Activity matters: a web-based resource to enable people with multiple sclerosis to become more active

Activity matters: a web-based resource to enable people with multiple sclerosis to become more... Abstract Increasing physical activity (PA) through exercise is associated with improvements in many of the symptoms associated with multiple sclerosis (MS) such as fatigue, strength, balance, and mobility. Despite this, people with MS remain largely inactive. Interventions that are grounded in theory and that aim to change PA behavior need to be developed. The purpose of this study was to describe the development process of a web-based resource, namely, “Activity Matters,” to enable people with MS to become more active. Development of the “Activity Matters” online intervention was guided by the UK’s Medical Research Council (MRC) framework for the development and evaluation of complex interventions and the behavior change wheel (BCW). Seven sources of data were used to inform the process and were mapped on to both the MRC and BCW frameworks. The intervention is theoretically based, and constructs including knowledge, memory, attention and decision processes, skills, social influences, environmental context and resources, beliefs about capabilities, beliefs about consequences, goals, and emotions were recognized as important. “Activity Matters” is the first MS PA intervention to be developed using the theoretical approach outlined by the BCW and MRC complex interventions frameworks. The next phase of this work is to test the usability, acceptability, and preliminary effectiveness of “Activity Matters” among people with MS. Implications Practice: Physical activity interventions for people with multiple sclerosis (MS) should aim to include behavior change techniques such as action planning, goal-setting, and social support. Policy: Policy makers who want to increase physical activity behaviors among people with neurological disorders should explore the use of the behavior change wheel (BCW) framework to improve research transparency and improve implementation. Research: Future research is needed to examine other MS-specific correlates of physical activity behavior and pilot MS physical activity interventions that have used the BCW framework. INTRODUCTION Multiple sclerosis (MS) is a chronic disease of the central nervous system (CNS) that is associated with demyelination, inflammation, and axonal degeneration [1]. There are more than 400,000 people living with MS in the USA and approximately 2.1 million worldwide [2]. The estimated annual economic cost to the USA is 28 billion dollars with reported annual costs per person between 18,000 and 39,000 dollars [3]. The disease is characterized by cognitive and ambulatory dysfunction, fatigue, depression, pain, deconditioning, and compromised quality of life (QOL) [4]. A growing body of evidence has shown that increasing physical activity (PA) through exercise is associated with improvements in many of these symptoms [5–9]. Despite this, people with MS (pwMS) remain largely inactive, even more than their healthy counterparts [10]. And, while behavioral interventions have successfully changed PA levels among pwMS in the short-medium term (up to 6 months), there is no evidence for any long-term (up to 12 months) change [11]. It is has been suggested these suboptimal effects are due to a lack of theoretical consideration at the development stages of these behavioral interventions [12], and evidence has shown that only few MS PA interventions have used theory [11]. Those that have, used the social cognitive theory (SCT) [13–15] and the transtheoretical model (TTM) [16]. However, how intervention developers have used these theories to describe the development of MS PA interventions has not been well described. This continues to pose a challenge for researchers. If interventions do not describe how they used theory from the beginning, then those interventions cannot be used to inform future design as the effective components and how change came about within an intervention cannot be identified. A framework proposed by the Medical Research Council (MRC) for the development and evaluation of complex interventions emphasizes the importance of theory in intervention development [17]. However, the MRC complex interventions framework does not provide researchers with suggestions for the most appropriate theory to use for the behavior in question. Given the large pool of behavioral models that exist, this has proven a challenge for intervention developers but fortunately this gap has been addressed with the development of the behavior change wheel (BCW) [18]. The BCW (Fig. 1) provides a detailed framework for the development of behavioral interventions through the stages outlined in the MRC complex interventions framework. The stages and steps of both frameworks have been previously mapped together [19] and this is outlined in Table 1. Table 1 Mapping steps of the behavior change wheel (BCW) to the three stages of the Medical Research Council (MRC) framework for the development of complex interventions [1]. MRC development stage  BCW steps  BCW stages  1. Identify the evidence base 2. Identify/develop theory 3. Model process and ouctomes  1. Define the problem in behavioral terms 2. Select the target behavior 3. Specify the target population 4. Identify what needs to change 5. Identify appropiate intervention functions 6. Identifying policy categories 7. Identifying behavioral change techniques 8. Determine the mode of delivery  1. Understand the behavior 2. Identify intervention options 3. Identify content and implementation options  MRC development stage  BCW steps  BCW stages  1. Identify the evidence base 2. Identify/develop theory 3. Model process and ouctomes  1. Define the problem in behavioral terms 2. Select the target behavior 3. Specify the target population 4. Identify what needs to change 5. Identify appropiate intervention functions 6. Identifying policy categories 7. Identifying behavioral change techniques 8. Determine the mode of delivery  1. Understand the behavior 2. Identify intervention options 3. Identify content and implementation options  View Large Table 1 Mapping steps of the behavior change wheel (BCW) to the three stages of the Medical Research Council (MRC) framework for the development of complex interventions [1]. MRC development stage  BCW steps  BCW stages  1. Identify the evidence base 2. Identify/develop theory 3. Model process and ouctomes  1. Define the problem in behavioral terms 2. Select the target behavior 3. Specify the target population 4. Identify what needs to change 5. Identify appropiate intervention functions 6. Identifying policy categories 7. Identifying behavioral change techniques 8. Determine the mode of delivery  1. Understand the behavior 2. Identify intervention options 3. Identify content and implementation options  MRC development stage  BCW steps  BCW stages  1. Identify the evidence base 2. Identify/develop theory 3. Model process and ouctomes  1. Define the problem in behavioral terms 2. Select the target behavior 3. Specify the target population 4. Identify what needs to change 5. Identify appropiate intervention functions 6. Identifying policy categories 7. Identifying behavioral change techniques 8. Determine the mode of delivery  1. Understand the behavior 2. Identify intervention options 3. Identify content and implementation options  View Large Fig 1 View largeDownload slide The behavior change wheel [19]. Fig 1 View largeDownload slide The behavior change wheel [19]. At the core of the BCW is the COM-B model in which behavior change is conceptualized by requiring a shift in a person’s capability (C), opportunity (O), and motivation (M). Capability can be physical or psychological, opportunity can be physical or social, and motivation can be reflective or automatic. These subdivisions can be further broken down into 14 theoretical domains, specified by the theoretical domains framework (TDF) [20]. The TDF is an amalgamation of 28 theoretical constructs from 33 theories of behavior change. The COM-B model and TDF further guide the choice of nine potential intervention functions: education, persuasion, incentivization, coercion, training, enablement, modeling, environmental restructuring, and restrictions. These intervention functions are in turn linked to a taxonomy of 93 behavior change techniques (BCTs) [21], which are the active components of an intervention that are designed to change behavior [18]. The structured approach of the BCW provides transparency to intervention developers. The BCW has been used to develop interventions that were acceptable and effective in changing varying behaviors including medication management, smoking cessation, and condom use, among others [19, 22, 23]. To the author’s knowledge, there are no reports of a MS PA intervention that has been developed using the BCW process. This paper will describe the development of an intervention to change PA behavior among pwMS using the steps of the MRC complex interventions framework and BCW. The intervention is named “Activity Matters” and aims to develop a web-based resource to enhance PA behavior among pwMS. AIMS The purpose of this study was to describe the theory underpinning the development process of the “Activity Matters” web resource to enable pwMS to become more physically active using the MRC complex interventions framework and the BCW. METHODS Seven sources of data were used to inform the development of “Activity Matters.” Five of these sources were research papers conducted by the authors. These included three systematic reviews and two original research studies. The additional two data sources were papers by MS PA research groups from North America and Europe. These included two systematic reviews. The seven data sources are highlighted in Table 2 and their methodology is published elsewhere. Table 2 Summary of included data sources   Data source title  Study design  Research aim(s)  1  Objective physical activity levels among people with multiple sclerosis—a meta-analysis (Casey et al. 2017–under review)  Meta-analysis  (1) To quantify physical activity (PA) levels in people with multiple sclerosis (MS) using objective measurement only. (2) To establish using a meta-analytical approach if people with MS are less physically active than a general population sample.  2  Changing physical activity behaviour in people with multiple sclerosis: a systematic review and meta-analysis of randomised control trials (Casey et al. 2017–accepted for publication)  Systematic review and meta-analysis  (1) To examine the totality of the evidence on the effectiveness of behavioral interventions on PA behavior in people with MS. (2) To use the theory coding scheme and establish how/if current PA behavioral interventions use theory. (3) To identify, using a behavior change technique (BCT) taxonomy, what BCTs are employed in the identified interventions to change PA behavior in people with MS.  3  What do people with ms want from a web-based resource to encourage increased physical activity behaviour? [24]  Qualitative semi-structured interviews and focus groups  (1) To investigate what people with MS want from a web based resource that encourages PA  4  Modifiable psychosocial constructs associated with physical activity participation in people with multiple sclerosis: a meta-analysis. [25]  Meta-analysis  (1) To synthesize current knowledge of the modifiable psychosocial constructs associated with PA participation in people with MS  5  Do multiple sclerosis symptoms moderate the relationship between self-efficacy and physical activity in people with multiple sclerosis? (Casey et al 2017–accepted)  Quantitative correlations and moderation  (1) To investigate the bivariate correlations between objective PA, self-efficacy, and a range of MS symptom measures. (2) To determine if any MS symptom measures moderate the relationship between self-efficacy and PA.  6  Systematic review of correlates and determinants of physical activity in persons with multiple sclerosis. [26]  Systematic review  (1) To review the current evidence regarding correlates and determinants of PA in people with MS  7  Physical activity and exercise training in multiple sclerosis: a review and content analysis of qualitative research identifying perceived determinants and consequences. [27]  Qualitative metasynthesis  (1) To provide rich and deep evidence of the perceived determinants and consequences of physical activity and exercise based on qualitative research in MS    Data source title  Study design  Research aim(s)  1  Objective physical activity levels among people with multiple sclerosis—a meta-analysis (Casey et al. 2017–under review)  Meta-analysis  (1) To quantify physical activity (PA) levels in people with multiple sclerosis (MS) using objective measurement only. (2) To establish using a meta-analytical approach if people with MS are less physically active than a general population sample.  