Peer-led walking programme to increase physical activity in inactive 60- to 70-year-olds: Walk with Me pilot RCT

Article history

The research reported in this issue of the journal was funded by the PHR programme as project number 12/133/04. The contractual start date was in December 2014. The final report began editorial review in May 2018 and was accepted for publication in October 2018. The authors have been wholly responsible for all data collection, analysis and interpretation, and for writing up their work. The PHR 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.

Declared competing interests of authors

Frank Kee was a member of the Public Health Research (PHR) Funding Board 2009–19 and the PHR Prioritisation Group 2016–19. Ruth F Hunter has received a National Institute for Health Research (NIHR) Career Development Fellowship. Ruth F Hunter and Wendy Hardeman have received funding from the NIHR Public Health Research programme separately from the current project grant. Wendy Hardeman has received funding from AbbVie Ltd (North Chicago, IL, USA) for consultancy outside the current project. The Northern Ireland Clinical Trials Unit received funds through the NIHR Public Health Research programme for its involvement in the study.

Copyright statement

© Queen’s Printer and Controller of HMSO 2019. This work was produced by Tully et al. under the terms of a commissioning contract issued by the Secretary of State for Health and Social Care. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK.

2019 Queen’s Printer and Controller of HMSO

Ageing and physical activity

Many countries, including the UK, are facing rapid growth in the proportion of the population aged ≥ 65 years. 1 Within the UK, Northern Ireland is projected to have the most rapid increase in the age of its population, with approximately 25% of the population projected to be aged ≥ 65 years by 2041. 2 Ageing is associated with functional decline, reduced quality of life and increased risk of morbidity, disability and mortality. 3 Payette et al. 3 have called for a renewed focus on the prevention of multimorbidity, which is set to double in the next 20 years. In addition, health problems emerge at a younger age in older adults from socioeconomically disadvantaged backgrounds, indicating the need for interventions targeting these individuals. 4

Physically active older adults are at a reduced risk of developing numerous chronic non-communicable diseases,5,6 all-cause mortality,7 poor self-rated health,8 falls9,10 and sarcopenia. 11 In addition to the physical health benefits, regular activity has been associated with improved cognitive function and reduced risk of dementia,12 and higher levels of health-related quality of life. 13 These associated physical and mental health benefits may lead to lower utilisation and cost of health-care services. 14 In addition, lower levels of physical activity are associated with poorer social health, such as increased social isolation (fewer number of interactions with others) and loneliness (feeling of being alone), in adults aged ≥ 65 years. 15,16

Physical activity levels of older adults in the UK

In the UK, it is recommended that older adults undertake at least 150 minutes of moderate-intensity physical activity per week. 17 Despite the possible benefits of being physically active, levels of inactivity increase with age. Two-thirds of adults aged ≥ 65 years are not meeting recommended levels, with significant inequalities in participation rates in people from socioeconomically disadvantaged areas. 18 Declining physical activity levels are a major public health concern in the UK due to the associated health-care costs, estimated to be £0.9B per year. 19 Coupled with the anticipated rise in the number of older adults in the UK and half of current lifetime spending on health care being incurred in old age,17 there is a need to develop effective interventions that promote active ageing.

Physical activity interventions for older adults

Systematic reviews of physical activity interventions for community-dwelling older adults20–23 have demonstrated that medium-term (up to 1 year) effects on physical activity are achievable with interventions that encourage older adults to perform some type of aerobic activity, of which walking is the predominant form. These reviews also highlight that many of the included interventions do not reach the people who would benefit the most. 21,22 Therefore, there is a need to develop interventions that specifically target groups who participate in low levels of physical activity, such as those from socioeconomically disadvantaged communities. These ‘hard-to-reach’ groups have their own unique needs that should be considered in designing an intervention.

The barriers to and motivators for physical activity reported by older adults are different from those in younger people. For older people, poor health and a lack of knowledge of, and belief in, the health benefits of physical activity are most frequently cited as the major barriers to regular participation. 24 Inactive older adults have identified their preference for individually tailored physical activity programmes, which take place outside intimidating settings such as gyms and which avoid the concern of slowing down others in group exercise. 25 Devereux-Fitzgerald et al. 26 recently reviewed the experience of older adults in previous physical activity interventions. Older adults’ doubts about their physical capability, or their need to engage in moderate-intensity physical activity in later life, were addressed through their experience of participating in the physical activity interventions. 26 Devereux-Fitzgerald et al. 26 also identified that older adults cited their enjoyment of social interaction with others in the intervention as a motivation to be physically active.

In addition to addressing individual and social determinants in physical activity interventions, research has demonstrated the influence of neighbourhood environments on supporting physical activity in older adults. Living in an area that is supportive of physical activity (i.e. more ‘walkable’) has been associated with higher levels of physical activity, especially in individuals who also have higher self-efficacy and social support. 27 Although it is not feasible to introduce wide-scale changes in the physical environment within behavioural interventions, previous research has shown the potential of physical activity interventions which seek to encourage the use of existing infrastructure for older adults. 28 Therefore, interventions designed on the basis of the socioecological model that seeks to address multiple levels of influence on physical activity behaviours (including individual, social and environmental factors) may have the potential to deliver sustained changes in physical activity. However, there are few interventions designed to address these multiple levels of influence in community-dwelling older adults.

Peer-led physical activity interventions

Peer-led interventions offer a model that may help older adults overcome many of the barriers to physical activity. Peer-led behaviour change interventions are a common and effective means of encouraging behaviour change, including in physical activity. 29,30 Peer mentors are trained, non-professional individuals, who are similar to the target population (e.g. in age and cultural background) and possess experiential knowledge of the target behaviour. 31,32 Peer mentors offer emotional support, motivation through positive reinforcement and relevant knowledge regarding problem-solving strategies. 33

In previous interventions, peer mentors have delivered skills training, provided advice and feedback, and offered social support. 32 The ‘motivational’ peer mentor is therefore an important source of social influence in interventions, addressing behavioural determinants such as self-efficacy, perceived competency to be active and self-determination. 32 However, most of the previous peer-led physical activity interventions did not employ a theoretical framework in their design phase, making it difficult to understand the potential mechanisms through which these interventions may have worked. 32

Aims of the ‘Walk with Me’ project

Using the Medical Research Council (MRC) framework for complex interventions,34 we designed and tested the feasibility of a multilevel peer-led physical activity intervention for older adults, tailored to meet the needs of the local community. The intervention package was developed after identifying appropriate behaviour change techniques (BCTs) through a rapid review of previous peer-led interventions. Following this, we conducted interviews with members of the target population to explore their preferences for, and their perceptions of, the feasibility of the BCTs identified in the rapid review. Using information from the first two stages, combined with behaviour change theory [social cognitive theory (SCT)] and input from practitioners regarding the context for the delivery of the proposed programme, we developed a peer-led physical activity intervention and logic model, and tested its feasibility in a pilot randomised controlled trial (RCT) (Figure 1). The aim of the pilot trial was to provide information on recruitment and attrition rates, intervention fidelity, data on the variability in objective physical activity measurements and the resources needed to support the development of a definitive trial. 35

FIGURE 1.

Integrated model to design intervention content.

Changes to the intervention delivery

It was originally planned that peer mentors would be managed under the existing walking group scheme in the Health and Social Care Trust. Owing to governance issues, it was not possible to arrange this in a timely manner, so the ‘Walk with Me’ study protocol needed to be amended. Therefore, some of the peer mentors were also insured and indemnified through Queen’s University Belfast.

Introduction

The first phase in the MRC complex intervention model is to gather relevant evidence and theory in order to develop a logic model for the implementation of the intervention, which includes the proposed causal pathways and relevant outcome measures. A rapid review approach36 was used to gather evidence and review the BCTs employed in previous peer-led physical activity interventions in adults aged > 18 years.

Peer-led interventions can be considered complex, as they involve multiple interacting BCTs. 34 This makes it difficult to identify the most effective techniques used within peer-led interventions to encourage physical activity behaviour change. 37 To standardise the extraction of components employed in previous interventions, Michie et al. 37 developed the BCT Taxonomy v1. This taxonomy provides standardised labels and definitions for 93 BCTs, hierarchically organised into 16 groupings. BCTs are ‘an observable, replicable, and irreducible component of an intervention, designed to alter or redirect causal processes that regulate behaviour’. 37 Previous evidence demonstrated an association between identification of BCTs and effective interventions for physical activity behaviour change. 38 Presently, there are no published studies identifying which BCTs are most widely used for physical activity behaviour change in peer-led interventions in older adults (aged > 60 years). The aim of our rapid review was to identify the BCTs employed in previous peer-led physical activity interventions.

Methods

Results

Overall, a total of 17,307 citations were identified from the database searches (Figure 2). After the removal of duplicates, 12,396 citations remained. After title and abstract screening, 162 full-text articles were assessed for inclusion. Most excluded studies did not measure free-living physical activity or were single-arm intervention studies with no control group (see Figure 2).

FIGURE 2.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram for rapid review.

