We undertook formative research with Australians living with moderate-to-severe traumatic brain injury to co-develop a discrete choice experiment survey about their physical activity preferences. |
This process significantly enhanced the content and format of the survey, the results of which will be used to adapt World Health Organization physical activity guidelines to address the needs of people with traumatic brain injury. |
Given that this formative development process is valuable yet often poorly reported, this paper describes it in sufficient detail for others to follow our process. |
1 Introduction
1.1 Study Overview and Aims
2 Methods
2.1 Theoretical Framework
2.2 Research Team Characteristics and Reflexivity
2.3 Design
Stages of research (goals) | Data collection methods | Data analysis methods |
---|---|---|
1. Identification of key constructs and initial expression of attributes | Review of the literature and iterative deliberative dialogue with stakeholders | Framework analysis |
2. Critique and refinement of attributes | Focus groups with people living with TBI | Qualitative description |
3. Prioritisation of attributes and refinement of levels | Focus groups with people living with TBI | Framework analysis |
4. Testing and refining language, format and comprehensibility in the draft survey | ‘Think-aloud’ interviews with people living with TBI | Framework analysis |
2.4 Recruitment
2.5 Data Collection and Analysis
2.5.1 Stage One: Identification of Key Constructs and Initial Expression of Attributes
2.5.2 Stage Two: Critique and Refinement of Attributes
2.5.3 Stage Three: Prioritisation of Attributes and Refinement of Levels
2.5.4 Stage Four: Testing Language and Formatting in the Draft Survey
3 Results
Stage Two: focus groups (n = 17) | Stage Three: focus groups (n = 9) | Stage Four: think-aloud interviews (n = 15) | |
---|---|---|---|
Age group (years) (n) | |||
13–17 | 2 | 0 | 1 |
18–25 | 1 | 1 | 0 |
26–35 | 0 | 0 | 1 |
36–45 | 5 | 2 | 5 |
46–55 | 7 | 6 | 6 |
56–65 | 2 | 0 | 2 |
Sex [n (%) male] | 11 (65) | 5 (56) | (8) 53 |
Time since injury (years) (n) | |||
1–5 | 5 | 3 | 6 |
> 5 | 12 | 6 | 9 |
State of residence | |||
NSW | 4 | 2 | 3 |
QLD | 3 | 3 | 2 |
VIC | 7 | 2 | 8 |
WA | 3 | 2 | 2 |
Setting | |||
Metropolitan | 17 | 9 | 13 |
Rural | 0 | 0 | 2 |
Physical activity status | |||
% meeting guidelines | 47 | 22 | 60 |
Less than pre-injury (n) | 12 | 8 | 10 |
Same as pre-injury (n) | 2 | 0 | 0 |
More than pre-injury (n) | 3 | 1 | 2 |
Not reported (n) | 0 | 0 | 3 |
Washington Short Set on Functioning (n) | |||
Vision | |||
No difficulty | 5 | 3 | 5 |
Some difficulty | 11 | 5 | 9 |
A lot of difficulty | 1 | 1 | 1 |
Hearing | |||
No difficulty | 10 | 3 | 8 |
Some difficulty | 6 | 4 | 6 |
A lot of difficulty | 1 | 2 | 1 |
Climbing steps | |||
No difficulty | 2 | 2 | 1 |
Some difficulty | 9 | 6 | 10 |
A lot of difficulty | 6 | 1 | 4 |
Remembering/concentrating | |||
No difficulty | 1 | 0 | 0 |
Some difficulty | 8 | 3 | 9 |
A lot of difficulty | 8 | 6 | 6 |
Self-care | |||
No difficulty | 5 | 4 | 6 |
Some difficulty | 10 | 5 | 8 |
A lot of difficulty | 2 | 0 | 1 |
Language | |||
No difficulty | 6 | 0 | 4 |
Some difficulty | 10 | 9 | 11 |
A lot of difficulty | 1 | 0 | 0 |
3.1 Reducing Attributes
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Discarding attributes, for example, Dose (intensity and frequency) was not identified by participants as important in their decision making about physical activity.
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Merging attributes, for example, Effect on TBI motor symptoms, physical function and fatigue + Effect on TBI cognitive function and cognitive fatigue + Effect on mood (depression, anxiety) were merged into two more generalised concepts of Health and Feeling of wellbeing and eventually reduced to Wellbeing as that was considered to include health.
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Renaming attributes, for example, Mode became Who else is doing the activity and, eventually, Who with.
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Reconceptualising attributes, for example, we initially differentiated between travel time for regular physical activities and special or one-off events (such as a national competition or ski trip), speculating that people would be prepared to travel longer for occasional events. We later focused on regular physical activities because they were more likely to form part of a healthy and sustainable program.
