Qualitative work was conducted to contribute to the evaluation of the intervention by observing education sessions and educator meetings around the 12-month time point, and by conducting focus groups with participants and educators at the end of the trial.
The aim was to provide in-depth qualitative data on how people engaged with the two levels of intervention over time, in particular how and why the more intense level of intervention helped (or did not help) participants to increase and sustain physical activity.
Observations
Sampling and recruitment
We purposively sampled five education sessions at the 12-month time point so that we could achieve a range in terms of educator, location and participant demographics. When booking participants into an education session that was scheduled to be observed, the booking administrator informed the participant about the observation; if a participant wanted to attend a session that was not being observed, they were offered a different session. On the day of the sessions, the researcher introduced themselves to the participants and explained the purpose of the observations; during the session, they observed from the back of the room to minimise distraction and interference.
Data capture
The researcher took anonymised handwritten field notes while not interfering with the education session.111,112 The focus of the observation was engagement with the intervention components, including with the education session itself, and how the participants talked about their experience and levels of physical activity (including pedometer use, diary and/or text messaging, where appropriate) during the first 12 months. Key modules in the PROPELS curriculum were ‘the participants’ story’ and ‘physical activity’, which facilitated participants to talk about the goals that they had set, the challenges that they faced, the strategies that they used to overcome these and the challenges that they had not overcome. The field notes informed the topics to be explored in the qualitative interviews later.
Focus groups and interviews
Focus groups took place in Leicester Diabetes Centre, the MRC Epidemiology Unit in Cambridge and community centres. The researcher conducting the focus groups took written informed consent from participants immediately prior to the focus group.
Sampling and recruitment
Trial participants
For the first set of focus groups, we purposively sampled participants to achieve a range of participants in terms of intervention arm (groups 2 and 3), demographics and location. Further focus groups and telephone interviews were subsequently conducted to widen the sample to include experiences of participants not achieved in the first set (see below). Participants were sent an information leaflet about the focus group and interview substudy, with a reply slip to indicate willingness to be contacted to find out more. A member of the PROPELS team contacted participants who returned the reply slip to discuss the focus group study, confirm willingness to participate and, when willing, arrange their attendance at a focus group.
Educators
We invited all educators who were involved in delivering education sessions and telephone calls in the PROPELS study to participate in an end-of-trial focus group. Educators were sent the invitation and participant information sheet by e-mail, inviting them to indicate their interest by replying to the e-mail. A member of the PROPELS research team then contacted those who had replied to discuss the focus group and, if they were happy to proceed, arrange their attendance at a focus group.
Data capture
Flexible, semistructured topic guides informed the focus group schedule. With trial participants this explored their reactions to being invited to participate in PROPELS and attitudes towards being ‘at risk’ of T2D; experiences of the group educations sessions; experiences of forming and following an action plan; views about attendance and engagement over 4 years; and experiences of the telephone call and text messaging maintenance support. With educators, the topic guide explored their experience of delivering the education sessions and telephone calls. With all focus groups, when summing up discussions around the maintenance of physical activity, we referred to key theoretical explanations from Kwasnicka et al.113 to prompt further discussions.
The researcher and assistant moderator conducting the focus groups debriefed immediately after each focus group for the purposes of preliminary analysis on both the data generated and the participant sample. This process informed the decision about when to stop data collection in terms of no new themes arising in relation to the specific research questions. A review of the data and sample from the first six focus groups indicated largely high levels of engagement with the intervention(s); thus, in the later focus groups, we actively aimed to recruit participants with lower engagement (e.g. those who had attended fewer education sessions and those who had requested to stop receiving the text messages). Furthermore, owing to the location of the focus groups, we had not reached participants in the more rural areas of the Cambridge site; therefore, we conducted telephone interviews with participants from this group.
Analysis
Focus groups were audio-recorded and transcribed verbatim. Analysis was informed by the Kwasnicka et al.113 theoretical explanations and the constant comparative method:107 transcripts were read and re-read; five broad codes relating to the categories identified by Kwasnika et al.113 were predefined; further open codes were generated from reading and re-reading; and all codes were subsequently refined and developed into a coding framework. Analysis was facilitated with the NVivo11 qualitative data-indexing package.
Findings
Final sample
Observations
Five 12-month education sessions were observed; these were in three different locations, delivered by 10 different educators (with two co-delivering each session) and included 40 participants with three accompanying relatives.
Focus groups and interviews
We conducted seven focus groups (n = 52) and six telephone interviews with trial participants (total trial participants, n = 58), and four focus groups and two individual interviews with educators (total educator participants, n = 16).
