What questions did your review seek to answer?

Our review aimed to understand if including behaviour change techniques in exercise programs could help individuals with COPD adhere to regular structured exercise in the long-term to promote the longevity of training-related gains.

Behaviour change techniques are the observable, replicable and irreducible ‘active ingredients’ that require a high level of specificity when delivered as part of an intervention seeking to change behaviour.

The specificity in reporting the active ingredients is akin to the precision required when prescribing exercises.

To use terms such as ‘supervision’ or ‘counselling’ when describing active ingredients applied during exercise programs forgoes the necessary specificity and undersells what is actually being delivered.

With this in mind, we wanted to examine if applying behaviour change techniques during exercise programs or maintenance strategies influenced the longevity of training-related gains 12 months after the program has ended.

We explored this through two main questions:

• For individuals with COPD who complete an exercise-training program provided at a sufficient dose to result in training-related gains, do these gains last for at least 12 months after program completion?
• Do factors, such as applying behaviour change techniques, influence the maintenance of training-related gains?

To what extent do people with COPD maintain training-related gains from an exercise-training program?

We identified that improvements in exercise tolerance and health- related quality of life persisted at 12 months following completion of an exercise-training program lasting at least four weeks.

However, it was unclear whether participants maintained improvements in the perception of dyspnoea during daily living activities.

Did the application of behaviour change techniques influence maintenance of training-related gains in exercise tolerance and health-related quality of life?

Participants maintained gains in exercise tolerance in studies where an increased number of behaviour changes techniques were applied during the initial program.

Participants maintained gains in health-related quality when studies identified a clear focus on achieving long-term adherence to exercise, and the applied behaviour change techniques were reported with clarity.

While clear reporting of techniques alone does not change behaviour, it suggests that researchers carefully chose and applied techniques to achieve their behavioural target.

Although our results were presented with very low certainty, they highlight the importance of specifically targeting behaviour change during exercise interventions to promote the longevity of gains.

What clinical implications do you draw from those results?

Thoughtful consideration of achieving and sustaining behaviour change are important when designing and delivering exercise- training programs to people with COPD.

There are various established resources on behaviour change, such as Michie’s behaviour change taxonomy, that clinicians can consider incorporating to exercise-training programs.

Techniques applied during the initial program appeared just as important as what is applied during maintenance programs to sustain behaviour change.

However, there is no consensus on which specific techniques ‘work’. Further research is required in this area.

From an educational perspective, clinicians who seek to achieve behaviour change with their clients—particularly in chronic diseases like COPD—should undertake practical training in order to develop a clear understanding of the theory.

This can enable clinicians to thoughtfully select, apply and integrate behaviour change techniques in exercise programs.

This is particularly important, as the delivery of these techniques is known to influence their efficacy.

Embedding behaviour change theory, practice and application in undergraduate curricula will equip future clinicians to deliver these interventions effectively.

What do you think research in this field of research should address next?

We believe future research could be explored in three key areas.

Effectiveness of behaviour change interventions—we were unable to explore which specific active ingredients were successful in promoting long-term adherence to structured exercise.

Future research could help clinicians understand how to select and tailor the active ingredients to the individual to promote behaviour change.

For example, are certain active ingredients or combinations more effective than others are?

How can we adopt a person-centred approach and personalise these techniques for each individual?

Optimal implementation of behaviour change interventions—in addition to which active ingredients are useful to apply, future research could also focus on how to deliver these techniques (eg, provider, format, materials, setting, intensity, tailoring and style) to promote their effectiveness.

Standardised reporting of behaviour change interventions—having a standardised method to report behaviour change interventions enables researchers to evaluate their effectiveness.

>>Sarah Hug is a part-time senior physiotherapist at Royal Perth Hospital and a final-year PhD candidate at Curtin University. Her thesis investigates consumer- driven ways to optimise utilisation of pulmonary rehabilitation programs among people with COPD, with a particular focus on behaviour change.