Methodological quality of included studies

Six of the nine studies employed a randomised controlled design. 40–43,45,46 Allocation concealment was used in two studies. 47,48 A further four studies were rated as having a low risk of bias from random sequence generation. 41–43,46 Outcome assessors were blind to the allocation of participants in three of the nine studies. 42,43,47 It was unclear if outcome assessors were blind to allocation in the other six studies. Six of the nine studies were deemed to have a low risk of attrition bias. 40–43,46,48 Reporting bias was evident in only one study,45 which did not report all of the prespecified outcomes. Finally, all nine studies reported using a validated measure of physical activity (Figure 3).

FIGURE 3.

Risk of bias in included studies.

Discussion

In this review of peer-led physical activity interventions, nine studies rated as having fair to good methodological quality were identified (i.e. low risk of bias). Interventions were designed around the social support that peer mentors could offer, either within groups or on a one-to-one basis. Intervention strategies were broadly developed to emphasise the peer mentor as a role model for positive behaviour change. Within the interventions, peer mentors delivered skills training, goal-setting and feedback, and problem-solving components. To equip them to do this, they were given short training sessions and offered ongoing support (see Table 2). Peer mentors were recruited either from groups of participants in previous interventions or from community centres. Physical activity was measured using validated instruments, but, as self-reported activity may be biased, there is a need for studies using objective measures of physical activity. A limitation of the study was that BCTs in the control groups were not coded, and thus we were unable to identify BCTs that were unique to the intervention. However, as we were not assessing effectiveness, this does not have an implication on the overall findings.

The BCTs employed in the interventions included in the review were used in the next stage of our study as the basis of interviews with older adults to determine their preferences for what could be included in an intervention.

Introduction

The rapid review of existing literature (see Chapter 2) reporting peer-led physical activity interventions identified common groups of BCTs employed in previous interventions; these were goals and planning; feedback and monitoring; social support; shaping knowledge; comparison of behaviour; repetition and substitution; and antecedents. This qualitative study aimed to explore the feasibility of using some of the most commonly used BCTs in these groups [goal-setting, self-monitoring (behaviour), social support (practical and emotional), problem-solving, instruction on how to perform the behaviour, demonstration on the behaviour and adding objects to the environment] in a peer-led intervention for older adults. These BCTs aligned to SCT, which emerged from the rapid review as a promising theoretical framework for the design of the intervention. We sought to inform the development of our intervention content by eliciting, through semistructured interviews, the opinions and preferences of older adults living in socioeconomically disadvantaged communities regarding the use of these BCTs.

Methods

The Office for Research Ethics Committees Northern Ireland gave ethics approval for the study (reference number 14/NI/1330).

Results

The characteristics of each participant are summarised in Table 4.

Themes

The key themes and subthemes are depicted in Figure 4. These included a distinction between day-to-day activity and physical activity; key determinants of physical activity; goal-setting and self-monitoring using a pedometer; characteristics of peer mentors; finding solutions to barriers to physical activity; and appealing attributes of demonstration walking. The themes are reported below, supported by relevant quotations, which are anonymised.

FIGURE 4.

Thematic map of ‘Walk with Me’ intervention development interview data.

Theme 1: distinction between day-to-day activity and physical activity

The interviewer clearly defined physical activity as activities in which people were ‘up and about’ and ensured that participants understood that physical activity is not limited to activities that are structured (e.g. going to the gym). In terms of the discussion, individuals echoed this understanding and described their typical day, which consisted of the activities of daily living, including housework (e.g. laundry, cooking and cleaning), as well as carer responsibilities for either grandchildren or partners:

. . . just have breakfast. And so I make my husband’s breakfast cause he’s not in good health . . . going to do the washing . . . go and get your washing upstairs and bring it down . . . I’d be up the stairs all the time . . . And would I never rest. I do knit . . .

Participant 9

The majority of individuals appeared to be busy simply carrying out day-to-day living activities, and physical activity was regarded as something that was for leisure, and not something that was ‘necessary’. It was also mainly limited to a number of physical activities, among which walking and gardening were the most frequently mentioned:

. . . the morning part of it was active enough, certainly, because erm my flower bed had got decidedly overgrown and um it needed a great deal of hoking and poking to get it into any sort of order at all.

Participant 3

My only activity at, at the moment is walking. Walking my dogs.

Participant 4

The findings suggest that older adults are potentially less physically active and may not be meeting the recommended guidelines for physical activity:

Really that’s all my activity because I’m not sport minded or anything [laughing].

Participant 2

Theme 2: key determinants of physical activity

Individual discussions suggested that there was a complex interplay between individuals’ beliefs about their health and how physical activity would affect it; the environment in which they lived and whether or not it allowed access to appropriate areas to walk; the level of support that they received, whether physical or social; and the amount of time that they could devote to physical activity. These various factors all appeared to have a potential influence on physical activity levels.

Health beliefs

Participants expressed feelings about the ‘inevitability’ that physical activity would decline over time as a result of changes in health and in social circumstances:

But unfortunately with erm the deterioration in my wife’s health I was gradually dropping, and the fact that I was getting older anyway (laughs).

Participant 3

Participants also suggested that existing health conditions prevented them from increasing their physical activity level:

Although I haven’t done it [physical activity] in about 2 months. Erm I think that one day I just done a bit too much and then fluid gathered in my knees. So, I need to be careful not to over do it.

Participant 11

However, participants also suggested that poor health could also be a motivator for increasing physical activity in the belief that it could alleviate the symptoms of existing conditions or even prevent new ones from developing:

I’m trying to use the hands. Trying to use the limbs by bending up and down . . . I still do it because I have to do it.

Participant 9

In addition, participants expressed a belief about the benefits of physical activity (e.g. for better mental health and weight management). Participants expressed different beliefs about their level of actual physical activity, with some believing that they should be taking more physical activity and others believing that their physical activity levels were adequate:

You’re out walking, you’re out active, you’re, you feeling better in yourself and your whole head lifts. My husband suffers badly with depression so, when we’re out walking, it lifts him. You’re out. Know what I mean?

Participant 9

I’m conscious that I need some sort of walking. Some sort of activity. I’ve retired now around 2 years. And erm I’ve noticed I’ve put on a bit of weight and I have myself, a certain weight I will not go over and I’m, you know, erm, normally watching my weight. And I am conscious that I need to be more active.

Participant 11

We are active, active enough. At the moment like . . . hopefully it stays that way.

Participant 10

However, the mixed belief regarding adequacy levels of physical activity may have been due to a misunderstanding about or a lack of awareness of the actual physical activity guidelines:

. . . but I don’t know what 300 steps would mean. Would that mean it’s good or bad?

Participant 9

Environmental support

Participants mentioned fear of traffic (cars and bicycles), dogs, antisocial behaviour and bad weather as key barriers to physical activity, even when appropriate places such as parks were available in their local areas:

Erm [coughs] I think that is becoming increasingly difficult as the roads, the roads have got so busy now. Aye. It’s not so pleasant. I can see myself now, um being reluctant enough to walk the roads with my dog because there’s so much traffic and so few now with . . . easy green edges to the roads where you can walk in comfort.

Participant 3

There’s green fields over there . . . But you wouldn’t walk. I mean I could walk about during the day, it’s fine. But at night, no, I wouldn’t.

Participant 9

Well I, I, don’t like walking round tow paths so I do not ‘cause it’s full of dogs’ doo doos and broken bottles. I don’t like that atmosphere along it. I like round [XXXX] bridge. I like places like that. You know, there’s good fresh air and you meet other people. You know what I mean? Somewhere like that you know. Or up the [XXXX] park. Now I would walk round [XXXX] park.’

Participant 11

I used to go to [XXXX] path but erm the amount of cyclists in that area. You’re just constantly stopping and starting and looking round you. And mostly cyclists. They don’t have a bell anymore and erm, . . . , they would probably frighten you sometimes. They’re right behind you before you realise they’re there.

Participant 12

However, having places to walk that were safe and accessible, or places that allowed them to get in touch with nature, could help to increase participants’ physical activity levels:

Well all the trees. There’s trees and nature. You see ducks and you see . . . So you go up there and you see ducks, and cows. Just trees. It’s not vandalised, not wrecked and ruined and destroyed. You know what I mean? So when you go up to the [XXXX] bridge, 10 minutes away in the car, sure it’s like a different world isn’t it?

Participant 13

Social and practical support for physical activity

Participants expressed a preference for combining social interaction with physical activity, thus making physical activity more enjoyable by focusing attention on socialising rather than on the activity itself:

I would like that one if you were going out with friends . . . you wouldn’t realise the distance . . . you don’t see time.

Participant 8

. . . you’re talking away and you’re. I would say, erm, and I would even think a couple of them there people would forget about their ailments when there’s a crowd cause they’re talking about different things.

Participant 12

Comments suggested that increased social support also increases confidence through learning from others or through the feeling of increased safety from the presence of others:

Safety in numbers. People feel safe out walking along with somebody else. Cause we’re afraid of the dogs and young ones and all messing about in the parks. Not so bad if . . . I’m on the toll path. But I’ve walked round [XXXX] park and I’ve felt a wee bit uneasy in it . . .

