Results
Between February and April 2014 we interviewed 43 trial participants by telephone. We attempted to contact 96 trial participants and successfully made contact with 44, of whom 1 declined to be interviewed, citing a recent bereavement. Interview duration ranged from 9–44 minutes, with an average duration of 21 minutes. Eight were conducted by JS with the remainder by RN. Thematic saturation was achieved prior to completing 40 interviews but, as planned, we continued in order to ensure a demographically balanced sample.
Interview participants’ characteristics [Tables 3 and 4]
Table 2
Behaviour change techniques used in the PACE-UP trial by practice nurses and in participant handbook and diary
Provide general information on behaviour-health link | 1 |
Provide information on consequences to individual | 2 |
Provide normative information about others’ behaviour | 4 |
Action planning | 7 |
Barrier identification | 8 |
Set graded tasks | 9 |
Prompt review of behavioural goals | 10 |
Prompt review of outcome goals | 11 |
Prompt rewards contingent on effort | 12 |
Prompt rewards contingent on successful behaviour | 13 |
Prompt self-monitoring of behaviour | 16 |
Prompting self-monitoring of behavioural outcome | 17 |
Prompting focus on past success | 18 |
Provide feedback on performance | 19 |
Provide information on when and where to perform the behaviour | 20 |
Provide instructions on how to perform the behaviour | 21 |
Teach to use prompts/cues | 23 |
Prompt practice | 26 |
Plan social support/social change | 29 |
Relapse prevention/coping planning | 35 |
Stress management/emotional control training | 36 |
Motivational interviewing | 37 |
Interview participants represented those who had increased and not increased their walking from all 6 practices, a range of ages and ethnicities, men and women, from both intervention groups and included some who had taken part as a couple.
Thematic and BCT analysis of interview responses (Tables 5 and 6)
Table 3
Summary of interview participant characteristics (n = 43)
Age
| 45-59 years | 20 |
| 60-75 years | 23 |
Gender
| Male | 14 |
| Female | 29 |
Ethnicity
| White British | 29 |
| Any other white background | 5 |
| Black African | 2 |
| Black Caribbean | 2 |
| White and black Caribbean | 1 |
| Bangladeshi | 1 |
| White and Asian | 1 |
| Indian | 1 |
| Chinese | 1 |
Primary care practice
| 1 | 7 |
| 2 | 7 |
| 3 | 7 |
| 4 | 7 |
| 5 | 7 |
| 6 | 8 |
Intervention group
| Nurse and pedometer | 21 |
| Pedometer by post | 22 |
Step count outcome
| Increase | 20 |
| No increase | 23 |
Group + step count outcome
| Increase + nurse/pedometer | 10 |
| Increase + pedometer by post | 10 |
| No increase + nurse/pedometer | 11 |
| No increase + pedometer by post | 12 |
Recruited as a couple?
| Yes | 7 |
| No | 36 |
Table 4
Interview participant details
1 | 1 | Female | No | Any other White background | Nurse | 3 | 48 | +1697 | Nil |
2 | 1 | Male | No | White British | Nurse | 3 | 45 | +113 | Nil |
3 | 1 | Male | No | White British | Pedometer | N/A | 53 | +3708 | Yes – preceding the trial |
4 | 1 | Male | No | Bangladeshi | Pedometer | N/A | 52 | −234 | Nil |
5 | 1 | Female | No | White British | Pedometer | N/A | 57 | +1718 | Nil |
6 | 1 | Female | No | White British | Pedometer | N/A | 51 | −2141 | Yes– preceding the trial and during the trial |
7 | 1 | Female | No | White British | Pedometer | N/A | 60 | −1808 | Yes – preceding the trial |
8 | 2 | Female | No | White British | Pedometer | N/A | 65 | −1781 | Nil |
9 | 2 | Female | No | Black Caribbean | Pedometer | N/A | 69 | +243 | Yes – preceding the trial and during the trial |
10 | 2 | Male | No | Black African | Nurse | 2 | 64 | −1920 | Yes – preceding the trial |
11 | 2 | Male | No | White British | Pedometer | N/A | 70 | +1543 | Yes – during the trial |
12 | 2 | Female | No | White and Black Caribbean | Nurse | 3 | 66 | +1211 | Yes – preceding the trial |
13 | 2 | Female | No | White British | Pedometer | N/A | 66 | −446 | Yes – preceding the trial and during the trial |
14 | 2 | Female | No | Any other White background | Nurse | 2 | 49 | +4756 | Nil |
15 | 3 | Female | No | Any other White background | Nurse | 3 | 49 | −1097 | Yes – during the trial |
16 | 3 | Female | No | White British | Nurse | 3 | 47 | +1573 | Nil |
17 | 3 | Female | No | Any other White background | Pedometer | N/A | 66 | −1027 | Yes – preceding the trial |
18 | 3 | Female | Yes | White British | Nurse | | 62 | −2836 | Nil |
19 | 3 | Female | No | White British | Pedometer | N/A | 66 | −1797 | Yes – preceding the trial |
20 | 3 | Male | Yes | White British | Nurse | 3 | 52 | +3924 | Yes – preceding the trial |
21 | 3 | Female | No | Black African | Nurse | 3 | 47 | +2962 | Yes – preceding the trial |
22 | 4 | Male | No | White British | Nurse | 3 | 63 | −2652 | Yes – preceding the trial and during the trial |
23 | 4 | Female | Yes | White British | Pedometer | N/A | 64 | +226 | Yes – preceding the trial and during the trial |
24 | 4 | Female | Yes | Any other White background | Pedometer | N/A | 50 | +1031 | Yes – preceding the trial |
25 | 4 | Male | No | White British | Pedometer | N/A | 67 | −955 | Yes – preceding the trial |
26 | 4 | Female | No | White British | Nurse | 3 | 65 | −2013 | Yes – preceding the trial |
