Behaviour change and physical activity interventions for physical activity engagement in community dwelling adults with chronic obstructive pulmonary disease: protocol for a systematic review

Introduction

Chronic obstructive pulmonary disease (COPD) is a complex disease and the third leading cause of death worldwide¹. The World Health Organisation (WHO) estimates that approximately 65 million people are currently living with moderate to severe COPD globally². COPD is a heterogenous disease, defined by persistent, irreversible obstructive airflow limitation and characterised by recurrent exacerbations¹. The disease mainly encompasses two phenotypes; emphysema and chronic bronchitis with symptoms including chronic airways inflammation, sputum production, cough, breathlessness and reduced oxygen levels³. With the exception of alpha-I anti-trypsin deficiency, COPD was thought to be caused by exposure to noxious substances, the main causative factor traditionally identified as smoking⁴. A body of emerging evidence, however, suggests that exposure to biomass fuels and air pollution, genetic abnormalities, poor nutrition, early childhood lung infection, chronic asthma and abnormal lung development could also contribute to an accelerated decline in lung function^4–8. COPD often co-exists with morbidities such as cardiovascular disease, cerebrovascular disease, diabetes and depression⁹. People living with COPD are therefore at high risk of developing poor outcomes, such as increased healthcare utilisation and poorer quality of life (QoL)⁷.

In COPD, patients can experience frequent exacerbations which can result in a gradual decline in physical and respiratory function over the disease trajectory¹⁰. Patients can experience periodic worsening of symptoms, referred to as acute exacerbations, which are often aggravated by environmental factors and/or respiratory infections¹¹. Medical management strategies in COPD, such as the use of inhaled medications^12–15, oxygen therapy^16,17 and ventilatory support^18,19 are commonly employed to reduce symptoms, frequency of exacerbations, hospital admissions and to improve quality of life (QoL) of those living with COPD^20–22. Non-pharmacological management of COPD in the form of pulmonary rehabilitation consists of a supervised, tailored programme, often six to 10 weeks duration, offering physiological, psychological and social health benefits²³ and is recognised as the gold standard of care in the management of COPD^1,6,24. Programmes are based on on-going assessments of the patient’s individual disease stage, exercise capacity and co-morbidities²⁵. Pulmonary rehabilitation can be integrated into patient care at any stage of the disease, with the over-arching goal of fostering patients’ long-term engagement with physical activity and healthy behaviours^23,26,27. High attrition rates from pulmonary rehabilitation programmes are common however, resulting in lower physical activity levels among people living with COPD²⁸.

Physical inactivity leads to higher rates of morbidity, mortality and poorer QoL^29,30, and people with COPD are less active than people without COPD³¹. The majority of people with COPD reduce their levels of activity in the earliest stages of the disease, walk at a slower pace and do not generally meet the WHO recommended physical activity guidelines of 150 minutes of moderate intensity exercise per week^29,32–34. The WHO’s “Rehabilitation 2030: a call for action” outlines not only the necessity for research in the area of rehabilitation, but also for the ease of accessibility and affordability of rehabilitation for all, as essential for health management². Troosters et al.³⁵ report an approximate decline in steps-per-day-per-year as minus 450 in this population, the cause of this decline being multi-factorial. As such, strategies to understand and address low activity levels in this cohort must also be multifactorial.

The benefits of hospital-based pulmonary rehabilitation, for those who have the opportunity to attend, are well evidenced²⁸. These benefits, however, are not always sustained. Egan et al.³⁶, for example, reports that attendees with COPD (n=45) at a seven week hospital-based pulmonary rehabilitation programme experienced greatest benefits in outcomes such as breathlessness (Borg p=0.001) and physical conditioning (Incremental shuttle walk test (ISWT) p=0.013, 6MWT p=0.001) in the short and medium-term (at seven weeks and 20 weeks), but these effects were not sustained in the long-term (at 52 weeks) (Borg p= 0.011, ISWT p= 0.028, 6MWT p= 0.030). It is suggested in the literature that supporting positive behaviour change in people with COPD could help to increase engagement with physical activity^35,37,38. In order to elicit effective behaviour change, appropriate behavior change strategies must form part of physical activity interventions in those with COPD, thus facilitating translation of the benefits gained in pulmonary rehabilitation into greater life-long physical activity^25,35.

