How the LiveWell Dorset lifestyle behaviour change service influences older adults’ physical activity behaviour: A generic qualitative study

Objectives There is uncertainty around the most effective characteristics and components of interventions to increase older adults' physical activity (PA) levels. This study aimed to explore how LiveWell Dorset (LWD), a lifestyle behaviour change support service based in Dorset, South-West England, influences older adults’ PA behaviour. Study design A qualitative study using a generic approach. Methods Semi-structured telephone interviews were held with 12 individuals aged 55 to 65 who had accessed LWD's support to increase their PA levels, to gather their views and experiences of the service. A thematic analysis of the interview data was conducted using a hybrid approach that incorporated both inductive and deductive processes. Additionally, interview content was coded for behaviour change techniques using the Behaviour Change Technique Taxonomy version 1. Results A number of key factors were identified that highlighted how the LWD service influences older adults’ PA behaviour. These included using a broad range of promotional and behaviour change strategies to facilitate initial engagement, providing opportunities for service users to receive social support from both professionals and peers, and emphasising person-centredness and empathy in interactions with service users. Conclusions The findings provide valuable information regarding the needs and preferences of older adults when attempting to influence their PA behaviour, and on the reportedly helpful components of interventions that aim to do so. The findings also support the need for future research into previously highlighted topics of interest such as the roles of systemic and contextual factors and professional empathy on PA intervention engagement and outcomes.


Introduction
Physical inactivity is a significant risk factor for the development of age-related ill health and long-term disease [1]. There is a wealth of evidence suggesting that participating in regular physical activity (PA) provides a multitude of preventative health and quality of life benefits for individuals as they reach middle-age and beyond. The improvements in cardiorespiratory fitness, muscle strength, balance and mobility that result from PA participation are associated with a lower risk of cardiovascular disease, depression, falls, muscle and bone loss and cognitive decline in older adults, along with improved emotional, social, cognitive and physical functioning [2,3]. World Health Organisation guidelines recommend that to obtain these benefits, 55-64 year olds should perform at least 300 minutes of moderate intensity PA per week, and over 65s at least 150 minutes [4]. However, at present, only around 60% of over 55s in the UK are considered physically active [5]. In response to this, increasing the PA levels of older adults has become a priority for public health interventions in the UK, in order to promote healthy ageing and reduce the risk of preventable health conditions developing [6].
Despite challenges in synthesising evidence from heterogeneous studies that used predominantly randomised controlled trial designs, the most recent umbrella systematic review confirmed the effectiveness of multi-modal and multi-component PA interventions for increasing the self-reported and objectively measured PA levels of communitydwelling older adults [7]. The interventions the review examined had been implemented across a range of community settings, delivered both face-to-face and remotely by a range of professionals (e.g. GPs, nurses, occupational therapists, fitness instructors, PA coaches), involved numerous modes of PA (e.g. walking, aquatic exercise, dance), and most commonly were of a three to 12 month duration. In particular, client-centred and personalised interventions involving tailored professional guidance and ongoing support were reported to lead to improved PA participation. However, the review concluded that there was general uncertainty around the most effective intervention characteristics and components to increase older adults' PA levels, as rarely were any consistently associated with positive or negative outcomes. It is therefore imperative that research continues to explore how different interventions influence older adults' PA behaviour, and to attempt to identify their most important features.
The LiveWell Dorset (LWD) integrated lifestyle service, based in Dorset, South-West England, is an intervention that offers behaviour change support online and via telephone to adults in the Dorset area, with the aim of helping them to meet the Government's recommended guidelines for PA, to reach and maintain a healthy weight, to keep within the recommended limits for alcohol consumption and to stop smoking. As part of Dorset's 2016/17 Sustainability and Transformation Plan, the LWD service was developed by its operators Public Health Dorset to offer support across these four lifestyle behaviours, instead of the traditional single pathway approach, in order to maximise the efficiency, scale, reach and impact of behaviour change support in the area with minimal increased cost [8]. LWD's design followed consultation with local residents regarding their needs and views on existing services, and drew upon behaviour change literature. Consequently, the guiding principle that came to underpin the design of the LWD service was that identifying an individual's barriers to change and selecting the behaviour change techniques to overcome them would most likely lead to positive results [9]. The LWD service pathway is depicted in Fig. 1. Individuals can self-refer to LWD, and there is also a facility for health care professionals to refer their patients. Upon registration with LWD, individuals undergo an assessment, where a 'behavioural diagnosis' is made regarding the factors most influencing their behaviour, and the lifestyle area to focus on. Furthermore, a collaborative discussion is held regarding the level of support they require to move forward, based on the current behavioural barriers that are contributing to difficulties in making or sustaining change. For some individuals, a low level of telephone and email follow-up support and signposting is then provided by LWD for up to 12 months to facilitate the process of behaviour change and the accessing of other local services. For others, four to six sessions of more intensive telephone coaching support is delivered. LWD also offers a wrap-around digital support interface consisting of a range of apps and online tools such as a local activity finder and a calorie calculator, as well as a private LWD Facebook group, which individuals can access once they have registered. LWD also launched the 'Five Ways Challenge' in 2020, an online programme developed to provide weekly group email support to help individuals to improve their wellbeing and cope during the COVID-19 pandemic by focusing on daily PA, as well as social connection, awareness, learning new skills and giving to others [8].
The aim of this study was to explore how the LWD service influences PA behaviour in older adults.