27 | 4 | Male | No | White and Asian | Pedometer | N/A | 61 | −611 | Yes – during the trial |
28 | 4 | Female | No | Chinese | Nurse | 3 | 72 | +4062 | Yes – preceding the trial |
29 | 5 | Male | No | White British | Nurse | 3 | 59 | −493 | Yes – during the trial |
30 | 5 | Female | No | White British | Nurse | 3 | 51 | +3269 | Yes – preceding the trial |
31 | 5 | Male | Yes | White British | Pedometer | N/A | 59 | −756 | Nil |
32 | 5 | Female | No | White British | Nurse | 3 | 63 | +1966 | Yes – during the trial |
33 | 5 | Female | No | White British | Nurse | 3 | 49 | −746 | Nil |
34 | 5 | Female | No | Black Caribbean | Pedometer | N/A | 73 | +403 | Yes – preceding the trial |
35 | 5 | Female | No | White British | Nurse | 3 | 64 | +2100 | Yes – preceding the trial |
36 | 6 | Female | No | White British | Pedometer | N/A | 64 | +1639 | Nil |
37 | 6 | Female | No | Indian | Pedometer | N/A | 51 | −1720 | Nil |
38 | 6 | Female | Yes | White British | Pedometer | N/A | 59 | +539 | Nil |
39 | 6 | Female | No | White British | Nurse | 2 | 61 | −1425 | Nil |
40 | 6 | Male | Yes | White British | Nurse | 3 | 48 | −3826 | Yes – during the trial |
41 | 6 | Male | No | White British | Nurse | 2 | 65 | −43 | Yes – during the trial |
42 | 6 | Male | No | White British | Pedometer | N/A | 72 | −2133 | Nil |
43 | 6 | Female | No | White British | Pedometer | N/A | 48 | +2253 | Nil |
Table 5
Summary of thematic and behaviour change technique analysis
Healthy Lifestyle | Feeling fitter | Providing general information on behaviour-health link |
| Sleep | Providing information on consequences to the individual |
| Weight loss | |
| Awareness of walking | |
Physical Health | Specific health problems | |
| Pain | |
Environment | Location of appointments | |
| Weather/season/climate | |
| Locality for walking | |
| Work | |
| Pets | |
Routine | Fixed routine | |
| Fluctuating routine | |
| New routine | |
Monitoring | Targets | Set graded tasks |
| Self-efficacy/self-monitoring | Prompt review of behavioural goals |
| External monitoring and feedback | Prompt review of outcome goals |
| Equipment used for monitoring | Prompt rewards contingent on effort |
| | Prompt self-monitoring of behaviour |
| | Prompt self-monitoring of behavioural outcomes |
| | Provide feedback on performance |
Social Perspectives | Peer support/encouragement | Barrier identification |
| Meeting others | Provide information on when and where to perform behaviour |
| Impact on others | Provide instruction on how to perform behaviour |
| | Relapse prevention/coping planning |
| | Providing normative information about others’ behaviour |
| | Plan social support/social change |
Table 6
Themes and sub-themes with supporting quotes
Healthy lifestyle
| Feeling fitter – both as a goal and an outcome | [via translator] She said that before the trial she feels so tired and she sometimes was worrying because she had… granddaughter but now she feel good and she can enjoy going … she can enjoy with her granddaughter in the park or sometimes around they walk. (IDN14) |
| | I mean you know I think it has made a difference and it does make me think about where I’m walking and how far I’m walking and the health benefits, so yes, I think it was a really good thing and I think it would be a really great thing if more people could actually have the support to do something like that. (IDN30) |
| Sleep | ..when I go walking, it helps and I sleep better as well when I go walking, and come back, I have a better night’s sleep, and all aches and pain disappear. (IDN34) |
| Weight loss – both as a goal and an outcome | And since the beginning of the uhh trial I’ve lost just over a stone in weight… I feel fitter now than I have done for years. (IDN11) |
| | I want to lose some weight and make myself healthy, just healthy, you know. (IDN28) |
| Awareness of walking as part of a healthy lifestyle | I think you know umm getting people to increase their step count is a great idea because it’s an easy way of exercising and you know and the health benefits are good, so I’m very much supportive of the aims of the study…You become more aware of the benefits of walking. (IDN38) |
Physical health
| Specific health problems – worsening and improving | I do have arthritis…and I had a bad spell during the middle where I’d done something to my knee..it was a pulled muscle or something.. So I struggled to walk too far. (IDN3) |
| | I was having some physio, that was in January, and with the combination of the physio and the walking, and I don’t know whether it was just because of swinging my arms and there was more movement, but I think it helped with that as well, and even the physio said he thought it had helped. (IDN30) |
| Pain | ..now what I have noticed is that, if I’m in to exercise regimes, that are sustained and regular, I feel much less of that pain. (IDN10) |
| | I had suffering a back ache, you know, and leg pain and things like that, but when I go walking, it helps. (IDN34) |
Environment
| Primary care as the location | Yes, that was good, because obviously it was very near home so it was ideal. (IDN15) |
| | Yes, I mean I think it’s … it’s good being able to do that. It’s fairly local for me, you know, easy to get to. Much easier than if I had to go to a hospital you know so, yes, that was easy. (IDN30) |
