Jack Downey

Physical activity can prevent and treat multiple diseases. Exercise referral schemes have been used extensively as one healthcare pathway. Schemes typically involve the referral of an inactive individual, with a long term condition, for a time limited exercise programme. Evidence has shown limited benefit, yet the exploration of implementation is under researched. National guidance, in the United Kingdom, recommends that exercise referral schemes should not be commissioned unless behaviour change practices are implemented. Nonetheless, novel evaluations, which are sensitive to the complex nature of behaviour change implementation, have not been undertaken. Therefore, this research sought to answer how, why, and in which circumstances behaviour change practices are implemented by exercise referral practitioners. Realist evaluation, a form of theory driven evaluation, was adopted to address the research question. Programme theory, the envisaged causal workings of implementation, was developed and tested to advance knowledge on how behaviour change practice can be achieved by exercise referral practitioners. An 8-month focused ethnography was used to develop programme theory. Subsequently, a survey was validated to empirically test programme theory. Adjudication between theory required an assessment of the fidelity to behaviour change practices. Therefore, vignettes were created and validated, which acted as a proxy to observations. The survey was then completed through online, and facilitated interviews, using a ‘think aloud’ methodology. The analysis showed that practice frameworks augment motivation when there is congruent practitioner characteristics and practice monitoring is utilised, whereas frameworks improve capability when faced with challenging attendees. Supportive leadership improves motivation when there is an organisational commitment to behaviour change and practitioners are passionate to empower attendees. Supportive leadership improves capability for implementation when a learning climate is created. Partnerships with medical professionals enhance implementation, through changes to motivation, when medical professionals commit and recognise the value of schemes, and partnerships enhance capability where medical professionals reinforce practice via congruent communication. On-going support enhances capability where practitioners are cognizant of their role and have lower behaviour change competencies, conversely, motivation is enhanced as practitioners become more capable. Exercise referral schemes risk being labelled ineffective without considering the implementation climate and fidelity to best practice guidance. This thesis provides portable and actionable findings, which could lead to a greater translation of behaviour change practices to applied settings in exercise referral and in other medically led community based self-management interventions.