2  Changing physical activity behaviour in people with multiple sclerosis: a systematic review and meta-analysis of randomised control trials (Casey et al. 2017–accepted for publication)  Systematic review and meta-analysis  (1) To examine the totality of the evidence on the effectiveness of behavioral interventions on PA behavior in people with MS. (2) To use the theory coding scheme and establish how/if current PA behavioral interventions use theory. (3) To identify, using a behavior change technique (BCT) taxonomy, what BCTs are employed in the identified interventions to change PA behavior in people with MS.  3  What do people with ms want from a web-based resource to encourage increased physical activity behaviour? [24]  Qualitative semi-structured interviews and focus groups  (1) To investigate what people with MS want from a web based resource that encourages PA  4  Modifiable psychosocial constructs associated with physical activity participation in people with multiple sclerosis: a meta-analysis. [25]  Meta-analysis  (1) To synthesize current knowledge of the modifiable psychosocial constructs associated with PA participation in people with MS  5  Do multiple sclerosis symptoms moderate the relationship between self-efficacy and physical activity in people with multiple sclerosis? (Casey et al 2017–accepted)  Quantitative correlations and moderation  (1) To investigate the bivariate correlations between objective PA, self-efficacy, and a range of MS symptom measures. (2) To determine if any MS symptom measures moderate the relationship between self-efficacy and PA.  6  Systematic review of correlates and determinants of physical activity in persons with multiple sclerosis. [26]  Systematic review  (1) To review the current evidence regarding correlates and determinants of PA in people with MS  7  Physical activity and exercise training in multiple sclerosis: a review and content analysis of qualitative research identifying perceived determinants and consequences. [27]  Qualitative metasynthesis  (1) To provide rich and deep evidence of the perceived determinants and consequences of physical activity and exercise based on qualitative research in MS  View Large Table 2 Summary of included data sources   Data source title  Study design  Research aim(s)  1  Objective physical activity levels among people with multiple sclerosis—a meta-analysis (Casey et al. 2017–under review)  Meta-analysis  (1) To quantify physical activity (PA) levels in people with multiple sclerosis (MS) using objective measurement only. (2) To establish using a meta-analytical approach if people with MS are less physically active than a general population sample.  2  Changing physical activity behaviour in people with multiple sclerosis: a systematic review and meta-analysis of randomised control trials (Casey et al. 2017–accepted for publication)  Systematic review and meta-analysis  (1) To examine the totality of the evidence on the effectiveness of behavioral interventions on PA behavior in people with MS. (2) To use the theory coding scheme and establish how/if current PA behavioral interventions use theory. (3) To identify, using a behavior change technique (BCT) taxonomy, what BCTs are employed in the identified interventions to change PA behavior in people with MS.  3  What do people with ms want from a web-based resource to encourage increased physical activity behaviour? [24]  Qualitative semi-structured interviews and focus groups  (1) To investigate what people with MS want from a web based resource that encourages PA  4  Modifiable psychosocial constructs associated with physical activity participation in people with multiple sclerosis: a meta-analysis. [25]  Meta-analysis  (1) To synthesize current knowledge of the modifiable psychosocial constructs associated with PA participation in people with MS  5  Do multiple sclerosis symptoms moderate the relationship between self-efficacy and physical activity in people with multiple sclerosis? (Casey et al 2017–accepted)  Quantitative correlations and moderation  (1) To investigate the bivariate correlations between objective PA, self-efficacy, and a range of MS symptom measures. (2) To determine if any MS symptom measures moderate the relationship between self-efficacy and PA.  6  Systematic review of correlates and determinants of physical activity in persons with multiple sclerosis. [26]  Systematic review  (1) To review the current evidence regarding correlates and determinants of PA in people with MS  7  Physical activity and exercise training in multiple sclerosis: a review and content analysis of qualitative research identifying perceived determinants and consequences. [27]  Qualitative metasynthesis  (1) To provide rich and deep evidence of the perceived determinants and consequences of physical activity and exercise based on qualitative research in MS    Data source title  Study design  Research aim(s)  1  Objective physical activity levels among people with multiple sclerosis—a meta-analysis (Casey et al. 2017–under review)  Meta-analysis  (1) To quantify physical activity (PA) levels in people with multiple sclerosis (MS) using objective measurement only. (2) To establish using a meta-analytical approach if people with MS are less physically active than a general population sample.  2  Changing physical activity behaviour in people with multiple sclerosis: a systematic review and meta-analysis of randomised control trials (Casey et al. 2017–accepted for publication)  Systematic review and meta-analysis  (1) To examine the totality of the evidence on the effectiveness of behavioral interventions on PA behavior in people with MS. (2) To use the theory coding scheme and establish how/if current PA behavioral interventions use theory. (3) To identify, using a behavior change technique (BCT) taxonomy, what BCTs are employed in the identified interventions to change PA behavior in people with MS.  3  What do people with ms want from a web-based resource to encourage increased physical activity behaviour? [24]  Qualitative semi-structured interviews and focus groups  (1) To investigate what people with MS want from a web based resource that encourages PA  4  Modifiable psychosocial constructs associated with physical activity participation in people with multiple sclerosis: a meta-analysis. [25]  Meta-analysis  (1) To synthesize current knowledge of the modifiable psychosocial constructs associated with PA participation in people with MS  5  Do multiple sclerosis symptoms moderate the relationship between self-efficacy and physical activity in people with multiple sclerosis? (Casey et al 2017–accepted)  Quantitative correlations and moderation  (1) To investigate the bivariate correlations between objective PA, self-efficacy, and a range of MS symptom measures. (2) To determine if any MS symptom measures moderate the relationship between self-efficacy and PA.  6  Systematic review of correlates and determinants of physical activity in persons with multiple sclerosis. [26]  Systematic review  (1) To review the current evidence regarding correlates and determinants of PA in people with MS  7  Physical activity and exercise training in multiple sclerosis: a review and content analysis of qualitative research identifying perceived determinants and consequences. [27]  Qualitative metasynthesis  (1) To provide rich and deep evidence of the perceived determinants and consequences of physical activity and exercise based on qualitative research in MS  View Large This study uses both the MRC complex interventions framework and the BCW to guide the analysis and synthesis of the seven data sources (Table 1). MRC Development Stage 1—identify the evidence base Data Source 1 was used for this stage and included Steps 1–3 from the BCW (Table 1). A meta-analysis of objective PA levels among pwMS was conducted to define the problem (BCW Step 1) of physical inactivity in this population and therefore a need for a resource such as “Activity Matters.” With regard to specifying the target behavior and population (BCW Steps 2 and 3), there is little evidence on the “ideal” objective PA measurement output for pwMS and no cut-off points exist [24]. Given these discrepancies in the measurement of PA among pwMS [24], it is suggested by the research team that the specified behavior for “Activity Matters” is any increase in an objective measure of PA, simply moving more (increased steps per day, increased MVPA per day, etc.). The specified population of pwMS is those who are ambulatory, with/without use of an aid due to the limited PA literature among those with higher disability. MRC Development Stage 2—identify/develop theory Data Sources 2–7[25–28] were used for this stage and included Steps 4–6 from the BCW. Six data sources aimed to understand PA behavior among pwMS and identify what needs to change (BCW Step 4). These sources included qualitative (n = 2 sources) and quantitative (n = 4 sources) methodologies. Four sources were conducted by the authors while the other two sources were known qualitative [28] and quantitative [27] reviews in the MS field. The sources included data on previous PA interventions, data on correlates and determinants of PA, data on barriers and facilitators of PA, and data on the role of MS symptoms on PA behavior among pwMS. To identify important intervention functions (BCW Step 5) for “Activity Matters,” relevant results from the six data sources (BCW Step 4) were extracted. Results were extracted if they added to understanding PA behavior among pwMS and were modifiable within interventions. Additionally, results reported in systematic reviews must have been examined in three or more studies to meet inclusion for extraction. Extracted results were then mapped on to the COM-B and TDF [20]. Once domains from the TDF were selected for the results, intervention functions were then identified by reviewing the possibilities for each domain as defined in the BCW guide [18]. If more than one intervention function was linked to each domain, we used the affordability, practicality, effectiveness, acceptability, side effects/safety, and equity (APEASE) criteria to choose relevant intervention functions for “Activity Matters” [29]. The APEASE criteria acknowledge that behavior change interventions operate within a social context, and that although effectiveness is the primary focus of interventions, it is clearly important to consider other contextual factors [29]. MRC Development Stage 3—model process and outcomes This stage includes BCW Steps 7 and 8. Using the BCW guide [18], potential BCTs were identified from the chosen intervention functions from Stage 2. These BCTs were reviewed with the APEASE criteria and through discussions among the research team (B.C., S.C., and M.B.). The selected BCTs were then translated into website functions which matched the qualitative needs of pwMS for a web-based PA resource [25]. The Internet was chosen as the mode of delivery. When developing a successful intervention, one must ensure it is delivered in a medium that matches the interest and usage profile of the target population [30]. Evidence suggests that the preferred method of delivering PA information to pwMS is via the Internet [31]. Recent evidence suggests that accessibility to the web is not an issue for pwMS and that more than 90% of ambulatory pwMS have access to a smartphone, which they believe has the potential to benefit health care information. This evidence supports the use of the Internet as the preferred medium for “Activity Matters.” RESULTS MRC Development Stage 1—identify the evidence base The systematic review on objective PA levels among pwMS resulted in 32 papers (Data Source 1). There was a total of 3,762 pwMS included, the sample was largely female (n = 3,118; 82.8%) and ambulatory with/without the use of an aid. Meta-analysis indicated statistically significant differences between the MS and general population samples with respect to PA outputs of (a) steps per day (mean difference: −3845 [95% CI = −4120.17, −3569.83], p < 0.0001), (b) activity counts per day (mean difference: −91377.69 [95% CI = −103827.8, −78927.54], p < 0.0001), and (c) minutes of MVPA per day (mean difference: 8.95 [95% CI = −12.52, −5.38], p < 0.0001), indicating pwMS are less physically active than the general population sample, who themselves were physically inactive. MRC Development Stage 2—identify/develop theory The relevant results from Data Sources 2–7 are outlined in Table 3. These findings are mapped on to the COM-B and TDF. TDF domains of knowledge, memory, attention and decision processes, skills, social influences, environmental context and resources, beliefs about capabilities, beliefs about consequences, goals, and emotion were highlighted as important from our data. Results were then mapped on to intervention functions. Intervention functions chosen to be used in “Activity Matters” included, education, enablement, environmental restructuring, persuasion, and incentivization. Table 3 Mapping of results from data sources on to the COM-B and TDF with appropriate intervention functions and proposed BCTs highlighted. COM-B component  TDF domain  Results  Intervention function  Proposed BCTs  Capability  Psychological  Knowledge  • Conflicting advice from health care professionals (Source 7) • Knowledge of benefits of exercise required to enable behavior (Source 3) • Knowledge of research evidence required to enable behavior (Source 3) • Knowledge of the types of exercises for varying PA and mobility levels (Source 3)  Education  • Information about health consequences • Information about social and environmental consequences • Information about emotional consequences • Vicarious consequences • Credible source.      