| Weather/season/climate | I enjoyed the fresh air and the exercise and I felt better for it. (IDN2) |
| | In winter it dies down a little bit, anyway, you just want to get out of cold and rain and you just make it home asap and you’re just less active. So there’s a seasonal thing definitely, you know, so if it’s summer, you are out and about all day anyway. (IDN1) |
| | Well obviously it’s much nicer to go for a walk in the spring or the summer or the autumn, so if you do hand these things out in the winter, people don’t think I’ll go for a walk, oh no, God it’s cold out there, it’s raining. (IDN13) |
| Locality for walking | ..it was really nice to start going out for little walks in the neighbourhood and finding places, little parks, and little cafes that I hadn’t been to before, so that was another positive thing. (IDN6) |
| | I think I’m lucky. I’ve got a small park, close to me and so whereas I may have walked to the shops, I would do three circuits or so of that and then go on to the shops. (IDN35) |
| Work | It depends what I’m doing because if I’m at work, then I’m obviously not as active because I’m in a small confined space and I just walk up and down when I need to sort of thing. (IDN7) |
| | An awful lot of what I maybe can do now is likely sedentary involvement. I’m doing online work which really confines me to sitting you know and doing a lot of work on the computer. And I have to make a conscious effort both for going out and doing the necessary walking. (IDN10) |
| Pets | I have moved in to a place with three dogs, can’t get any better, so I walk more I think maybe now. (IDN1) |
| | I know this week I haven’t got the dog and we’ve been really busy and I’ve been much more car bound so I would dread to think what my steps were this week. And that’s why I think, having a dog, is fantastic, because you have to go out anyway. (IDN33) |
Routine
| Fixed routine – unable to increase walking | I didn’t find it physically that difficult to actually reach it, but just very time consuming and I just with working I found that I..just didn’t have the sort of time or enthusiasm for doing that. (IDN2) |
| | The walking is because I do the same all the time you know. Every day is my routine walk you know, going to work... Because you know I do it every day, the walking in this way, I don’t need any help for anyone. (IDN4) |
| | I’ve had a very bad year, work-wise, well I’m working under a lot of pressure, and time to go and do things wasn’t really there. (IDN22) |
| | I mean there is a limit to the amount of exercise … time I can spend exercising in a day. (IDN31) |
| Fluctuating routine – sometimes allowing for walking, sometimes not | Well I don’t think I ever reached the actual total targets. I did on odd days. But you know it was all depended on my umm … commitment because, if I was you know … out somewhere and that, I couldn’t do the walking, it was alright when I was just at home and I could just walk round the roads and get my steps up, do you see what I mean? (IDN19) |
| | I mean, to me, it very much depends what’s going on in my life. I have a dog, I have a husband who at the beginning of last year changed his job so he’s at home much more, which has changed my routine enormously. And I … that has really affected my exercising. But I mean on a daily basis I’m very busy. So I’m probably good on steps, yes. But when I don’t have the dog, which I haven’t done for the last few weeks, then it goes down enormously. (IDN33) |
| New/flexible routine | …a really good outcome, I’ve just thought, we hardly ever use the car. Only when I do a big shop. Or we’re going to visit someone, we hardly ever use the car. That’s a real plus. (IDN18) |
| | Yes, everyone in my house now, we don’t drive to the shops, we all walk to the shops…Because I’m the one who drives so I just say I’m not driving, I’m walking.. so we end up walking, so that’s the influence, it was easier for me just to jump in to the car, now I have to think twice do I really have to? (IDN21) |
| | I did try to increase it to five times a week, and I’ve certainly kept that up now, so for instance, I’ve been to the gym this morning. Tomorrow I’ll make sure that I walk in to town and walk back again, so that at least five times a week, doing at least minimum of 30 minutes, but three times a week it’s an hour or more. I think the PACE-UP programme has kind of set me off on a new regime of keeping fit. (IDN39) |
Monitoring
| Targets | It seemed like a challenge and I think it’s one of those things as well that, when you’re … you’re given a challenge, umm… I think I started slipping once it had finished and that is because I didn’t have that challenge there anymore. (IDN30) |
| | It was very positive, it was very positive in that every time I managed to achieve and go beyond it was … there was a real boost. (IDN37) |
| | Sometimes it was a bit demoralising because you kind of thought, oh, I can’t possibly do that number of steps, you felt like you were never reaching your goal, so that was probably a bit … it wasn’t de-motivating but it’s a slightly demoralising to think you’re not reaching your targets isn’t it, so I think maybe the targets … should consider the targets you are setting people with a time or maybe I just should walk faster or something. (IDN38) |
