Background

Time spent in sedentary behaviour (sitting/lying down) has recently emerged as an important topic. Too much time spent in sedentary behaviours is linked with ill health and mortality. This seems to be independent of physical activity: a short burst of activity such as an exercise class will not offset the detrimental health effects of many hours sitting. Research suggests that sedentary behaviour is particularly common in stroke survivors who may spend up to 80% of their waking day sitting or lying down. Interventions to reduce sitting time have enormous potential, would be low cost and may be more achievable than a structured exercise programme, particularly in stroke survivors afraid of another stroke or falling.

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Aims & Objectives

We aim to enhance health and disability outcomes for stroke survivors through the development and evaluation of strategies to reduce overall time spent sedentary and break up long bouts of sedentary time.

Objectives:

  1. Ensure that intervention development is informed by up-to-date review of the quantitative and qualitative evidence.
  2. Inform development of an intervention by observations and qualitative investigation of sedentary behaviour with stroke survivors, their carers and health professionals including exploring their capability, opportunities and motivation to address this behaviour.
  3. Use co-production principles to develop intervention strategies to reduce sedentary behaviour in people after stroke.
  4. Test the implementation of the intervention and clarify trial design components in three stroke services.
  5. Conduct a large pragmatic cluster randomised trial (cRCT) evaluation of the developed intervention with internal pilot, process evaluation and cost-effectiveness analysis.*

* Due to the unprecedented effects of the COVID-19 pandemic on National Health Service (NHS) services, in discussion with the funders, in spring 2022, a decision was taken to reduce the trial in size and scope to become an external pilot trial rather than a definitive trial. As a result, effectiveness will not be evaluated; all analyses will be of an exploratory nature.

Methods

As part of the RECREATE programme of work (comprising 5 workstreams), we propose to develop and evaluate a complex intervention to reduce sedentary behaviour after stroke. We will develop the intervention with appropriate implementation plans through a co-production approach incorporating behaviour change principles.

Workstream 1
Update of the quantitative and qualitative evidence relating to sedentary behaviour through systematic review of the literature. The literature will be analysed to identify behaviour change techniques contributing to effectively reducing sedentary behaviour.

Workstream 2
Observations (in hospital and in the community) and semi-structured interviews in two stroke services will be undertaken to inform the co-production process. Interviews with patients and their carers, at six and nine months post-stroke (approximately 10 at each time point, in each service), and with members of the multidisciplinary team, will explore the capability, opportunity and motivation to address sedentary behaviours from their perspectives. Interviews will be analysed using Framework Analysis.

Workstream 3
Informed by previous workstreams and behaviour change principles, development of an agreed intervention to reduce sedentary behaviour through use of co-production principles in two stroke services.

Workstream 4
A case study and action research approach will be used in three services to clarify: content; methods of delivery of the intervention; fidelity assessment and capture learning from, and acceptability to, staff and participating stroke survivors. Trial procedures relating to patient eligibility criteria, recruitment process and data collection will also be clarified. It is anticipated that 15 patients (and carers if available) will be recruited in each service.

Workstream 5
A multicentre pragmatic pilot cluster Randomised Controlled Trial (cRCT) evaluating an intervention to reduce sedentary behaviour in stroke survivors with embedded process and economic evaluations.
Information for participants (stroke survivors and carers) can be found here: https://ctru.leeds.ac.uk/recreate/participants/

Outputs

Johansson JF, Shannon R, Mossabir R, Airlie J, Ozer S, Moreau LA, Farris A, Mead G, English C, Fitzsimons CF, Clarke DJ, Forster A, on behalf of the RECREATE Programme Management Group. Intervention to reduce sedentary behaviour and improve outcomes after stroke (Get Set Go): a study protocol for the process evaluation of a pilot cluster randomised controlled trial (RECREATE)BMJ Open 2023;13:e075363. http://orcid.org/0000-0003-3622-9598