The key demographic and baseline characteristics of participants included in the focus groups and interviews compared with those of the overall PROPELS cohort are shown in . Those included tended to be less socially deprived, older, more likely to be white European, more likely to be male and more physically active than the general PROPELS population.
Characteristics of focus groups and interview participants compared with the overall PROPELS cohort
In this chapter, we provide an overview of some of the prominent themes that emerged, with a focus on the focus group and interview data, concentrating on themes that provide some insight into the main trial results, namely the increase in physical activity levels at around 12 months (in the Walking Away Plus study arm) that was not sustained at 48 months.
Walking Away Plus
As described in Chapter 3, while both intervention study arms received a pedometer, those in the Walking Away Plus study arm also received maintenance support in the form of a telephone call from an educator (1 week after the education session), tailored text messaging and an activity diary to facilitate step-counting for reporting their weekly count by text message.
Participants from both intervention study arms spoke at length about pedometers and the ways in which these helped their awareness and activity, for example by helping them to learn first their average number of steps and how daily step-counts fluctuate, and then whether or not they met their daily goal of increased step count. Over and above this, many of those in Walking Away Plus arm were mindful of the need to send in their weekly step count, particularly early in the study:
H:
You’re very aware, especially having the pedometers at the beginning of the study, and the monitors, you know, looking at the time and just going oh crikey, it’s 3 o’clock already and I haven’t done half of what I should be doing.
FG-P4
The activity diary was a prominent feature for many of these; a couple of participants even brought their activity diary to the focus group to demonstrate how they had maintained it for the whole study:
H:
I have got mine; I have a record, all the [steps].
Moderator:
Did you do that daily?
H:
Daily, daily, every day. I put it on my, near my bedroom, you know, chest drawer, and morning when I go, when I wear it, do zero, and then at night time I write it down, how many steps done.
FG-P2
Others made their own version of the diary when they had filled all of the pages of their first one, or produced their own version on a spreadsheet:
B:
Focusing on action-planning and targets was really important for me – being a science-based person. In fact I created a spreadsheet, I went on a diabetic site in the States that listed all the activities and the calories that they would do. And from the PROPELS study you could see what they thought was calories relative to steps. And I linked all the activities that I was likely to do to steps and calories, and put it in the spreadsheet. So if I was doing cycling or walking or swimming or whatever, or housework or cleaning the car. I could relate that to number of steps, and I could log what I’d done during the day and come out with a steps equivalent at the end of the day, and then weekly, monthly, so on.
FG-P3
The majority of Walking Away Plus participants spoke positively about the text messages. A couple of participants had kept the messages on their telephone and read some out loud or mentioned particular messages during the focus group. In reporting how the text messages had helped, some participants explained that these served as reminders about being in the study in terms of maintaining physical activity, often acknowledging that this would help with the tendency to lapse:
N:
I guess it was good because it reminded you in between the sessions that you were committed to a lifestyle change. [. . .] because of our inherent indolence we’re going to fall off the straight and narrow, so anything that can help bring us back and remind us of what we’re doing is probably a good thing.
S:
The texting was really helpful, because you do sort of lapse. [. . .] if we’d gone off track, and then it was saying, ‘start texting your steps in’. [. . .] it kind of got you – certainly – back to focusing on it.
FG-P2
The text messages did not suit everyone, as evidenced by the 18.9% of participants who requested that messages stop. However, those in the focus groups who described some of the texts as annoying, amusing or irrelevant (e.g. regarding the tips for different types of activity) still appreciated their use:
N:
And they were a sort of shotgun approach; that they shot at different bits of your lifestyle, I seem to remember. And the one that really sticks in my mind [was] that I had to do press-ups while I was cleaning my teeth!
FGP2
M:
. . . so you could be like all day shifting bricks, then you get a text, ‘while you’re doing the hoovering, you could go this way and that way’, or ‘you could balance two tins’, and you’ve lost your temper [. . .] what do they think I’m doing, just sitting here watching TV?! I do find them a bit funny, [but] at the end of the day there’s people that probably little things like doing that, and walking to the shop rather than going in the car, is a big help to everybody. And I’m fully aware that even myself, when I went on this course, instead of just like driving now, I go to the shops and I make sure [I walk].
FG-P4
The telephone calls that Walking Away Plus participants received approximately 1 week after the education sessions appeared to be very welcome:
B:
I mean a lot of the [text messages] were obviously just automated . . . and the responses to your steps – by my testing – were also automated and amusing. The phone calls were really interesting. Probably more encouraging in some ways than the text messages.