| Self-efficacy/self-monitoring | Well part of it, part of it, but I myself pushed myself more as well because I didn’t go to the nurse that often, then I was on my own, so I had to be dependable on my own strength and walk. (IDN12) |
| | What would she say, walk a bit quicker, eat a bit less? It’s common sense I knew in the first place…I don’t think a nurse or anybody else telling me what I should do would really make much difference, quite honestly. (IDN23) |
| | I’m quite a self-motivated person so I don’t … I think if I’ve agreed to do something, then I will try and achieve that target, whether somebody tells me face to face or by post, so I think it’s dependent on the individuals maybe, individual choice. (IDN38) |
| External monitoring and feedback | So that even when I feel like I am giving up, it’s more like I am thinking, but no, somebody will be watching me! (IDN21) |
| | ..it’s having someone to get some feedback from because then you know you aren’t doing things in vain. (IDN22) |
| | There’s nothing like the fact that you know you’re going to meeting someone and talk about it to make you do it, you know, when I was at work, we used to have this thing about, as I said, you’d rather do things they enjoy or things they are checked up on… It’s basically the routine of being checked up on by someone else and being part of a group of people. (IDN29) |
| | Yes, it would have been incredibly useful, yes, it would have been. It would have been, for two-fold, one to get some sort of feedback, the other one just to sustain that level of interest in the programme. Purely because you’re having to … you’re being monitored and you’re having to respond to certain key stones, key points, and I think by the very nature of human beings, when we’re being monitored, we do things. (IDN37) |
| Equipment used for monitoring | Oh I did always look. Actually it was quite … and if I had had a low … the weekend tends to be lower, it did just jog my … yes, it made me think, okay, fine, I must do a little bit more. (IDN33) |
| | I wasn’t too sure about its accuracy because sometimes I would do a similar route and it would give a different reading, quite a large different reading. (IDN11) |
| | Sometimes it [the pedometer] didn’t pick things up, I used to get annoyed because it wouldn’t pick things up in the gym, I’d think oh, I’ve just done about 2,000 strides, and I’ve looked down and think, ooh, you didn’t get any of that. (IDN43) |
Social perspectives
| Peer support/encouragement (including positive thoughts about group setting) | It’s a bit like talking to people who are in the same situation as yourself, you know, because no-one understands the issues of someone better than someone who is in that situation themselves. I’m not saying that there are other ways of coaching and supporting people, but I’m just thinking of the things that tend to change peoples’ behaviour. (IDN29) |
| | I think sometimes it can be helpful to talk in a group because you might have an idea that somebody else hasn’t thought of and vice versa. (IDN30) |
| | I think you could sort of encourage each other, yes, it’s more fun doing stuff with other people really isn’t it. (IDN43) |
| Meeting others (including positive thoughts about group setting) | Sometimes I’m walking, and I meet somebody, and they will stop and talk to me and ask me the reason why. And I’ll say to them, walk with me, and we would talk, you know, and that I think that was very good. (IDN9) |
| | Sometimes it’s a way of getting to meet other people in your area that you could actually, I suppose say, shall we all do this together and something like that, you never know. (IDN18) |
| Impact on others | I’ve got a son of 16, its made me kind of like if he says can I have lift or something like that, I say, and because I do a lot of driving with my job, the last thing I want to do is get in the car, I say, no, but I’ll walk up there with you, and sometimes he says no thanks, I’ll walk on my own, but its made me more … I think its increased his walking as well because of … because of this. I think it has been really good from that point of view, yes. (IDN16) |
| | I think we’ve now managed to encourage our sister-in-law to start walking. She’s now been going out walking because she can see the benefits of how we’ve got on, you know, because we go for quite long brisk walks and we don’t get out of breath or anything, so umm she sort of thought, oh, well I’ll start my walking now, because she’s quite overweight. (IDN20) |
We had anticipated that there would be differences in the responses given by those who had and those who had not increased their walking. However, we found that there was substantial overlap between the responses of these two groups, with many participants for whom the trial had not been a ‘quantitative success’ still feeling they had gained a great deal from participating. For this reason, we have not attempted to analyse the interviews according to those who had increased or not increased their activity, but rather drawn themes from their responses as a whole.