Memory, attention, and decision processes  • Fatigue as a barrier to PA/exercise (Source 7)  Education  • Information about health consequences • Information about emotional consequences • Vicarious consequences    Physical  Skills  • Appropriate exercises for PA level and mobility level need to be provided (Sources 3 and 7)  Enablement  • Problem solving • Graded tasks • Action planning • Goal setting (behavior) • Review behavioral goal • Focus on past success  Opportunity  Social  Social influences  • Peer support as a facilitator to exercise/PA (Sources 3 and 7)  Environmental restructuring  • Restructuring the social environment    Physical  Environmental context and resources  • No accessibility or disability facilities act as barriers to exercise/PA (Source 7) • Exercise modality choice facilitator to exercise/PA (Source 3 and 7)  Enablement  • Action planning • Problem solving • Goal-setting (behavior) • Review behavioral goals • Focus on past success  Motivation  Reflective  Beliefs about capabilities  • Self-efficacy has a moderately strong association with PA (Source 4 and 6)  Enablement persuasion  • Verbal persuasion about capability • Mental rehearsal of successful performance • Focus on past success • Self-talk      Beliefs about consequences  • Outcome expectancies has a moderate association with PA (Source 4)  Education  • Information about health consequences • Information about social and environmental consequences • Information about emotional consequences      Goals  • Goal-setting has mediated change in PA in previous interventions (Source 2) • Goal-setting has a moderately strong association with PA (Sources 4 and 6)  Enablement  • Goal-setting (behavior) • Goal-setting (outcome) • Action planning • Review behavioral goals • Review outcome goals    Automatic  Emotion  • Fear/apprehension as a barrier to exercise/PA (Source 7) • Feelings of accomplishment (Source 7) • Anxiety/depression/fatigue triad has associations with exercise self-efficacy (Source 5)  Incentivization enablement  • Social support (unspecified/practical) • Reduce negative emotions • Action planning • Problem solving • Social incentive • Self-incentive  COM-B component  TDF domain  Results  Intervention function  Proposed BCTs  Capability  Psychological  Knowledge  • Conflicting advice from health care professionals (Source 7) • Knowledge of benefits of exercise required to enable behavior (Source 3) • Knowledge of research evidence required to enable behavior (Source 3) • Knowledge of the types of exercises for varying PA and mobility levels (Source 3)  Education  • Information about health consequences • Information about social and environmental consequences • Information about emotional consequences • Vicarious consequences • Credible source.      Memory, attention, and decision processes  • Fatigue as a barrier to PA/exercise (Source 7)  Education  • Information about health consequences • Information about emotional consequences • Vicarious consequences    Physical  Skills  • Appropriate exercises for PA level and mobility level need to be provided (Sources 3 and 7)  Enablement  • Problem solving • Graded tasks • Action planning • Goal setting (behavior) • Review behavioral goal • Focus on past success  Opportunity  Social  Social influences  • Peer support as a facilitator to exercise/PA (Sources 3 and 7)  Environmental restructuring  • Restructuring the social environment    Physical  Environmental context and resources  • No accessibility or disability facilities act as barriers to exercise/PA (Source 7) • Exercise modality choice facilitator to exercise/PA (Source 3 and 7)  Enablement  • Action planning • Problem solving • Goal-setting (behavior) • Review behavioral goals • Focus on past success  Motivation  Reflective  Beliefs about capabilities  • Self-efficacy has a moderately strong association with PA (Source 4 and 6)  Enablement persuasion  • Verbal persuasion about capability • Mental rehearsal of successful performance • Focus on past success • Self-talk      Beliefs about consequences  • Outcome expectancies has a moderate association with PA (Source 4)  Education  • Information about health consequences • Information about social and environmental consequences • Information about emotional consequences      Goals  • Goal-setting has mediated change in PA in previous interventions (Source 2) • Goal-setting has a moderately strong association with PA (Sources 4 and 6)  Enablement  • Goal-setting (behavior) • Goal-setting (outcome) • Action planning • Review behavioral goals • Review outcome goals    Automatic  Emotion  • Fear/apprehension as a barrier to exercise/PA (Source 7) • Feelings of accomplishment (Source 7) • Anxiety/depression/fatigue triad has associations with exercise self-efficacy (Source 5)  Incentivization enablement  • Social support (unspecified/practical) • Reduce negative emotions • Action planning • Problem solving • Social incentive • Self-incentive  TDF theoretical domains framework; BCT behavior change technique; PA physical activity. View Large Table 3 Mapping of results from data sources on to the COM-B and TDF with appropriate intervention functions and proposed BCTs highlighted. COM-B component  TDF domain  Results  Intervention function  Proposed BCTs  Capability  Psychological  Knowledge  • Conflicting advice from health care professionals (Source 7) • Knowledge of benefits of exercise required to enable behavior (Source 3) • Knowledge of research evidence required to enable behavior (Source 3) • Knowledge of the types of exercises for varying PA and mobility levels (Source 3)  Education  • Information about health consequences • Information about social and environmental consequences • Information about emotional consequences • Vicarious consequences • Credible source.      Memory, attention, and decision processes  • Fatigue as a barrier to PA/exercise (Source 7)  Education  • Information about health consequences • Information about emotional consequences • Vicarious consequences    Physical  Skills  • Appropriate exercises for PA level and mobility level need to be provided (Sources 3 and 7)  Enablement  • Problem solving • Graded tasks • Action planning • Goal setting (behavior) • Review behavioral goal • Focus on past success  Opportunity  Social  Social influences  • Peer support as a facilitator to exercise/PA (Sources 3 and 7)  Environmental restructuring  • Restructuring the social environment    Physical  Environmental context and resources  • No accessibility or disability facilities act as barriers to exercise/PA (Source 7) • Exercise modality choice facilitator to exercise/PA (Source 3 and 7)  Enablement  • Action planning • Problem solving • Goal-setting (behavior) • Review behavioral goals • Focus on past success  Motivation  Reflective  Beliefs about capabilities  • Self-efficacy has a moderately strong association with PA (Source 4 and 6)  Enablement persuasion  • Verbal persuasion about capability • Mental rehearsal of successful performance • Focus on past success • Self-talk      Beliefs about consequences  • Outcome expectancies has a moderate association with PA (Source 4)  Education  • Information about health consequences • Information about social and environmental consequences • Information about emotional consequences      Goals  • Goal-setting has mediated change in PA in previous interventions (Source 2) • Goal-setting has a moderately strong association with PA (Sources 4 and 6)  Enablement  • Goal-setting (behavior) • Goal-setting (outcome) • Action planning • Review behavioral goals • Review outcome goals    Automatic  Emotion  • Fear/apprehension as a barrier to exercise/PA (Source 7) • Feelings of accomplishment (Source 7) • Anxiety/depression/fatigue triad has associations with exercise self-efficacy (Source 5)  Incentivization enablement  • Social support (unspecified/practical) • Reduce negative emotions • Action planning • Problem solving • Social incentive • Self-incentive  COM-B component  TDF domain  Results  Intervention function  Proposed BCTs  Capability  Psychological  Knowledge  • Conflicting advice from health care professionals (Source 7) • Knowledge of benefits of exercise required to enable behavior (Source 3) • Knowledge of research evidence required to enable behavior (Source 3) • Knowledge of the types of exercises for varying PA and mobility levels (Source 3)  Education  • Information about health consequences • Information about social and environmental consequences • Information about emotional consequences • Vicarious consequences • Credible source.      Memory, attention, and decision processes  • Fatigue as a barrier to PA/exercise (Source 7)  Education  • Information about health consequences • Information about emotional consequences • Vicarious consequences    Physical  Skills  • Appropriate exercises for PA level and mobility level need to be provided (Sources 3 and 7)  Enablement  • Problem solving • Graded tasks • Action planning • Goal setting (behavior) • Review behavioral goal • Focus on past success  Opportunity  Social  Social influences  • Peer support as a facilitator to exercise/PA (Sources 3 and 7)  Environmental restructuring  • Restructuring the social environment    Physical  Environmental context and resources  • No accessibility or disability facilities act as barriers to exercise/PA (Source 7) • Exercise modality choice facilitator to exercise/PA (Source 3 and 7)  Enablement  • Action planning • Problem solving • Goal-setting (behavior) • Review behavioral goals • Focus on past success  Motivation  Reflective  Beliefs about capabilities  • Self-efficacy has a moderately strong association with PA (Source 4 and 6)  Enablement persuasion  • Verbal persuasion about capability • Mental rehearsal of successful performance • Focus on past success • Self-talk      Beliefs about consequences  • Outcome expectancies has a moderate association with PA (Source 4)  Education  • Information about health consequences • Information about social and environmental consequences • Information about emotional consequences      Goals  • Goal-setting has mediated change in PA in previous interventions (Source 2) • Goal-setting has a moderately strong association with PA (Sources 4 and 6)  Enablement  • Goal-setting (behavior) • Goal-setting (outcome) • Action planning • Review behavioral goals • Review outcome goals    Automatic  Emotion  • Fear/apprehension as a barrier to exercise/PA (Source 7) • Feelings of accomplishment (Source 7) • Anxiety/depression/fatigue triad has associations with exercise self-efficacy (Source 5)  Incentivization enablement  • Social support (unspecified/practical) • Reduce negative emotions • Action planning • Problem solving • Social incentive • Self-incentive  TDF theoretical domains framework; BCT behavior change technique; PA physical activity. View Large MRC Development Stage 3—model process and outcomes Proposed BCTs were matched to the intervention functions (Table 3). The final list of BCTs employed in “Activity Matters” is outlined in Table 4 along with the website functions. Not all proposed BCTs were included in the final list of BCTs after using the APEASE criteria and results of the original qualitative data source [25]. Table 4 Mapping of results to BCTs and mapping of BCTs to website functions for “Activity Matters.” Findings  BCT(s)  Website function  • Conflicting advice from health care professionals  • Credible source  • Verbal and visual communication from a health care professional/researcher/person with MS in favor of the benefits of PA for people with MS.  • Knowledge of benefits of exercise required to enable behavior  • Information about health consequences • Information about social and environmental consequences • Information about emotional consequences • Vicarious consequences • Credible source  • Text on the benefits of PA across a range of outcomes for people with MS. This text will be supplemented with videos of people with MS and health care professionals/researchers discussing the benefits of PA.  • Knowledge of research evidence required to enable behavior  • Information about health consequences • Information about social and environmental consequences • Information about emotional consequences • Credible source  • Verbal and visual communication of the range of benefits of PA from a credible researcher in the area of MS and PA.  • Fatigue as a barrier to PA  • Information about health consequences • Information about emotional consequences • Vicarious consequences • Action planning  • Text-based information on the benefits of PA in terms of improving fatigue. Additional text information on how to overcome barriers to PA such as fatigue. This is supplemented by videos of people with MS discussing overcoming barriers to PA.  • Appropriate exercises need to be given  • Problem solving • Focus on past success  • Prompt the person with MS to focus on past success with PA and provide the evidence for varying exercise options through text. The patient will then problem solve which exercise to choose by completing an action plan.  • Peer support as a facilitator to PA  • Restructuring the social environment  • Prompt to find an exercise buddy for the chosen exercise behavior. Also, provide links on the website to the local MS society and exercise classes happening there. Also the intervention will have a designated Facebook page to discuss exercise and MS with other individuals on activity matters.  • No accessibility or disability facilities act as barriers to PA  • Action planning • Problem solving  • Set an action plan for the time and place the chosen exercise behavior will occur. Provide list of potential barriers with regard to accessibility and disability for this time and place. Problem-solve the solution through this action plan.  • Exercise modality choice is a facilitator to PA  • Action planning • Focus on past success  • Prompt the person with MS to focus on past success with PA and provide the evidence for varying exercise options through text. The exercise options will be linked to one’s PA ability and mobility level. • Set an action plan for the chosen exercise.  • Self-efficacy has a moderately strong association with PA  • Verbal persuasion about capability • Mental rehearsal of successful performance • Focus on past success • Self-talk  • Provide text and video content from people with MS and their success with exercise. Also provide text encouraging the person with MS that they are capable of exercise. Do this by having information on exercise for varying mobility/PA levels. • Prompt the person with MS to focus on past success with exercise behaviors. Tell them to talk aloud and rehearse mentally successful performance of the behavior. • Complete weekly exercise logs and promote use of self-regulatory techniques such as pedometers to enhance self-efficacy.  • Outcome expectancies has a moderate association with PA  • Information about health consequences • Information about social and environmental consequences • Information about emotional consequences  • Provide text and visual information on the benefits of PA for people with MS on a range of outcomes.  • Goal-setting has mediated change in PA in previous interventions and has a moderately strong association with PA  • Goal-setting (behavior) • Goal-setting (outcome) • Action planning • Review behavioral goals • Review outcome goals  • Set an action plan of the desired behavior. Within this action plan, set goals for the exercise behavior and also for the outcomes of this behavior. For example, goal to walk 20 minutes, three times a week with a goal to improve walking speed. These goals will also be reviewed weekly for the period of the intervention.  • Fear/apprehension as a barrier to PA  • Social support (unspecified/practical) • Reduce negative emotions • Action planning • Problem solving  • Set action plan and list barriers to PA acknowledged by the person with MS. Problem-solve how to reduce this barrier(s). • Reduce negative emotions by providing text and video of people with MS discussing positive experiences with PA. Provide direction to social media page to discuss fears with other people with MS through open discussion forum.  • Feelings of accomplishment a facilitator to PA  • Social incentive • Self-incentive  • Inform the person with MS that if goals are met they should reward themselves with a small reward of their choosing (e.g., go to cinema) • Inform the person with MS that if goals are met they will be provided a verbal reward (congratulated on reaching exercise goals)  • Anxiety/depression/fatigue triad has associations with exercise self-efficacy  • Social support (unspecified/practical) • Reduce negative emotions • Action planning • Problem solving  • Set action plan and provide person with MS with a list of potential barriers (including anxiety, depression, and fatigue). Suggest problem-solving ideas of how to overcome these barriers if present. • Provide link to social media page where people with MS can discuss experiences with anxiety/depression/fatigue as a barrier to PA. • Provide link to support channels for depression/anxiety.  Findings  BCT(s)  Website function  • Conflicting advice from health care professionals  • Credible source  • Verbal and visual communication from a health care professional/researcher/person with MS in favor of the benefits of PA for people with MS.  • Knowledge of benefits of exercise required to enable behavior  • Information about health consequences • Information about social and environmental consequences • Information about emotional consequences • Vicarious consequences • Credible source  • Text on the benefits of PA across a range of outcomes for people with MS. This text will be supplemented with videos of people with MS and health care professionals/researchers discussing the benefits of PA.  • Knowledge of research evidence required to enable behavior  • Information about health consequences • Information about social and environmental consequences • Information about emotional consequences • Credible source  • Verbal and visual communication of the range of benefits of PA from a credible researcher in the area of MS and PA.  • Fatigue as a barrier to PA  • Information about health consequences • Information about emotional consequences • Vicarious consequences • Action planning  • Text-based information on the benefits of PA in terms of improving fatigue. Additional text information on how to overcome barriers to PA such as fatigue. This is supplemented by videos of people with MS discussing overcoming barriers to PA.  • Appropriate exercises need to be given  • Problem solving • Focus on past success  • Prompt the person with MS to focus on past success with PA and provide the evidence for varying exercise options through text. The patient will then problem solve which exercise to choose by completing an action plan.  • Peer support as a facilitator to PA  • Restructuring the social environment  • Prompt to find an exercise buddy for the chosen exercise behavior. Also, provide links on the website to the local MS society and exercise classes happening there. Also the intervention will have a designated Facebook page to discuss exercise and MS with other individuals on activity matters.  • No accessibility or disability facilities act as barriers to PA  • Action planning • Problem solving  • Set an action plan for the time and place the chosen exercise behavior will occur. Provide list of potential barriers with regard to accessibility and disability for this time and place. Problem-solve the solution through this action plan.  • Exercise modality choice is a facilitator to PA  • Action planning • Focus on past success  • Prompt the person with MS to focus on past success with PA and provide the evidence for varying exercise options through text. The exercise options will be linked to one’s PA ability and mobility level. • Set an action plan for the chosen exercise.  • Self-efficacy has a moderately strong association with PA  • Verbal persuasion about capability • Mental rehearsal of successful performance • Focus on past success • Self-talk  • Provide text and video content from people with MS and their success with exercise. Also provide text encouraging the person with MS that they are capable of exercise. Do this by having information on exercise for varying mobility/PA levels. • Prompt the person with MS to focus on past success with exercise behaviors. Tell them to talk aloud and rehearse mentally successful performance of the behavior. • Complete weekly exercise logs and promote use of self-regulatory techniques such as pedometers to enhance self-efficacy.  • Outcome expectancies has a moderate association with PA  • Information about health consequences • Information about social and environmental consequences • Information about emotional consequences  • Provide text and visual information on the benefits of PA for people with MS on a range of outcomes.  • Goal-setting has mediated change in PA in previous interventions and has a moderately strong association with PA  • Goal-setting (behavior) • Goal-setting (outcome) • Action planning • Review behavioral goals • Review outcome goals  • Set an action plan of the desired behavior. Within this action plan, set goals for the exercise behavior and also for the outcomes of this behavior. For example, goal to walk 20 minutes, three times a week with a goal to improve walking speed. These goals will also be reviewed weekly for the period of the intervention.  • Fear/apprehension as a barrier to PA  • Social support (unspecified/practical) • Reduce negative emotions • Action planning • Problem solving  • Set action plan and list barriers to PA acknowledged by the person with MS. Problem-solve how to reduce this barrier(s). • Reduce negative emotions by providing text and video of people with MS discussing positive experiences with PA. Provide direction to social media page to discuss fears with other people with MS through open discussion forum.  • Feelings of accomplishment a facilitator to PA  • Social incentive • Self-incentive  • Inform the person with MS that if goals are met they should reward themselves with a small reward of their choosing (e.g., go to cinema) • Inform the person with MS that if goals are met they will be provided a verbal reward (congratulated on reaching exercise goals)  • Anxiety/depression/fatigue triad has associations with exercise self-efficacy  • Social support (unspecified/practical) • Reduce negative emotions • Action planning • Problem solving  • Set action plan and provide person with MS with a list of potential barriers (including anxiety, depression, and fatigue). Suggest problem-solving ideas of how to overcome these barriers if present. • Provide link to social media page where people with MS can discuss experiences with anxiety/depression/fatigue as a barrier to PA. • Provide link to support channels for depression/anxiety.  BCT behavior change technique; MS multiple sclerosis; PA physical activity. View Large Table 4 Mapping of results to BCTs and mapping of BCTs to website functions for “Activity Matters.” Findings  BCT(s)  Website function  • Conflicting advice from health care professionals  • Credible source  • Verbal and visual communication from a health care professional/researcher/person with MS in favor of the benefits of PA for people with MS.  • Knowledge of benefits of exercise required to enable behavior  • Information about health consequences • Information about social and environmental consequences • Information about emotional consequences • Vicarious consequences • Credible source  • Text on the benefits of PA across a range of outcomes for people with MS. This text will be supplemented with videos of people with MS and health care professionals/researchers discussing the benefits of PA.  • Knowledge of research evidence required to enable behavior  • Information about health consequences • Information about social and environmental consequences • Information about emotional consequences • Credible source  • Verbal and visual communication of the range of benefits of PA from a credible researcher in the area of MS and PA.  • Fatigue as a barrier to PA  • Information about health consequences • Information about emotional consequences • Vicarious consequences • Action planning  • Text-based information on the benefits of PA in terms of improving fatigue. Additional text information on how to overcome barriers to PA such as fatigue. This is supplemented by videos of people with MS discussing overcoming barriers to PA.  • Appropriate exercises need to be given  • Problem solving • Focus on past success  • Prompt the person with MS to focus on past success with PA and provide the evidence for varying exercise options through text. The patient will then problem solve which exercise to choose by completing an action plan.  • Peer support as a facilitator to PA  • Restructuring the social environment  • Prompt to find an exercise buddy for the chosen exercise behavior. Also, provide links on the website to the local MS society and exercise classes happening there. Also the intervention will have a designated Facebook page to discuss exercise and MS with other individuals on activity matters.  • No accessibility or disability facilities act as barriers to PA  • Action planning • Problem solving  • Set an action plan for the time and place the chosen exercise behavior will occur. Provide list of potential barriers with regard to accessibility and disability for this time and place. Problem-solve the solution through this action plan.  • Exercise modality choice is a facilitator to PA  • Action planning • Focus on past success  • Prompt the person with MS to focus on past success with PA and provide the evidence for varying exercise options through text. The exercise options will be linked to one’s PA ability and mobility level. • Set an action plan for the chosen exercise.  • Self-efficacy has a moderately strong association with PA  • Verbal persuasion about capability • Mental rehearsal of successful performance • Focus on past success • Self-talk  • Provide text and video content from people with MS and their success with exercise. Also provide text encouraging the person with MS that they are capable of exercise. Do this by having information on exercise for varying mobility/PA levels. • Prompt the person with MS to focus on past success with exercise behaviors. Tell them to talk aloud and rehearse mentally successful performance of the behavior. • Complete weekly exercise logs and promote use of self-regulatory techniques such as pedometers to enhance self-efficacy.  • Outcome expectancies has a moderate association with PA  • Information about health consequences • Information about social and environmental consequences • Information about emotional consequences  • Provide text and visual information on the benefits of PA for people with MS on a range of outcomes.  • Goal-setting has mediated change in PA in previous interventions and has a moderately strong association with PA  • Goal-setting (behavior) • Goal-setting (outcome) • Action planning • Review behavioral goals • Review outcome goals  • Set an action plan of the desired behavior. Within this action plan, set goals for the exercise behavior and also for the outcomes of this behavior. For example, goal to walk 20 minutes, three times a week with a goal to improve walking speed. These goals will also be reviewed weekly for the period of the intervention.  • Fear/apprehension as a barrier to PA  • Social support (unspecified/practical) • Reduce negative emotions • Action planning • Problem solving  • Set action plan and list barriers to PA acknowledged by the person with MS. Problem-solve how to reduce this barrier(s). • Reduce negative emotions by providing text and video of people with MS discussing positive experiences with PA. Provide direction to social media page to discuss fears with other people with MS through open discussion forum.  • Feelings of accomplishment a facilitator to PA  • Social incentive • Self-incentive  • Inform the person with MS that if goals are met they should reward themselves with a small reward of their choosing (e.g., go to cinema) • Inform the person with MS that if goals are met they will be provided a verbal reward (congratulated on reaching exercise goals)  • Anxiety/depression/fatigue triad has associations with exercise self-efficacy  • Social support (unspecified/practical) • Reduce negative emotions • Action planning • Problem solving  • Set action plan and provide person with MS with a list of potential barriers (including anxiety, depression, and fatigue). Suggest problem-solving ideas of how to overcome these barriers if present. • Provide link to social media page where people with MS can discuss experiences with anxiety/depression/fatigue as a barrier to PA. • Provide link to support channels for depression/anxiety.  Findings  BCT(s)  Website function  • Conflicting advice from health care professionals  • Credible source  • Verbal and visual communication from a health care professional/researcher/person with MS in favor of the benefits of PA for people with MS.  • Knowledge of benefits of exercise required to enable behavior  • Information about health consequences • Information about social and environmental consequences • Information about emotional consequences • Vicarious consequences • Credible source  • Text on the benefits of PA across a range of outcomes for people with MS. This text will be supplemented with videos of people with MS and health care professionals/researchers discussing the benefits of PA.  • Knowledge of research evidence required to enable behavior  • Information about health consequences • Information about social and environmental consequences • Information about emotional consequences • Credible source  • Verbal and visual communication of the range of benefits of PA from a credible researcher in the area of MS and PA.  • Fatigue as a barrier to PA  • Information about health consequences • Information about emotional consequences • Vicarious consequences • Action planning  • Text-based information on the benefits of PA in terms of improving fatigue. Additional text information on how to overcome barriers to PA such as fatigue. This is supplemented by videos of people with MS discussing overcoming barriers to PA.  • Appropriate exercises need to be given  • Problem solving • Focus on past success  • Prompt the person with MS to focus on past success with PA and provide the evidence for varying exercise options through text. The patient will then problem solve which exercise to choose by completing an action plan.  • Peer support as a facilitator to PA  • Restructuring the social environment  • Prompt to find an exercise buddy for the chosen exercise behavior. Also, provide links on the website to the local MS society and exercise classes happening there. Also the intervention will have a designated Facebook page to discuss exercise and MS with other individuals on activity matters.  • No accessibility or disability facilities act as barriers to PA  • Action planning • Problem solving  • Set an action plan for the time and place the chosen exercise behavior will occur. Provide list of potential barriers with regard to accessibility and disability for this time and place. Problem-solve the solution through this action plan.  • Exercise modality choice is a facilitator to PA  • Action planning • Focus on past success  • Prompt the person with MS to focus on past success with PA and provide the evidence for varying exercise options through text. The exercise options will be linked to one’s PA ability and mobility level. • Set an action plan for the chosen exercise.  • Self-efficacy has a moderately strong association with PA  • Verbal persuasion about capability • Mental rehearsal of successful performance • Focus on past success • Self-talk  • Provide text and video content from people with MS and their success with exercise. Also provide text encouraging the person with MS that they are capable of exercise. Do this by having information on exercise for varying mobility/PA levels. • Prompt the person with MS to focus on past success with exercise behaviors. Tell them to talk aloud and rehearse mentally successful performance of the behavior. • Complete weekly exercise logs and promote use of self-regulatory techniques such as pedometers to enhance self-efficacy.  • Outcome expectancies has a moderate association with PA  • Information about health consequences • Information about social and environmental consequences • Information about emotional consequences  • Provide text and visual information on the benefits of PA for people with MS on a range of outcomes.  • Goal-setting has mediated change in PA in previous interventions and has a moderately strong association with PA  • Goal-setting (behavior) • Goal-setting (outcome) • Action planning • Review behavioral goals • Review outcome goals  • Set an action plan of the desired behavior. Within this action plan, set goals for the exercise behavior and also for the outcomes of this behavior. For example, goal to walk 20 minutes, three times a week with a goal to improve walking speed. These goals will also be reviewed weekly for the period of the intervention.  • Fear/apprehension as a barrier to PA  • Social support (unspecified/practical) • Reduce negative emotions • Action planning • Problem solving  • Set action plan and list barriers to PA acknowledged by the person with MS. Problem-solve how to reduce this barrier(s). • Reduce negative emotions by providing text and video of people with MS discussing positive experiences with PA. Provide direction to social media page to discuss fears with other people with MS through open discussion forum.  • Feelings of accomplishment a facilitator to PA  • Social incentive • Self-incentive  • Inform the person with MS that if goals are met they should reward themselves with a small reward of their choosing (e.g., go to cinema) • Inform the person with MS that if goals are met they will be provided a verbal reward (congratulated on reaching exercise goals)  • Anxiety/depression/fatigue triad has associations with exercise self-efficacy  • Social support (unspecified/practical) • Reduce negative emotions • Action planning • Problem solving  • Set action plan and provide person with MS with a list of potential barriers (including anxiety, depression, and fatigue). Suggest problem-solving ideas of how to overcome these barriers if present. • Provide link to social media page where people with MS can discuss experiences with anxiety/depression/fatigue as a barrier to PA. • Provide link to support channels for depression/anxiety.  BCT behavior change technique; MS multiple sclerosis; PA physical activity. View Large Using the information in Table 4, the authors have developed an outline of the proposed “Activity Matters” intervention. This is illustrated in Table 5. The intervention is 12 weeks in duration and aims to increase objective PA levels among ambulatory pwMS. Outcome measurements will be taken at baseline, post-intervention, 6 months, and 12 months. These will include but are not yet limited to, objective PA measurement, exercise self-efficacy, goal-setting, social support, fatigue, depression and anxiety, and a range of symptom outcomes. The intervention will use a web-based learning management system. It will include 11 structured modules and four phonecalls with a facilitator while also incorporating a designated social media page to enhance social support. Participants will also receive booster phonecalls after the 12-week program, once monthly for 3 months. The content of the modules, phonecalls, and social media page will be based upon the findings in Table 4. Table 5 Outline of the “Activity Matters” intervention. Activity matters  Weekly outline  Week number    Phonecall from facilitator  1  Module 1: Benefits of physical activity  1  Module 2: Goal-setting  1  Module 3: Choosing the right activity  2  Module 4: Action planning  2  Module 5: Self-monitoring  3  Module 6: Barriers and symptom management  4  Module 7: Social support  5  Module 8: Feedback and keeping an exercise diary  6  No Modules–Phonecall  7  Module 9: Having a bad day and goal revision  8  No Modules–Phonecall  9  Module 10: Maintaining the behavior  10  No Modules–Phonecall  11  Module 11: Feedback and keeping it going.  12    Additional features      Weekly completion of an exercise “action plan” for the week ahead    Weekly completion of an exercise log for the week past      Participants followed for 3 months post intervention with phonecall from facilitator each month post-trial    Activity matters  Weekly outline  Week number    Phonecall from facilitator  1  Module 1: Benefits of physical activity  1  Module 2: Goal-setting  1  Module 3: Choosing the right activity  2  Module 4: Action planning  2  Module 5: Self-monitoring  3  Module 6: Barriers and symptom management  4  Module 7: Social support  5  Module 8: Feedback and keeping an exercise diary  6  No Modules–Phonecall  7  Module 9: Having a bad day and goal revision  8  No Modules–Phonecall  9  Module 10: Maintaining the behavior  10  No Modules–Phonecall  11  Module 11: Feedback and keeping it going.  12    Additional features      Weekly completion of an exercise “action plan” for the week ahead    Weekly completion of an exercise log for the week past      Participants followed for 3 months post intervention with phonecall from facilitator each month post-trial    View Large Table 5 Outline of the “Activity Matters” intervention. Activity matters  Weekly outline  Week number    Phonecall from facilitator  1  Module 1: Benefits of physical activity  1  Module 2: Goal-setting  1  Module 3: Choosing the right activity  2  Module 4: Action planning  2  Module 5: Self-monitoring  3  Module 6: Barriers and symptom management  4  Module 7: Social support  5  Module 8: Feedback and keeping an exercise diary  6  No Modules–Phonecall  7  Module 9: Having a bad day and goal revision  8  No Modules–Phonecall  9  Module 10: Maintaining the behavior  10  No Modules–Phonecall  11  Module 11: Feedback and keeping it going.  12    Additional features      Weekly completion of an exercise “action plan” for the week ahead    Weekly completion of an exercise log for the week past      Participants followed for 3 months post intervention with phonecall from facilitator each month post-trial    Activity matters  Weekly outline  Week number    Phonecall from facilitator  1  Module 1: Benefits of physical activity  1  Module 2: Goal-setting  1  Module 3: Choosing the right activity  2  Module 4: Action planning  2  Module 5: Self-monitoring  3  Module 6: Barriers and symptom management  4  Module 7: Social support  5  Module 8: Feedback and keeping an exercise diary  6  No Modules–Phonecall  7  Module 9: Having a bad day and goal revision  8  No Modules–Phonecall  9  Module 10: Maintaining the behavior  10  No Modules–Phonecall  11  Module 11: Feedback and keeping it going.  