Study Design
A qualitative study involving semi-structured telephone interviews was conducted. Ethical approval was obtained from Bournemouth University (ref. 28034).

Participants and recruitment
Based on resource availability, the aim was to conduct 12 telephone interviews with a convenience sample of individuals aged 55 and over who had accessed LWD's support to increase their PA levels, to gather their views and experiences of the service.
Potential participants were identified via LWD, who acted as the recruitment gatekeeper. LWD posted an advertisement on the LWD Facebook page seeking individuals aged 55 and over who had accessed the support of the service to become more active and were willing to take part in a telephone interview. Those interested in participating were asked to fill out a web form to provide their email and telephone contact details along with permission for LWD to share these details with the study researcher (AJP) to enable contact to be made. LWD passed on the details of individuals who completed the form to AJP on a first come, first served basis, and AJP co-ordinated all further study activities. AJP called potential participants to explain the purpose of the study and answer any questions that they had. If they were willing to participate, a telephone interview was arranged for a date and time convenient to them.

Interview procedures
The telephone interviews were conducted by AJP. Participants were sent an information sheet and a copy of the consent form via email several days prior to the telephone interview. On the day of the interview, AJP answered any questions that participants had about either form, and explained the consent process. If they agreed to take part, their verbal consent was recorded prior to the start of the interview.
For the interviews, a generic qualitative approach was employed. Generic qualitative research seeks to discover and understand people's subjective opinions and reflections of things in the outer world [10]. It, "focuses on descriptions of what people experience" [11], "simply seeks to understand a phenomenon, a process, or the perspectives and worldviews of the people involved" [12], and emphasises people's perceptions and feelings rather than the 'meanings' that might underlie them [13].
A topic guide was used during interviews to ensure key areas of interest were covered, while still allowing for flexibility and the possibility to follow up on unprompted content. The process of developing the topic guide involved a series of face-to-face discussions between LWD and AJP about the LWD service and its operations, as well as the examination of LWD 'standard operating procedures' documents by AJP. As summarised in Table 1, the topic guide contained questions about the support that participants had accessed through LWD, how LWD had facilitated their initial engagement with the service, and the outcomes of their LWD experiences. Furthermore, to gain a rounded understanding of LWD's influence on PA behaviour, questions relating to participants' previous PA backgrounds were also included. The telephone interviews were audio-recorded using a digital audio-recorder directly connected to the telephone and transcribed verbatim.

Analysis
A thematic analysis was conducted by AJP [14], using a hybrid approach that incorporated both inductive and deductive processes [15]. Before initial familiarisation with the interview transcripts took place, a priori codes were first added to a codebook in Microsoft Word [16], largely drawn from the original interview topic guide. Then, following familiarisation, important patterns and common threads were searched for in the interview data, at which point emerging posteriori codes were added to the codebook. Once all codes had been added, they were discussed in a debrief session with the co-author (ST). The list of a priori and posteriori codes were then merged into themes, which were subsequently vetted by ST. Illustrative quotations relating to each theme were then indexed and collated, ready for summarising, reporting and interpretation.
Furthermore, to provide an additional layer of information on how LWD influences PA behaviour, the interview content was coded by AJP for behaviour change techniques (BCTs) using the BCT Taxonomy version 1 (BCTTv1) [17,18]. BCTs were coded if they pertained to components of LWD that attempted to facilitate participants' progression through the service or influence their PA behaviour. Using the BCTTv1, BCTs were identified within participants' narratives on the basis of being observable, replicable and irreducible. All BCT labels were checked by ST, with disagreements on any labels resolved by discussion and consensus. Both authors had undertaken online training in BCT coding prior to the labelling process.