Participant 10

Physical support was also a motivator to increasing physical activity whereby providing physical aids to carry out gardening or a secure physical environment could increase physical activity levels:

Give me the tools. Instead of you bending down in pain, get the tools to dig but you standing up . . . so that would be. I would need to get out there and buy those tools that would be my solution. That’s my barrier.

Participant 9

However, the intensity of social support was seen as an important determinant of physical activity, and both lack of support and too much support were potential barriers to physical activity:

. . . if I need to go somewhere, to the hospital for an appointment to the clinic, my daughters are down straight away. Pick me up in the car, so, I don’t get to walk, and I would, and that, that would stop me from, you know.

Participant 9

Time

Participants suggested that their lack of physical activity was due to lack of time because of the many other activities that they took part in, as well as the carer responsibilities that they had for either partners or grandchildren:

I would like to have been gone out and having a walk. But that’s like a barrier. I have to stay in and mind three children.

Participant 7

However, even when time was available, participants preferred to take part in less intense physical activities (e.g. knitting and reading), and so appeared to lack motivation to increase their physical activity level:

I put her into the activity centre and then I’d sit and chat to my friends.

Participant 7

. . . drops me off . . . and will come back and pick me up for I wouldn’t walk all the way back.

Participant 7

Theme 3: goal-setting and self-monitoring (using a pedometer)

Self-monitoring and goal-setting were perceived as helpful approaches to increasing physical activity and, in particular, participants perceived that the pedometer would have a positive influence on their activity levels. Four subthemes were highlighted: pedometer usability, existing routine, setting own goals and living alone.

Pedometer usability

In general, participants expressed a positive attitude towards the pedometer:

Yes that would be a good thing. Yes . . . my son . . . uses that at work. He’d walk 5 mile a day.

Participant 11

There was a general awareness of the pedometer among participants, all of whom had either seen or heard of a pedometer before. In fact, one participant had actually used a pedometer for monitoring steps previously for a different study:

. . . and that would keep me active. That would keep me more active than erm because I do walk about a bit in the home . . .

Participant 9

Yes. I’ve seen them before. Our kids got them one time at McDonalds [Chicago, IL, USA] . . . wee wee yellow ones, and they were using them . . .

Participant 10

However, despite the overall positive view regarding pedometers, there were concerns about their actual use in practice:

Sure the last time . . . there wasn’t a step come up on it. So I wonder if this one’s working? That one wasn’t working sure it wasn’t?

Participant 10

In addition, participants also highlighted that pedometers should be simple to use:

I don’t want something like a magic phone . . . because I’ll not be able to use it [laughs].

Participant 4

. . . well that there’s handy . . . where erm you just, say clip it on to your jeans or something, and um, you just push a button and it starts, and pushes a button and it stops. Anything complicated, I wouldn’t be able to use, you know. But something like that there!

Participant 5

Participants also suggested that the device should be easy to wear and easy to see:

You have to be able to see it . . . the other one I used you were constantly putting your glasses on and off so that was a distraction too. But that has a nice clear face.

Participant 8

. . . the way I thought that if you could get like an arm band . . . it’s better than having something clipped on you.

Participant 8

Existing routine

Participants expressed an interest in using the pedometer because they felt that this would fit into their existing routines. For example, participants preferred to, or were more interested in, monitoring or counting current steps rather than trying any additional or new types of activities:

. . . so I really have a routine, most of the week . . . and then I’d be able to see what I’d done one day and what I’m doing on another day. Some days wouldn’t be as many as others. So it would give me a, a bit of a picture.

Participant 10

However, this does show that the provision of pedometer per se may not be sufficient to enact behaviour change and that participants need to be encouraged to use the pedometer to set step goals and monitor their progress:

But I wouldn’t want to be doing this diary all the time.

Participant 10

Setting own goals

Participants expressed a preference for being able to set their own goals, as opposed to having them set by someone else. This was mainly due to the feeling that self-set goals would be tailored to their own physical fitness or capability rather than general goals that might not be achievable:

Well the goal-setting, because it’s, as long as it’s, I set my own goals . . . you know . . . and doesn’t put too much pressure on individuals to achieve them.

Participant 12

It would really encourage you, I’d be ‘here, I gotta go out the night and all. I’ve got to fill this here in. see how many steps I’d done . . . It would encourage me just to be able to look and say ‘Look what I’ve done – 8000 today’, and then when it’s coming up to tea time I’d be going ‘come on let’s go and do another one . . . we’ll maybe try and get up to 10’ . . . I think that would be encouraging.

Participant 12

There was also a feeling that, even if goals were set, there should be flexibility to take account of ‘off’ days when existing conditions or tiredness might prevent them from achieving the targets:

I would get maybe, say for argument’s sake, about 50 yards before the pain, the pain gets gradually worse . . . you know. When would you want me to draw the line?

Participant 12

Finally, participants expressed concern about the added pressure that setting goals might put on them, despite the fact that doing this would motivate them to try to increase their physical activity levels:

I wouldn’t want the guilt on me . . . if I didn’t do the right amount. And I wouldn’t want to be feeling that I’d fallen behind . . .

Participant 12

Living alone

The use of a pedometer to set goals and monitor activity was viewed as a potentially useful solution for people living alone because it was something that could be carried out independently without any additional support:

. . . even in the house, you could do that on your own with the pedometer . . . that would interest me.

Participant 5

Participants expressed a view that people living alone could easily slip into levels of non-activity because there was no one else to motivate or encourage them to take part in physical activity. They saw the pedometer as a source of motivation and encouragement:

And in fact in a family environment possibly the, the advantages might be doubtful. But for anyone living alone. I think it would be a very useful in that it’s quite easy to lapse into a way of life which . . . would predominantly inactive . . .

Participant 3

Theme 4: characteristics of peer mentoring

Social support in the form of peer mentoring was viewed favourably by participants, and comments suggested that, for a peer-led intervention to be successful, the specifics of both the peer and the activity should be considered. In addition, participants suggested that they should have the opportunity to meet with the peer mentor at least once per week. Some participants said they would prefer to have peer contact by telephone, whereas others preferred face-to-face contact, and at a neutral location rather than at their home.

Mentoring for physical activity

Participants identified key components of the activity that needed to be addressed in order to motivate them to take part. First, the activity needed to be well planned, in terms of both timing and route of walking, but arrangements needed to be flexible:

When he phones and lets you know what’s happening in advance then you can pre-plan what’s going to happen or pre-plan to go to these different activities.

Participant 11

In addition, participants felt that the programme planned should create opportunities to try new activities (e.g. swimming), to visit places within their local area or outside their area that they had not been before, or to resume previous activities that they had stopped because their circumstances had changed (e.g. as a result of illness). Attention should also be given to including activities that the participants themselves identified as being pleasurable:

I do feel peer mentoring can introduce you to new ideas. Just because you’re elderly, it doesn’t mean to say you can’t have new ideas . . . you can show the peer something that you enjoy doing . . .

Participant 4

Activities needed to reflect the shared interests and the capabilities of both the peer and the participant:

I’d be interested in what they [the peer mentor?] would like to do too.

Participant 4

People might be reluctant to go out with other people on the basis that they might be . . . walking much further than they would.

Participant 3

In addition, the benefits of any planned activities should be stated at the outset of the programme so that there could be an understanding of the purpose in order to increase motivation to participate:

. . . she said it was good for your health. Good for your mental health, and once she mentioned mental health sort of thing, people listened. And this’ll relax you and relieve stress of the day.

Participant 9

In addition, although the aim of the physical activity intervention may be to increase levels of activity, its other potential beneficial effects were of significance. One interviewee commented on how motivation to continue with the programme long term was derived from their positive experience of it, specifically reporting how it helped promote relaxation:

So relaxing. And that’s what got me motivated.

Participant 9

Attributes of the peer mentor

The attributes of the peer were considered to be key to ensuring the success of a peer-led intervention. Participants expressed a desire for the peer mentor to be not only experienced and well trained but also medically aware to build confidence and trust:

. . . if they have got experience, that can restore your confidence, offering advice, discussing problems . . . Problem-solving with you . . .

Participant 4

. . . the peer would need to know, look this woman has high blood pressure, and this one has diabetes and she needs to carry something . . . Now my friend, she knows me well, and she has asthma and see before we go out like, [XXXX] knows to have all her things with her and she, she lets me know. So, that I’m aware when I’m out with her that this is a bag she has this particular coloured inhaler in . . .

Participant 10

In addition, although participants did not feel that they needed to have the same demographic characteristics as the peer mentors, such as age, they did consider that a peer mentor needs to be someone who is themselves physically active and physically capable to help and provide encouragement. However, it was also noted that other resources should be readily available if help were needed:

Even a young person. It wouldn’t matter what age they were. I think a young person anyway would get you up and get you out.

Participant 9

As long as they were a wee bit more active, . . . that they were able to . . . erm. It would be no good if they were worse than me probably . . . these days we all carry mobile phones.

Participant 5

The only other characteristic of the peer that was identified as important was sex: it was generally felt that the peer mentor should be of the same sex as the participant. However, it was suggested that participants with partners may not need a peer.