Airlie J, Burton L, Copsey B, English C, Farrin A, Fitzsimons CF, Holloway I, Horrocks J, Johansson JF, Mead G, Moreau LA, Ozer S, Patel A, Yaziji N, Forster A, on behalf of the RECREATE Programme Management Group. RECREATE: a study protocol for a multicentre pilot cluster randomised controlled trial (cRCT) in UK stroke services evaluating an intervention to reduce sedentary behaviour in stroke survivors (Get Set Go) with embedded process and economic evaluations. BMJ Open 2023;13:e074607. https://doi.org/10.1136/bmjopen-2023-074607

Johansson JF, Lam N, Ozer S, Hall J, Morton S, English C, Fitzsimons C, Lawton R, Forster A, Clarke D. A Systematic Review of Process Evaluations of Interventions in Trials Investigating Sedentary Behaviour in Adults. BMJ Open 2022;12(1):e053945; http://dx.doi.org/10.1136/bmjopen-2021-053945

Hall JF, Corepal R, Crocker TF, Lam N, Burton L, Birch K, Carter G, Clarke DJ, English C, Farrin A, Fitzsimons CF, Hall J, Holloway I, Ozer S, Lawton R, Mead G, Morton S, Patel A, Forster A. A systematic review and meta-analysis of non-workplace interventions to reduce time spent sedentary in adults. medRxiv 2021. https://doi.org/10.1101/2021.05.27.21256673

Morton S, Hall J, Fitzsimons C, Hall J, English C, Forster A, Lawton R, Patel A, Mead G, Clarke DJ. A qualitative study of sedentary behaviours in stroke survivors: non-participant observations and interviews with stroke service staff in stroke units and community services. Disability and Rehabilitation 2021, 44(20):5964-5973. https://doi.org/10.1080/09638288.2021.1955307

Hall J, Morton S, Hall J. Clarke DJ, Fitzsimons CF, English C, Forster A, Mead GE, Lawton R. A co-production approach guided by the behaviour change wheel to develop an intervention for reducing sedentary behaviour after stroke. Pilot Feasibility Studies 2020; 6:115. https://doi.org/10.1186/s40814-020-00667-1

Hall J, Morton S, Fitzsimons CF, Hall JF, Corepal R, English C, Forster A, Lawton R, Patel A, Mead G, Clarke DJ. Factors influencing sedentary behaviours after stroke: findings from qualitative observations and interviews with stroke survivors and their caregivers. BMC Public Health 2020;20:967. https://doi.org/10.1186/s12889-020-09113-6

Corepal R, Hall JF, English C, Farrin A, Fitzsimons CF, Forster A, Lawton R, Mead G, Clarke D.  A protocol for a systematic review of process evaluations of interventions investigating sedentary behaviour in adults.  BMJ Open 2019;9:e031291. https://bmjopen.bmj.com/content/9/9/e031291

Rawlings G, Willliams R, Clarke D, English C, Fitzsimons C, Holloway I, Lawton R, Mead G, Patel A, Forster A. Exploring adults’ experiences of sedentary behaviour and participation in non-workplace interventions designed to reduce sedentary behaviour: a thematic synthesis of qualitative studies. BMC Public Health 2019;19:1099. https://doi.org/10.1186/s12889-019-7365-1

Morton S, Fitzsimons C, Hall J, Clarke D, Forster A, English C, Chastin S, Birch KM, Mead G. Sedentary behavior after stroke: A new target for therapeutic intervention. International Journal of Stroke 2019;14(1):9-11. https://doi.org/10.1177/1747493018784505

Partners & Collaborators

Investigators
Anne Forster, David Clarke, Karen Birch, Gill Carter, Ivana Holloway, Sue Oxley, Amanda Farrin, Anita Patel, Coralie English, Gillian Mead, Rebecca Lawton, Claire Fitzsimons.

Collaborators
Bradford Teaching Hospitals NHS Foundation Trust, University of Leeds, University of Edinburgh, Kings College London and University of Newcastle (Australia)

Timescales

01/10/2017- 30/09/2024

Funding agency

National Institute for Health and Care Research (NIHR)

Further information

For further information contact Anne Forster

This summary presents independent research funded by the National Institute for Health and Care Research Programme Grants for Applied Research (NIHR PGfAR)  (Grant Reference Number: RP-PG-0615-20019). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.