The engagement of older people living with chronic lung disease in a peer support community‐based exercise programme: A qualitative study

Abstract Background Chronic lung disease is a common and complex condition. Pulmonary rehabilitation programmes—either hospital‐based or in the community are recommended in evidence‐based clinical practice guidelines. Aim To explore the experience of older people with chronic lung disease involved in a peer support community‐based exercise maintenance programme. Design and Method Participants were a part of the Lungs in Action programme run in a local community leisure centre through Lung Foundation Australia. All the programme participants (n = 25) were invited by an independent person through email and/or letter to participate in the study and provided with a participant information and consent form. Participants who returned consent forms were scheduled for group interviews. Participants were recruited over a 2‐week period between 30 August and 13 September 2022. We conducted qualitative group interviews using a semi‐structured interview guide to explore the experiences of older people living with chronic lung disease. Data were analysed using reflexive thematic analysis. Results A total of 14 participants (eight female and six male) aged between 64 and 86 years were interviewed. Three themes emerged from the data: motivation, authentic social engagement, and sustainable achievement. Motivation stemmed from the participants' perceived health benefits, and from the trainers' motivation and encouragement. Participants discussed how sharing experiences created an environment of trust and understanding, fun and friendship. Social engagement and creating authentic relationships were key aspects raised by participants. Feeling more confident in themselves and being able to accomplish physical tasks, making activities of daily living more manageable featured highly in participants' responses. Discussion and Conclusion Community‐based peer support exercise groups enable environments for people with chronic lung disease to maintain physical fitness, and to connect with others to form friendships and have fun.

Discussion and Conclusion: Community-based peer support exercise groups enable environments for people with chronic lung disease to maintain physical fitness, and to connect with others to form friendships and have fun.
breathlessness, chronic lung disease, community-based programmes, peer support, pulmonary rehabilitation

| INTRODUCTION
2][3][4] Chronic lung disease represents a growing burden internationally, with 4.1 million deaths annually. 1,5,6In Australia, one in every three people is affected by chronic lung disease, 7,8 and most are aged over 70 years, contributing to 8% of the total burden of disease. 9en chronic lung disease is diagnosed by a respiratory specialist, over 90% of people are referred to a community or hospital-based pulmonary rehabilitation exercise and education programme. 10These evidence-based care pathways are cornerstone treatments for people with chronic respiratory disease, 11 and ensure improved exercise capacity, health-related quality of life and reduced hospital admission. 12,13Referral to these programmes is a first step to equipping individuals with the skills needed to exercise safely and manage breathlessness, reducing the frequency of acute exacerbations, and thereby helping people effectively self-manage, remain well and avoid hospitalisation. 12ercise tolerance is a key element needing to be maintained following pulmonary rehabilitation to maintain the benefits achieved.This is a priority for all pulmonary rehabilitation programmes globally. 14though structured exercise programmes do not differentially impact exercise adherence, 15 it is evident there are several other benefits for older people, such as peer support, 16 fostering friendships 17 and minimising loneliness 18 and social isolation. 194][25] Traditionally, community-based exercise programmes for older people have primarily focused on promoting physical function, stability and/or independence and decreasing frailty, due to physical activity participation declining with age. 26 empowering participants to take responsibility for their own health and well-being and engage with others, a fostering of an internal locus of control and an increased ability to manage change occurs. 27Shifting the focus to the person involved, self-management and self-determination are encouraged, bringing a positive understanding of health and empowerment to the individual.This can promote connection and peer support with others in a positive and supportive environment with people who have a shared lived experience of chronic disease. 22Many older people choose to participate in an exercise programme if they can do it with others in a social manner with the possibility of forming and maintaining positive and supportive friendships. 25Formal interventions such as Lungs in Action offer opportunities for participants to share a unique type of social support with others who share characteristics, 28 in this case chronic lung disease.Shared lived experiences in formal programmes enables peer support in helping each other to manage the same condition, potentially offering a sense of connectedness and purpose. 29 Australia, people with chronic lung disease, following pulmonary rehabilitation, are regularly referred to as Lungs in Action. 30Lungs in Action is conducted throughout Australia in approximately 35 locations.It is conducted to maintain the health benefits initially achieved in acute pulmonary rehabilitation programmes for people with chronic lung disease, building skills to live well with chronic lung disease in the community.The aims of Lungs in Action are to improve fitness, independence and connection to the community. 30Lungs in Action is a communitybased programme led by trained professionals leading tailored exercises twice a week for participants, inclusive of resistance training and cardio (walking). 30The programme enables opportunities to exercise safely and to meet others with a lived experience of chronic lung disease in a supportive, understanding community.This research explored a group of older people (over 60 years) with chronic lung disease who had participated in Lungs in Action for up to 9 years together.Older people commonly desire social engagement and seek opportunities to be involved with others. 31There is a need to explore the social engagement needs and participation of people living with chronic lung disease.
Given the impact of social isolation and lockdowns due to the COVID-19 pandemic, this is of particular importance, as evidenced in the United Nations' Decade of Healthy Ageing 2021-2030 document. 2