12    Additional features      Weekly completion of an exercise “action plan” for the week ahead    Weekly completion of an exercise log for the week past      Participants followed for 3 months post intervention with phonecall from facilitator each month post-trial    View Large DISCUSSION The aim of this paper was to describe the development process of an Internet-based intervention that aims to change PA behavior among pwMS. The intervention is called “Activity Matters.” To our knowledge, this is the first MS PA intervention that has been developed using the MRC complex interventions and BCW frameworks. Using a range of data sources and following the steps of the BCW, the “Activity Matters” intervention has been developed. The intervention is theoretically based and TDF domains including, knowledge, memory, attention and decision processes, skills, social influences, environmental context and resources, beliefs about capabilities, beliefs about consequences, goals, and emotions were recognized as important and included in the intervention. Intervention functions that will be used include: education, enablement, environmental restructuring, persuasion, and incentivization. Strengths and challenges This is the first MS PA intervention to use the MRC complex interventions framework and the BCW approach. Although other MS PA interventions have used theory, including the SCT and TTM [13–15], these intervention developers have adopted a top-down approach and often do not detail the development process of the intervention using these theories. The BCW and MRC complex interventions framework use a bottom-up approach and provide increased transparency for future replication. In addition, the COM-B and the TDF provide a wide array of theoretical constructs upon which to draw upon which one singular model could not. Another strength of this paper includes the use of a large number of data sources. This paper includes the seven data sources of which five are original research produced by the authors. In addition, the data sources used include qualitative and quantitative research methods. Although the BCW process is both systematic and transparent, there are challenges associated with its use. The researcher must make subjective and pragmatic decisions. The use of the APEASE criteria reduces this subjectivity. For example, when aiming to choose one intervention function versus another, the answer is often determined by the practicality or affordability and not always effectiveness. Using the BCW process to develop an intervention and increase transparency of intervention design is a lengthy process. The authors began working on the development of “Activity Matters,” almost 4 years ago. This included the time to complete each of the included data sources and the mapping stages of the BCW. At this point, the intervention has yet to be assessed for usability, practicality, and therefore effectiveness. This timeframe should be taken into account for future funding applications in which the BCW framework is proposed. Implications for future research Despite the large number of data sources used, it is possible there is more we do not know about PA behavior among pwMS. There are possibly other known correlates of PA that have not been studied and therefore are not known. As the development of PA interventions for pwMS continues, researchers should be aware of new publications arising on correlates and predictors of PA behavior among pwMS that could be added to the theoretical model underpinning “Activity Matters” and described in this paper. In addition, among all seven data sources used, the sample of pwMS used were largely ambulatory people living with the disease. Little is known about those with higher disability caused by MS including those who use wheelchairs. Future research should include these participants. This paper provides a detailed outline of the theoretical development of a web-based intervention to change PA behavior among pwMS. Future research by the authors will include the clinical evaluation of the “Activity Matters.” The website functions outlined in this paper will be created with assistance from a software developer and web designer. Once developed, before testing for effectiveness, the authors will test the usability and acceptability of the web intervention for pwMS. The authors will also conduct qualitative research with health care professionals and policy makers who work with pwMS and can influence change. The aim will be to understand how health care professionals can use “Activity Matters” routinely in their practice to ensure adoption. In addition, these interviews will explore whether health care professionals discuss PA with their MS and if not how to overcome this. It is hoped these findings will lead to the inclusion of specific health care professional content on the “Activity Matters” web resource. CONCLUSION This paper describes the development of an Internet intervention to change PA behavior among pwMS called “Activity Matters.” It is the first MS PA intervention to use the theoretical approach outlined by the MRC complex interventions framework and the BCW. “Activity Matters” will use intervention functions including education, enablement, environmental restructuring, persuasion, and incentivization. These intervention functions have been linked to a number of BCTs including action planning, goal-setting, and problem-solving. The next phase of this work is to test the usability, acceptability, and preliminary effectiveness of “Activity Matters” among pwMS. Acknowledgments: B. Casey was funded for this work by MS Ireland through the ‘Ireland Fund’. Compliance with Ethical Standards Primary Data: The findings reported in this paper have not been previously published, and the manuscript has not being simultaneously submitted elsewhere. Also, the authors have full control of all primary data, and they agree to allow the journal to review their data if requested. Conflict of Interest: None declared Ethical Approval: This article does not contain any studies with human participants performed by any of the authors. This article does not contain any studies with animals performed by any of the authors. Informed Consent: This study does not involve human participants and informed consent was therefore not required. References 1. Trapp BD, Nave KA. Multiple sclerosis: an immune or neurodegenerative disorder? Annu Rev Neurosci . 2008; 31: 247– 269. Google Scholar CrossRef Search ADS PubMed  2. Dilokthornsakul P, Valuck RJ, Nair KV, Corboy JR, Allen RR, Campbell JD. Multiple sclerosis prevalence in the United States commercially insured population. Neurology . 2016; 86( 11): 1014– 1021. Google Scholar CrossRef Search ADS PubMed  3. Ma VY, Chan L, Carruthers KJ. Incidence, prevalence, costs, and impact on disability of common conditions requiring rehabilitation in the United States: stroke, spinal cord injury, traumatic brain injury, multiple sclerosis, osteoarthritis, rheumatoid arthritis, limb loss, and back pain. Arch Phys Med Rehabil . 2014; 95( 5): 986– 995.e1. Google Scholar CrossRef Search ADS PubMed  4. Lublin FD. Clinical features and diagnosis of multiple sclerosis. Neurol Clin . 2005; 23( 1): 1– 15. Google Scholar CrossRef Search ADS PubMed  5. Kjølhede T, Vissing K, Dalgas U. Multiple sclerosis and progressive resistance training: a systematic review. Mult Scler J . 2012: 18( 9): 1215– 1228. Google Scholar CrossRef Search ADS   6. Pilutti LA, Greenlee TA, Motl RW, Nickrent MS, Petruzzello SJ. Effects of exercise training on fatigue in multiple sclerosis: a meta-analysis. Psychosom Med . 2013; 75( 6): 575– 580. Google Scholar CrossRef Search ADS PubMed  7. Gunn H, Markevics S, Haas B, Marsden J, Freeman J. Systematic Review: The Effectiveness of Interventions to Reduce Falls and Improve Balance in Adults With Multiple Sclerosis. Arch Phys Med Rehabil . 2015; 96( 10): 1898– 1912. Google Scholar CrossRef Search ADS PubMed  8. Snook EM, Motl RW, Gliottoni RC. The effect of walking mobility on the measurement of physical activity using accelerometry in multiple sclerosis. Clin Rehabil . 2009; 23( 3): 248– 258. Google Scholar CrossRef Search ADS PubMed  9. Motl RW, Gosney JL. Effect of exercise training on quality of life in multiple sclerosis: a meta-analysis. Mult Scler . 2008; 14( 1): 129– 135. Google Scholar CrossRef Search ADS PubMed  10. Kinnett-Hopkins D, Adamson B, Rougeau K, Motl RW. People with MS are less physically active than healthy controls but as active as those with other chronic diseases: An updated meta-analysis. Mult Scler Relat Disord . 2017; 13: 38– 43. Google Scholar CrossRef Search ADS PubMed  11. Sangelaji B, Smith CM, Paul L, Sampath KK, Treharne GJ, Hale LA. The effectiveness of behaviour change interventions to increase physical activity participation in people with multiple sclerosis: a systematic review and meta-analysis. Clin Rehabil . 2016; 30( 6): 559– 576. Google Scholar CrossRef Search ADS PubMed  12. Michie S, Johnston M, Abraham C, Lawton R, Parker D, Walker A; “Psychological Theory” Group. Making psychological theory useful for implementing evidence based practice: a consensus approach. Qual Saf Health Care . 2005; 14( 1): 26– 33. Google Scholar CrossRef Search ADS PubMed  13. Dlugonski D, Motl RW, Mohr DC, Sandroff BM. Internet-delivered behavioral intervention to increase physical activity in persons with multiple sclerosis: sustainability and secondary outcomes. Psychol Health Med . 2012; 17( 6): 636– 651. Google Scholar CrossRef Search ADS PubMed  14. Motl RW, Dlugonski D, Wójcicki TR, McAuley E, Mohr DC. Internet intervention for increasing physical activity in persons with multiple sclerosis. Mult Scler . 2011; 17( 1): 116– 128. Google Scholar CrossRef Search ADS PubMed  15. Pilutti LA, Dlugonski D, Sandroff BM, Klaren RE, Motl RW. Internet-delivered lifestyle physical activity intervention improves body composition in multiple sclerosis: preliminary evidence from a randomized controlled trial. Arch Phys Med Rehabil . 2014; 95( 7): 1283– 1288. Google Scholar CrossRef Search ADS PubMed  16. Carter A, Daley A, Humphreys Let al.   Pragmatic intervention for increasing self-directed exercise behaviour and improving important health outcomes in people with multiple sclerosis: a randomised controlled trial. Mult Scler . 2014; 20( 8): 1112– 1122. Google Scholar CrossRef Search ADS PubMed  17. Craig P, Dieppe P, Macintyre S, Michie S, Nazareth I, Petticrew M; Medical Research Council Guidance. Developing and evaluating complex interventions: the new Medical Research Council guidance. Bmj . 2008; 337: a1655. Google Scholar CrossRef Search ADS PubMed  18. Michie S, van Stralen MM, West R. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement Sci . 2011; 6: 42. Google Scholar CrossRef Search ADS PubMed  19. Sinnott C, Mercer SW, Payne RA, Duerden M, Bradley CP, Byrne M. Improving medication management in multimorbidity: development of the MultimorbiditY COllaborative Medication Review And DEcision Making (MY COMRADE) intervention using the Behaviour Change Wheel. Implement Sci . 2015; 10: 132. Google Scholar CrossRef Search ADS PubMed  20. Cane J, O’Connor D, Michie S. Validation of the theoretical domains framework for use in behaviour change and implementation research. Implement Sci . 2012; 7: 37. Google Scholar CrossRef Search ADS PubMed  21. Michie S, Richardson M, Johnston Met al.   The behavior change technique taxonomy (v1) of 93 hierarchically clustered techniques: building an international consensus for the reporting of behavior change interventions. Ann Behav Med . 2013; 46( 1): 81– 95. Google Scholar CrossRef Search ADS PubMed  22. Webster R, Bailey JV. Development of a theory-based interactive digital intervention to improve condom use in men in sexual health clinics: an application of qualitative methods using the behaviour change wheel. Lancet . 2013; 382: S102. Google Scholar CrossRef Search ADS   23. Fulton EA, Brown KE, Kwah KL, Wild S. StopApp: using the behaviour change wheel to develop an app to increase uptake and attendance at NHS Stop Smoking Services. Healthcare . 2016; 4 (2):31. 24. Casey B, Coote S, Donnelly A. Objective physical activity measurement in people with multiple sclerosis: a review of the literature. Disabil Rehabil Assist Technol . 2017; 13 (2): 1– 8. Google Scholar PubMed  25. Casey B, Hayes S, Browne C, Coote S. What do people with MS want from a web-based resource to encourage increased physical activity behaviour? Disabil Rehabil . 2016; 38( 16): 1557– 1566. Google Scholar CrossRef Search ADS PubMed  26. Casey B, Coote S, Shirazipour Cet al.   Modifiable Psychosocial Constructs Associated With Physical Activity Participation in People With Multiple Sclerosis: A Systematic Review and Meta-Analysis. Arch Phys Med Rehabil . 2017; 98( 7): 1453– 1475. Google Scholar CrossRef Search ADS PubMed  27. Streber R, Peters S, Pfeifer K. Systematic Review of Correlates and Determinants of Physical Activity in Persons with Multiple Sclerosis. Arch Phys Med Rehabil . 2016; 97( 4): 633– 645.e29. Google Scholar CrossRef Search ADS PubMed  28. Learmonth YC, Motl RW. Physical activity and exercise training in multiple sclerosis: a review and content analysis of qualitative research identifying perceived determinants and consequences. Disabil Rehabil . 2016; 38( 13): 1227– 1242. Google Scholar CrossRef Search ADS PubMed  29. Michie S, Atkins L, West R. The Behaviour Change Wheel: A Guide to Designing Interventions . London, United Kingdom: Silverback Publishing; 2014. 30. Dlugonski D, Wójcicki TR, McAuley E, Motl RW. Social cognitive correlates of physical activity in inactive adults with multiple sclerosis. Int j Rehabil Res . 2011; 34( 2): 115– 120. Google Scholar CrossRef Search ADS PubMed  31. Wardell L, Hum S, Laizner AM, Lapierre Y. Multiple sclerosis patients’ interest in and likelihood of using online health-care services. Int J MS Care . 2009; 11( 2): 79– 89. Google Scholar CrossRef Search ADS   © Society of Behavioral Medicine 2018. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Translational Behavioral Medicine Oxford University Press

Activity matters: a web-based resource to enable people with multiple sclerosis to become more active

Loading next page...
 
/lp/ou_press/activity-matters-a-web-based-resource-to-enable-people-with-multiple-NvoSXGCyuJ
Copyright
© Society of Behavioral Medicine 2018. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.
ISSN
1869-6716
eISSN
1613-9860
D.O.I.