The most important component of a peer-led intervention for participants was the relationship that would develop. All participants felt that the relationship should be based on friendship, and a few key components that could secure the success of friendship development were dentified. First, participants identified the need for the peer and participant to have shared interests, and several participants suggested that, similar to dating, the peer’s interests and the participant’s interests should be ‘matched’ to ensure compatibility:

. . . before a peer was selected, that . . . there was a list that you could put down the sort of things that interest you.

Participant 4

Well I would like go out with somebody that’s not doom and gloom. A bit of jokiness . . . that’s what you need. What would be important to walk with is two or three people that you can have a wee bit of banter. You don’t want to hear about the price of tea. You don’t want to hear about their aches and pains. I don’t want to be conferring about aches and pains with anybody. I would avoid having a walk.

Participant 13

Participants suggested that the peer should be voluntarily motivated to spend time with them rather than being paid to do so:

. . . rather than . . . someone who is duty bound, to go ‘walkies’ on Wednesday afternoon, no matter whether it’s pouring or, or the roads are icy or whatever . . .

Participant 4

There was a feeling that friendship would lead to a stronger bond of loyalty, which would act as a physical activity motivator. In other words, friendship would ensure that people would be more reluctant to let others down and incentivise them to meet and carry out activities with the peer:

There’s always the, the feeling that ‘well I should turn up’ because if I don’t I’m letting, letting them down.

Participant 3

Theme 5: finding solutions to barriers to physical activity

Participants were not aware of what problem-solving might involve until it was explained to them. However, it was one of the most preferred options, perhaps because participants felt that it was something that they did on a day-to-day basis anyway. It was considered that problem-solving should be integrated into an overall programme rather than being used as a standalone activity:

I mean, if you’re, you’re getting to the point of deciding that we’re going to have regular walks together you would then come down to the point of where you were actually going to go.

Participant 3

However, participants identified many potential barriers relating to physical activity, including health-related issues; for example, arthritis may prevent walking or gardening, fear for personal safety may prevent walking in areas that were not busy or crowded, and child-minding responsibilities meant that it could be difficult to find time for physical activity. In general, participants felt that finding solutions to barriers was a useful exercise and that problem-solving with another person could help them see the broader picture and find solutions that they may not find by themselves:

It’s great if somebody helps me, because I just see the barrier. You know? And then if somebody like you was to talk about I would go ‘yeah that would be a good solution there’, you know.

Participant 9

However, there was a concern that solutions needed to be applied, progress monitored and feedback given on an ongoing basis to ensure success:

It’s just not practical. No.

Participant 2

Theme 6: appealing attributes of the demonstration walk

The inclusion of a ‘demonstration walk’ as part of the proposed intervention, whereby the peer mentor and participant would go for a walk together, in order to identify potential routes and locations in the local area, was not widely welcomed. The majority of participants suggested that they might consider taking part in a peer-led walk on a weekly basis if the areas outlined in the peer-led activity (above) were addressed. In addition, two areas that could increase motivation to taking part in the demonstration walk were identified.

Group versus one-to-one peer walk

Participants felt that a demonstration walk, if performed as a group activity, could be more enjoyable than walking only with a mentor, as it could provide an opportunity to meet other people with common interests and friendships could be developed within the group:

Where there are other people like yourself who would welcome you, welcome your company.

Participant 4

There was also a feeling that a group could avoid some of the difficulties that perhaps may arise in a one-to-one peer relationship. Thinking of performing the activity as a group was considered to be less daunting and to offer greater opportunity to meet someone with similar interests and capabilities:

. . . maybe even three or four people, . . . because maybe in a group, it’s easier.

Participant 5

However, participants also perceived that, although the group had advantages over a one-to-one peer relationship, it could be less attractive because it felt more like a structured activity and could be a less flexible arrangement:

A structured appointment is, is not a good idea, um, because older people have good days and bad days or don’t fancy putting on a, a waterproof and braving the storm.

Participant 4

I don’t really like the idea of a structured appointment.

Participant 4

Recruitment to a peer-led walking programme

In considering preferred approaches to recruitment, some participants reflected on their experience of joining various clubs. Although they had joined clubs in response to seeing information about them, they knew of other people who would have been eligible to join but did not:

There’s a lot of people in the same situation as what I am in the area but they don’t seem to be coming forward.

Participant 11

There was discussion within the group about the targeted selection of individuals for invitation to join a peer mentoring intervention. It was considered that such an approach from someone from the intervention would have been a more effective method of encouraging recruitment and one participant described how a personal approach had engendered enthusiasm for accepting an invitation to join another group. Such a personal approach to recruitment, rather than relying on posters and leaflets, was considered appropriate in order to ensure common interests or capability among prospective participants:

Well I was stopped one time when, when I was in shopping and this guy stopped me and erm he was telling me that he was trying to set this group up for a certain age, well not a certain age, but a certain gender of people and he was telling me the activities that they plan . . .

Participant 11

It was emphasised in the discussion that information relating to how to join a peer mentor walking group should be made very clear and that the process of recruitment should be as simple as possible for older individuals.

Well, . . . I’m not sure how they get in contact with people or do you have to get in contact with them? They [walking groups] might well make it easier for people to get in touch with them.

Participant 3

Discussion

Interviews revealed that older adults have busy lives, including housekeeping and carer responsibilities, and therefore engaging in other regular physical activity is not seen as a necessity. Walking appeared to be a common and preferred activity across all participants.

Similar to previous research,52 the findings suggest that increasing physical activity in older adults is a complex phenomenon because of the interplay between physical, psychological and environmental factors. For example, the current study identified that health-related beliefs, social support and the characteristics of the local neighbourhood environment are important determinants of physical activity that need to be considered in the development of any physical activity intervention development. However, the current study findings revealed that there were key areas within each BCT which should be explored with a target population, in order to address their barriers to physical activity.

Participants reported leading busy lives, but are not necessarily physically active. To increase physical activity, interventions should seek to increase awareness of the recommended physical activity guidelines and highlight the key health, emotional and social benefits of physical activity for older adults in order to persuade older adults to prioritise physical activity.

Tailoring interventions to personalised physical activity goals, such as step goals,20 can lead to sustained increases in physical activity. Our participants reported that they liked the idea of goal-setting and self-monitoring because they are easy to do and because they can be integrated into existing routines, leading to increased self-efficacy for physical activity. 53 However, the interviews revealed the importance of participants setting their own goals and of the ease of use of monitoring devices, so attention must be paid to selecting the right activity monitor (simple, easy to read, easy to carry and robust) and to delivering appropriate training on how to use it, and allowing participants to set their own goals.

Providing physical activity in combination with appropriate levels of support (whether physical support, such as gardening tools or walking aids, social support, such as peer mentoring or demonstration walking, or simply providing physical activity within a social setting), could decrease feelings of social isolation and loneliness, and increase feelings of motivation, confidence and safety, as well as make physical activity more enjoyable and ultimately increase overall levels of physical activity. Interventions that capitalise on social inclusion, such as peer mentoring or a demonstration walk, have great potential to succeed in increasing physical activity. 52 However, the relationship with the peer or the group is important to ensuring success, so a matching exercise to ensure shared interests between the peer/group and participant is key.

Discussion about the environment identified several defining characteristics which could increase physical activity. For example, individuals suggested that important features of the environment included a facilitated environment (well-maintained paths, aesthetically pleasing, scenic, close to nature, free of pollution), a safe environment (free from traffic, cyclists, dogs and crime), and one that was accessible (local or not). They also mentioned bad weather as a barrier to physical activity. Therefore, planned activities should take place away from traditional physical activity locations (e.g. gyms), but in a physically supportive environment (one that is ‘walkable’), with transport readily available or provided, and which also provides indoor or protected locations to facilitate walking in any weather. In addition, discussions around the demonstration walk identified a need to ensure robust recruitment that was proactive and personal to promote participation.

Interviews revealed conflicting beliefs relating to health, with individuals expressing the belief that physical activity can prevent and improve symptoms of current health conditions, such as arthritis, but can also create health issues through physical exhaustion or make existing symptoms worse, which could result in a lack of independence and the loss of the ability to get out and about. Thus, pain management is key to increasing physical activity, as is the tailoring of physical activity to individual needs. 54

In summary, there is merit in utilising each of the BCTs explored within the context of this study as each addresses barriers to physical activity. Interventions which include goal-setting and feedback, problem-solving, social support through peer mentors and behavioural practice with a peer mentor, as identified through the interview discussions, are perceived to have the greatest likelihood of succeeding in increasing physical activity in an older population living in an area of socioeconomic disadvantage.

Participants

This study targeted community-dwelling older adults, aged 60–70 years and living in areas of socioeconomic disadvantage. For this study, socioeconomically disadvantaged communities were defined as those falling within the most disadvantaged quartile of electoral wards, based on the NIMDM (URL: www.nisra.gov.uk). For ease of administration, the pilot study was conducted in the SEHSCT and the Northern Health and Social Care Trust in Northern Ireland, which cover a large geographical area and a mix of urban and rural settings.