Overview
In total, telephone interviews with 12 individuals aged 55 to 65 who had previously accessed LWD for support with increasing their PA levels were conducted. Nine participants were female and three were male ( Table 2). Interview durations ranged from 40 to 60 minutes (mean 48 [SD 5.5] minutes). All individuals who had volunteered to participate in the study were interviewed, and study recruitment ended once the target of 12 completed telephone interviews had been reached.

Qualitative themes
Six themes were identified: previous physical activity behaviours and associated barriers; outcomes and impact of LiveWell Dorset experience; finding out about LiveWell Dorset; initial engagement with LiveWell Dorset; specific LiveWell Dorset support; and general LiveWell Dorset approach.

Previous physical activity behaviours and associated barriers
Reflecting back to the time immediately prior to their involvement with the LWD service, most participants reported that their PA levels had been well below the recommended 150 minutes of moderate intensity PA per week. Participants cited a number of barriers to PA participation that they had been facing, including long-term physical health conditions and injuries, mental health problems resulting from negative life circumstances such as bereavement and relocation, a lack of motivation to exercise alone, concerns about the health risks posed by exercise following an extended period of sedentarism, and limited time and energy due to work commitments:

It was awful. I would leave in the morning at six thirty, work in a highpressure job, often I would say at least a 60-h week. And you come back…let's say seven o'clock at night, and I'm going again at half past six in the morning, do I really want to go have a work out at the gym or do I want to go home?
And so I tried to combat that by swimming, a kilometre, every lunch time at work… but actually some days I found myself falling asleep in my office, you know, the physical exertion was just too much.

Outcomes and impact of LiveWell Dorset experience
The majority of participants reported that LWD influenced them to make positive changes to their PA behaviour:

So I've done loads of walking. I've done lots of YouTube exercise videos, I've done strength workouts, yoga, pilates, abs, all sorts of fitness. [Participant 7]
Participants also showed evidence of a newfound ability to problem solve and self-manage their PA behaviour as a result of LWD's support:

I do my [online] classes on the Tuesday evening and the Thursday evening. And in the morning I get up in the morning and I just put my gym kit on and I work in that gym kit so that I'm ready to go. And if I don't feel like it, just logging in and occasionally not turning the camera on straightaway and taking the first few steps. There's never been a night where I haven't done the full class. [Participant 8]
In addition to changes relating to their PA behaviour, participants also frequently spoke about weight loss as an outcome of their experience with LWD, as well as improved physical and mental health.

Finding out about LiveWell Dorset
Participants reported first becoming aware of the LWD service through a number of different channels. For some, the source was a health care professional:  A number of participants did state that they felt LWD relied too much on online promotion, which might not always be the most effective means of reaching older adults. A number of additional promotional strategies were suggested, including advertising in community venues such as supermarkets and libraries, and involving past service-users as volunteer LWD 'champions'. Aside from talking about how they found out about LWD, a number of participants also alluded to the timing, and when they found out about the service as being important to their subsequent engagement:

Initial engagement with LiveWell Dorset
Having become aware of LWD, participants identified a number of characteristics that initially made them want to engage with the service. For some, it was simply the name that they found appealing, and its association with wellbeing: As well as the free costs of the LWD service, a desire to repay the support and interest that LWD had shown them during their initial assessment also provided an incentive to move forward for some participants:

Specific LiveWell Dorset support
Participants accessed varying types and levels of LWD support. Following initial engagement with LWD, three received full coaching, three completed the Five Ways Challenge, three received low-level support in the form of follow-up phone calls or emails after their introductory assessment, and three did not receive any further intervention following their registration. All participants had access to the private LWD Facebook group and the array of online tools and apps.
Those participants who received coaching liked the self-directed nature of the coaching process: They also found that the weekly action planning worksheets that were supplied helped to support commitment and reflection: These sheets that you could print out… It was like a diary for me to fill in to show that I've actually achieved something each day, rather than just, you know, drifted and watched Netflix films… but also it makes you think in a positive way… I look back every now and again, and it's a little reminder of everything I've done. [Participant 7] Participants also found that the weekly Five Ways Challenge emails they received were helpful for providing ideas and trustworthy links to content: A number of participants reported the usefulness of certain online tools and apps in aiding changes in their PA behaviour, such as the 'Active Ten' app, which automatically records brisk walking when the phone is placed in the pocket: The Active Ten app, which I picked up and had been using ever since… It just charts or logs as you walk. You have got to walk fairly briskly to jog it into action. And every ten minutes that you walk briskly, it rewards you with a shower of bunting and what have you, filling a challenge cup and it will chart up through the day how many of these cups you fill… Well I will deliberately set out to walk more briskly… It makes such a big difference… It's reinforcement. [Participant 10]

