Exploring the perspectives of stroke survivors and healthcare professionals on the use of mobile health to promote physical activity: A qualitative study protocol

Design

This research will employ a qualitative design to explore stakeholder perspectives on the use of mHealth for the promotion of PA⁴². A qualitative descriptive approach was chosen for its ability to offer broad and rich information, as well as straight descriptions of participants’ attitudes toward the development of a potential mHealth-based intervention^43,44. This approach is noted for its usefulness in gaining preliminary insight into a topic and in collecting the first-hand experiences of patients and HCPs⁴³. The conduct and reporting of this study will be in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist for focus groups to ensure rigor, comprehensiveness and credibility⁴⁵.

Research team roles and prior experience

All focus groups will be moderated, transcribed and analysed by D.C., an occupational therapist and PhD candidate. D.C. has completed training in qualitative research which focused on developing the skills of early-career researchers as part of his graduate studies. It included a focus on developing reflexive skills, strategies for improving credibility during analysis, as well as writing. D.C. also has experience of appraising and synthesising qualitative research⁴⁰. K.R. is a senior lecturer in occupational therapy and an experienced qualitative researcher. K.R. will provide critical feedback throughout the analysis and dissemination stages. S.H. is a lecturer in physiotherapy and an experienced quantitative researcher. S.H., as the principal investigator, has led on the conceptualisation of this research and will contribute to the analysis and dissemination stages. J.F. is an experienced quantitative researcher and health economist with experience in randomised controlled trials of health interventions and programmes for stroke survivors. He has played a large role in planning the study and will also play a role in the final stages of analysis and writing. J.W. is an experienced health psychologist with extensive experience in mobile technology and health behaviour change. J.W. has contributed to the development of the topic guides and will contribute to the analysis, particularly with regards health behaviour change.

Recruitment and participants

Community-dwelling stroke survivors and HCPs will be recruited purposively. Previous research suggests that an estimated 80% of themes are identifiable within three to four focus groups⁴⁶ and that the modal recommendation for number of individuals participating in a focus group is eight⁴⁷. However, recruitment will continue until data saturation has been reached, as indicated by redundancy in the data and no new themes being generated⁴⁸.

Stroke survivors will be recruited from an early supported discharge service for acute stroke patients associated with a regional hospital in the Mid-West of Ireland and local stroke support groups in the Mid-West and Dublin regions of Ireland. Stroke survivors living in the community and able to voluntarily participate will be sought. However, those with severe impairment following stroke will be excluded as it may preclude an individual’s ability to use mHealth apps^32,49 and the development of a mHealth intervention for those with more severe impairment is beyond the scope of the current study. Individuals with minimal cognitive and communication impairments are sought to ensure ability to engage in focus group discussions.

HCPs will be recruited through the same acute hospital setting as stroke survivors, as well as two professional bodies (the Association of Occupational Therapists of Ireland and the Irish Society of Chartered Physiotherapists), and Twitter. Representatives from medical, nursing, and the allied health professions will be eligible to attend the focus groups.

All participants must be willing and able to provide informed consent. There is no connection between researchers and participants in either stakeholder group.

Data collection

Focus groups are a popular method of data collection in health research⁵⁰ and have previously been used to explore lifestyle beliefs and behaviours⁵¹ as well as the adoption of technology⁵² by stroke survivors. They will be used to capitalise on the shared experiences⁵³ within the two stakeholder groups. A semi-structured topic guide comprised of open-ended questions is typical in qualitative descriptive studies⁴³ and will support the researcher to remain flexible by adapting questions and expanding on ideas^42,47. This method allows participants to build on one another’s comments by developing, undermining and qualifying their statements and generating rich data in the process⁴². Importantly, focus groups do not discriminate against individuals who have difficulty reading or writing and can encourage contributions from those who feel they might have nothing to say or those intimidated by one-to-one interviews⁵³. The power differential between HCPs and patients has been explored previously⁵⁴ and, with a view to minimising the effect of this, focus groups with stroke survivors will be conducted separately from those with HCPs to facilitate candid discussion. Each focus group is expected to last one hour and, in instances where scheduling difficulties or non-attendance occurs, one-to-one interviews will be completed using the same topic guide.

Data will be stored in accordance with the University of Limerick’s Data Protection Policy. Participants will be assigned a unique participant number as each focus group is transcribed. A separate, password-protected Excel file will hold participants’ details and their unique participant number on a password protected laptop. Audio files will be deleted after transcription and the research team will only have access to anonymised transcripts. These transcripts will be stored on a password-protected laptop. Transcripts will not be offered to participants. Consent forms will be stored on-site at the School of Allied Health in a locked cabinet. Data will be retained for seven years. After this time, all electronic copies of data will be deleted and all hard copies will be shredded.