In total, we found 152 discrete examples of BCTs being alluded to by participants, 54 in the pedometer by post group and 98 in the nurse group. The only BCT domain in which the pedometer by post group references dominated was in those related to self-monitoring. Responsiveness to the BCTs used in the handbook, diary and nurse consultations is discussed alongside the main thematic analysis.
Healthy lifestyle
The importance of a healthy lifestyle emerged both as a motivator for participation and/or an outcome of taking part in the trial. Participants discussed the concepts of feeling fitter, improved sleep, weight loss and their awareness of walking as part of a healthy lifestyle within this theme.
The concept of feeling generally fitter was important and was discussed in terms of living longer for grandchildren, being able to enjoy life more fully and keeping more active into older age:
“I mean I think the walking does make a difference, it certainly does… I don’t do jogging, but walking certainly does, because it keeps you moving, keeps you fitter.”
(IDN22, male, aged 63, white British, nurse group, no increase).
“..it’s just a straightforward correlation between walking more and being generally fitter in old age, sort of makes sense.”
(IDN 29, male, aged 59, white British, nurse group, no increase).
Examples of more specific motivations were the benefits of exercising for sleep and weight management. Some lost weight during the trial and some expressed disappointment that they did not lose more weight:
“
I sleep better as well when I go walking, and come back, I have a better night’s sleep”
(IDN34, female, aged 73, black Caribbean, pedometer only group, increase).
“I consciously knew I was overweight when I started it and, at the end of it, I think I’d probably shed over a stone, so … seven kilos, six or seven kilos.”
(IDN3, male, aged 53, white British, pedometer only group, increase).
“I was hoping I might lose some weight doing the trial but I didn’t.”
(IDN7, female, aged 60, white British, pedometer only group, no increase).
Participants expressed great awareness of walking as part of a healthy lifestyle and many felt that this awareness had been enhanced by their experience of taking part in the trial:
“We want to keep fit… I think it’s made us extremely aware and looking at friends that are not half as active and that have complaints, touch wood, we’re doing well.”
(IDN18, female, aged 62, white British, nurse group, no increase).
Linked in with the healthy lifestyle theme are techniques 1 and 2 from Michie’staxonomy [
15]; providing general information on behaviour-health link and providing information on consequences to the individual. We found substantial evidence that participants valued the provision of this information both from the practice nurse and from the trial literature:
“I thought it was very good and it did bring to mind how much exercise or not one is doing, so from that aspect, I found it umm … very useful for me.”
(IDN39, female, aged 61, white British, nurse group, no increase).
“You become more aware of the benefits of walking and try to walk places rather than drive and try to build in time to walk because obviously it takes longer to walk somewhere than drive, or get the bus or whatever. I think you try … you become more in tune with your health, so I’ve tried to lose some weight and things like that alongside the walking.”
(IDN38, female, aged 59, white British, pedometer only group, increase).
Physical health
Physical health was discussed by participants, in terms of specific health conditions as both being a barrier to increasing their activity and as a motivation to increase activity so as to improve physical health. Of note, 37% mentioned at least one health problem that preceded the trial, 14% mentioned a health problem that occurred for the first time during the trial and 12% mentioned both. Only 37% of participants did not discuss health problems during their interview. Most felt that walking was beneficial:
“I think it makes it (arthritis) better… Because the more I walk the better I am. I’ve mainly got osteoarthritis in my hands, but sometimes my knees feel weak, but the walking doesn’t hinder me, it helps it because it keeps you more lubricated.”
(IDN26, female, aged 65, white British, nurse group, no increase).
“Because it’s good for your blood pressure, it’s good for high cholesterol, good for diabetes.”
(IDN9, female, aged 69, black Caribbean, pedometer only group, increase).
However, a minority felt that attempting to increase their walking may have been detrimental:
“And unfortunately… being part of the trial and trying to increase the level of activity was probably the worst thing I could have done. But we didn’t know that and I so wanted it to work but I’ve learned a lot about the illness [myalgic encephalomyelitis, ME] and know that I would have to increase it in tiny tiny steps.” (IDN6, female, aged 51, pedometer only group, white British, no increase).
“I somehow I think I overdid it and injured my knee, which meant that I was limited in the amount of walking I could do.”
(IDN25, male, aged 67, white British, pedometer only group, no increase).
Several participants specifically mentioned pain, and all felt that walking in fact reduced their symptoms:
“I enjoyed it because it helps me to … makes my body… the pain in my knees and my shoulder. That helps… the more I go, the pain gradually decreased.”
(IDN9, female, aged 69, black Caribbean, pedometer only group, increase).
