‘There Must Be Something We Could Do Better’: Exploring Health Care Professionals’ Physical Activity Promotion Practices After Stroke in Hospital Settings
Authors:   , Regoczi Dora 
Published: May 2024

Physical activity is an integral part of stroke rehabilitation and secondary prevention, and several factors are known to hinder or facilitate stroke survivors’ physical activity behaviour. However, evidence suggests the resumption or initiation of physical activity post-stroke does not solely depend on the individual but is also significantly influenced by the help and support they receive from Health Care Professionals. While a clear argument exists that stroke survivors should be encouraged and supported to increase their physical activity levels, the best way to do this is currently unclear. Further research is needed to capture Health Care Professionals’ views, attitudes, and experiences of physical activity promotion after stroke, especially in the hospital setting. Therefore, the overall aim of this programme of work was to explore and systematically evaluate Health Care Professionals’ views and experiences of physical activity promotion for stroke survivors in hospital settings and to develop an intervention model to enhance physical activity promotion in this setting. It has been previously argued that evidence-based guidelines on physical activity and best practice recommendations for Health Care Professionals are often not implemented effectively, which may be due to the lack of theoretical understanding of the processes involved in changing the target behaviour. Consequently, this thesis adopted a theory-driven approach to explore and understand current practices and key factors influencing Health Care Professionals’ promotion of physical activity after stroke in hospital settings. After careful methodological considerations and an extensive review of potential theoretical frameworks, the Behaviour Change Wheel and the Theoretical Domains Framework were selected to guide the empirical studies in this thesis. These theoretical frameworks were selected as they enable the exploration and explanation of the observed behaviour and provide a framework to implement meaningful changes to improve this behaviour. The first step of this explorative process was to design and conduct a bespoke cross-sectional survey with Health Care Professionals working with stroke survivors in hospital settings across the United Kingdom (Study 1). The theory-based survey aimed to identify and systematically categorise relevant facilitators and barriers to physical activity promotion and compare different professional groups' views and experiences. Overall, 49 Health Care Professionals completed the questionnaire. Results identified 13 out of the 14 domains of the Theoretical Domains Framework to influence physical activity promotion in this setting. Significant differences were found between physiotherapists and non-physiotherapists, especially regarding their knowledge, skills, and perception of their professional role and identity. Free-text data highlighted that while most participants agreed that physical activity is part of a holistic recovery after stroke, they also agreed that physical activity promotion is more a personal choice. To change practice, participants called for a multifaceted approach to change, including the provision of more resources, more context-specific guidelines, and an overall cultural shift in their workplace. The initial survey (Study 1) highlighted a need to gather further in-depth data to understand current practices and potential solutions better. Therefore, in Study 2, the perceptions of physiotherapists (n=8) were explored in-depth through semi-structured interviews. Data was analysed both inductively and deductively using the Theoretical Domains Framework. The main findings from the inductive analysis included the reasons behind an overall hesitancy to promote physical activity in the hospital, a willingness to change practice, the importance of behaviour change in physical activity promotion, and the need to bridge the gap across the stroke pathway. The deductive analysis was aligned with the findings of the previously conducted survey study (Study 1): physiotherapists believed that they had the necessary knowledge and skills to promote physical activity, but they also expressed that stroke survivors’ characteristics, the lack of resources, and the lack of support from colleagues can hinder their efforts to promote physical activity. Overall, it was evident from the study findings that physiotherapists are keen to improve their practice. Still, they would like to receive more directive support and resources to do so. The findings from these empirically driven studies led to the development of an evidence-based, theory-driven intervention model using the eight steps of the Behaviour Change Wheel framework. This last stage identified a list of behaviour change techniques and intervention strategies that could be utilised and further tailored to the specific needs of each inpatient stroke setting across the United Kingdom. A specialised, interactive education training session and the training of physical activity promotion champions were proposed as potential interventions based on the conducted behaviour analysis. Case-by-case implementation by a behaviour change specialist and co-creation with key stakeholders is recommended as best practice to increase Health Care Professionals’ physical activity promotion behaviour after stroke in the hospital. The final chapter of this thesis provides an overall discussion of the key findings of the conducted research studies and how the identified knowledge, practice, and theory gaps were addressed throughout. Alongside the strengths and limitations of the thesis, critical considerations of using a theoretical approach to explore Health Care Professionals’ physical activity promotion behaviour are also discussed. Potential future research directions include the refinement and testing of the proposed intervention model, collecting observational data to support the self-reported data, and creating a validated questionnaire for service evaluation and context-specific behaviour analysis. While the thesis focused on directly exploring Health Care Professionals’ views and experiences of physical activity promotion, optimising their physical activity promotion behaviour is anticipated to also indirectly increase stroke survivors’ physical activity levels and overall quality of life.