Recruitment

Previous research has identified difficulties in recruiting participants from socioeconomically disadvantaged communities. 58 We therefore employed a range of active and passive recruitment strategies to maximise the potential for efficient recruitment and to explore which methods appeared most effective. Active strategies involved the identification and referral of potential participants by community and voluntary organisations and in-person presentations to community groups based in target communities. Passive recruitment methods included the following: sending study information, along with a letter from their general practitioner (GP), to suitable patients from primary care practices in target communities; the distribution of leaflets and posters through general practices, community centres, libraries, health centres, faith-based groups and churches; and the use of e-mail lists and social media outlets of project partners. All practices with postcodes in the target electoral wards were identified from the Business Services Organisation records in Northern Ireland. Eleven practices were chosen for initial contact and selected with the aim of recruiting participants from a range of geographical locations and with varied characteristics. The practices were contacted by telephone and brief information was passed to the practice manager with an invitation to meet with the researcher to discuss the study in further detail. Each practice was offered an honorarium of £150 in recognition of the time involved and the administration costs of setting up the study, with a further £50 if two or more of the practice’s patients participated in the study.

Individuals who wished to participate were asked to contact the study team by telephone, in writing or by e-mail. Following initial contact, participants were screened for eligibility and invited to return written consent to participate. Those participants who were eventually recruited were asked how they learned of the study.

Eligibility criteria

The following inclusion criteria were employed to assess eligibility:

• male or female aged 60–70 years

• living in a socioeconomically disadvantaged community (defined as the lowest quartile of super output areas according to the NIMDM)

• competent to give informed consent

• not currently physically active (assessed using the General Practice Physical Activity Questionnaire)59

• community dwelling (i.e. living in their own home)

• planning to stay in the current residence during the next year

• able to communicate in English

• no self-reported recent history (within the last 6 months) of myocardial infarction or stroke, or physical limitations that would limit ability to participate in a walking programme (assessed using the Physical Activity Readiness Questionnaire). 60

Randomisation and allocation concealment

After baseline outcome measures were completed, participants were randomised to the intervention or the control group using block randomisation with randomly permuted block sizes. An independent statistician from the Northern Ireland Clinical Trials Unit generated the randomisation sequence using a computer program, and treatment allocations were concealed in sealed, sequentially numbered opaque envelopes. The envelope was not opened until after completion of baseline measures, at which point participants were informed of their group allocation.

‘Walk with Me’ intervention

The 12-week intervention comprised three stages: (1) activation (weeks 1–4), (2) goal-setting and problem-solving (weeks 5–8) and (3) signposting participants to other activity programmes in their community to encourage them to maintain their activity (weeks 9–12). Typically, meetings between mentors and participants began in an environment (community centre/coffee shop close to the planned walk location) where they could discuss the participants’ physical activity patterns in the previous week. During this time, participants and mentors also completed study records using weekly templates (see Appendix 3), discussed goal-setting and problem-solving, and set goals for the coming week. The structure for a typical meeting was outlined during the initial introductory session between a member of the research team, the participant and the mentor, and the participants and mentors were encouraged to continue this format to help establish a rapport with one another and to facilitate the delivery of the intervention content. Following a discussion of the planned duration and route, mentors and participants would then take part in a walk in the local environment/park. At the end of a typical session, plans were made to meet the following week, or 2 weeks later, to progress the programme. A full list of the BCTs to be delivered in the intervention is given in Table 5.

The intervention began with a face-to-face meeting between the peer mentor, the participant and a member of the research team. The role of the member of the research team was to facilitate initial discussions. At this introductory meeting, the discussion focused on building rapport, defining the role of the peer mentor and describing the main BCTs of the intervention (e.g. goal-setting, reviewing behavioural goals, problem-solving). At the end of this initial meeting, the participant was given a pedometer (Yamax SW-200) and a participant information and resource booklet which contained study contact details, weekly step diaries and a physical activity action-planning template. The participant and peer mentor undertook a short (5-minute) ‘familiarisation’ walk, during which the participant was shown how the pedometer worked and the accuracy of the device in recording steps was checked. The meeting concluded with the exchange of contact details and a plan to meet the following week.

The initial period of the intervention (activation stage, weeks 1–4) was designed to enable the participant and peer mentor to establish a rapport (e.g. by building a trusting relationship that is necessary for successful peer mentoring). During the first week, the participant recorded their baseline levels of physical activity using the pedometer. Following this, the participant, with the support of the mentor, set an initial step goal based on the average steps per day during the first week. 61,62 Participants and mentors discussed what a reasonable goal for the next week would be. The participant was encouraged to consider increasing their daily steps by 500 steps per day and continuing for the next week (approximately 5 minutes/day), and then the mentor and participant discussed how many more steps per day would be practical. Once a goal was decided on, the participant was asked to rate, on a 10-point Likert scale, how confident they were that they could meet this goal. If they rated their confidence as ≤ 7, the goal was revised downwards until they rated their confidence as ≥ 8. The participant and mentor then drew up an action plan to incorporate additional physical activity into the participant’s weekly schedule, and the participant agreed to meet to walk with their mentor at least once every 2 weeks. At these walks the peer mentor was able to advise the participant of the frequency, intensity, time and type of physical activity they should be taking part in (e.g. by discussing the physical activity guidelines for older adults, copies of which were included in the participant information and resource booklet).

The programme continued (weeks 5–8) with the participant and mentor meeting regularly to walk and discuss goals/barriers to increasing physical activity. These meetings enabled the mentor to demonstrate the appropriate walking pace to achieve moderate-intensity physical activity and enabled the participant to set individual physical activity goals by taking into consideration their capabilities. Weekly activity targets were reviewed and agreed. If the participant had difficulty increasing their physical activity, the mentor discussed strategies to overcome barriers to increasing physical activity (e.g. by discussing opportunities for physical activity in the local neighbourhood environment). During this period, the mentor and participant began to make plans to attend a local community- or leisure centre-based walking group or other local physical activity opportunities (to take place during weeks 10–12) that would help the participant maintain their activity level when the structured component of the intervention came to an end.

The final 4 weeks of the intervention emphasised behaviour rehearsal and practice by the participant walking regularly in a locally accessible physical activity environment (e.g. local park). In order to increase physical activity habit formation, the peer mentor prompted rehearsal and repetition of physical activity behaviour by meeting and discussing physical activity goals with the participant, via weekly/biweekly walks and contact over the telephone. The final weeks of the structured component of the intervention provided an opportunity for the participant and mentor to discuss other community-based physical activity opportunities and to attend a local community group to facilitate the maintenance of physical activity behaviours at the conclusion of the 12-week intervention.

Peer mentors

Control group

After the collection of baseline data was complete, individuals allocated to the control group were given an information booklet on active ageing (the same booklet that was given to the intervention group). They did not receive any additional support to change their activity over the course of the research study. After the 6-month data collection point they were given the opportunity to discuss with a member of the research team the availability of local physical activity opportunities (e.g. local walking groups).

Outcome measures

Outcome measures were assessed at baseline, post intervention (12 weeks) and 6 months after baseline. The primary outcome measure was average daily minutes of moderate to vigorous physical activity (MVPA), measured over a 7-day period using a waist-worn ActiGraph GT3X+ accelerometer (ActiGraph, LLC, Pensacola, FL, USA). Non-wear time was defined as a run of zero counts lasting > 60 minutes. At least 5 valid days (including one weekend day) were required for inclusion in the analysis; a valid day was defined as a 24-hour period in which > 600 minutes of wear time were recorded. 64 Activity counts were recorded in 10-second epochs. Freedson cut-off points were applied to the data to calculate time spent daily sedentary (≤ 100 counts/minute) or undertaking light (101–1951 counts/minute), moderate (1952–5724 counts/minute) or vigorous (≥ 5725 counts/minute) physical activity. 65

To explore how participants adjusted their daily physical activity routines in response to the intervention, time spent in recreational-, occupational-, domestic- and travel-related physical activity was assessed using the validated EPIC Physical Activity Questionnaire (second version) self-reported physical activity questionnaire. 66

Secondary outcomes (see Figure 6) included physical and mental health, and mental well-being and were measured using the Short Form questionnaire-12 items (SF-12),67 the General Health Questionnaire-28 items (GHQ-28)68 and the Warwick–Edinburgh Mental Well-being Scale (WEMWBS). 69,70 Health-related quality of life was assessed using the EuroQol-5 Dimensions, five-level version (EQ-5D-5L), questionnaire. 71 Social engagement was measured with the UCLA Loneliness Scale72 and the Lubben Social Network (LSN) Scale. 73 Physical activity and social activity self-efficacy (10-point Likert scale rating confidence in ability to remain physically or socially active despite circumstances such as bad weather, boredom and pain),74 and physical activity and social activity outcome expectancies (five-point Likert scale rating likelihood of outcomes such as good health, improved appearance, reduced stress, companionship and motivation),75 were also measured. The internal consistency for the self-efficacy and outcome expectancy scales was high (Cronbach’s α = 0.91, 0.92, 0.88 and 0.91, respectively).