Environment
Many participants reflected on the environment in which they lived and the impact this had on their ability to increase their walking. This included the sub-themes of the primary care setting for the trial, the weather and season, the locality for walking, participants’ working environment and the influence of pets.
Primary care was universally thought to be an appropriate and convenient location to deliver this type of intervention:
“Yes, yes, that’s easy for me. I walked there and walked back so it’s a nice sort of 15 minute walk.”
(IDN16, female, aged 47, white British, nurse group, increase).
“..you wouldn’t want someone to have to travel and people know how to get to their doctors don’t they?
(IDN 29, male, aged 59, white British, nurse group, no increase).
The environment also had an impact on participants’ experience in terms of the weather. Some felt that dark, cold and wet weather was no hindrance, while others admitted that it probably affected their progress:
“I don’t pay too much attention to what happens out there, as long as it’s not floods. The winter, you know, inclement as they tend to be, are not a barrier.”
(IDN10, male, aged 64, black African, nurse group, no increase).
“..if it involves going for a walk around [the local area] in the evening, in the rain, no, it’s not that appealing, I mean, if I’d been doing it in the summer, I would have found it easier if it was light in the evening and the weather was nice, I could have walked round the park or something, but that’s not really an option in the middle of winter” (IDN2, male, aged 45, white British, nurse group, no increase).
The locality for walking was also an important factor for some of our interviewees, with some reflecting how a pleasant walking environment facilitated their increase in activity while others discussed how less pleasant surroundings were a barrier:
“If you have a park and things in the area, of course, I think that’s more motivational than if you live at Piccadilly Circus”
(IDN1, female, aged 48, any other white background, nurse group, increase).
“I think it also depends on where you live. I mean I’m lucky, I live near the common, so it’s really easy for me to just go out and walk, rather than just walking round the streets and things. And so it probably has to be related to the area … progress has to be related to where it is that you live.”
(IDN33, female, aged 49, white British, nurse group, no increase).
Many of our participants were working in part or full time jobs and they perceived that this had a substantial impact on their ability to engage with the trial. Some found that they could build walking into their working day, while others felt this was simply not possible:
“10,000 steps in a day is a lot of walking, but you know … in my previous job I would have been doing, on a regular basis, daily basis I’d have said, comfortably. In this job you know I have to … I don’t get up and walk around like I used to.”
(IDN3, male, aged 53, white British, pedometer only group, increase).
“..when I started that, I was working, and I had a sedentary job, although you get up and walk around, you know, but then I retired at Easter last year, so then I started doing walking groups”
(IDN13, female, aged 66, white British, pedometer only group, no increase).
“Because I work full time, you know, I go out, I walk the dog, umm, I’ve got a full time job, you know, and there’s not that many hours always to get that number of steps in.”
(IDN38, female, aged 59, white British, pedometer only group, increase).
Having a pet was discussed by several participants as affecting their levels of physical activity:
“We’ve got a dog now, so I do quite a lot of walking with her… She has to go out so we go out for quite long walks, especially at weekends, you know.”
(IDN20, male, aged 52, white British, nurse group, increase).
Routine
Participants spoke about their routine in relation to increasing their activity, identifying the influences of fixed or flexible routines and the emergence of new ones whilst participating in the trial.
Participants found that having a fixed, busy routine was often a barrier to increasing their walking due to the resulting time constraints. This was a particular problem for participants who were working in sedentary jobs or jobs that required long hours; it also included participants who were retired and reported established routines as a result of family roles or roles in their community:
“I feel a bit … was letting myself down because I go to work very early in the morning and when I come back I’m totally tired… It would have been alright had, as I said, had I come back here, had different type of job I think, yes.”
(IDN27, male, aged 61, white and Asian pedometer only group, no increase).
“I do find it very difficult finding the time to do all that before so many other things I need to do, and look after my grandson, a three year old, it’s not easy, and I used to get really really tired…… obviously I could not keep up the you know the amount of steps every day. I’m not really sort of bothered as much how many steps I do, it’s how much time I can afford to go walking.”
(IDN17, female, aged 66, any other white background, pedometer only group, no increase).
Other participants explained that the fluctuating nature of their routine could be a facilitator at times and a barrier at others. Some felt that this may have affected the trial outcome as they were not monitored during what they perceived to be a representative week at the 12-month follow up:
“I have so much to do because even though I’m retired and that, I’m always doing something, and … depends what the day’s like to how much you can walk or you can you know take a long walk if you haven’t got an appointment somewhere or something like that, you know what I mean, so I could never quite reach that, but then again, at the end, I did.”
(IDN26, female, aged 65, white British, nurse group, no increase).
“I think the last week that I was monitored was a week when I didn’t do as many steps as perhaps I had some of the other weeks… it does fluctuate a bit I would say, but that particular week was less than I would have done normally in a week.”
(IDN16, female, aged 47, white British, nurse group, increase).
