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Table 3 Qualitative themes and sub themes and exemplar quotes extracted from stroke survivor interviews and healthcare professional focus group

From: Feasibility, acceptability, and fidelity of Physical Activity Routines After Stroke (PARAS): a multifaceted behaviour change intervention targeting free-living physical activity and sedentary behaviour in community-dwelling adult stroke survivors

Themes (T)

Sub themes (ST)

Exemplar quotes

1. Recruitment procedures require optimisation to facilitate a larger scale evaluation

A. The recruitment process didn’t generate as much interest as expected

‘…We gave out quite a lot of the information leaflets, but obviously a lot of them didn't want to take part.’ (HCP2)

‘…We had quite a few people that refused to take part, didn’t we? We did ask quite a few people that didn’t want to do it.’ (HCP3)

‘…I had one guy that just said, “I don’t want to be a guinea pig.’ (HCP5)

B. HCP time, commitment and confidence was a barrier to recruitment

‘…I think it was time. I think there were certain periods of time where we were that busy that we didn’t really have the time to do PARAS. (HCP3)

‘…Maybe how we sold the study maybe not very well or we just asked them if they wanted to be part.’ (HCP4)

‘…Being scrutinised doing something new…you’re not going to be comfortable anyway’ (HCP1) [use of a Dictaphone recording intervention delivery]

C. HCPs selected patients based on level of function and motivation

‘…We had a lady that we thought it would be good for but we just knew she wouldn’t engage in it. It just wouldn’t have worked with her….. Maybe we should have put her into this. We thought about it but we just thought, “Oh no, it’s not going to work.” (HCP3)

‘…I found that out of all of the patients that could be potentials, it would be the higher-level ones that I’d pick every time to engage with something like this, just to be able to read, communicate, probably physically a bit more able as well. I don’t know why.’ (HCP7)

‘…I mean really we probably should have chosen those patients who perhaps are more housebound…. I suppose you worry that if somebody looks at that benefits thing and wants all those benefits and then you’re going to do sit to stand every couple of hours, you think, “Is that going to make them feel that they’re getting any of those benefits?” (HCP4)

2. PARAS provided HCPs with new strategies to target increased physical activity with patients

A. PARAS aided development of behavioural strategies but additional training on motivation strategies for those more impaired would be beneficial

‘…I think one of the benefits I’ve had and I use it with people more than probably I ever have really considered, it was what are the barriers.’ (HCP3)

‘…I think it would be handy to have more training on the psychology side of things a little bit, the questioning and motivating patients because we definitely did shy away from the odd patient that we thought, “Well they’re not going to engage in it,” but how to engage those patients that you really can’t engage.’ (HCP3)

‘…I did find it difficult to guide patients through the process who were less mobile.’ (HCP9)

B. Feedback on intervention delivery was reported to be useful

[feedback from study team] ‘…I think that’s useful because when you’re doing it, you’re on your own so you don’t quite know how you’re doing. So I think just to get some feedback how people are doing.’ (HCP3)

‘…The feedback that you sent was really useful just to get an idea of that. I think just to prompt you to remind you that it’s going on, you see PARAS.’ (HCP3)

‘…Yes, it was helpful to have it, yes. I mean I think like anything, it’s something that’s new. I think my feedback, there were quite a few things that I could have done differently but I needed to know that because otherwise you don’t know if you’re doing the right thing or not.’ (HCP3)

C. Recording intervention delivery negatively affected confidence of some HCPs

‘…I don’t think the Dictaphone made everybody as relaxed as they could be…..you’ve got that pressure on yourself whereas normally you’d go in, you’d have a chat, you do your goal setting and it would all flow quite naturally.’ (HCP8)

‘…I think it’s a bit cringe knowing that your conversation is being recorded. It was always in the back of your mind, “I need to turn it on. It’s being recorded,” and you maybe weren’t as, I wasn’t as relaxed as I might have been because I knew you’d be listening.’ (HCP3)

3. The PARAS intervention is acceptable but requires minor modifications to improve delivery

A. PARAS delivery time could be reduced by providing patients with preparatory information

‘…I think it took a long time.’ (HCP6)

‘…I think probably the three assessment tools at the beginning take quite a bit of the time.’ (HCP5)

‘…Something I wondered about whether or not it would save a little bit of time is giving the patients the information before. You know all the information about the benefits of exercise and the outcomes, giving them that to look at before because it felt a little bit like they were pressured into reading all this information.’ (HCP3)

B. Delivery of PARAS might be more appropriate earlier in the care pathway for some patients

‘...If we have this as an inpatient from rehab then that could follow, there’d be a little journey, rehab journey or something that could follow them out into the community and their goals would change from month to month.’ (HCP5)

‘...I think from the physio in hospital actually, from that early stage to when they’re going to send you home and for the early discharge team to work with you, that would be good.’ (NTP05, M, 58yrs)

‘…Timing earlier….’yes… I think when you first come out of hospital. Yes. I think that would have been better than the physiotherapist coming in here and saying, “Right, get up. We’re going to do this, we’re going to do that,” and you weren’t ready for that.’ (STP02, M, 64yrs)

C. HCP support is a critical part of intervention delivery

‘…I think it was about right.’ (NTP05, M, 58yrs)

‘…I found it very helpful. She explained it well enough.’ (STP02, M, 64yrs)

‘…Yeah, you know, just keeping you right really on how to go.’ (NTP01, M, 67)

D. The components of the PARAS intervention worked well together and were useful and motivational

‘...Yes, it [the workbook] just helps you to focus on what you want to gain.’ (NTP05, M, 58yrs)