Process evaluation

Based on the MRC guidance on process evaluation,76 we used a mix of approaches. The fidelity of the delivery and receipt of the intervention was assessed through structured observation of intervention delivery by a member of the research team responsible for mentor training, semistructured interviews and focus groups with peer mentors and participants as part of the post-intervention follow-up (see Chapter 7), and review of intervention records and participant diaries. A member of the research team observed all of the first meetings between the peer mentor and the participant in person. The delivery was reviewed with the peer mentor as part of ongoing training. In addition, for each peer mentor, a randomly selected further meeting between them and a participant was audio-recorded to assess the content fidelity of delivery. The dose of intervention delivered was assessed by asking the peer mentors and a random sample of 12 trial participants to complete weekly checklists and record a diary of contacts. The peer mentor diary included information on the number of attempts to make contact with participants and the duration of each successful contact.

To assess if the intervention was working through the pathways proposed in the intervention logic model, changes in physical activity and social activity self-efficacy, and physical activity and social activity outcome expectancies, were measured. Post-intervention focus groups and semistructured interviews (see Chapter 7) were used to provide context to the research by examining how potential external factors may have influenced the delivery and functioning of the intervention.

Feasibility of conducting a definitive trial

The feasibility of conducting a definitive trial, defined as the ability to recruit participants within the time frame and retain a significant proportion of them within the trial, was assessed based on the recruitment and attrition rates and the qualitative feedback from participants and mentors. The recruitment rate was assessed by calculating the total number recruited as a proportion of the predefined target of 60 participants, within the time frame of the study. We predetermined that we would not proceed to a main RCT unless a recruitment rate of ≥ 60% was achieved. Attrition was measured as the proportion of participants who did not complete outcome measures at 6 months after baseline, either because they dropped out or because they failed to complete outcome measures. We predetermined that we would not proceed to a main RCT unless the attrition rate was < 30%, calculated as the number of participants who returned data at 6 months as a proportion of the number who started the study.

In addition, the decision to proceed to a definitive trial would be informed by the rates of unexplained adverse events in the intervention and the peer mentors’ views on feasibility of delivering the intervention, whether or not it could be delivered within the timeline and the sufficiency of the training and ongoing support.

Acceptability of the intervention

The acceptability of the intervention was assessed through a post-study exit questionnaire. The questionnaire, which was similar to that used in a previous physical activity intervention,77 required intervention group participants to rate their experience of the intervention and satisfaction with the information they received about this study.

In addition, all participants in the intervention group were invited to attend post-intervention focus groups or one-to-one semistructured interviews (see Process evaluation) with a researcher independent of the intervention delivery to discuss their views on the feasibility and acceptability of the intervention. Participants were asked to explore reasons for success in the intervention and challenges to increasing their physical activity. They were asked what they would change about the intervention if they were to take part again.

Peer mentors also were invited to attend separate post-intervention focus groups or one-to-one semistructured interviews (see Process evaluation) to provide feedback on their experiences of the intervention. Topics included challenges to intervention delivery, perceived success, barriers to implementation and suggestions on how to improve the delivery of the intervention. Primary questions related to the different BCTs employed, reviewing each in turn, considering what worked to increase engagement in walking for some individuals and what did not work for others. Control group participants were invited to attend semistructured interviews in which they were asked to give their feedback on their involvement in this arm of the study and their motivation to become involved in the research.

Transcripts from the focus groups and interviews were independently analysed using content and thematic analysis by two researchers. 50 These focus groups and interviews will further inform the development and design of a fully powered trial by enabling appropriate refinement of the intervention’s components and delivery for the subsequent RCT.

Assessment of harms

Although there is a low risk of harm from walk interventions, participants were encouraged to report adverse events resulting from activity (e.g. musculoskeletal problems, shortness of breath or falls). Adverse events reported by participants were recorded on a standard proforma. 78

Sample size

As this was a pilot study, no formal sample size calculation was conducted. However, it was expected that 60 participants would provide sufficient information to estimate variability in the primary outcome and inform the decision around a predicted effect size, to inform a sample size calculation for a fully powered future trial.

Measurement of the resource use associated with the intervention and associated costs

We measured costs from a public sector funder perspective. Resources were categorised according to the stage in the process at which they were incurred [planning and preparation for delivery (stage 1) or intervention delivery (stage 2)], in keeping with other trials of public health intervention. 79–82 Resources associated with the development of the intervention (stage 0) were not included in the overall costs, as they would not be incurred should the intervention be adopted into practice in the future. Details about the steps involved in developing the intervention are presented in Chapter 1 of this report. Stage 1 costs included recurring costs associated with the intervention materials and the delivery of peer mentor training by a trainer. Stage 2 costs covered trainer input associated with the initial intervention meeting between trainer, peer mentor and participant, ongoing meetings between trainer and peer mentors, and the provision of pedometers.

As the identification of the relevant resources occurred during study set-up, the research team was able to record the resource use prospectively over the course of the trial. The trainer in the trial was a post-doctoral research fellow employed by a university. However, we envisage that, if ‘Walk with Me’ were rolled out, then the role of the research fellow would be replaced by a health improvement officer (band 5). Training of mentors took place in community centres and coffee shops and no costs were associated with the training location. All mentors required criminal records checks by AccessNI and were paid expenses.

Piloting the health service use log

Although the trial was not designed to estimate cost-effectiveness, participants were asked to keep a record of their use of health and social care services using a study-specific log over the 6-month study period in order to pilot the use of the tool for a future definitive trial from a health service perspective (see Appendix 4). For each participant, the quantity of each service used was multiplied by the unit cost of that service to estimate the total cost of use. The costs for each service were then summed to calculate the total cost of all health service use for each participant. Unit costs were obtained from publicly available sources and set at 2017 prices (Table 6). 79 At the end of the health service use log, we asked participants to express how much they agreed/disagreed with particular statements about the log using a five-point Likert scale. As the time horizon for the analysis was < 1 year, discounting of costs was not necessary.

Statistical analysis

As this was a pilot study, statistical tests to determine the effectiveness of the intervention were not performed. Instead, the effects of the intervention were represented by point estimates. For the change in primary and secondary outcomes from baseline to each follow-up time point, 95% confidence intervals (CIs) were calculated. 83 Analysis was conducted by a researcher blind to group allocations. The Office for Research Ethics Committees Northern Ireland gave ethics approval for the study (reference number 14/NI/1330) and the trial was registered as ISRCTN23051918. Peer mentor recruitment commenced in July 2016. Baseline recruitment of participants commenced in December 2016, and post-intervention and 6-month follow-up data were collected between March 2017 and January 2018.

Objective 1: participant and peer mentor recruitment and retention

General practices were selected to represent a range of geographical locations within the target socioeconomically disadvantaged areas. Of the 11 GP surgeries that were invited to participate, nine agreed to participate and to display a poster in their waiting areas. Seven of the 11 practices also agreed to send postal invitations (400 letters were sent to eligible patients), and in another practice the GPs decided that they would invite patients verbally at a weekend clinic at which influenza vaccinations were given (20 patients were invited). These five practices also agreed to opportunistically invite patients identified as eligible during surgeries (none was recruited).

Participant recruitment strategies also included presentations to community groups and older adults’ groups meeting in local libraries (n = 13), and display of flyers/posters in leisure centres (n = 4). In addition, five community-based older adults’ associations e-mailed their members to tell them about the study; an advert was placed in a free newspaper; and two organisations that telephone older and vulnerable adults on a daily basis informed their clients about the study. Challenges in and opportunities for recruiting individuals to physical activity research studies from general practice are discussed further in Chapter 8.

The peer mentors who delivered the intervention (n = 13) were recruited through a mixture of local community groups (n = 6), leisure centres (n = 3), general practices (n = 2) and referral from the physical activity co-coordinator based in the health and social care trust (n = 2).

To identify community groups to approach, we spoke to physical activity co-ordinators, searched online for groups and e-mailed 25 local elected representatives asking for a referral to groups in their community. In addition, we attempted to place adverts about the study in local newspapers, but this was not possible without incurring substantial cost.

Overall, from these various sources, 105 individuals (36 men and 69 women) contacted the study team and expressed an interest in participating. Of these, 56 individuals heard about the study through a letter from their GP and a further four individuals responded after seeing a poster or flyer in their health centre. Nineteen individuals responded to an e-mail from a leisure centre or an association for older adults and two individuals responded after seeing a flyer in their leisure centre. Fourteen individuals responded after attending a presentation at a community group run in a library, leisure centre or community centre. Four individuals heard about the study from a friend or family member and a further four individuals heard about the study through the health trust. Finally, one individual heard about the study through a poster in their local library and one individual through an advert in a community newspaper.

In total, 50 (48%) of the 105 individuals who expressed an interest in the study were deemed eligible and entered the study. The reasons for excluding individuals are summarised in Figure 7 (27 individuals were already physically active, 26 individuals were too busy to commit to the intervention or not interested in participating when they received further details and two individuals were excluded as they were too old and were not well enough to be eligible to participate). Therefore, 50 of the prespecified sample size of 60 participants were recruited (82%) over a 12-month period.

FIGURE 7.

Consolidated Standards of Reporting Trials (CONSORT) flow diagram for the ‘Walk with Me’ pilot RCT.