A third group of participants spoke about a new routine which they had established with some attributing this directly to the trial and others feeling that they had been ready to make a lasting change towards healthier living anyway:
“Since I’ve been doing this trial… my partner and I do walk the extra bus stop, I do walk more than I used to, so I am trying to do more walking since I’ve started this trial…I don’t walk as far as I’d like to, obviously, because in my daily life, as I said, I can’t do it, but I do walk … definitely I do walk more. If I hadn’t done this study I would most probably be getting on the bus at the bus stop at the bottom of my road.”
(IDN7, female, aged 60, white British, pedometer only group, no increase).
Monitoring
Monitoring, including both self-monitoring and external monitoring provided by the trial nurses, research assistants and trial equipment, was a broad theme mentioned by almost all participants. In most cases monitoring was perceived to be helpful and motivating but some participants discussed how failing to reach targets or not trusting the accuracy of the equipment could be a barrier.
Participants differed in their opinions regarding self-monitoring and targets, some suggesting they were already self-motivating, while others felt more empowered to self-monitor and self-motivate after completing the trial. Monitoring of behaviours and their outcomes were also important elements of the BCTs used in the trial (items 16 and 17 of Michie’staxonomy [
15]):
“Yes, setting my own targets and now, umm … well, it’s something that I’ve got used to now and I’m determined to keep it up.”
(IDN11, male, aged 70, white British, pedometer only group, increase).
“..well having something which counts the steps makes one conscious of it and filling out a little booklet every day, likewise, it just creates some personal pressure”
(IDN31, male, aged 59, white British, pedometer only group, no increase).
Others valued the opportunity to discuss their progress with a nurse and felt this was an important factor in their progress. Participants reflected that the practice nurse was able to prompt review of behavioural goals, outcome goals and provide feedback on performance (items 10, 11 and 19 of Michie’staxonomy [
15]):
I think it was helpful seeing the nurse because it sort of made it more important to maybe think, oh well, oh gosh, I should have done that so I’d better do a bit more the next day. Not everybody might like that, but I found that quite helpful.”
(IDN35, female, aged 64, white British, nurse group, increase).
“..they kept saying how well I was doing, and all this sort of thing, so it made me want to continue. I think it was … a part motivation, yes, because I knew I had to face somebody and I didn’t want to fail.”
(IDN32, female, aged 63, white British, nurse group, increase).
“Very good, very helpful, it was really helpful, yes. Umm … I think, again, on that situation, it’s umm … it’s having someone to get some feedback from because then you know you aren’t doing things in vain.”
(IDN22, male, aged 63, white British, nurse group, no increase).
However, the concept of rewarding oneself when a target has been met (item 12 of Michie’s taxonomy [
15])was not frequently commented on by participants and those who did mention the use of rewards did not find them helpful:
“It [the handbook] said things like, if you’ve reached your target this week, well done, haven’t you done well, treat yourself to a cup of tea. I found that rather condescending and umm … patronising. It just wrangled a bit … I don’t need a pat on the head and a piece of sugar” (IDN41, male, aged 72, white British, pedometer only group, no increase).
The monitoring provided by the trial equipment, particularly the pedometer, was a motivating factor for many participants although some doubted the accuracy of the pedometer and once they had ‘lost faith’ in the equipment its value as a monitoring device inevitably decreased:
“I love the pedometer. I still use it. I’ll put it on one day, because it’s easy to forget, you know, sometimes you can only do like 6,000 or something, and if that is happening, I’ll maybe put it on for a couple of days then I’ll think, right, I’ve got to do a bit more. So it’s probably just to give me that motivation again.”
(IDN30, female, aged 51, white British, nurse group, increase).
“I gave up wearing the pedometer because I didn’t find that it registered the steps I was doing and, actually, I was quite disappointed when I first started wearing that because I thought, well, I’ve been walking for over an hour today and it had registered something like about 30 steps, and you think, well that’s obviously wrong, so I didn’t find the pedometer itself very useful and I soon gave up using that.”
(IDN39, female, aged 61, white British, nurse group, no increase).
Setting goals and targets to increase the number of steps taken during the physical activity intervention was found to be both motivating and demoralising and many participants commented on this during their interview:
“I think maybe because I just decided, after a few weeks, that it was unrealistic. I maybe just stopped trying at all rather than saying, you know, maybe it would have been better to say, okay, if it started off at 6,000, maybe I could have done 8,000 a day or something, but I just found 10,000 too much of a step up really to do, so I thought stop trying a little bit really.”
(IDN2, male, aged 45, white British, nurse group, no increase).
“..it was quite nice… having like a bit of a goal. When I was on the trial doing that amount of steps where you had the goals to achieve, which I thought would be quite easy, and sometimes it was like, oh crikey, how am I going to fit that in to the day or the week you know. But necessary I think so … although it was a bit of a nuisance, I think it was necessary.”
(IDN16, female, aged 47, white British, nurse group, increase).
