Abstract
BackgroundThe ‘Older People’s Exercise intervention in Residential and nursing Accommodation’ (OPERA) cluster randomised trial evaluated the impact of training for care home staff together with twice-weekly, physiotherapist-led exercise classes on depressive symptoms in care home residents, but found no effect. We report a process evaluation exploring potential explanations for the lack of effect.MethodsThe OPERA trial included over 1,000 residents in 78 care homes in the UK. We used a mixed methods approach including quantitative data collected from all homes. In eight case study homes, we carried out repeated periods of observation and interviews with residents, care staff and managers. At the end of the intervention, we held focus groups with OPERA research staff. We reported our first findings before the trial outcome was known.ResultsHomes showed large variations in activity at baseline and throughout the trial. Overall attendance rate at the group exercise sessions was low (50%). We considered two issues that might explain the negative outcome: whether the intervention changed the culture of the homes, and whether the residents engaged with the intervention. We found low levels of staff training, few home champions for the intervention and a culture that prioritised protecting residents from harm over encouraging activity. The trial team delivered 3,191 exercise groups but only 36% of participants attended at least 1 group per week and depressed residents attended significantly fewer groups than those who were not depressed. Residents were very frail and therefore most groups only included seated exercises.ConclusionsThe intervention did not change the culture of the homes and, in the case study homes, activity levels did not change outside the exercise groups. Residents did not engage in the exercise groups at a sufficient level, and this was particularly true for those with depressive symptoms at baseline. The physical and mental frailty of care home residents may make it impossible to deliver a sufficiently intense exercise intervention to impact on depressive symptoms.
Highlights
Depression is common in older people living in residential and nursing homes
The OPERA (‘Older People’s Exercise intervention in Residential and nursing Accommodation’) trial was a cluster randomised trial based in care homes, in which we set out to test the impact of a whole home intervention including a structured, progressive physical activity programme on the incidence and prevalence of depressive symptoms [7]
Analysis After the trial had closed and while the analysis of the trial results was ongoing, we carried out a first analysis of the process evaluation results that we presented to the trial management team before the trial outcomes were known [6]
Summary
Depression is common in older people living in residential and nursing homes (care homes). The OPERA (‘Older People’s Exercise intervention in Residential and nursing Accommodation’) trial was a cluster randomised trial based in care homes, in which we set out to test the impact of a whole home intervention including a structured, progressive physical activity programme on the incidence and prevalence of depressive symptoms [7]. Process evaluations may be employed early in the development of new complex interventions or as a technique to study the implementation of interventions of proven effectiveness but, as Oakley and colleagues have argued, they may greatly improve and inform the findings of randomised controlled trials (RCTs) [9]. The ‘Older People’s Exercise intervention in Residential and nursing Accommodation’ (OPERA) cluster randomised trial evaluated the impact of training for care home staff together with twice-weekly, physiotherapist-led exercise classes on depressive symptoms in care home residents, but found no effect. We report a process evaluation exploring potential explanations for the lack of effect
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