Title: Development and preliminary testing of strategies to enhance routine physical activity in care homes
Funder: Department of Health and Social Care

Abstract: AIMS To develop and preliminarily test strategies to enhance physical activity in the daily life routines of care home residents to improve their physical, psychological and social well-being. BACKGROUND Increase in life expectancy has led to a shift in demographics, with particular expansion in the age group 85 years and older. As many health conditions are age-related, there is a concurrent increase in the demand for long-term care. Residents of care homes are amongst the frailest in our population and place considerable burden on NHS primary and secondary services. Observational research has demonstrated that care home residents spend the majority of their time inactive, despite the known benefits of maintaining (or increasing) levels of physical activity and decreasing sedentary behaviour. We have updated the Cochrane review addressing rehabilitation in long-term care. This reported 67 studies and demonstrated that strategies to enhance physical activity can be implemented in care homes with reported benefits. However, many of the interventions evaluated were dependent on external resources (e.g. therapists) and gains were not sustained. We propose a research programme in which we will work with care home staff and residents to develop a range of methods to increase physical activity embedded in the daily routines of care homes that will be suitable for the majority of residents. We have undertaken development work in two care homes which included observations and interviews with residents and staff to inform our understanding of current levels of activity and what might work in practice. RESEARCH ENVIRONMENT The Academic Unit of Elderly Care and Rehabilitation has 20 years experience in the development and evaluation of complex interventions. It currently holds research funding of approximately &pound;8 million from the MRC and NIHR. RESEARCH PLAN Five overlapping workstreams will be undertaken. Workstream 1 ~ we will undertake ethnographic work to test the understandings we have gained from the Programme Development Grant (PDG) within a wider range of care homes. Work will include observations and interviews to clarify our thinking on barriers, opportunities and factors that indicate that a care home (and their staff) are open to change. Workstream 2: Clarification of measures We aim to improve levels of physical activity and therefore require a valid and reliable measure of activity in a population of frail older people. In development work we have identified the Actigraph GTX-3 and GeneActiv accelerometers as possible measures and propose to test these with a larger population of residents and evaluate a newly developed physical activity questionnaire. Workstream 3 Using information obtained in the development work and previous workstreams we will use techniques of intervention mapping to develop practical mechanisms for increasing activity and appropriate methods of implementation (for example, training materials). Workstream 4 Working with action groups (which will include residents and staff) in four care homes we will refine the proposed mechanisms and methods to promote practical implementation in a range of care home settings. Workstream 5 Undertake a feasibility study in 12 care homes, with allocation by minimisation at the level of the care home, to test for feasibility and effect on physical function, mood and quality of life) and to gather data to inform a future large scale trial. OUTPUTS AND DISSEMINATION Our work will begin the staged process of developing a complex intervention embedded in the routine of care homes to promote physical activity tailored to the context and environment of individual care homes and thereby enhance quality of life for this neglected group. We will also develop manualised strategies for implementation of interventions in care homes which will be suitable for use in other behaviour change initiatives. Our work will be disseminated through the local Care Home Forum, local and national contacts with Adult Social Care and links with national care home providers through co-applicants and the Steering Group. RESEARCH TEAM The research team has the clinical, quantitative and qualitative expertise required for implementation of this research, supported by colleagues from the Leeds Clinical Trials Research Unit. JUSTIFICATION OF RESOURCES This is a complex programme of interlinking workstreams and requires an experienced programme manager to facilitate implementation. Additional qualitative researchers are required to undertake the work in Workstream 1, 4 and 5 and colleagues are required to test and implement outcome measures in workstreams 2 and 5. PROJECT MANAGEMENT The co-applicants will form the Programme Management Group, which will meet bi-monthly; additionally five delivery teams will be established (one for each workstream). A Programme Steering Group will meet twice a year. We will adopt ethical procedures consistent with our target population, i.e. older people who have cognitive and physical frailty. PUBLIC INVOLVEMENT We will be guided by our consumer advisory group, resident champions and co-applicant Joan Firth. We will also work closely with the Care Home Forum, which has a membership of 180 owners and managers of care homes across Bradford.

Lay abstract: Life expectancy has increased dramatically over the last century leading to changes in the demography of the population. There has been a particular expansion of the 85 years and over age group. Increasing age is associated with increasing disability, as many disabling conditions, such as stroke, dementia, arthritis, cardio-respiratory disease are age-related. One consequence of this ageing population is a steady increase in demand for long-term care. Residents in long-term care are particularly high users of hospital services and admissions to hospital are disruptive to their well-being. Observational research has reported that care home residents spend the majority of their time inactive, with low levels of interaction with staff. This leads to increased dependency and low mood. Although one way to increase activity is for physiotherapists to provide exercise classes, with the limited number of such staff available this is an unrealistic option for many. We have reviewed the evidence for ways to increase activity in residents which have been of benefit. One approach is to enhance routine activity, for example promoting activities of daily living such as walking to the toilet, walking to the dining room, and making the most of routine opportunities to promote activity. We propose a programme of research to work with care home staff and residents to develop and test methods to enhance activity. The work will include observations in care homes and interviews with residents, staff and relatives to obtain their views and gain knowledge of possible barriers. We will combine this with the evidence to provide some suggestions of how to increase activity levels. These will be tested out and developed in four homes. We then hope to produce a schedule of activities and ways to change routine practice in care homes to be tested in a trial. In the trial of 12 homes, six will receive the new intervention and six will continue with usual care. We will record over nine months whether the intervention produced the desired aim of increasing the physical activity levels of residents. We will also assess affect on physical function, mood and quality of life and see whether admissions to hospital and contact with GPs and other health professionals were reduced without detrimental effects (for example increasing number of falls). We will also consider the costs associated with the intervention. If this work shows that the methods we have developed do enhance physical activity, we plan to progress to a large national study. We will work with national and international colleagues to deliver this research and ensure that we are up to date with all new evidence in this field.

Research activity codes: 3.1 PRIMARY PREVENTION INTERVENTIONS TO MODIFY BEHAVIOURS OR PROMOTE WELL-BEING
Health categories: GENERIC HEALTH RELEVANCE