Of the 50 individuals who participated, 26 (52%) received a letter from their GP inviting them to take part. A further 14 individuals (28%) took part after seeing a flyer or poster in their health centre. Five individuals (10%) were referred into the study by a friend, four individuals (8%) were recruited from groups in local libraries and one individual (2%) was recruited by a community organisation.

Before the end of the 12-week intervention, seven people had dropped out and did not complete the post-intervention measurements (four reported a change in their life circumstances, e.g. an increasing care commitment for an elderly relative such that they believed that they could not commit fully to the project; three reported a change in health condition/completion of a surgical procedure, the cause of which was unrelated to participation in the study), resulting in a retention rate at 12 weeks of 86% (43/50). All 43 participants (intervention group, n = 22; control group, n = 21) who were retained in the study returned data at 6 months. The percentage of participants who dropped was higher in the control group (19%) than in the intervention group (12.5%), indicating that the intervention did not discourage participation.

Objectives 2 and 3: the resources needed and feasibility of conducting a definitive trial

The results for recruitment and retention indicated that support from general practice, as well as from community organisations, is key to the development of a definitive trial. Further results regarding the level of completeness of valid data returned within the various outcome measures, including the extent of changes observed and process measures used in the pilot study, are reported below.

Objective 4: sample size calculation for definitive trial

Based on a mean difference in the change between groups of 4.8 minutes per day of MVPA (Cohen’s d = 0.29) at 6 months, and a SD of 16.6, 316 participants per group would be required at 90% power and a significance level of 0.05, allowing for 20% dropout as shown in the pilot RCT. We did not identify clustering of the results by peer mentor, with no obvious pattern in the data, suggesting that it was not the case that some peer mentors were more effective at delivering the intervention than others. We have therefore not adjusted the sample size to account for clustering.

If the individual in the control group who returned to work as a postman is excluded from the sample size calculation, then, based on a mean difference between groups of 10.6 minutes of MVPA per day (Cohen’s d = 0.64) and a SD of 16.6, 66 participants per group would be required at 90% power and a significance level of 0.05, allowing for 20% dropout. This effect size is similar to that found in a previous systematic review of pedometer interventions (Cohen’s d = 0.68). 84

A medium effect size (Cohen’s d) of 0.5 is a conservative estimate of the anticipated effect size (approximately mid-way between the values presented above). This is equivalent to a difference between groups of 8.5 minutes per day of MVPA at 6 months. Using this estimate, a sample size of 107 per group or a total sample size of 214 individuals would therefore be required for a definitive trial, at 90% power and a significance level of 0.05, allowing for 20% dropout.

Objectives 5 and 6: measure the resource use associated with the intervention and pilot the use of a health and social care service use instrument

The key resources identified for the planning and preparation stage (stage 1) are presented in Table 14, along with the associated costs. The costs are based on the training of 13 peer mentors and 24 participants. The total cost to deliver the intervention was £5055 and the mean cost per participant was £211. The main driver of costs was the time input required by the trainer, amounting to 5 hours of contact on a one-to-one basis with each mentor, and 1 hour of contact with every participant and their assigned peer mentor. These costs would be lower if peer mentors were paired with larger groups of participants, as this would mean fewer peer mentors would be required and therefore fewer training sessions delivered by the trainer. Similarly, if peer mentor training was delivered to larger groups of peer mentors instead of on a one-to-one basis, fewer training sessions would be required. However, the results of this study indicated that these alternative structures are not feasible. We also explored the impact of a band 4 health improvement officer delivering the training, as this would also be within the remit of their role, and the mean cost per participant reduced to £185.

Introduction

In keeping with the MRC framework for developing complex interventions,34 the ‘Walk with Me’ study was piloted to determine the acceptability of the programme and the feasibility of a definitive trial. The feasibility of the trial was discussed in Chapter 6; this chapter presents information on its acceptability based on the results of a qualitative evaluation undertaken with a subsample of those who delivered and received the ‘Walk with Me’ programme.

Aim and objectives

This phase of the project sought to explore the acceptability of the ‘Walk with Me’ study. More specifically, the objectives were to explore the acceptability of the intervention components from the perspective of those who received and delivered it; identify barriers to success and implementation; and identify possible improvements to the intervention that could be made.

Methods

Qualitative methodology involving interviews and focus groups was used to explore the acceptability of the ‘Walk with Me’ study, in order to identify possible changes to the intervention and proposed trial design, to improve their acceptability and the likelihood of successful delivery of a definitive RCT. Interviews and focus groups were conducted between March 2017 and January 2018.

Results

This section presents our findings within two main themes: first, the acceptability of the ‘Walk with Me’ study from the perspective of peer mentors, members of the intervention group and members of the control groups; and, second, participants’ motivation to become involved in the study. Exemplar quotes are included to support these findings; however, all quotations have been anonymised. Therefore, the views of peer mentors (coded as PM1–8), intervention participants (coded as IP1–7) and control participants (coded as CP1–3) are labelled throughout this section.

Overall, peer mentors and members of the intervention and control groups spoke very positively about the ‘Walk with Me’ study. The majority described the intervention as an enjoyable experience and mentioned that they would be willing to take part in a further future study or to recommend the intervention to a friend:

I enjoyed the experience.

PM2

I thoroughly enjoyed it I have to say, I thought it was good.

IP5

Control participants believed that the ‘Walk with Me’ study could help older adults to increase their physical activity levels. In addition, the social support component of the intervention was viewed positively, suggesting that peer mentors might be a key feature influencing the acceptability of the programme:

I think especially when you reach that age group you’re either, before that you’re either into a mode of exercising and looking after yourself or you’re not and if you’re not in that mode then I think something that sort of heightens the idea that you should be I think is very good.

CP2

It would be worthwhile if it gets people motivated and gets people going . . . it’s good for the social aspect too.

CP2

Discussion

Conclusion

To conclude, these findings suggest that the ‘Walk with Me’ programme and proposed trial protocol were well received by those involved, the intervention has the potential to encourage older adults to walk more and suggested protocol changes have informed the design of a definitive trial.

Introduction

Previous research has suffered from the under-recruitment of older adults into research studies. Reasons cited are that older adults may be less healthy and therefore may not meet narrow inclusion criteria or refuse to participate. 87 Physical activity studies often report low response rates to invitations to participate,88 though the need to improve understanding of effective methods to recruit trial participants has been recognised. 89

In the ‘Walk with Me’ study, recruitment via general practice accounted for approximately half of the individuals who expressed an interest in taking part in the study. However, previous research has shown that it is difficult to engage GPs in research. Nevertheless, engaging GPs in research can play a key role in extending knowledge and translating new information into practice. The most common reasons given by GPs for not participating in research are a lack of time, a preference for clinical care over research, lack of skills to conduct research and research regarded as less relevant in terms of clinical or professional value. 90,91

To further explore the feasibility of recruiting older adults and the barriers to and opportunities of recruiting participants to a physical activity research study from general practice, we conducted qualitative interviews with participants and staff from general practice.

Methods

A purposive sample of GPs engaged in recruiting participants for the ‘Walk with Me’ study were invited to take part in a short face-to-face semistructured interview. The aim of these semistructured interviews was to explore the barriers to GPs’ participation in recruitment of patients to physical activity research. In addition, practice managers were also invited for interview. Practice managers have direct knowledge of the running of a practice and workload of GPs and it was considered that their views would provide information about enablers of and barriers to recruitment from general practice. The interviews took place in each participant’s own practice. The interview schedule (see Report Supplementary Material 2) was developed after reviewing responses to a brief questionnaire returned from GPs in participating practices about their experience of recruiting to the ‘Walk with Me’ study and their views of how recruitment could be improved (responses were received from 24 GPs). Each interview was recorded and transcribed verbatim. Iterative analysis allowed further exploration of issues identified in earlier interviews. Interviews were conducted by a female trainee GP (DC) who was trained in qualitative methodology.

Further interviews were conducted with six intervention participants who had been recruited from general practices. A convenience sample of participants who had recently finished the intervention were invited to take part, and all agreed. The purpose of these interviews was to explore patients’ views on themes identified in GP interviews in relation to barriers to and facilitators of recruitment. The interviews took place at a location of the interviewee’s choice, including the local leisure centre, the interviewee’s home and the local park (as the participant wanted the interview to coincide with their morning walking schedule). Each interview was recorded and transcribed before the next interview took place to allow iterative analysis.

Results

Discussion

Changes required for a main trial

The pilot trial has been a critical step in moving towards a definitive, fully powered RCT of a peer-led physical activity intervention for older adults. Several modifications are suggested to improve the implementation and evaluation of the intervention for a main trial.