In particular, the telephone calls seemed to be more helpful – or additional help – for realistic goal-setting than the education sessions alone. By comparison, participants in the Walking Away study arm often mentioned struggling to think of an action plan in the session:
M:
You can write all sorts of things down, but things happen, don’t they, you can’t . . . I don’t do action plans! I can’t.
Moderator:
So did you not set one in the [session]?
M:
Well I think I probably wrote something down in the session, just to keep them happy.
FG-P5
Educators noted how many Walking Away participants commented how they wished that they were in the ‘texting group’, and this was still evident for some in the end-of-study focus groups:
J:
I would have liked more contact myself, because it’s very easy to fall off. It could be I think. Because it’s a long time between, you actually hear from PROPELS again, if you’re on the second group. And I feel that quite a few people maybe could drop off in that time. I didn’t, fortunately. But I would love to have heard from PROPELS. Sometimes I thought maybe it had actually disappeared, or I’d dropped off the list or something.
FG-P2
Altogether, although Walking Away Plus, and the text messages in particular, did not suit the needs and preferences of all those in that study arm, the general feeling of being ‘kept on track’ and being monitored was well received, with many participants reporting that they missed receiving the messages after the trial ended.
Limited sustainability of physical activity levels
When participants (in both of the intervention arms) reflected on how their activity levels have changed (increased, decreased, fluctuated and so on) throughout the 48 months, a salient theme was the impact of a major health/illness event during the period, for example hernia or prostate operations, hip/knee replacements, musculoskeletal issues and other injuries from falls or accidents. Many spoke of associated disappointment, having increased their activity levels initially, and the difficulty of getting back to pre-incident activity levels. For example:
C:
I had to have a hernia operation in the middle of what was the PROPELS. [. . .] I must be honest, the first 6 months after my hernia op, I couldn’t maintain what I did prior to it. But I’m back to where I was now if that makes sense. But that did come in the middle of it, yeah, you sort of drop and come back again.
M:
Same with me. When I had my operation I was told not to do any cardiovascular for 6 months, because although it was healed up on the outside, it wasn’t quite healed up from the inside.
FG-P1
H:
After I had my bicycle accident, I couldn’t actually get out of a chair, so I mean I really wasn’t able to do . . . I went from 28, 30 thousand steps to nothing, and there was nothing I could do about it.
FG-P5
Ageing and its associated physiological changes were referred to by many other participants when they were explaining a decrease in their activity levels, which often occurred after increased activity in the earlier years of the study:
L:
And I can remember when we did the pedometer and first measure, I was doing 17,000 steps a day, which surprised them. But I had a dog and I gardened and did various things. But gradually over the course I got less active, and I would say I was less active now than I was when I started. Partly because my dog got old and decrepit. [Laughter] And I started getting old and decrepit, so I wasn’t doing as much gardening or walking for that reason.
FG-P5
Several participants mentioned ageing as a reason why they could no longer ‘do that extra bit’ required for increasing activity levels, preferring instead to plateau with their step count or activity goals. Reaching a plateau and being satisfied with an average step count was given as an explanation by several who had stopped monitoring and recording, and not just in the context of ageing:
C:
I was just going to say, because we monitored ourselves for 4 years, and we did all these walks that people are doing, I can tell you, from my house to [the] park, 6.2 miles. So you don’t need to, you know exactly what you’ve walked.
Moderator:
So you don’t need to monitor because you know . . .
C:
The distance.
Moderator:
Is that the same as what you do?
W:
I know, the walking I do, about three-and-a-half thousand. You know, you can estimate it. I stopped after . . . I think [the pedometer] broke, I thought what do I want that on for?
FG-P1; participant C had taken part in Walking Away Plus and participant W had taken part in Walking Away
Other participants described the impact that work and other commitments had had on the fluctuation in their activity levels during the years of the study; one described the impact of this on a period in the middle of the study:
M:
In the first year I did do a lot more exercise and watched what I eat. And then I had a dip, because I had 2 years [working away in a demanding environment]. And then it’s gone up a lot, because now I go running and I still do me steps, and when I get to 10,000 steps I don’t . . . I still carry on walking.
FG-P4
A couple of participants described how they had lost motivation after the study ended and, hence, had since reduced their activity levels:
A:
I only did it for the study [. . .] Because I work shifts, I’ve got two young children, got a dog, I work nights, so I’m sleeping in the day, some days I did struggle to do it. So [during the study] I tried to compensate, get up half an hour early and go to the gym before I started work.
