisms to the current study emerged including those operating at an individual level, such as having the confidence to talk about weight management and recognition of the importance and value of weight management. At an interpersonal level, mechanisms included discussing weight management at the right time and without blame. However, most mechanisms were operating at primary care practice level, requiring changes to systems or culture, such as developing consensus around working to promote weight management, not assuming ‘one size fits all’ and improving communication between practices and weight management services. Importantly, this review also identified contextual factors including varying patient and practitioner characteristics and competing priorities. 247

In an evidence synthesis, which included a realist approach, different versions of a health-related lifestyle advisor role in improving health were explored. Levels of acceptability were high, with advisors helping to remove barriers to prescribed behaviour and creating facilitative social environments. However, there was only limited evidence suggesting that lifestyle advisors have a positive impact on health knowledge, behaviours and outcomes, and there was some ambiguity about the role and the impact of the lay and peer characteristics of the interventions,248 thus indicating that further development of this role and subsequent research is required. Finally, similar evidence in a realist review found potential benefits of promoting physical activity when health care was located in leisure settings including theories relevant to the creation of a physical environment that re-enforces a physical activity culture and supports behaviour change, improvement of staff and patient experience, increased collaboration and co-ordination between health professionals, and increased awareness of facilities. Theories explaining the challenges of embedding physical activity in the NHS concerned the logistics of service delivery and inconsistency of clinical schedules. 249 One example of a strategy designed to create a culture of physical activity across a larger population is ‘Move More’ in Sheffield, which has been commissioned in three locations where medical intervention and physical activity are combined. 250

As far as we are aware, this study is the first to co-design intervention resources that embody realist programme theories, particularly in the area of physical activity promotion for the primary care management of people with long-term conditions. There are limited examples of the application of realist methods to facilitate intervention development. One such example is a study developing a complex intervention for improving outcomes in elderly patients following hip fracture. Three programme theories were developed and used to inform intervention development: improving patient engagement by tailoring the intervention to individual needs, reducing fear of falling and improving self-efficacy to exercise and perform activities of daily living, and co-ordination of rehabilitation delivery. 251 Studies have also used participatory methods to co-create new ways of working. For example, ‘Movement as Medicine’ included stakeholder work to develop a prototype intervention136 and the Choose to Move programme in Canada has been shown to enhance physical activity, mobility and social connectedness in older adults. 252 This study also highlighted the central role of community-based partner organisations when scaling up complex interventions in diverse settings, alongside the need to interact with stakeholders to develop collaborations and engage at multiple levels, in multiple sectors. 252

Strengths of this work

This project had a strong and embedded co-production element. People with long-term conditions, primary care health professionals, researchers with relevant expertise and experience and other relevant stakeholders were involved regularly at all stages, both as research participants and as members of the study oversight groups. The Study Management Group and independent Project Advisory Group provided scrutiny and advice, but also academic input into the development of the programme theories and co-design processes. Research participants were involved in co-creation activities designed to facilitate input into the development of programme theories and associated Function First resources. An initial stakeholder analysis strengthened this co-production element by ensuring that we captured insight from relevant groups.

We carried out systematic, comprehensive and transparent literature searches to identify a wide range of evidence that could be used to identify underlying programme theories. We used Covidence software to enable a team of reviewers to contribute to all aspects of the review process involving a large data set of publications. The theory-building work informed the inclusion and exclusion criteria, which were refined in an iterative manner. Implementation of the ‘good and relevant enough’ criteria at the data extraction stage allowed a more inclusive approach within the synthesis. Discussion among review team members, and iteration as the review progressed and programme theories were developed, was essential to ensure rigour. Discussion about the nature and quality of the evidence also helped to inform thinking about the emerging programme theory as the synthesis developed.

We co-designed a set of tangible resources that embodied the programme theories. These resources were designed to be flexible and to augment existing initiatives that are working successfully. They need further development and refinement before they can be used in primary care consultations.

A strength of co-design is that it involves giving new ideas tangible form and testing how these will work in the real world. It is ‘solution’ focused, looking to introduce something into the world that will create change. It considers the ‘solution’ at various scales, from the specific to the general, from the individual to the mass market. It considers technical as well as aesthetic matters. Co-design is democratic and pragmatic, ensuring that the issues relating to desirability, feasibility and viability have been considered by the involved stakeholders both throughout the generation of ideas and the embodiment of those ideas into tangible forms. It provides a solution within constraints; for example, if cost is the limiting factor, then the solution will be tailored to fit the budget.