General LiveWell Dorset approach
Regardless of the type of support accessed, a number of general characteristics of LWD's approach to influencing PA behaviour consistently attracted positive comments from participants. For instance, LWD's self-directed approach was often appreciated: I think most people would like to feel that they're doing it for themselves, even though they're being gently nudged in the right direction. LWD's focus on 'small steps' and breaking larger behavioural goals down into smaller chunks was also frequently appreciated by participants:

It was absolutely achievable. And the fact that you could achieve it made you feel better. I think the fact that he just kept reminding us to just do little steps. Just do little steps. Don't worry about how far you're going. Just keep going forward. That's the most important thing. [Participant 11]
A number of participants also found encouragement to be a valuable and motivational element of LWD's approach:

Behaviour change techniques
Fifteen different BCTs were identified as being used by LWD to facilitate participants' progression through the service or to influence their PA behaviour. The most commonly identified BCTs were social support (unspecified) and adding objects to the environment. Table 3 provides an overall summary of the BCTs along with the components of the LWD service they related to. Definitions of the identified BCTs can be found in Supplement 1.

Discussion
Through gathering the views and experiences of individuals who had accessed LWD's support to increase their PA levels, it has been highlighted how the LWD service influences older adults' PA behaviour. This information is important, because with uncertainty around the most effective intervention characteristics and components to increase older adults' PA levels, there exists a need for further evidence in this area [7].

Principal findings
Despite initially facing a range of barriers to PA participation, participants reported that they had achieved increases in their PA levels and an improved ability to problem-solve and self-manage their PA behaviours as a result of their time with LWD, as well as noting impacts in other areas of their lives such as improved physical and mental health, and weight loss. In terms of how LWD influenced these changes, a number of key factors appear relevant.
Participants reported that LWD deployed a broad range of useful behaviour change strategies across the different types of support offered in order to facilitate their progress. These included providing diary worksheets for participants to plan and record their weekly activities as part of the Five Ways Challenge, and conducting goal-setting exercises during coaching sessions. The variety of strategies was also reflected in the BCT coding, which identified 15 different BCTs as being used by LWD to facilitate participants' progression through the service or to influence their PA behaviour. This finding supports previous reviews of literature on beneficial intervention components to increase the PA levels of older adults, where it has been established that behavioural and cognitive-focused behaviour change strategies are important elements of successful PA interventions [19,20], and that effective interventions typically incorporate greater numbers of BCTs, and utilise a blend of behavioural, motivational and/or cognitive methods to influence PA behaviour [7,19,21].
Participants also reported that LWD's approach to promoting initial awareness of the service through various channels, focus on opportunistically targeting individuals at key points in their life, and offering of a straightforward, quick and flexible registration process, helped to facilitate their initial engagement. As alluded to above, PA interventions, and related research, typically place a large emphasis on the 'active ingredients' of interventions that positively influence older adults' PA behaviour, such as BCTs and underpinning theoretical models [7]. However, with initial engagement representing the entry-point of participation, this finding highlights the equal importance of designing PA interventions that are accessible, so that they are eventually able to go on to influence PA behaviour. Previous reviews have also underlined this notion. The importance of looking beyond the behavioural and cognitive aspects of PA promotion and considering whole system-oriented approaches and the systemic and contextual factors and processes that encourage older adults' engagement with PA interventions has been highlighted, along with the need for future research to explore this area in greater detail [7,19,20]. A total absence of PA interventions for older adults co-created with input from their intended end-users has also previously been noted [7]. Including the intended recipients as stakeholders in the intervention development process, which LWD's operators seemingly did when they carried out consultations with local residents when designing their service, may be one method to ensure the most accessible interventions.
Aside from specific behaviour change strategies, participants also frequently reported that the social support offered to them by LWD was helpful, which included the 'open line' of email or telephone communication provided. Participants also reported that the social support offered by other service users through LWD was appreciated, such as through the LWD Facebook group. This finding again supports previous reviews that have reported that social contact and support are particularly important facilitators of PA participation in ageing populations [7,[22][23][24]. In the most recent review, it was stated that emotional support from other people is linked with intrinsic motivation for PA, and consequently, participation in PA [22]. The review concluded that PA interventions for older adults should specifically seek to provide social support for individuals, which LWD appears to do in a variety of ways. Closely aligned to the notion of social support, participants also reported that LWD's person-centred approach was helpful. For instance, participants valued LWD's encouragement of their autonomy and selfaccountability, and also felt that the support they offered was tailored to their needs. In addition to person-centredness, the empathy at the heart of LWD's approach was also frequently appreciated. Supporting previous research, person-centredness, and in particular, tailoring has been noted as an important element of effective PA interventions for older adults, with robust evidence backing its value [7]. However, the finding that participants valued the empathy they received is more novel, with this concept less extensively researched for its role in influencing PA behaviour, and a need for further enquiry previously highlighted [7]. Long-standing evidence in the field of psychotherapy suggests that the levels of empathy displayed by professionals strongly predict positive patient outcomes in psychology-based treatments. This suggests that it is important that the role of empathy is directly examined in relation to the outcomes of PA interventions for older adults, given that like psychotherapeutic interventions, they aim to enact some form of healthy, adaptive behaviour, centred on interactions between professional and service-user, or 'change agent' and 'change seeker' [25,26].

