# data[].attributes.body
Can move 1. perceptions of changing SB as an arrow appearing and moving across the six domains for presentation  even though perceptions play out in different ways, their inherent perceptions underpin their experience
++ read super responders and see if common thread -- see attributes
-- any quotes to pull out regarding self-efficacy

For thesis
- pull out quotes re: perceptions of changing SB - things we couldn't change (e.g. physical incapability overwhelming - insert quote)

Summary of Sarah's feedback - why current model doesn't explain
WIthin model, need to see how people's perceptions then moderate their experience of the intervention - current model seems more linear when its more complex.
Whether or not people responded/didnt...have to look at their responses/perceptions in context of that. E.g. how many people talked about it who were responders vs. didnt - so you can clearly see what do we need to do to change their behaviour successfully. For thesis --> IDENTIFY + PULL OUT PATTERNS what is it about people who responded to intervention, what is different in their perceptions. Key message we want to pull out - if there's no pattern, we may need to use other methods/questions to explain why it's so difficult to change behaviour.

RQ1: perceptions, pull out as separate box (Figure 1) and explore that in thesis.
RQ2: (Figure 2) Opening sentence like "perceptions of SB underpinned the way participants experienced the Rx..Although the majority found it acceptable and were satisfied with components of the intervention, they still reported barriers to reducing SB e.g. physical limitations and comorbidities, prioritising enjoyment of SB over potential perceived benefits to health")
(break down according to COM-B domains isntead of by Rx components)

Physical capability: few participants reported Rx directly improved levels of breathlessness/pain/fxal capacity. Majority spoke in great deal about their limitations in terms of braethlessness, exacerbations, managing chronic pain, and these problems weren't directly addressed the Rx and continued to prevent participants reduce SB despite their motivation/understanding. (examples)
Psychological capability: many satisfied with education component of Rx which they felt improved awareness + provided greater understanding of how to self-manage e.g. problem solving skills (examples)
next paragraph: break it down between responders and non-responders. E.g. those with higher levels of self efficacy found education component highly motivating and that helped drive behaviour change (e.g. R4: i really needed something to help me motivate myself and understand my breathing...that motivation for me to do walking, that helped). In contrast, people who did not feel Rx improved/increased perceived benefit felt reducing SB would not improve health (e.g. P1 - i'm not that kind of person - psychological consequences P44 reference 1 - the whole process was just talking.....she gave me enthusiasm......--> people with high self efficacy then felt more motivated to change (i.e. education increases motivation). Education also increases knowledge and confidence leading to change. However in some, education was insufficient to lead to change. Education makes people more motivated to change, reduces anxiety, increases consequence, some don't change.

Physical opportunity

Reflective motivation
Conflicting perceptions about satisfaction and priorities with goal setting process. On one hand some felt it provided sense of achievement and pushed them. However some participants found it difficult to find ways to change their SB because it was such an enjoyable activity + prioritised their enjoyment. Include quote in presentation, or others like P3 - crosswords.
One particular aspect of goal setting process that seemed to motivate participants was achieving a certain step target and receiving real-time feedback from the FitBit (more related to reflective motvn aspect now - physical opportunity more about providing awareness/reminders).

Certain personal drivers appeared to enhance the satisfaction with the Rx (e.g. participants who had personal encounters with illness strongly perceived that increasing PA and reducing SB was going to prevent those negative consequences for them and (insert quote e.g. want to be here for grandkids etc). or if goals were orientated around weight loss and that was a motivation people appeared more motivated.
Those who perceived becoming less active was a natural process of aging lacked motivation and engagement in goal setting process.
Examples of passive...or people who perceive themselves to be active, was difficult to set goals. (P1 or P7 - "was already fit" or wanted more or something else like PR)

# data[].attributes.body
Results =

Main factors influencing perception of SB (RQ1)

People's perceptions of Rx (acceptability + satisfaction e.g. participants expressed enjoying setting of intervention, components such as written action plan, important to build rapport with HCP). Overall, majority found device to prompt behaviour was useful.

How it influenced behaviour - all components raised in above addressed again - helped to increase education + awareness and increase feelings of psychological capability to change behaviour. Collaborative goal setting + incremental progressive goal setting helped push participants and increase reflective motivation to change.

Drawing links between the two - was there consistent component of Rx that people said influenced SB in positive way?

??? Or can structure under heading of each component (e.g. Jawbone - address all above) (might be better)
-- Four main components: Jawbone, goal setting, therapeutic relationship, education
- Under each one:

how did people perceive it (+ or -)?

In terms of COM-B model, how did it influence behaviour?

