Increasing walking in individuals with intermittent claudication
: The roles of walking treatment and illness cognitions

Student thesis: Doctoral ThesisDoctor of Philosophy


Background: Intermittent claudication (IC) is ischaemic leg pain associated with reduced walking ability. Walking is a recommended but underused treatment for IC. The Theory of Planned Behaviour (TPB) and Common Sense Model of Illness Representations (CSM) are frameworks for understanding and changing health behaviours, such as walking, through appropriate behaviour-change techniques (BCTs). This research evaluated cognitions about walking treatment and illness defined by the TPB and CSM, respectively, to inform the development and evaluation of a behaviour-change intervention (BCI) in people with IC.
Methods: Medical Research Council guidelines for developing and evaluating complex interventions informed five studies, including people with IC: a) a systematic review of randomised-controlled trials (RCTs) of interventions applying BCTs targeting walking; b) a qualitative exploration of experiences of and beliefs about walking and IC; c) a cross-sectional observational evaluation of TPB and CSM constructs for explaining walking intention and objective walking ability (6 Minute Walk Distance [6MWD]); d) a feasibility study of an RCT evaluating a physiotherapist-led BCI targeting objective walking behaviour (pedometer step count) and ability (6MWD); and e) a nested qualitative study evaluating the acceptability of the RCT and BCI to participants and a physiotherapist.
Results: a) The systematic review identified 6 RCTs, which reported 11 BCTs. Barrier identification and problem solving, self-monitoring, and feedback on performance were included in effective interventions. b) In the qualitative study (n=19), two themes (and five subthemes) emerged: 1) Walking is an overlooked self-management opportunity (IC is benign and leg pain can be overcome; IC is severe and there is nothing I can do); and 2) Tailored walking guidance is desired (Varied outcome expectations of walking; Barriers to walking to intensity; and Limited purposeful walking for exercise) among people with IC. c) A cross-sectional study (n=142) explained 73% and 28% of variance in walking intention and 6MWD. TPB constructs (β=0.23, 0.35, and 0.34 for attitude, subjective norm and perceived behavioural control) and perceived consequences (β=0.15) contributed to walking intention, whereas CSM constructs (β=-0.20, 0.32, 0.22, and 0.18 for treatment control, personal control, coherence, and risk factor attributions) contributed to 6MWD, beyond past walking behaviour. d) Feasibility of an RCT evaluating a home-based BCI was demonstrated (n=24): intervention adherence (71%), study retention (92%), and treatment fidelity evaluation methods met feasibility criteria, and a moderate treatment effect (Hedges g=0.39, 95% CI -0.47, 1.25) on objective walking behaviour, but not 6MWD, was found. e) Feasibility and acceptability of the protocol and interventions was confirmed by narrative accounts of participants and the physiotherapist in a nested qualitative study.
Conclusions: The TPB and CSM were evaluated and applied in the systematic development of a walking BCI for people with IC. Few high-quality RCTs were identified which evaluate BCTs targeting walking for IC, walking is overlooked as a self-management opportunity among people with IC who desire tailored walking guidance, and walking treatment cognitions explain walking intention, whereas illness cognitions explain objective walking ability. An RCT evaluating a home-based physiotherapist-led BCI targeting BCTs was feasible, and acceptable to participants with IC and the physiotherapist.
Date of Award2016
Original languageEnglish
Awarding Institution
  • King's College London
SupervisorJohn Weinman (Supervisor) & Lindsay Bearne (Supervisor)

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