| Aim
To explore the experience of older people with chronic lung disease involved in a peer support community-based exercise maintenance programme.

| Setting
Participants in the study were all participants of the Lungs in Action community programme run through Lung Foundation Australia.The exercise programme in this research is located in Wollongong, 80 km south of Sydney, New South Wales, Australia.

| Study design
The research study methodology is informed by a critical ontological perspective where multiple realities are accepted.The ontological perspective this research study took was a person-centred 32 perspective where the intent of the research is to explore the reality that exists within the context where the research is undertaken for the people involved.This research design sought to better understand the experience of the participants, gaining insight into key aspects of engaging in a peer support community.
To achieve understanding, we conducted qualitative group interviews with participants of the Lungs in Action community exercise programme.Group interviews are evidenced to provide a synergistic setting to gather insight into cultural and community norms. 33They provide an environment where participants are influencing and influenced by others, like in real-life settings. 34The interview guide is available in Supporting Information: Appendix S1.One of the researchers (R. M.) is also a personal trainer who provides exercise instruction and support for the Lungs in Action participants.Due to this pre-existing relationship, she had nothing to do with recruitment or data collection.

| Data collection
We developed a semi-structured interview guide to explore the experiences of older people living with chronic lung disease being involved in a community peer support exercise programme.Questions included how participants were introduced to the programme and the perceived benefits of the programme.Participants were asked to discuss their perspectives and experiences of being involved in the Lungs in Action programme, including what is important to them about being involved and the key benefit for them personally.
Interview guide development was informed by the literature and reviewed by an expert panel, including study investigators.Both group interviews were conducted face-to-face by an experienced qualitative researcher (K.M. S.) at the centre where the programme is facilitated.The interviews were an average of 58 min (SD = 0.5445) in duration.Interviews were audio-recorded and transcribed verbatim, using a third-party professional transcription service.Transcripts were checked for accuracy by checking against the audio recording (K.M. S.) and deidentified with participants being assigned labels.

| Analysis
Reflexive thematic analysis was conducted to interpret the experiences and perspectives of participants.Reflexive thematic analysis is an inductive, data-driven, iterative approach enabling patterns and meanings to be captured from qualitative data. 33,35This ensures the themes identified best reflect participant views without fitting them into a preconceived coding framework. 34Four members of the research team (R. M., C. M., K. M. S., P. D.) each individually coded both group interview transcripts to identify categories within the data before consulting as a group to check and agree on the initial codes and consider differences in interpretation.To develop a richer more nuanced reading of the data, three of the team (R. M., C. M., K. M. S.) further reviewed and refined the coding frame to include emerging new codes and suggest overarching themes.The final thematic structure was agreed by the research team to clearly and comprehensively describe our analysis and we agreed saturation of codes had been achieved.
Throughout the process, we engaged collaboratively and reflexively, aware that our experiences and sociocultural backgrounds shaped our interpretation. 33,35,36The four members of the research team robustly discussed each stage of analysis using Braun and Clarke's method of reflexive thematic analysis 35 until coming to consensus with regard to the final themes.Each member was reflexive in their approach, aware of subjectivity and potential influences.This encouraged a deep sustained data immersion and reflection. 35is study was approved by the University of Wollongong's Human Research Ethics Committee (2022/248).The COREQ checklist on qualitative reporting 37 is provided in Supporting Information: File S1.