We identified that it was possible to engage older adults aged 60–70 years to sign up to the trial. It should be noted that the individuals who agreed to participate were relatively healthy, and more tailoring of the recruitment process is needed in order to recruit less healthy individuals, given the focus of the intervention. Though the participants were classified as inactive when registering their interest in the study, accelerometer data revealed that they were reasonably active at baseline. Participants in this study were undertaking, on average, 32 minutes of MVPA per day at baseline. This is higher than the average MVPA in a sample of 1186 adults (aged 60–69 years) who participated in the National Health and Nutrition Examination Survey (NHANES) study in the USA (14.2 minutes of MVPA/day). 92 However, the levels of physical activity in our participants were lower than the levels of a similar cohort of 298 adults (aged 60–75 years) recruited to a recently reported walking intervention from general practice in England (43 minutes of MVPA/day). 93

In addition, two-thirds of participants were female. This is similar to the findings of a previous systematic review of recruitment to walking interventions, which identified that 70% of participants are female. 58 In addition, most (70%) of the male participants in our study were recruited through their GP, which suggests that this may be the most feasible way to recruit male participants to the study. Foster et al. 58 recommended monitoring participants’ responses to recruitment approaches and using different recruitment strategies, where necessary, to ensure balanced recruitment. Careful monitoring of recruitment by sex would be an important aspect of a definitive trial.

Given our finding that the most efficient way to recruit participants was through general practices, this is also likely to be the avenue to identify and recruit less healthy individuals. GPs supported the idea of recruiting patients to a physical activity trial, but the process needs to take place with minimal intrusion on the delivery of direct patient care. Using general practices to recruit participants is becoming increasingly complex and we have identified a variety of approaches that can be used (e.g. synchronising recruitment efforts with other activities in the practice, such as clinics).

After indicating their interest in participating, individuals were willing to accept randomisation to either an intervention or a control group; although those in the control group did express a desire for more than a waitlist condition. Future peer-led interventions could consider using an attention-matched control group, like that of Castro et al. ,42 who offered nutrition support instead of physical activity, although this may impact on the secondary outcomes. We therefore propose adding brief nutrition advice for the control group.

The ‘Walk with Me’ intervention included only individuals aged 60–70 years. Some community groups gave informal feedback that this may be restrictive in terms of implementation of the strategy in the real world, as their practice is to offer programmes to anyone who wishes to take them up (i.e. they would identify individuals outside this age band who would benefit from the programme and be capable of participating). There is therefore a case to be made to omitting an upper age limit from future inclusion criteria and using a measure of functional ability to identify eligible participants. We also propose removing the upper age limit for peer mentors, as participants indicated that the peer mentors’ ability to motivate and support was more important than their age for the successful delivery of the intervention.

The quality of data from the primary outcome was good, with at least 93% of participants returning a valid accelerometer data set at any time point. This demonstrates that the outcome measure was acceptable. Some participants reported that the self-reported outcomes were burdensome and took too long to complete. This may be the reason for the relatively lower rates of completeness of self-reported outcomes at baseline. These measures therefore need to be reduced in terms of their time requirement, and duplication of focus, such as avoiding the use of both GHQ-28 and SF-12 questionnaires. In addition, a measure of self-reported physical activity may not be needed. The purpose of including it was to capture the domains of physical activity where changes occurred, but it may not be sensitive enough to capture changes. As identified in Chapter 7, some participants expected to receive a health check as part of the intervention. We therefore propose adding measures of blood pressure and body mass index to a future study. In addition, greater efforts will be required to encourage the return of data from those who discontinue the intervention but do not withdraw from the study, including the offer of telephone interviews to collect outcome data.

In the post-intervention interviews, some participants reported that they would like to have had more support from the mentors in setting goals. Some participants felt they were left to set their own goals in the later parts of the programme, though this was not corroborated by the fidelity checklists. It will be important to emphasise the importance of following the approach to goal-setting set out in the programme manual with mentors in the ongoing support that is offered.

Assessment of fidelity and record-keeping proved challenging within the intervention. This may be because peer mentors and participants are not professionals and therefore are not used to the type of record-keeping which has worked well in previous walking programmes in clinical settings. 61 The importance of record-keeping will need to be emphasised with peer mentors and participants. Some modifications, with user input, to checklists to reduce the burden of record-keeping should be planned before undertaking a definitive trial. Other options will need to be explored, including mobile telephone apps or websites to make recording information less burdensome. In addition, a protocol for creating regular backups of digital audio-recordings will prevent the loss of data.

We propose amending the exclusion criteria to exclude those not in work at the start of the intervention, but planning on returning to work before the end of follow-up. This would avoid the situation that arose in our pilot study, in which a participant in the control group returned to work as a postman over the course of the study and increased the group’s average step count through work-related activity which could not be directly attributable to the intervention.

As described in our post-intervention interviews, the burden of paperwork was a barrier to the delivery of the programme and potentially to the development of the relationship between the peer mentor and participant. Reducing the volume of paperwork should help to foster good peer mentor–participant relationships.

During training, peer mentors were advised that if they encountered difficulties in their relationship with a participant then they should contact a member of the research team as soon as possible. In this scenario, the researcher would speak with both parties in an attempt to resolve issues. However, during the intervention we did not experience any difficulties in the relationship between peer mentors and participants.

Peer mentors reported that the main barriers to delivering the intervention were (1) finding a time that was mutually suitable for them and participants to meet and (2) the weather (see Chapter 7). Therefore, some training needs to be added to reinforce the importance of a flexible approach to working with participants and finding alternative venues (e.g. local shopping centres) to walk in when the weather is poor. This may be achieved through a top-up training session with peer mentor (delivered at the half-way point of the intervention), which may help to refresh training on the delivery of key intervention BCTs.

Strengths and limitations

We have noted the lessons learnt from the current pilot study in Changes required for a main trial. However, there are a few additional points that should be noted.

Conclusions

There is a paucity of evidence of the effects of peer-led walking programmes in older adults. The ‘Walk with Me’ intervention, developed from existing evidence, with input from community stakeholders, based on SCT and designed with the aim of promoting physical activity among older physically inactive adults in a socioeconomically disadvantaged population, was acceptable to participants. Our pilot study has informed approaches to recruitment and peer-mentoring planning for future work. Notably, participants reported that they valued recruitment via their GP, as this is someone they trust and would have confidence in their recommendation to participate. A need to reduce the burden of self-reported outcomes and address intervention fidelity in the later stages of the intervention was identified. This should be balanced against participants’ desire to have objective health measures, such as blood pressure and body mass index, included. Quantitative and qualitative information suggested that it would be feasible to conduct a definitive RCT to evaluate the intervention.

Contributions of authors

Mark A Tully (Professor of Public Health) was the chief investigator of the project and took overall responsibility for the delivery of the project and writing of the report.

Conor Cunningham (Project Manager) project managed the study and co-drafted the report.

Ashlene Wright (PhD Student) contributed to the conduct and analysis of the rapid review.

Ilona McMullan (Research Assistant) completed the intervention development interviews, co-analysed the data and co-wrote the relevant chapter of the report.

Julie Doherty (Research Assistant) completed the post-intervention qualitative investigation, co-analysed the data and co-wrote the relevant chapter of the report.

Debbie Collins (GP trainee and Masters in Research Student) completed the interviews about recruitment, co-analysed the data and co-wrote the relevant chapter of the report.

Catrine Tudor-Locke (Professor of Kinesiology) contributed to the design of the peer-led intervention, the conduct of the trial and was a member of the project management group.

Joanne Morgan (Director of Community Development and Health Network) contributed to the development of recruitment methods, the conduct of the trial and was a member of the project management group.

Glenn Phair (Junior Health Economist) co-analysed the health economics data and was a member of the project management group.

Bob Laventure (Director of Later Life Training) advised on tailoring the intervention to older adults and was a member of the project management group.

Ellen EA Simpson (Senior Lecturer in Psychology) supervised the collection of qualitative data, co-analysed the data and co-authored the relevant chapters, contributed to the conduct of the trial and was a member of the project management group.

Suzanne M McDonough (Professor of Health and Rehabilitation) contributed to the design of the project, the assessment of fidelity of the intervention, the conduct of the trial and was a member of the project management group.

Evie Gardner (Head of Statistics) contributed to the design of the project, supervised the statistical component of the research and was a member of the project management group.

Frank Kee (Professor of Public Health) contributed to the design of the project, the conduct of the trial and was a member of the project management group.

Marie H Murphy (Professor of Exercise and Health) contributed to the design of the project, the conduct of the trial and was a member of the project management group.

Ashley Agus (Health Economist) led on the analysis of the health economics data and was a member of the project management group.

Ruth F Hunter (Lecturer in Physical Activity and Public Health) contributed to the design of the project, conduct of the trial and was a member of the project management group.

Wendy Hardeman (Senior Lecturer in Health Psychology at the School of Health Sciences) contributed to the design of the intervention, the conduct of the trial and was a member of the project management group.

Margaret E Cupples (Emeritus Professor of General Practice) contributed to the design and conduct of the project, co-analysed the qualitative data and was a member of the project management group.

All authors read, commented and agreed the final draft report.

Publication

Tully MA, Cunningham C, Cupples ME, Farrell D, Hardeman W, Hunter RF, et al. Walk with Me: a protocol for a pilot RCT of a peer-led walking programme to increase physical activity in inactive older adults. Pilot Feasibility Stud 2018;4:117.

Data-sharing statement

All data requests should be submitted to the corresponding author for consideration. Access to anonymised data may be granted following review.

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 PHR 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 PHR programme or the Department of Health and Social Care.