‘...There was plenty of information. It helped me to pick at what was feasible for me to do and what wasn’t, what was too far.’ (STP02, M, 64yrs)

‘...I found this [the physical activity repository] really useful.’ (HCP7)

‘...Yes, just having it all in one place and just being able to flick through because you can use it for other patients as well.’ (HCP7)

‘…So I can look back at the earlier documentation and see how I have improved. So that is motivational [self-monitoring tools].’ (NTP05, M, 58yrs)

‘…As soon as I gave him the chart and the pedometer, he was off. He really enjoyed the measuring things, having a chart and having it written down. That motivated him a lot which I was stunned at because we couldn’t get him to do anything before that.’ (HCP1)

E. Self-monitoring of physical activity for stroke survivors is challenging due to gait impairments and a lack of stroke specific tools

‘...It really comes to the speed that your legs are moving that’s the problem because I think these are really designed for more sporty people who are doing a lot of movement and fairly quick movement, whereas most people in our situation are doing slow movement.’ (SRP01, M, 63yrs)

‘...The only really major set-back that we had was the pedometers won’t work on me. so I think it’s a gait thing… It’s a bit disappointing because you’re thinking that would be a great way of judging how well you’re doing and actually how far.’ (STP01, M, 58yrs)

‘…If that was on an app, that would mean that you would see your progress, instantly and you could probably map it. It if it was possible to do that, yes it would be good.’ (NTP05, M, 58yrs)

4. PARAS was reported to aid motivation, mood, self-regulation and physical activity.

A. Improvements in physical activity were reported in relation to goals set during PARAS

‘…But walking and things like that have improved now, done obviously a lot more exercise and movement as a result of the study compared to what I was doing before, which I think is the ultimate aim’ (SRP01, M, 63yrs)

‘...When I first started walking, I got as far as the bridge, this side of the bridge and came back again and I was completely shattered and now I can … that’s not even the start of my walk.’ (STP01, M, 58yrs)

‘…So I have increased the distance quite a lot and to begin with, I was only doing about 200 steps, well I say 200 because I only count up one side, I count on my left side, so that’s 400 steps, which is about 100 metres, roughly. Now I can do a lot more than that.’ (NTP05, M, 58yrs)

B. PARAS was reported to aid motivation and mood

‘...So I think it is motivational in that way and it does improve your mood. (NTP05, M, 58yrs)

‘...Yes, because just sitting here watching television, it’s depressing. So just getting out and being more active instead of just sitting here.’ (STP02, M, 64yrs)

‘...The fact that you’re actually applying yourself to something, rather than just sat here, it’s a bit extreme to say what I’m going to say, without a purpose, if you like.’ (STP01, M, 58yrs)

C. PARAS facilitated development of self-regulatory skills

‘... I think it’s really helpful keeping track of what I do each day and really reflecting on how I can improve that.’ (NTP05, M, 58yrs)

‘...It’s given me an incentive to do it and an ability to measure how you’re getting on, I think that’s important, if you can measure it, I think that makes a big difference in making you push yourself.’ (STP01, M, 58yrs)

‘…It’s more when you’re out and about that you’ve got to find ways round things. This sort of thing makes you tend to look at things like that and you’ve got to try and find alternative methods of doing things.’ (SRP01, M, 63yrs)

D. PARAS aided understanding of stroke recovery

‘...It was to go fishing but that never happened because I need two hands for that. That will never happen. …. It’s not going to happen, not for a long time anyway, not for the foreseeable future.… But I’m getting round to the fact that I’ll never go back to what I used to do. That’s never going to help me. I’ll just resent myself of the fact that that will never happen. Like I say, I take it a day at a time and just try and find what to do.’ (STP02, M, 64yrs)

‘…I mean I do know it’s going to be a long slog and I’m not going to get everything back but that’s just being realistic and then you have to say, well as long as you know that, start off with that and then think, well I’m going to get as much as I can back and if I get to the end and I think, I can’t get anything else back now, that’s it, I’m just going to go back to normal, I’m going to forget about trying to get further and further, if you like.’ (STP01, M, 58yrs)

‘…Well, I raised the bar a bit high initially – I said half a mile, but now I felt, half a mile you canny beat, so I come down to quarter of a mile.’ (SRP05, M, 69yrs)

5. The PARAS intervention was perceived to be different from usual care

A. PARAS promotes person-centred goal setting, as opposed to therapist-led goal setting

‘...[physio prior to PARAS] I felt they were trying to set their goals. They weren’t asking me what goals I had. They didn’t want to ask me that. They were just coming in, “Right, we’ll do this today. Right, we’ll take you outside.’ (STP02, M, 64yrs)

‘...When I did this study with her, it was a different type of thing. It was to change the outlook from just getting up out of the chair, bending your knee, stamping your feet a few times to then achieving other things.’ (SRP05, M, 64yrs)

‘...I think it was more them setting the goals. That was very different.’ (HCP6)

‘…We’re busy giving them a prescription, aren’t we? “This is your exercise what you should do,” rather than, like you say, listening a bit more to find out actually what do they really want to do so I think it’s good but this even helps further just to ask those open questions and listen and clarify things.’ (HCP6)

B. Supported self-management processes applied in PARAS potentially reduce reliance on health services

‘...It’s more sustainable, isn’t it, if someone is coming up with the idea themselves and they’re self-monitoring.’ (HCP1)

‘…Patients can learn skills to set their own goals after discharge and have the resilience to prepare for barriers and setbacks.’ (HCP 9)

‘…I think if you looked at it longer term if they were to keep it up, it would potentially prevent re-referral into services if they’ve taken the ownership to do it themselves.’ (HCP3)