Applications
With uncertainty around the most effective intervention characteristics and components to increase older adults' PA levels, there is a need for research exploring how different interventions influence older adults' PA behaviour [7]. The findings of this study provide useful information on how one particular intervention, LWD, appears to do so. This information can now potentially contribute to the understanding of 'real-world' public health practitioners on the needs and preferences of older adults as they attempt to change their PA behaviour, and on how to develop the components of interventions that they will willingly engage with. To further this understanding, the current findings also provide additional rationale for future research into previously highlighted topics of interest, such as the role of systemic and contextual factors and processes in encouraging older adults' initial engagement with PA interventions, and the role of professional empathy in PA intervention outcomes.

Limitations
Some limitations of this study should be noted. Firstly, the sample size was small, comprised of older adults from a rural geographical region and relatively narrow age range, which arguably limits the generalisability of the findings. Relatedly, a further limitation was the selfselection of interview participants. This may have related in some way to the behaviours, attributes and opinions being investigated, as well as to pre-existing levels of positivity towards LWD. Pragmatic factors limited the methods that were used to recruit participants, but it is fair to say that additional insights might have been gained with a less self-selected sample. For instance, a purposive sample of individuals that had been referred to LWD but didn't engage, or who engaged but dropped out, may have yielded very different and relevant information. Finally, content saturation was not reached during data collection. Resource constraints on the number of interviews that could be conducted, and the heterogeneous nature of participants' LWD experiences likely contributed to this. However, as data analysis partly involved deductive processes, with a priori codes derived from the original interview topic guide, it could be argued that as the pre-determined issues of interest were adequately represented in the data, the lack of traditional content saturation was not detrimental [27].

Conclusions
In this qualitative study a number of factors have been identified highlighting how the LWD service influences PA behaviour in older adults. These include using a broad range of promotional and behaviour change strategies to facilitate initial engagement, providing individuals with opportunities to receive social support from both professionals and peers, and emphasising person-centredness and empathy. Despite the limitations of this study, its findings provide valuable information to public health practitioners on some of the potential needs and preferences of older adults when attempting to influence their PA behaviour, and on reportedly helpful components of interventions that aim to do so. The findings also provide additional rationale for future research into previously highlighted areas of interest such as the roles of systemic and contextual factors and professional empathy on PA intervention engagement and outcomes.

Contributors
The primary author conceptualised, designed and conducted this work, with assistance from the co-author. The primary author secured funding for this work from Active Dorset. The primary author prepared an initial draft paper, with the co-author contributing to subsequent drafts, and both authors approving the final manuscript.

Funding
This work was supported by Active Dorset (grant number RED10671, 2018) via funding they initially received from Sport England. Active Dorset had no role in: data collection; data analysis and interpretation; and manuscript preparation, review and approval.

Ethics approval
Ethical approval for this work was obtained from Bournemouth University (ref. 28034).

Data sharing statement
No additional data are available.

Declarations of competing interest
None.