In which participants did it influence behaviour (link to RQ1 - e.g. participants who already had high levels of self-efficacy + internal locus of control found Jawbone very useful and pushed them + enjoyed getting feedback compared to those who had high levels of enjoyment in SB, even though they felt vibrations they prioritised SB over standing up)

+ include graph
OR NOW, ORGANISE ACCORDING TO COM-B COMPONENTS --- see pink sticky note...

DISCUSSION

From RQ1 - these are the perceptions we found. While info itself was not new (consistent with previous facilitators + behaviours research on people with COPD + older adults on changing SB). What is novel is the information is necessary prior to conducting Rx and Rx should be informed by these perceptions and individualised before executing it. Need that info prior to doing intervention - we know physical and psychological limitations prevent COPD. But what we did learn is Rx might need to be targeted to target specific motivations of individuals - maybe good to explore beforehand (e.g. weight loss identified as goal, would inform Rx to target that to motivate participants). Link to SEAT study = e.g. participants saying needed to have medical side of things taken care of before engaging in Rx; people felt hopeless + condition progressive

Main components of behaviour that Rx addressed

Addressed psychological capability, physical opportunity, motivation

Matches hypothesis that these are modifiable aspects of behaviour

Talk about other interventions which have targeted SB and whether or not they worked

E.g. occupational studies increasing physical opportunity by giving people a standing desk.

E.g. small steps - incremental goal setting to give people a sense of success.

These appear to be effective components of intervention as what participants perceive.

Aspects of Rx that participants perceived as not influencing behaviour/couldn't change

E.g. very few participants said Rx improved breathlessness/pain (i.e. physical capability) --> timing of interventions, maybe people need to go PR first or have comorbidities addressed before can start to address SB

Should this be an intervention that should be combined with PR?

Perhaps one size fits all approach (e.g. all participants attend Rx before PR) won't work. Intricacies of when this intervention shuold be posed to people is an interesting question

Options = before PR, during, after. Decision making process dependent on people's original fitness level and belief on what is limiting atm. E.g. if psychological limitations, maybe being speaking them in this way through the Rx is best. If physical limitations, perhaps PR first would be best.

(addendum/note to self: e.g. P11 mentioned not feeling confident/more capable of doing more intense PA after Rx; mentioned benefits of previous engagement in PR)

Couldn't change how much SB is habitual + enjoyable. E.g. gives older adults a sense of purpose and meaning, many SB perceived to have cognitive benefits (e.g. crosswords). Maybe while we thought SB was more feasible, maybe it's something we shouldn't be changing as it gives people a sense of enjoyment. Maybe should be focusing on driving LIPA as focus of Rx (i.e. more movement is better e.g. walk more rather than specifically addressing SB i.e. sit less) (see COPD SEAT)

Suggestions for future improvements

Participants wanted longer follow up - may need more time for behaviour change to take place, not just over 6 weeks

Earlier access to MDT - for these people maybe PR is what they need to go to first.

Personalised approach - determination of timing of BCRx with other important interventions like PR

Limitations

While the COM-B model gave structure within which to code people's statements, it was limited in xyz. Deductive approach. Methodology (e.g. use of framework to view data) --> not everything neatly fits in model.

Further investigations triangulating the response outcomes of the objective measures of RCT with people's perceptions obtained from qualitative analysis may be something that needs to be done in future work.

# data[].attributes.body
Break results up according to RQ1 and RQ2

Summary + link to table including quotes

If we decide on incorporating responders vs. non-responders can link to another table within the same aim

OR can do RQ1, RQ2, 3
++ include participant flow chart diagram, see email from Zoe (in press copy of support)

Discussion
Paragraph 1 = main findings (e.g. first study that showed xyz). Main findings were....
Discussive paragraph on each of the main results - e.g. paragraph about aim 1 and 2 themes, and responders vs. non --> incorporate literature. Make sure discussion paragraph is clear as if reader hasn;t read previous parts.

Consider other paragraphs: limitations (e.g. not capturing control group, drop outs, people who declined to participate as would probs have differing perceptions on SB, used COM-B framework as deeply ingrained in intervention)

Conclusion paragraph
Future studies of this need to occur
Or make up suggestions based on limitations for future studies

# data[].attributes.body
?Sounds like phrased more so from researcher's perspective/repeating rationale of how intervention was structured (i.e. to ideally target xyz)
--- should sound fine if backed up by quotes

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Replacing SB with standing perceived to be unnatural, inconvenient

# data[].attributes.headline
Which parts of behaviour did the BCRx influence as per COM-B

# data[].attributes.subject
Which parts of behaviour did the BCRx influence as per COM-B

# data[].attributes.body
The behaviour change intervention was perceived to influence SB in the following ways:

1.  Improving psychological capability by educating participants and equipping them with self-management strategies

2.  Providing physical opportunities to reduce SB by using cues and real-time feedback

3. Encouraging reflective motivation through collaborative and progressive goal setting

4. Facilitating automatic motivation through the therapeutic relationship and by personally experiencing benefits of LIPA.