10.1093/tbm/iby028
Publisher site
See Article on Publisher Site

Abstract

Abstract Increasing physical activity (PA) through exercise is associated with improvements in many of the symptoms associated with multiple sclerosis (MS) such as fatigue, strength, balance, and mobility. Despite this, people with MS remain largely inactive. Interventions that are grounded in theory and that aim to change PA behavior need to be developed. The purpose of this study was to describe the development process of a web-based resource, namely, “Activity Matters,” to enable people with MS to become more active. Development of the “Activity Matters” online intervention was guided by the UK’s Medical Research Council (MRC) framework for the development and evaluation of complex interventions and the behavior change wheel (BCW). Seven sources of data were used to inform the process and were mapped on to both the MRC and BCW frameworks. The intervention is theoretically based, and constructs including knowledge, memory, attention and decision processes, skills, social influences, environmental context and resources, beliefs about capabilities, beliefs about consequences, goals, and emotions were recognized as important. “Activity Matters” is the first MS PA intervention to be developed using the theoretical approach outlined by the BCW and MRC complex interventions frameworks. The next phase of this work is to test the usability, acceptability, and preliminary effectiveness of “Activity Matters” among people with MS. Implications Practice: Physical activity interventions for people with multiple sclerosis (MS) should aim to include behavior change techniques such as action planning, goal-setting, and social support. Policy: Policy makers who want to increase physical activity behaviors among people with neurological disorders should explore the use of the behavior change wheel (BCW) framework to improve research transparency and improve implementation. Research: Future research is needed to examine other MS-specific correlates of physical activity behavior and pilot MS physical activity interventions that have used the BCW framework. INTRODUCTION Multiple sclerosis (MS) is a chronic disease of the central nervous system (CNS) that is associated with demyelination, inflammation, and axonal degeneration [1]. There are more than 400,000 people living with MS in the USA and approximately 2.1 million worldwide [2]. The estimated annual economic cost to the USA is 28 billion dollars with reported annual costs per person between 18,000 and 39,000 dollars [3]. The disease is characterized by cognitive and ambulatory dysfunction, fatigue, depression, pain, deconditioning, and compromised quality of life (QOL) [4]. A growing body of evidence has shown that increasing physical activity (PA) through exercise is associated with improvements in many of these symptoms [5–9]. Despite this, people with MS (pwMS) remain largely inactive, even more than their healthy counterparts [10]. And, while behavioral interventions have successfully changed PA levels among pwMS in the short-medium term (up to 6 months), there is no evidence for any long-term (up to 12 months) change [11]. It is has been suggested these suboptimal effects are due to a lack of theoretical consideration at the development stages of these behavioral interventions [12], and evidence has shown that only few MS PA interventions have used theory [11]. Those that have, used the social cognitive theory (SCT) [13–15] and the transtheoretical model (TTM) [16]. However, how intervention developers have used these theories to describe the development of MS PA interventions has not been well described. This continues to pose a challenge for researchers. If interventions do not describe how they used theory from the beginning, then those interventions cannot be used to inform future design as the effective components and how change came about within an intervention cannot be identified. A framework proposed by the Medical Research Council (MRC) for the development and evaluation of complex interventions emphasizes the importance of theory in intervention development [17]. However, the MRC complex interventions framework does not provide researchers with suggestions for the most appropriate theory to use for the behavior in question. Given the large pool of behavioral models that exist, this has proven a challenge for intervention developers but fortunately this gap has been addressed with the development of the behavior change wheel (BCW) [18]. The BCW (Fig. 1) provides a detailed framework for the development of behavioral interventions through the stages outlined in the MRC complex interventions framework. The stages and steps of both frameworks have been previously mapped together [19] and this is outlined in Table 1. Table 1 Mapping steps of the behavior change wheel (BCW) to the three stages of the Medical Research Council (MRC) framework for the development of complex interventions [1]. MRC development stage  BCW steps  BCW stages  1. Identify the evidence base 2. Identify/develop theory 3. Model process and ouctomes  1. Define the problem in behavioral terms 2. Select the target behavior 3. Specify the target population 4. Identify what needs to change 5. Identify appropiate intervention functions 6. Identifying policy categories 7. Identifying behavioral change techniques 8. Determine the mode of delivery  1. Understand the behavior 2. Identify intervention options 3. Identify content and implementation options  MRC development stage  BCW steps  BCW stages  1. Identify the evidence base 2. Identify/develop theory 3. Model process and ouctomes  1. Define the problem in behavioral terms 2. Select the target behavior 3. Specify the target population 4. Identify what needs to change 5. Identify appropiate intervention functions 6. Identifying policy categories 7. Identifying behavioral change techniques 8. Determine the mode of delivery  1. Understand the behavior 2. Identify intervention options 3. Identify content and implementation options  View Large Table 1 Mapping steps of the behavior change wheel (BCW) to the three stages of the Medical Research Council (MRC) framework for the development of complex interventions [1]. MRC development stage  BCW steps  BCW stages  1. Identify the evidence base 2. Identify/develop theory 3. Model process and ouctomes  1. Define the problem in behavioral terms 2. Select the target behavior 3. Specify the target population 4. Identify what needs to change 5. Identify appropiate intervention functions 6. Identifying policy categories 7. Identifying behavioral change techniques 8. Determine the mode of delivery  1. Understand the behavior 2. Identify intervention options 3. Identify content and implementation options  MRC development stage  BCW steps  BCW stages  1. Identify the evidence base 2. Identify/develop theory 3. Model process and ouctomes  1. Define the problem in behavioral terms 2. Select the target behavior 3. Specify the target population 4. Identify what needs to change 5. Identify appropiate intervention functions 6. Identifying policy categories 7. Identifying behavioral change techniques 8. Determine the mode of delivery  1. Understand the behavior 2. Identify intervention options 3. Identify content and implementation options  View Large Fig 1 View largeDownload slide The behavior change wheel [19]. Fig 1 View largeDownload slide The behavior change wheel [19]. At the core of the BCW is the COM-B model in which behavior change is conceptualized by requiring a shift in a person’s capability (C), opportunity (O), and motivation (M). Capability can be physical or psychological, opportunity can be physical or social, and motivation can be reflective or automatic. These subdivisions can be further broken down into 14 theoretical domains, specified by the theoretical domains framework (TDF) [20]. The TDF is an amalgamation of 28 theoretical constructs from 33 theories of behavior change. The COM-B model and TDF further guide the choice of nine potential intervention functions: education, persuasion, incentivization, coercion, training, enablement, modeling, environmental restructuring, and restrictions. These intervention functions are in turn linked to a taxonomy of 93 behavior change techniques (BCTs) [21], which are the active components of an intervention that are designed to change behavior [18]. The structured approach of the BCW provides transparency to intervention developers. The BCW has been used to develop interventions that were acceptable and effective in changing varying behaviors including medication management, smoking cessation, and condom use, among others [19, 22, 23]. To the author’s knowledge, there are no reports of a MS PA intervention that has been developed using the BCW process. This paper will describe the development of an intervention to change PA behavior among pwMS using the steps of the MRC complex interventions framework and BCW. The intervention is named “Activity Matters” and aims to develop a web-based resource to enhance PA behavior among pwMS. AIMS The purpose of this study was to describe the theory underpinning the development process of the “Activity Matters” web resource to enable pwMS to become more physically active using the MRC complex interventions framework and the BCW. METHODS Seven sources of data were used to inform the development of “Activity Matters.” Five of these sources were research papers conducted by the authors. These included three systematic reviews and two original research studies. The additional two data sources were papers by MS PA research groups from North America and Europe. These included two systematic reviews. The seven data sources are highlighted in Table 2 and their methodology is published elsewhere. Table 2 Summary of included data sources   Data source title  Study design  Research aim(s)  1  Objective physical activity levels among people with multiple sclerosis—a meta-analysis (Casey et al. 2017–under review)  Meta-analysis  (1) To quantify physical activity (PA) levels in people with multiple sclerosis (MS) using objective measurement only. (2) To establish using a meta-analytical approach if people with MS are less physically active than a general population sample.  2  Changing physical activity behaviour in people with multiple sclerosis: a systematic review and meta-analysis of randomised control trials (Casey et al. 2017–accepted for publication)  Systematic review and meta-analysis  (1) To examine the totality of the evidence on the effectiveness of behavioral interventions on PA behavior in people with MS. (2) To use the theory coding scheme and establish how/if current PA behavioral interventions use theory. (3) To identify, using a behavior change technique (BCT) taxonomy, what BCTs are employed in the identified interventions to change PA behavior in people with MS.  3  What do people with ms want from a web-based resource to encourage increased physical activity behaviour? [24]  Qualitative semi-structured interviews and focus groups  (1) To investigate what people with MS want from a web based resource that encourages PA  4  Modifiable psychosocial constructs associated with physical activity participation in people with multiple sclerosis: a meta-analysis. [25]  Meta-analysis  (1) To synthesize current knowledge of the modifiable psychosocial constructs associated with PA participation in people with MS  5  Do multiple sclerosis symptoms moderate the relationship between self-efficacy and physical activity in people with multiple sclerosis? (Casey et al 2017–accepted)  Quantitative correlations and moderation  (1) To investigate the bivariate correlations between objective PA, self-efficacy, and a range of MS symptom measures. (2) To determine if any MS symptom measures moderate the relationship between self-efficacy and PA.  6  Systematic review of correlates and determinants of physical activity in persons with multiple sclerosis. [26]  Systematic review  (1) To review the current evidence regarding correlates and determinants of PA in people with MS  7  Physical activity and exercise training in multiple sclerosis: a review and content analysis of qualitative research identifying perceived determinants and consequences. [27]  Qualitative metasynthesis  (1) To provide rich and deep evidence of the perceived determinants and consequences of physical activity and exercise based on qualitative research in MS    Data source title  Study design  Research aim(s)  1  Objective physical activity levels among people with multiple sclerosis—a meta-analysis (Casey et al. 2017–under review)  Meta-analysis  (1) To quantify physical activity (PA) levels in people with multiple sclerosis (MS) using objective measurement only. (2) To establish using a meta-analytical approach if people with MS are less physically active than a general population sample.  2  Changing physical activity behaviour in people with multiple sclerosis: a systematic review and meta-analysis of randomised control trials (Casey et al. 2017–accepted for publication)  Systematic review and meta-analysis  (1) To examine the totality of the evidence on the effectiveness of behavioral interventions on PA behavior in people with MS. (2) To use the theory coding scheme and establish how/if current PA behavioral interventions use theory. (3) To identify, using a behavior change technique (BCT) taxonomy, what BCTs are employed in the identified interventions to change PA behavior in people with MS.  3  What do people with ms want from a web-based resource to encourage increased physical activity behaviour? [24]  Qualitative semi-structured interviews and focus groups  (1) To investigate what people with MS want from a web based resource that encourages PA  4  Modifiable psychosocial constructs associated with physical activity participation in people with multiple sclerosis: a meta-analysis. [25]  Meta-analysis  (1) To synthesize current knowledge of the modifiable psychosocial constructs associated with PA participation in people with MS  5  Do multiple sclerosis symptoms moderate the relationship between self-efficacy and physical activity in people with multiple sclerosis? (Casey et al 2017–accepted)  Quantitative correlations and moderation  (1) To investigate the bivariate correlations between objective PA, self-efficacy, and a range of MS symptom measures. (2) To determine if any MS symptom measures moderate the relationship between self-efficacy and PA.  6  Systematic review of correlates and determinants of physical activity in persons with multiple sclerosis. [26]  Systematic review  (1) To review the current evidence regarding correlates and determinants of PA in people with MS  7  Physical activity and exercise training in multiple sclerosis: a review and content analysis of qualitative research identifying perceived determinants and consequences. [27]  Qualitative metasynthesis  (1) To provide rich and deep evidence of the perceived determinants and consequences of physical activity and exercise based on qualitative research in MS  View Large Table 2 Summary of included data sources   Data source title  Study design  Research aim(s)  1  Objective physical activity levels among people with multiple sclerosis—a meta-analysis (Casey et al. 2017–under review)  Meta-analysis  (1) To quantify physical activity (PA) levels in people with multiple sclerosis (MS) using objective measurement only. (2) To establish using a meta-analytical approach if people with MS are less physically active than a general population sample.  