The use of material culture such as LEGO Serious Play and the physical prototypes to share ideas and knowledge in co-design processes is a vital component for democratising the process by removing the exclusivity of technical language. It is also a ‘designerly’ skill and inherent to ‘designerly’ ways of thinking. This makes it a notable feature that distinguishes ‘designerly’ co-design (led by and facilitated by designers such as in this study) from ‘design-like’ co-design (led by and facilitated by non-designers). 253 The visual and physical objects made become boundary objects for sharing ideas and knowledge. We hypothesise that this relationship with material culture has implications between the final physical manifestation (the intervention) and knowledge mobilisation or use of the intervention. Material objects can mediate and afford people agency, guide a person through a series of actions or words, and give them a tool with which to perform a specific action. For example, when a person unpacks a new mobile telephone, the package, its contents and the way it is packed should lead the consumer through a series of intuitive steps. This agency that the consumer is afforded is mediated by the design of the box, its contents and the way that it is arranged.

The use of qualitative interviews to help refine the programme theories is an established part of realist method and was extremely valuable in this study. As described by Mukumbang et al. ,254 these interviews helped to ‘reinforce and maintain theoretical awareness and contribute to trustworthiness’. They were also helpful in other ways: guiding further literature reviewing, enabling more in-depth exploration with stakeholders we had not yet been able to hear from, contributing to a greater understanding of context and acting as a sense-checking point for the developing ideas.

Overall, the realist approach offers a theory-driven explanation that considers theoretical depth, breadth and transferability. Guided by realist principles, it is based on the assumption that reality is dynamic. Theorising was not purely deductive (theory-testing) or inductive (theory-building), thus providing more scope for deeper theorising and greater ontological depth, and potentially wider applicability of the resulting theories. 255 The key methodological strength of a realist approach is the requirement to pay attention to context. The analytical stance assumes that individuals, including patients and primary care staff, and the systems in which they live and work, bring different perspectives to the promotion of physical activity and physical function. Consequently, different patterns of outcomes may be observed, which can be specific to time and place, and, in this sense, the successful promotion of physical activity in primary care can be described as emergent. Any structured attempts to improve activity therefore meet the definition of a complex intervention and require particular methods for development and evaluation. Although the purpose of some systematic review approaches is to manage and control for context in the specification of an overall effect size, a realist approach has enabled us to focus our analysis on the interactions between context and physical activity interventions. We have done this by specifying conjectured, contingent hypotheses about what might work and how physical activity programmes generate engagement and success.

Finally, this study was conducted in a highly iterative, at times almost cyclical manner. Originally intended as a largely linear and sequential process, it emerged during the process of conducting the study that the iterative nature of the interaction between elements of the study added unanticipated strength and richness. It facilitated a greater integration of the different sources of data and enhanced the depth and breadth of the findings. This demonstrated that it is possible to deliberately overlap stages in a realist synthesis with embedded co-design, enabling the process to be more emergent. This became a much more natural evolvement of knowledge and helped to improve our collective understanding of the evidence into a shared body of knowledge, which was then embodied into the ‘product’. In fact, the striking ease with which the two methodological approaches (realist review and co-design) related to each other led us to reflect on their similarities and differences. ‘What works, for whom in specific circumstances’ connects the two as a fundamental way of expressing realist synthesis, yet also an important aspect of design. Although similar, realist is more cognitive and theoretical, whereas design is more practical, tangible, based on making tools, artefacts or materials. However, employing a design–evaluation cycle is hypothesised to improve the design and implementation of complex innovation by using programme theories to develop design propositions, which are evaluated through realistic evaluation, resulting in further refinement of programme theories. 256

Challenges, limitations and alternative approaches

A realist approach generates evidence-based hypothetical ‘recommendations’ that are developed at a specific time and place, by specific stakeholders. They are context specific and, as with all methods based on qualitative findings, they may not apply in a different set of circumstances.

The literature searching identified a large volume of literature due to the broad research area. The aim was to be comprehensive to capture a diverse range of evidence. This meant that we had to manage large numbers of publications and had to adapt our reviewing methods to deal with this large volume. The Covidence software was helpful in managing the data and for screening abstracts. Screening guidelines and inclusion/exclusion criteria went through multiple stages of refinement by the project group who all understood and agreed on the final criteria. This meant that all members of the project group could take part in the screening of abstracts.