FG-P1
External influences on activity levels
Focus groups enabled comparison in situ of the experiences of participants from both Walking Away and Walking Away Plus; other than the additional support for those in the latter arm, experiences were typically similar. A number of prominent factors are worth noting for their potential influence on the activity of participants in both study arms.
The most noteworthy is the rise in popularity and ownership of smartphones and other devices for measuring and monitoring one’s physical activity from the time that the initial PROPELS education sessions were held in 2012–13 to when the post-trial focus groups were conducted with participants in 2019. At the outset, educators recalled the challenges of helping Walking Away Plus participants register with the text messaging, with many participants (and the educators themselves) being unfamiliar with the workings of their mobile telephone:
Educator A:
There’s that very first bit, where in the very first year when we had to keep the people behind to go through the telephone setting up with them.
Educator B:
Telephone set-up was an absolute nightmare.
Educator C:
Helping people set their mobile phone up, horrendous!
FG-E1
By comparison, in the end-of-study focus groups, the majority of participants were wearing Fitbits (Fitbit, San Francisco, CA, USA) or iPhone (Apple Inc., Cupertino, CA, USA) watches; many referred to using these or a smartphone for step-counting or similar, regardless of the intervention arm that they had been in or of their age. For example:
A:
Yeah, one of the ladies in one of our sessions produced this Fitbit, and I thought, ‘ooh, I want one of those’ [. . .] I got one for Christmas and so I’m still wearing it now, and I really like it.
Moderator:
And do you measure . . . do you look at it every day?
A:
Well it syncs with the computer every day, and then I look back and say, ‘ooh yes, that’s when I went to so and so’. You know, I find it really quite interesting to see. It sends you weekly reports.
FG-P5
A:
It’s just a step counter on my iPhone. What it doesn’t show of course is that I’ve also done a 40-mile bike ride.
B:
Does it not count, does it not count the bike ride?
A:
Yeah, you can do that on something called Strava [Strava, San Francisco, CA, USA]. Strava monitors walking, running, bike riding, and every time I go on a bike ride . . . I put Strava on.
FG-P3
It appears that, during the course of the study, while Walking Away Plus participants appeared to increasingly use these newer technologies to support reporting their step count back to the PROPELS team via text, Walking Away participants were increasingly using these too. Hence, it is likely that participants in the control arm were also adopting such technology and, in turn, adapting their behaviour. Indeed, the rapid increase in self-monitoring technologies over the years when PROPELS was running should be noted as a contextual influence on participants in all three study arms.
Summary and discussion
To summarise, key themes from the focus groups provide insight into the main trial results. In terms of the 12-month increase in activity levels, the components of Walking Away Plus were described by participants as aiding physical activity increase. Pedometers and activity diaries facilitated the weekly step count to submit via text messages. Many found this self-monitoring useful and interesting, with some even taking this a step further by creating spreadsheets or other methods of long-term monitoring. Although some participants found the text messaging irritating or irrelevant, many appreciated the way that it served as a useful reminder and as a method for logging weekly step counts. When hearing about it, many Walking Away participants expressed regret at not having had the continued contact with the study that it provided.
Focus group participants reflected on how their activity levels had changed (and why) throughout the 48 months; some talked about incidents that had led them to reducing their activity levels and whether or not and how they managed to increase their levels again; in some instances, this involved changing type of activity (e.g. because of an injury). Notably, as the intervention aimed to support individuals in increasing and maintaining physical activity levels themselves, analysis focused on what participants did themselves, drawing on what they had learnt from the intervention and with the tools provided for self-monitoring, as opposed to someone or something else intervening for them to re-engage.
Participants’ accounts and discussions revealed several explanations for the limit in the sustainability of activity increase found by the trial. For some, factors related to ageing and associated health risks and conditions were prominent; falls, accidents or surgery – and associated recovery – led to long periods of reduced activity, while others spoke of a general feeling of physically not being able to do as much with their increasing age. Work and other commitments had an impact on some participants. Whereas several participants described maintaining self-monitoring activity after the study ended, others no longer saw the need, often because they were satisfied with their new habitual levels, or, for a few, had reduced motivation.
Based on an analysis of the end-of-study focus groups, recommendations for improving the intervention might include:
identifying an additional form of support that participants could call on in the event of a major health issues/illness, such as an extra telephone call to ‘reset’ the text messaging, and change the tailoring factors accordingly
identifying an additional mechanism for maintaining motivation in the long term
incorporating newer self-monitoring technologies that have become popular within the target age group (Fitbit, Strava, etc.).