The importance of being set graded tasks (item 9 in Michie’s taxonomy [
15]) was also identified by two participants:
“I don’t know if it’s … was a nurse or more the programme as such, you know, how to stagger things and how to kind of like split them off, so yes, 30 minutes a day, but it could be 10 minutes, 10 minutes, 10 minutes. So that’s very useful I think.”
(IDN1, female, aged 48, any other white background, nurse group, increase).
“Psychologically, you know, to increase slowly over a period, and then keep a certain amount, is probably a good thing.”
(IDN3, male, aged 53, white British, pedometer only group, increase).
Support and social perspectives
Some participants reflected on the importance of nurse support, peer support, the support of friends and family and how their trial participation influenced those around them.
The support and encouragement provided by the nurse was greatly valued by participants, particularly with regard to identifying and overcoming barriers (item 8 of Michie’s taxonomy [
15]) as was the importance of the support of the nurse or trial literature in providing advice on how, where and when to perform the behaviour changes (item 20 and 21 of Michie’s taxonomy [
15]):
“It’s something that I’ve never thought of because when I was talking, the complications, she says, no, no, just leave your car a distance, and then start walking, yes, she was very helpful.”
(IDN21, female, aged 47, black African, nurse group, increase).
“I suppose it’s just things like when you park the car, you know, park further away from where you would normally, maybe get off the train a stop early, that sort of thing.”
(IDN16, female, aged 47, white British, nurse group, increase).
“I think there was a lot of useful information in there [the handbook] because you had that, you know, like leaving your car and walking, which I did, and you know, different groups that you could join or going out with friends and, yes, there were lots of helpful suggestions and also I think, from what I remember, it signposted you to other websites and things.” (IDN30, female, aged 51, white British, nurse group, increase).
With any health behaviour change, relapse is an important risk. We looked for evidence of relapse prevention planning (item 35 of Michie’staxonomy [
15]) and found a few examples where this had been mentioned and valued by participants, but interestingly the examples related to the trial handbook or equipment rather than the practice nurses:
“Well the only thing I can think is you know sometimes if you let something slip and then it’s hard to get back into it, you know, if I’m perfectly honest, that has happened a couple of times where I’ve thought oh I can’t be bothered, but then, as it said in the booklet, which I think was good in the booklet, if you do find yourself slipping, don’t beat yourself up about it. You know, carry on and start again. I think, you know, if it’s … if you just keep that in mind, it’s a good approach.”
(IDN30, female, aged 51, white British, nurse group, increase).
“I think the booklet was good and the sort of comments, you know, about don’t get dispirited and things like that, I think that was excellent.. I think there was a point where they sort of said, you know, don’t give up now, or something like that, you know, at the point where … the novelty might have worn off…”
(IDN35, female, aged 64, white British, nurse group, increase).
“Definitely wearing the pedometer… I really do feel that’s kept us on the straight and narrow.”
(IDN18, female, aged 62, white British, nurse group, no increase).
We specifically asked participants how they would feel about a similar trial which involved meeting with a nurse or facilitator in a group rather than individually. While some felt that this would be less desirable due to logistical and privacy considerations, many felt that they would have benefitted greatly from this and the possible benefits of meeting in a group also link to item 4 in Michie’s taxonomy [
15] of providing normative information about others’ behaviour:
“..if it involved each person reporting back on their success or failure at meeting the sort of previous targets, it might be a bit awkward in a group possibly”
(IDN2, male, aged 45, white British, nurse group, no increase).
“When you are with other people, and then you see the same problems they are facing, some of them might come up with other ideas… you know, we would meet the first day and we will see each other and then, if you want, you can form a team, support network, I don’t even know who else in my area was doing it.”
(IDN21, female, aged 47, black African, nurse group, increase).
“I think what would have been useful would have actually got some data on what the universe is doing you know, doing in terms of the highest step count, the lowest, the average, the mean..”
(IDN40, male, aged 48, white British, nurse group, no increase).
“And also reassurance, because I think, with the weather and that, she said that a few … I wasn’t alone in the fact that it had been a bit of a difficult keeping it going sort of thing, so that helps to know that.”
(IDN16, female, aged 47, white British, nurse group, increase).
Meeting individuals whilst walking in their local area was described as being a benefit of trial participation for some participants:
“..you know, it got me out in to the neighbourhood and both for my health but also socially, I was meeting other people, so that’s another positive thing.”
(IDN6, female, aged 51, white British, pedometer only group, no increase).
Finally, some participants reflected on the beneficial effect that their trial involvement had on those around them, linking to item 29 of Michie’s taxonomy [
15]), planning social support/social change:
“…because my family and friends were aware, it was, you know, quite good because you’d sort of say shall we meet up and do this or go in to the nearest town but walk there rather than take the car, that type of thing.”
(IDN15, female, aged 49, any other white background, nurse group, no increase).
“…it's something I want to keep up, because I just felt that it was such a benefit, and even the kids would come out with me sometimes.”
(IDN30, female, aged 51, white British, nurse group, increase).