Healthy behaviour change interventions can be complex, and are often targeted at a number of levels e.g. policy level, community level and/or interpersonal level in order to achieve the optimal combination for each individual person³⁸. For behaviour change interventions to succeed they should involve all stakeholders, including the patient and multidisciplinary team³⁹. The most effective behaviour change techniques are evidence-based and targeted at affecting change in the factors influencing an individual’s behaviour³⁸. While several theories exist with which to examine an individual’s behaviour, for example the theory of planned behaviour⁴⁰ and the transtheoretical model of behavioural change⁴¹, there is a paucity of such research related to behaviour change and physical activity engagement and people with COPD.

Michie et al.’s⁴² COM-B model of behaviour change is well recognised in health literature. The COM-B model sets out to contextualize an individual’s behaviour from the perspective of capability, opportunity and motivation⁴³. When used in conjunction with the theoretical domains framework (TDF)⁴², a framework that synthesizes 33 theories of behaviour change into 14 domains related to, for example, knowledge, skills, beliefs, motivation, memory, influences and emotion⁴⁴, the COM-B model and the TDF combine to provide a lens through which analysis of an individual’s key behavioural determinants can take place, and thus the identification of appropriate behaviour change interventions. The COM-B and TDF have been used successfully to support behaviour change in a number of chronic conditions, for example in physical activity and counselling in obesity^45,46, timely symptom presentation in cancer⁴⁷ and behaviour change techniques in diabetes⁴⁸. However, to date the behaviour change model has rarely been applied to physical activity and adults with COPD living in the community.

In one of the few studies to examine behaviours of people with COPD using the TDF, Wshah et al.³⁷ qualitatively explored and reported on the determinants of sedentary behaviour of 14 participants with COPD. This study found that participants lacked insight into the meaning of sedentary behaviour and, when mapped to the TDF, participants’ sedentary behaviour was mainly influenced by lack of knowledge, beliefs pertaining to capabilities, environment, resources and society. Studies in COPD have reported strategies such as tele-coaching⁴⁹ self-management⁵⁰, and counselling^51,52 as effective behaviour change mechanisms to increase physical activity. In these studies, however, authors did not examine determinants of behaviour, sample sizes were small and attrition rates were high^35,53–55. It remains unclear, therefore, which are the most effective behaviour change and physical activity interventions to promote and increase engagement with physical activity in COPD. The aim of this systematic review is to evaluate behaviour change and physical activity interventions, aimed at improving outcomes for community dwelling adults with COPD. As observed in other chronic disease research, the COM-B model and TDF can work synergistically to examine the underlying determinants of behaviour and inform appropriate behaviour change strategies⁴⁴. Interventions from included studies will be identified and mapped against Michie’s theoretical domains framework in order to help inform clinical practice and relevant policy change for this important cohort of people with COPD.

Methods

This systematic review will focus on randomised controlled trials which include behaviour change and physical activity interventions for community dwelling adults with a diagnosis of COPD. This systematic review will be reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines⁵⁶. The review was registered at PROSPERO (CRD42021264965) on the 29^th June 2021. This protocol is reported in line with the PRISMA-P guidelines⁵⁷.

Conclusion

The primary aim of this systematic review is to evaluate behaviour change and physical activity interventions with the aim of improving outcomes for community dwelling adults with COPD. Secondary aims include identification and mapping of behaviour change interventions and their subsequent impact on physical activity levels, to Michie et al.’s TDF⁴², identification of commonly used theoretical frameworks against which community-based behaviour change and physical activity interventions are mapped, and to profile the scope of interventions used for people with COPD with respect to improving outcomes.

While recent literature has identified that behaviour change and physical activity interventions may be beneficial for increasing physical activity engagement in people with COPD^35,55, a systematic review of recent randomised controlled trials has yet to be published. The increasing burden of COPD on patients and healthcare systems globally warrants examination of methods to improve the QoL and management of people with COPD. This systematic review will consider behaviour change and physical activity interventions for community dwelling adults with all stages of COPD and their impact, if any, on levels of, or engagement with physical activity. It is hoped that the outcomes of this review will be applicable to patients, clinicians and policy-makers to inform their use of interventions for increasing engagement of community dwelling adults with COPD with physical activity. On completion, the results of this review will be submitted for peer-reviewed publication in this field and disseminated among relevant patient groups, clinicians and policy- makers at conferences, seminars and via social media.

Study status

The review has not yet been initiated.

Data availability