During Stage One: following literature review and initial ideas-generation by core research team | End of Stage One: following deliberative dialogue with wider investigator group | End of Stage Two: following ‘attribute’ focus groups | End of Stage Three: following ‘levels’ focus groups | End of Stage Four: following think-aloud interviews |
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1. Type of activity/exercise 2. Out-of-pocket cost including travel costs 3. Type of inclusion 4. Location/type of setting 5. Who is leading or supervising or coaching the activity (and their expertise working with people with TBI) 6. Mode 7. Amount of supervision 8. Dosage (frequency and duration) 9. Travel time for general sessions 10. Travel time for special sessions 11. Activity mix 12. Effort or preparation 13. Effect on TBI motor symptoms, physical function and fatigue 14. Effect on TBI cognitive function and cognitive fatigue 15. Effect on mood (depression, anxiety) 16. Effect on your overall feeling of well-being 17. Additional reasons, e.g. social engagement, fun/enjoyment, competition/achievement, adventure/risk, structure/purpose, weight loss, respite for self/carera | 1. Type of physical activity 2. Your out-of-pocket cost 3. Travel time 4. Who else is doing the activity 5. Skills/knowledge of the activity leader/facilitator 6. Accessibility of the environment/setting 7. Health benefits of doing the activity 8. Effect on your overall feeling of wellbeing 9. Additional reasons, e.g. social engagement fun/enjoyment, competition/achievement, adventure/risk, transport availability, activity intensity and frequency, options for a range of activities, equipment requirements, how easy or difficult an activity is to master, how much preparation time or effort is required, respite for self/carer | 1. Type of physical activity 2. Your out-of-pocket cost 3. Travel time 4. Who else is doing the activity 5. Skills/knowledge of the activity leader/facilitator 6. Accessibility of the environment/setting 7. Benefits of doing the activity 8. Effect on your wellbeing | 1. Type of physical activity 2. Out-of-pocket cost 3. Travel time 4. Who else is doing the activity 5. Activity facilitator’s skills/knowledge 6. Accessibility of the setting 7. Effect on your wellbeing | 1. Type of activity 2. Out-of-pocket cost 3. Travel time 4. Who with 5. Facilitated by 6. Accessibility of setting |
Final attributes | Attribute levels |
---|---|
Type of activity | Sport in a structured competition (some examples might include lawn bowls club competition, netball district competition, marathon, wheelchair basketball club challenge) |
Sport with informal competition for fun (some examples might include a running group, soccer in local park, lunchtime or school basketball game) | |
Physical recreation with purpose of mental, social and/or physical satisfaction (some examples might include Tai Chi, Yoga, dance, body surfing, bushwalking, rock climbing, aqua aerobics, walking the dog) | |
Structured exercise program with purpose or goal to improve fitness, strength, flexibility and/or function (some examples might include a physiotherapy prescribed exercise program, gym program, treadmill or cycle ergometer, strength training) | |
Out-of-pocket cost | $0 per session |
$15 per session | |
$40 per session | |
$100 per session | |
Travel time | 5 minutes or less each way |
15 minutes each way | |
30 minutes each way | |
70 minutes each way | |
Who with | The activity is organised only for people with a disability like mine |
The activity is organised for people with any type of disability | |
The activity is open to everyone (mainstream) | |
I do the activity by myself | |
Facilitated by | The activity is facilitated by a person with experience of the activity and experience working with people with disability |
The activity is facilitated by a person with NO experience of the activity but experience working with people with disability | |
The activity is facilitated by a person with experience of the activity but NO experience working with people with disability | |
The activity is facilitated by a person with experience of the activity and experience working with people with disability | |
Accessibility of setting | Accessibility is manageable, but not ideal |
Highly accessible, caters well for my needs |
3.2 Final Survey Modifications
Survey components | Overview of modifications |
---|---|
Participant information | Removed jargon and unnecessarily formal terminology Used more specific language, e.g. referring to ‘the survey’ rather than ‘the study’ Reordered sections so those perceived as most important came first Reduced text overall Committed to providing an audio option in the online survey to reduce cognitive and eye fatigue |
Consent form | Rearranged bullet points into a more logical sequence Minor language refinement |
Screening questions | Modified language to be more specific, e.g. asking ‘Have you been diagnosed with a brain injury?’ rather than ‘Do you have a brain injury?’ Added explanations for personal questions, e.g. next to the question ‘What was the main cause of your brain injury?’ we stated ‘(this survey is only for people who are living with a traumatic brain injury)’ |
Survey instructions | Changed the tense to emphasise hypothetical scenarios, e.g. travel time was defined as ‘How much time it would take to get to the activity’ rather than ‘How much time it takes to get to the activity’ |
DCE question blocks | Removed Wellbeing attribute (as described above) Changed ‘Physical activity scenario’ to ‘Physical activity option’ Reduced the prominence of examples given for the Type of activity attribute Moved the main DCE question, ‘Would you be willing to add this physical activity to your current weekly schedule?’ , to precede the attribute list rather than follow it Added an explanatory statement to the top of the page for questions 2–6 to reduce confusion: ‘This option may seem similar to a previous option, but some of the features are different’ Replaced the option of ‘0 minutes’ travel time with ‘5 minutes or less’ travel time as some participants argued that 0 minutes was not possible |
Physical activity questions | Refined questions for specificity, e.g. rather than asking respondents to identify three forms of physical activity they engage in, we asked for ‘up to three’ |
Function | Refined mobility categories |
Demographics | Modified questions to be more inclusive, e.g. adding to and amending terminology in categories of mobility and employment status |