To identify programme theories as soon as possible at the start of the review, we carried out a broad literature search early in the project. This search aimed to capture descriptions of all interventions that had been designed to improve physical function in primary care for people with long-term conditions. This gave us a large library of relevant papers that we could select from but presented a large number of data to sift. An alternative option would have been to build up the initial programme theory areas based on preliminary scoping and a review of reviews, and then to design a purposive search designed for each of the identified theory areas.

The grey literature search included a review of websites and publications of relevant UK organisations. However, only a small number (five items of grey literature and five guidelines) were included in the final data set. We recognise the importance of these other sources of evidence for avoiding publication bias, to provide useful contextual information and to understand interventions and programmes that are already used in practice. We faced a challenge in capturing undocumented knowledge. Although we did not extensively survey social media communication channels, the review benefited from the strength of the stakeholder group and attendees at the workshops who were able to identify additional unpublished evidence.

Despite having identified a large number of published data on physical activity interventions for people with long-term conditions, we found that in most of these publications there was a lack of detailed description (thick description) of the organisational context, delivery planning, patient characteristics and the circumstances that led to the success of the intervention. We also found fewer published reports of negative results, or descriptions of complications that had led to interventions not being as successful as planned. However, we aimed to identify, and present in this report, the clearest evidence describing what lies beneath the success of an intervention.

As a result, coverage of what ‘does not work’ may appear to be less well covered than ‘what works’. Some of this is due to framing (i.e. we tended to frame our statements and programme theories more positively than negatively). However, it is important to note that although more difficult to find, we did make a point of exploring ‘what does not work’ in the literature. For example, ‘one size fits all’ approaches, and interventions introduced without consideration of existing schemes and pathways, appeared to work less well.

The LEGO Serious Play method, facilitated by experienced researchers, successfully enabled all participants to reflect and build models to help them explain their thoughts regarding the questions posed in the ‘theory-building’ workshops. However, the following two challenges are standard to the practice of co-design. First, there were some challenges associated with instilling confidence in participants to build models on an abstract topic. However, facilitators led participants through a series of skills-building ‘warm-up’ type activities that helped participants feel comfortable using the methods. Second, one participant explained how the activity was an emotional process because the activity and questions posed were reflective in nature and likened it to ‘therapy’. This was not a new finding and is common to many methods that encourage reflection, deeper thought and explanation. We reiterated at future workshops that although there would be scheduled breaks, it was also completely acceptable for anyone, to take a break at any time if they felt that they needed a physical or emotional break. There were two ‘new’ challenges that arose during the LEGO workshops. First, one of the workshop participants was partially sighted but was able to contribute fully to the workshops; we spent more time with them, explaining what was in front of them and using larger LEGO blocks. Second, it proved more challenging to encourage professional participants to reflect on their professional experiences of working with people with long-term conditions, rather than their own personal experiences of physical activity and physical function.

Co-design is often criticised for being too specific, focusing on the needs of the participants in the process, resulting in personal rather than generalisable solutions. Design strategies, such as the use of personas, is a mechanism for addressing this as it asks co-design participants to design for other people (the personas) that are more widely representative. This weakness was mitigated further by introducing the evidence through the medium of card games at the start of the co-design process. This shared the wider, generalisable evidence with the co-design participants. Thereafter, the visual story of the whole project and the list of evolving CMOs was displayed on the wall for every co-design workshop, ensuring that the participants maintained this wider context and understanding of the evidence throughout the co-design activities.

There are many initiatives promoting physical activity. There are challenges when introducing yet another physical activity programme in a saturated environment. From the outset, we aimed to complement and not compete with these campaigns. We acknowledged and addressed this by involving representation from relevant bodies in our activities and including a specific search for existing initiatives and campaigns. We believe that many of these initiatives could address some of our programme theories, for example the promotion of physical literacy among all practice staff, and facilitating behaviour change within the consultation. However, these initiatives do not address all of our five programme theories and are individually insufficient to promote physical activity and preserve physical function in all of the people with long-term conditions managed in primary care. We have designed a multicomponent intervention, in which several of the components could be interchanged with materials that have already been developed.

We also acknowledge that despite using a stakeholder analysis, our range of stakeholders included people with similar socioeconomic status, ethnicity and attitudes and, therefore, the findings may be limited in their application. However, although indirect, these varying considerations were represented in the literature and in workshop activities that involved considering issues from the perspective of a range of different people.