| RESULTS
Data were collected from a total of 14 participants ranging in age from 64 to 86 years.Eight were female and six were male.There were eight participants in group interview 1 and six in the second.
We identified three themes describing participants' perceptions and experiences of the peer support group: motivation; authentic social engagement; and sustainable achievement.An overarching premise encompassing all three themes is living experience.Figure 1 illustrates the themes and subthemes.Each theme and related subtheme are described below and illustrated with exemplar quotations.Quotes are attributed to participants using numbers, for example, P1 and the group interview, for example, GI1.

| Motivation
Study participants perceived the physical health benefits of the exercise programme were a key motivator to continue with the programme, with comments such as 'they explain to you with that rehab thing that if you exercise and get your large muscles stronger, then your recovery-the oxygen you have you can do more with it… and once you get that in your brain, it's a pretty good motivator to do it' (P2, GI2).
Participants felt the exercise programme was helping to improve their health and well-being; 'Well, I think my health is improving and I'm getting a bit of fitness back, and I'm breathing a bit easier because I was really breathless at one stage.So that's really helping me' (P7, GI1).Several participants were motivated to get fitter to be able to play with their grandchildren.Others mentioned the programme helped keep them out of hospital; 'Well, the knowledge that it's important to do it.It's definitely a motivator.I don't want to go back into hospital if I can help it' (P2, GI2).Some were determined not to be a burden on their family; 'I don't want to be a burden to my family' (P1, GI2) and thus were motivated to continue with the programme.
Many participants also perceived the programme helped improve mood and mental health.Improvements in their physical health appeared to have a flow on effect to their mental health.As one participant said 'it's a positive thing for the mind to know that you can do a bit better, that you can do some things.You can go for a walk.However, a recent systematic review of peer support for people with chronic conditions revealed this study outcome was only assessed in approximately 45% of the 31 studies included. 28Peer support is considered a complex community-based social intervention, underpinned by both social identity theory 39 and social comparison theory. 40Community and social group membership can help to inspire a sense of belonging and can provide a behavioural framework through a set of social norms and conventions.Further, peer support may be applied by participants to compare themselves to others and used to validate their experiences and judge comparisons to create a sense of hope, as part of their self-management and recovery.Hope and ambition are important to consider when setting personal goals. 28These goals varied within the programme, although included walking, sharing meals and social activities such as ten-pin bowling and dancing.
Recruitment was facilitated through the assistance of the community leisure centre where the Lungs in Action programme is delivered.All programme participants (n = 25) were invited by an independent person through email and/or letter to participate in the study and given a participant information and consent form.Participants who returned consent forms were scheduled for group interviews by researcher K. M.S. who had no pre-existing relationship with any of the participants or theLungs in Action programme.Participants were recruited over a 2-week period between 30 August and 13 September 2022.Inclusion criteria were all Lungs in Action programme participants.Exclusion criteria were anyone not enroled in the Lungs in Action programme.
And the thing that I've learnt-it's all right to be out of breath.It's Ok' (P3, GI2).Participants spoke about the exercise programme in terms of giving them 'a reason to get out of bed' (P2, GI1), lifting their mood and giving them energy: It does lift your mood…You force yourself to come because you know when you come out of here, your endorphins are all flying.(P2, GI2) The other thing about coming to the group is you might come, and you've got no motivation, or no F I G U R E 1 living 4.1 | Peer support programmes help support motivation and the development of self-efficacy Self-efficacy and motivation are important programme outcomes, often attributed to peer support, as elucidated in our study.