# data[].attributes.body
Perceptions of changing SB were shaped by four factors:

1. Physical limitations

(particularly breathlessness, lower limb pathologies)

2. Psychological limitations

(subthemes include fear and anxiety associated with increased PA, lack of perceived benefits of reducing SB)

3. The perceived inevitability of sedentary behaviour

(dependent on age, job demands, enjoyment, lack of awareness)

4. Personal drivers for reducing sedentary behaviour.

(subthemes include encounters with illness increases motivation to reduce SB, influence of friends and family, weight loss, high self-efficacy)

Anomalies: P11 - responder despite seemingly low levels of motivation/patient-activation (?)

# data[].attributes.headline
Future improvements for the intervention

# data[].attributes.subject
Future improvements for the intervention

# data[].attributes.body
Increase duration of intervention to enable habit formation

Long-term follow up

Access to other health professionals and/or resources within the multidisciplinary team

# data[].attributes.body
Summary (e.g. physical limitations to reducing SB included OA, LBP)

Supporting quotes

Differences between responders and non-responders

Literature findings (e.g. participants enjoyed having HCP come to their home as it minimised travel. Supported by x et al. study on home-based rehab)

NB: current qual literature mainly on PA - address in intro and define difference. SB as low end of PA. Do a quick lit review but mainly 1) SEAT-COPD study and 2) Small steps paper, ??cardiac rehab. Oldder adults community dwelling = McEwan, 2016 small steps + study prince - chase up if qual data.

Anomalies

# data[].attributes.headline
Acceptability and satisfaction with other components of intervention

# data[].attributes.subject
Acceptability and satisfaction with other components of intervention

# data[].attributes.body
Written action plan

Device (comfort, ease of putting it on, charging)

# data[].attributes.body
Was "nice", "personal", "caring" to receive intervention in the home (therapeutic relationship)

Presence of/supervision from qualified health professional increases safety/confidence, helps validate health concerns

Experienced benefits of LIPA (stress relief, enjoyable, 'feeling better')

# data[].attributes.body
Collaborative goal setting

Incremental/progressive goal setting provides a sense of achievement and "pushes" participants

# data[].attributes.body
? Rapport and meaningful relationships formed with the health professional
? Open lines of communication enables participants to receive timely reassurance and advice
Therapeutic relationship with a qualified health professional facilitates compliance

# data[].attributes.body
Choice to have intervention delivered in participants' home minimises travel and provides flexibility with participants' other commitments

Cues and real-time feedback (via Jawbone/Fitbit device or via activPAL) directly prompts breaks in SB or increases in LIPA (though sometimes ignored if perceived to be inconvenient e.g. while engaging in enjoyable SB)

# data[].attributes.body
Increased awareness/feedback on SB++

Education (understanding health effects of SB and PA, understanding of COPD, self-management strategies)

Though different participants had different takeaway points re: education

# data[].attributes.body
? Direct improvements in breathlessness, pain or functional capacity

# data[].attributes.headline
RQ2: Participants' perceptions of BCRx and how it influenced SB

# data[].attributes.subject
RQ2: Participants' perceptions of BCRx and how it influenced SB

# data[].attributes.body
Fear + anxiety associated with increased PA, esp. when susceptible to breathlessness

Lack of understanding/of perceived benefits of reducing SB

# data[].attributes.body
COPD-specific

Breathlessness, dyspnoea

Prone to infections, exacerbations

Multi-morbidity

LL issues ++

?General deconditioning

# data[].attributes.body
Encounters with illness (personal + loved ones)

Patient activation/self-efficacy/internal locus of control

Wanting to enhance wellbeing/longevity/functional capacity

Manifests in implementation of self-management strategies

Influence of friends and family

Incidental and intentional PA undertaken together

Encouragement provided to reduce SB

Weight loss

# data[].attributes.headline
SB is enjoyable, habitual, necessary, relaxing

# data[].attributes.subject
SB is enjoyable, habitual, necessary, relaxing

# data[].attributes.body
Difficulty changing habits

Age (some resigned)

Work/job demands

Enjoyment

Lack of awareness of own SB