Implications for primary care

If general medical practice in the UK is to address the low levels of physical activity, and poor physical functioning of people with long-term conditions then current practice needs to change. Involving the whole practice, nurturing physical literacy and developing a commitment that it is everyone’s role to promote physical activity at every appropriate opportunity is important and would need a change in the emphasis of the practice team and additional resources to support behaviour change. Initiatives already exist for this, for example Public Health England and Sport England have developed the Moving Healthcare Professionals Programme. 134 However, this training needs to include all the practice staff, and not only the enthusiastic clinicians. There are also many initiatives that have been developed to promote physical activity behaviour change during consultations, for example the Faculty of Sport and Exercise Medicine UK initiative ‘Moving Medicine’. 135 However, time constraints and competing priorities are significant barriers to using these materials in all consultations for people with long-term conditions. Our work suggested that a new role could be developed for a credible professional who has protected time for this activity. This physical activity advisor could be a nurse, a physiotherapist, a physician associate, or one of the new roles in health care such as social prescribing navigators or exercise scientists. The job description for this role and the funding model needs further development. Our work also suggests that it is important to engage with local providers of physical activity opportunities and fully utilise electronic directories that are being developed for social prescribing. It is acknowledged that these resources and new roles need to be flexible enough to apply in the differing contexts of different general medical practices. The development of primary care networks, or clusters of practices, provides the opportunity for a common approach with the sharing of resources. This would have cost implications but may also have direct benefits to the NHS in terms of reduced consultations and demand for services. Developing all these components into a combined ‘Function First’ intervention, which addresses the CMOs is more likely to be acceptable in practices that are already committed to increasing physical activity in their populations. However, partial adoption of these components would enable some changes to be made in practices where physical activity promotion is less part of the practice culture.

Recommendations for research

The prototype multicomponent ‘Function First’ intervention is not yet ready to be implemented in primary care. In line with the Medical Research Council framework for complex interventions, a further research programme could be developed. 257 The first phase would develop and refine the intervention components. Several of the programme components have already been developed in other initiatives (e.g. Moving Healthcare Professionals Programme and Moving Medicine); however, other components, such as the physical activity advisor, need further development. The job description would need to be agreed across a range of stakeholders, using methods to gain a consensus. A range of potential professionals who could perform this role, including nurses, physiotherapists, occupational therapists, health psychologists, physician associates, exercise physiologists and behaviour change experts, would need to be discussed. Existing electronic diaries of local social prescribing opportunities would need to be adapted for use in this group. The different components could be combined into a single multicomponent intervention and then piloted in one or two general medical practices to obtain feedback about acceptability among patients and staff. This would also provide information about feasibility in busy NHS settings and alongside existing physical activity promotion schemes.

The second phase would involve a feasibility study to test trial methods in a group of practices. This would include recruitment and retention rates, acceptability of randomisation and outcome measurement. The feasibility study would help choose the most appropriate primary outcome, as well as advise on the objective measurement of physical activity and the testing of physical function.

This feasibility study would inform the methods and the sample size for a third-phase, definitive randomised controlled trial in a large sample of practices, of different types and locations throughout the UK, to assess effectiveness. The trial would include a concurrent economic evaluation to assess cost-effectiveness and a concurrent process evaluation to determine whether or not what was delivered in the trial was as intended in the programme theory.

Finally, further research would benefit from increased representation of different socioeconomic and ethnic groups.

Ethics approval

Ethics approval was received from the Healthcare and Medical Sciences Academic Ethics Committee (reference 2018–16308) and from the NHS Wales Research Ethics Committee 5 (references 256729 and 262726).

Contributions of authors

Rebecca-Jane Law (https://orcid.org/0000-0002-1435-5086) (Co-chief Investigator, Research Officer) was principal author and original co-applicant, overall study lead and researcher, responsible for drafting and revising content critically for important intellectual content, led the collection and interpretation of data, and provided final approval of the version to be published.

Joseph Langley (https://orcid.org/0000-0002-9770-8720) (Co-investigator, Senior Research Fellow in Healthcare Innovation) was an original co-applicant and responsible for the co-design elements of the study (Chapters 2 and 3, in particular), provided substantial contribution to the collection and interpretation of data, was responsible for drafting and revising content critically for important intellectual content, and provided final approval of the version to be published.

Beth Hall (https://orcid.org/0000-0003-4980-3720) (Co-investigator, Academic Support Librarian) was an original co-applicant and conducted systematic and purposive literature searches, gave methodological advice on evidence synthesis, provided substantial contribution to the collection and interpretation of data, was responsible for drafting and revising content critically for important intellectual content (Chapter 2, in particular), and provided final approval of the version to be published.

