There is more to supervised exercise than exercise itself : a mixed methods study of supervised exercise with the chronic disease self-management program for people with COPD
Creators: name: Cameron-Tucker, HL
Publisher: name: University Of Tasmania
Year: 2023

description: Chronic obstructive pulmonary disease (COPD), a progressive respiratory condition, significantly affects the lives of those managing its daily impact. Exercise is recognised as an important management strategy. This thesis investigates the addition of supervised exercise to the Stanford Chronic Disease Self-Management Program (CDSMP) in people with COPD. The CDSMP is a group-based program designed to facilitate the acquisition of self-management skills, and does not have an exercise component. This thesis provides opportunity to consider theories of health behaviour change and the role of self-efficacy in the self-regulation of behaviours, such as exercise. The effect of the CDSMP on self-reported exercise was reviewed, finding a lack of published research concerning supervised exercise with the CDSMP. To investigate the effect of supervised exercise with the CDSMP older adults were allocated to the CDSMP, with or without supervised exercise, in a parallel group randomised controlled clinical trial with a pre/post test design over two years. A mixed methods approach was used to provide a more detailed analysis of the effect of supervised exercise than one method alone, giving quantitative evidence enriched by the lived experience of participants. Objective outcomes included physical capacity (primary outcome), self-reported exercise, stage of change for exercise, exercise self-efficacy, shortness of breath, heath-related quality of life and self management behaviours. Change in outcomes between groups and within group was measured by appropriate statistical tests. Qualitative methods of enquiry using semistructured interviews and thematic analysis uncovered the lived experience of the people who participated in the CDSMP with or without supervised exercise. Eighty-four participants were randomised. There were 15 withdrawals, due to ill health and other commitments. This thesis demonstrated a small statistically significant increase in physical capacity for the intervention and control groups, but no significant difference between them. However, the clinical significance of the within-group change was not reached. Further research is required in this area. There were no significant differences between groups for any secondary outcome, although analysis of effect sizes indicated that supervised exercise confers a benefit to those who participate: they exercised more frequently, for longer duration, had less breathlessness and improved quality of life physical component summary compared with those who did not have supervised exercise. However, neither one hour of weekly supervised exercise, in the absence of a structured home programme, nor the CDSMP alone, was sufficient to produce more than small improvements in outcomes. Qualitative findings revealed participants bring to healthcare interactions a personal meaning of self-management defined by their lived experiences and strategies developed in response to living with COPD. Similar sources of motivation act across the CDSMP and supervised exercise, thereby supporting the construct of self-efficacy and signifying the pivotal role of perceived personal control as a mediator of behaviour change. However, the experience was not viewed positively by all, indicating the need to be alert to possible adverse psychological effects of interventions and to identify at-risk individuals. Participants endorsed supervised exercise, emphasising the importance of respecting their preferences. This study suggests that the process of facilitating behaviour is not concerned with 'who knows best', but rather with how the interaction between health professional and participant facilitates a consideration of self and the best possible behaviours to manage life with long-term health conditions, pointing to a framework for participant-centred engagement in healthcare. In conclusion, supervised exercise of one hour per week does not need to be an integral component of the CDSMP, but offered as an optional adjunct, underpinned by a participant-centred approach. Methods of increasing the clinical significance of the small increase in distance walked need to be explored.