Topic guides

Topic guides were developed by reviewing relevant qualitative literature and are available as Extended data⁵⁵. As noted above, a systematic review was conducted to explore the experiences of adults using mHealth for the promotion of PA⁴⁰. Although no studies exploring the experiences of stroke survivors were identified, it did note the central role of motivation. For this reason, behaviour change theory was considered important in developing the topic guides. Guidelines from the National Institute for Health and Care Excellence (NICE) recommend that interventions targeting behaviour change should incorporate relevant theory and highlight the Capability, Opportunity and Motivation (COM-B) Model⁵⁶ developed by Michie and colleagues as part of their Behaviour Change Wheel framework⁵⁷. This model proposes that behaviours arise from an interaction between capability, opportunity, and motivation, and that a successful behaviour change intervention must address deficits related to one or more of those conditions^56,57. The COM-B model has previously been applied to guide an exercise intervention in adult stroke survivors⁵⁸ and was selected to inform the topic guides for both stakeholder groups. Qualitative studies exploring patient and HCP attitudes towards digital health interventions for blood pressure management^59,60 and barriers and facilitators to PA in stroke survivors^61–63 also contributed to the included questions.

The topic guide for stroke survivors will explore their current level of PA in the context of the COM-B model⁶⁴ in preparation for asking them to consider using mHealth to promote PA. This topic guide will incorporate a “think aloud” component where participants interact with a mHealth app while saying out loud their thoughts⁴¹. This strategy was selected to facilitate discussion by making the idea of a mHealth intervention less abstract. Think-aloud strategies have been recommended for engaging end-users in mHealth app development⁶⁵ and have been used effectively in exploring patients’ attitudes towards digital health interventions^59,66,67. The app selected for stroke survivors to interact with is “Active 10” by Public Health England⁶⁸. It encourages brisk walking and was selected because it is currently being promoted by general practitioners^69–72 and public health nurses^73,74 and because it contains features commonly reported in apps aimed at promoting PA^35–37.

The topic guide for HCPs will explore their perspectives on barriers and facilitators to PA in stroke survivors^61–63 in the context of the COM-B model⁶⁴. Questions specific to HCPs were informed in part by a systematic review exploring barriers and facilitators to mHealth adoption by health professionals⁷⁵. This review identified 179 elements related to barriers and facilitators and separated these into four domains. These domains included mHealth characteristics (e.g. perceived usefulness and ease of use), individual factors (e.g. familiarity with mHealth and technology), external factors related to the human environment (e.g. patients’ attitudes to mHealth), and external factors related to the organisational environment (e.g. workload and human resources).

Analysis

Focus groups will be audio-recorded, transcribed and exported to NVivo (Version 12, QSR International) for analysis by D.C. Thematic analysis was selected for its theoretical flexibility, as well as its ability to generate findings which are accessible to the educated general population, supporting dissemination to HCPs and stroke survivors alike⁷⁶. An iterative approach to analysis will be taken where data collection and analysis occur concurrently to inform one another⁷⁷. The current study will rely on an essentialist/realist paradigm, which assumes a unidirectional relationship between meaning and experience and language, and supports the theorising of participants’ experiences, meanings and realities in a straightforward way⁷⁶. Data will be analysed inductively with codes based on the content of data rather than relying on existing concepts or frameworks⁷⁶. Themes will be identified on a semantic level with a focus on the explicit content of the transcripts⁷⁶. Standard approaches to ensuring trustworthiness will be employed, including engaging in reflexivity through the self-disclosure of biases and assumptions which might influence the interpretation of data, documentation of decisions made throughout the process in the form of an audit trail, and negative case analysis with a view to scrutinising emerging themes against any discrediting data^78,79.

The thematic analysis will be carried out in accordance with the six steps outlined by Braun and Clarke^76,80. The first step will involve familiarisation with the data. This will be achieved initially through transcription and again through reading and rereading the data. Initial thoughts will be recorded during this process to inform the next step. The second step will involve generating initial codes systematically across the data set⁷⁶. All segments of data potentially relevant to the research question will be coded. In the third step, searching for themes will commence. This will involve identifying overlapping codes⁸⁰, with each theme representing a pattern of responses in the data⁷⁶. Step four will involve reviewing potential themes. This will require questioning the boundaries of and judging whether there is sufficient data to support each theme. In step five, clear definitions and names will be established for each theme. The sixth step involves producing the final report. This will be achieved through the preparation of a manuscript which weaves together the themes in a logical and meaningful manner, generating a compelling story of the data drawn from the analysis⁷⁶. Themes will be supported by anonymised quotations from participants.

Ethics approval and consent to participate

Ethical approval has been granted by the HSE Mid-Western Regional Hospital Research Ethics Committee [REC Ref 102/17] and the Faculty of Education and Health Sciences Research Ethics Committee at the University of Limerick [2019_04_04_EHS]. At the start of each focus group, D.C. will review the participant information leaflet with participants. It will be made clear in writing and orally that the current study forms a component of D.C.’s doctoral studies, that participation is voluntary in nature, that the right to withdraw at any time is guaranteed, that data will be stored securely and that participants will not be identifiable in any output generated. Each focus group will only commence when informed consent from all participants is received.

Dissemination

Following the analysis, the findings will be submitted for publication in peer-reviewed journals. They will also be presented at relevant international academic conferences in the areas of mHealth or stroke. The findings will be presented locally to attendees of groups which support stroke survivors.

Underlying data

No underlying data are associated with this article.

Extended data

Open Science Framework: Exploring the perspectives of stroke survivors and healthcare professionals on the use of mobile health to promote physical activity. https://doi.org/10.17605/OSF.IO/W4JQZ⁵⁵.

This project contains the stakeholder topic guides.