Christopher Burton (https://orcid.org/0000-0003-1159-1494) (Co-investigator, Professor of Health Services Research) was an original co-applicant and gave advice on realist methods, implementation and rehabilitation, provided substantial contribution to the interpretation of data, was responsible for drafting and revising content critically for important intellectual content (Chapter 3, in particular), and provided final approval of the version to be published.

Julia Hiscock (https://orcid.org/0000-0002-8963-2981) (Co-investigator, Research Fellow and Medical Sociologist) was an original co-applicant and gave a sociological perspective and advice on qualitative methods, provided substantial contribution to the collection and interpretation of data, was responsible for drafting and revising content critically for important intellectual content, and provided final approval of the version to be published.

Lynne Williams (https://orcid.org/0000-0003-2575-9710) (Co-investigator, Reader) was an original co-applicant and gave a nursing perspective and advice on realist methods, contributed to the interpretation of data, was responsible for drafting and revising content critically for important intellectual content, and provided final approval of the version to be published.

Val Morrison (https://orcid.org/0000-0002-4308-8976) (Co-investigator, Professor of Psychology) was an original co-applicant, provided advice from a health psychology perspective on physical activity for people with long-term conditions, contributed to the collection and interpretation of data, was responsible for drafting and revising content critically for important intellectual content, and provided final approval of the version to be published.

Andrew B Lemmey (https://orcid.org/0000-0003-1667-4539) (Co-investigator, Professor of Clinical Exercise Physiology) was an original co-applicant, provided advice on physical activity for people with long-term conditions, contributed to the collection and interpretation of data, was responsible for drafting and revising content critically for important intellectual content, and provided final approval of the version to be published.

Candida Lovell-Smith (Co-investigator, public research partner) was an original co-applicant, provided advice from a public perspective on physical activity for people with long-term conditions, contributed to the development of public-facing materials and the collection and interpretation of data, helped draft and revise content critically for important intellectual content, and provided final approval of the version to be published.

John Gallanders (Co-investigator, public research partner) advised from a public perspective on physical activity for people with long-term conditions, contributed substantially to analysis workshops and the collection and interpretation of data, was responsible for drafting and revising content critically for important intellectual content, and provided final approval of the version to be published.

Jennifer Cooney (https://orcid.org/0000-0002-9828-8000) (Lecturer in Sports Physiology) advised from a sports physiology perspective, contributed substantially to the collection and interpretation of data, was responsible for drafting and revising content critically for important intellectual content, and provided final approval of the version to be published.

Nefyn H Williams (https://orcid.org/0000-0002-8078-409X) (Co-Chief Investigator, Professor in Primary Care) advised from a general practice perspective, provided support for the new Co-chief Investigator, contributed substantially to the collection and interpretation of data, was responsible for drafting and revising content critically for important intellectual content, and provided final approval of the version to be published.

Publications

Law RJ, Williams L, Langley J, Burton C, Hall B, Hiscock J, et al. ‘Function First-Be Active, Stay Independent’ – promoting physical activity and physical function in people with long-term conditions by primary care: a protocol for a realist synthesis with embedded co-production and co-design. BMJ Open 2020;10:e035686.

Law RJ, Langley J, Hall B, Burton C, Hiscock J, Williams L, et al. ‘Function First’: how to promote physical activity and physical function in people with long-term conditions managed in primary care? A study combining realist and co-design methods. BMJ Open 2021;11:e046751.

Data-sharing statement

This is an evidence synthesis involving qualitative data collection and, therefore, the data generated is not suitable for sharing beyond that contained within the report. Further information can be obtained from the corresponding author.

Patient data

This work uses data provided by patients and collected by the NHS as part of their care and support. Using patient data is vital to improve health and care for everyone. There is huge potential to make better use of information from people’s patient records, to understand more about disease, develop new treatments, monitor safety, and plan NHS services. Patient data should be kept safe and secure, to protect everyone’s privacy, and it’s important that there are safeguards to make sure that it is stored and used responsibly. Everyone should be able to find out about how patient data are used. #datasaveslives You can find out more about the background to this citation here: https://understandingpatientdata.org.uk/data-citation.

Disclaimers

This report presents independent research funded by the National Institute for Health Research (NIHR). The views and opinions expressed by authors in this publication are those of the authors and do not necessarily reflect those of the NHS, the NIHR, NETSCC, the HS&DR programme or the Department of Health and Social Care. If there are verbatim quotations included in this publication the views and opinions expressed by the interviewees are those of the interviewees and do not necessarily reflect those of the authors, those of the NHS, the NIHR, NETSCC, the HS&DR programme or the Department of Health and Social Care.