2  Changing physical activity behaviour in people with multiple sclerosis: a systematic review and meta-analysis of randomised control trials (Casey et al. 2017–accepted for publication)  Systematic review and meta-analysis  (1) To examine the totality of the evidence on the effectiveness of behavioral interventions on PA behavior in people with MS. (2) To use the theory coding scheme and establish how/if current PA behavioral interventions use theory. (3) To identify, using a behavior change technique (BCT) taxonomy, what BCTs are employed in the identified interventions to change PA behavior in people with MS.  3  What do people with ms want from a web-based resource to encourage increased physical activity behaviour? [24]  Qualitative semi-structured interviews and focus groups  (1) To investigate what people with MS want from a web based resource that encourages PA  4  Modifiable psychosocial constructs associated with physical activity participation in people with multiple sclerosis: a meta-analysis. [25]  Meta-analysis  (1) To synthesize current knowledge of the modifiable psychosocial constructs associated with PA participation in people with MS  5  Do multiple sclerosis symptoms moderate the relationship between self-efficacy and physical activity in people with multiple sclerosis? (Casey et al 2017–accepted)  Quantitative correlations and moderation  (1) To investigate the bivariate correlations between objective PA, self-efficacy, and a range of MS symptom measures. (2) To determine if any MS symptom measures moderate the relationship between self-efficacy and PA.  6  Systematic review of correlates and determinants of physical activity in persons with multiple sclerosis. [26]  Systematic review  (1) To review the current evidence regarding correlates and determinants of PA in people with MS  7  Physical activity and exercise training in multiple sclerosis: a review and content analysis of qualitative research identifying perceived determinants and consequences. [27]  Qualitative metasynthesis  (1) To provide rich and deep evidence of the perceived determinants and consequences of physical activity and exercise based on qualitative research in MS    Data source title  Study design  Research aim(s)  1  Objective physical activity levels among people with multiple sclerosis—a meta-analysis (Casey et al. 2017–under review)  Meta-analysis  (1) To quantify physical activity (PA) levels in people with multiple sclerosis (MS) using objective measurement only. (2) To establish using a meta-analytical approach if people with MS are less physically active than a general population sample.  2  Changing physical activity behaviour in people with multiple sclerosis: a systematic review and meta-analysis of randomised control trials (Casey et al. 2017–accepted for publication)  Systematic review and meta-analysis  (1) To examine the totality of the evidence on the effectiveness of behavioral interventions on PA behavior in people with MS. (2) To use the theory coding scheme and establish how/if current PA behavioral interventions use theory. (3) To identify, using a behavior change technique (BCT) taxonomy, what BCTs are employed in the identified interventions to change PA behavior in people with MS.  3  What do people with ms want from a web-based resource to encourage increased physical activity behaviour? [24]  Qualitative semi-structured interviews and focus groups  (1) To investigate what people with MS want from a web based resource that encourages PA  4  Modifiable psychosocial constructs associated with physical activity participation in people with multiple sclerosis: a meta-analysis. [25]  Meta-analysis  (1) To synthesize current knowledge of the modifiable psychosocial constructs associated with PA participation in people with MS  5  Do multiple sclerosis symptoms moderate the relationship between self-efficacy and physical activity in people with multiple sclerosis? (Casey et al 2017–accepted)  Quantitative correlations and moderation  (1) To investigate the bivariate correlations between objective PA, self-efficacy, and a range of MS symptom measures. (2) To determine if any MS symptom measures moderate the relationship between self-efficacy and PA.  6  Systematic review of correlates and determinants of physical activity in persons with multiple sclerosis. [26]  Systematic review  (1) To review the current evidence regarding correlates and determinants of PA in people with MS  7  Physical activity and exercise training in multiple sclerosis: a review and content analysis of qualitative research identifying perceived determinants and consequences. [27]  Qualitative metasynthesis  (1) To provide rich and deep evidence of the perceived determinants and consequences of physical activity and exercise based on qualitative research in MS  View Large This study uses both the MRC complex interventions framework and the BCW to guide the analysis and synthesis of the seven data sources (Table 1). MRC Development Stage 1—identify the evidence base Data Source 1 was used for this stage and included Steps 1–3 from the BCW (Table 1). A meta-analysis of objective PA levels among pwMS was conducted to define the problem (BCW Step 1) of physical inactivity in this population and therefore a need for a resource such as “Activity Matters.” With regard to specifying the target behavior and population (BCW Steps 2 and 3), there is little evidence on the “ideal” objective PA measurement output for pwMS and no cut-off points exist [24]. Given these discrepancies in the measurement of PA among pwMS [24], it is suggested by the research team that the specified behavior for “Activity Matters” is any increase in an objective measure of PA, simply moving more (increased steps per day, increased MVPA per day, etc.). The specified population of pwMS is those who are ambulatory, with/without use of an aid due to the limited PA literature among those with higher disability. MRC Development Stage 2—identify/develop theory Data Sources 2–7[25–28] were used for this stage and included Steps 4–6 from the BCW. Six data sources aimed to understand PA behavior among pwMS and identify what needs to change (BCW Step 4). These sources included qualitative (n = 2 sources) and quantitative (n = 4 sources) methodologies. Four sources were conducted by the authors while the other two sources were known qualitative [28] and quantitative [27] reviews in the MS field. The sources included data on previous PA interventions, data on correlates and determinants of PA, data on barriers and facilitators of PA, and data on the role of MS symptoms on PA behavior among pwMS. To identify important intervention functions (BCW Step 5) for “Activity Matters,” relevant results from the six data sources (BCW Step 4) were extracted. Results were extracted if they added to understanding PA behavior among pwMS and were modifiable within interventions. Additionally, results reported in systematic reviews must have been examined in three or more studies to meet inclusion for extraction. Extracted results were then mapped on to the COM-B and TDF [20]. Once domains from the TDF were selected for the results, intervention functions were then identified by reviewing the possibilities for each domain as defined in the BCW guide [18]. If more than one intervention function was linked to each domain, we used the affordability, practicality, effectiveness, acceptability, side effects/safety, and equity (APEASE) criteria to choose relevant intervention functions for “Activity Matters” [29]. The APEASE criteria acknowledge that behavior change interventions operate within a social context, and that although effectiveness is the primary focus of interventions, it is clearly important to consider other contextual factors [29]. MRC Development Stage 3—model process and outcomes This stage includes BCW Steps 7 and 8. Using the BCW guide [18], potential BCTs were identified from the chosen intervention functions from Stage 2. These BCTs were reviewed with the APEASE criteria and through discussions among the research team (B.C., S.C., and M.B.). The selected BCTs were then translated into website functions which matched the qualitative needs of pwMS for a web-based PA resource [25]. The Internet was chosen as the mode of delivery. When developing a successful intervention, one must ensure it is delivered in a medium that matches the interest and usage profile of the target population [30]. Evidence suggests that the preferred method of delivering PA information to pwMS is via the Internet [31]. Recent evidence suggests that accessibility to the web is not an issue for pwMS and that more than 90% of ambulatory pwMS have access to a smartphone, which they believe has the potential to benefit health care information. This evidence supports the use of the Internet as the preferred medium for “Activity Matters.” RESULTS MRC Development Stage 1—identify the evidence base The systematic review on objective PA levels among pwMS resulted in 32 papers (Data Source 1). There was a total of 3,762 pwMS included, the sample was largely female (n = 3,118; 82.8%) and ambulatory with/without the use of an aid. Meta-analysis indicated statistically significant differences between the MS and general population samples with respect to PA outputs of (a) steps per day (mean difference: −3845 [95% CI = −4120.17, −3569.83], p < 0.0001), (b) activity counts per day (mean difference: −91377.69 [95% CI = −103827.8, −78927.54], p < 0.0001), and (c) minutes of MVPA per day (mean difference: 8.95 [95% CI = −12.52, −5.38], p < 0.0001), indicating pwMS are less physically active than the general population sample, who themselves were physically inactive. MRC Development Stage 2—identify/develop theory The relevant results from Data Sources 2–7 are outlined in Table 3. These findings are mapped on to the COM-B and TDF. TDF domains of knowledge, memory, attention and decision processes, skills, social influences, environmental context and resources, beliefs about capabilities, beliefs about consequences, goals, and emotion were highlighted as important from our data. Results were then mapped on to intervention functions. Intervention functions chosen to be used in “Activity Matters” included, education, enablement, environmental restructuring, persuasion, and incentivization. Table 3 Mapping of results from data sources on to the COM-B and TDF with appropriate intervention functions and proposed BCTs highlighted. COM-B component  TDF domain  Results  Intervention function  Proposed BCTs  Capability  Psychological  Knowledge  • Conflicting advice from health care professionals (Source 7) • Knowledge of benefits of exercise required to enable behavior (Source 3) • Knowledge of research evidence required to enable behavior (Source 3) • Knowledge of the types of exercises for varying PA and mobility levels (Source 3)  Education  • Information about health consequences • Information about social and environmental consequences • Information about emotional consequences • Vicarious consequences • Credible source.      Memory, attention, and decision processes  • Fatigue as a barrier to PA/exercise (Source 7)  Education  • Information about health consequences • Information about emotional consequences • Vicarious consequences    Physical  Skills  • Appropriate exercises for PA level and mobility level need to be provided (Sources 3 and 7)  Enablement  • Problem solving • Graded tasks • Action planning • Goal setting (behavior) • Review behavioral goal • Focus on past success  Opportunity  Social  Social influences  • Peer support as a facilitator to exercise/PA (Sources 3 and 7)  Environmental restructuring  • Restructuring the social environment    Physical  Environmental context and resources  • No accessibility or disability facilities act as barriers to exercise/PA (Source 7) • Exercise modality choice facilitator to exercise/PA (Source 3 and 7)  Enablement  • Action planning • Problem solving • Goal-setting (behavior) • Review behavioral goals • Focus on past success  Motivation  Reflective  Beliefs about capabilities  • Self-efficacy has a moderately strong association with PA (Source 4 and 6)  Enablement persuasion  • Verbal persuasion about capability • Mental rehearsal of successful performance • Focus on past success • Self-talk      Beliefs about consequences  • Outcome expectancies has a moderate association with PA (Source 4)  Education  • Information about health consequences • Information about social and environmental consequences • Information about emotional consequences      Goals  • Goal-setting has mediated change in PA in previous interventions (Source 2) • Goal-setting has a moderately strong association with PA (Sources 4 and 6)  Enablement  • Goal-setting (behavior) • Goal-setting (outcome) • Action planning • Review behavioral goals • Review outcome goals    Automatic  Emotion  • Fear/apprehension as a barrier to exercise/PA (Source 7) • Feelings of accomplishment (Source 7) • Anxiety/depression/fatigue triad has associations with exercise self-efficacy (Source 5)  Incentivization enablement  • Social support (unspecified/practical) • Reduce negative emotions • Action planning • Problem solving • Social incentive • Self-incentive  COM-B component  TDF domain  Results  Intervention function  Proposed BCTs  Capability  Psychological  Knowledge  • Conflicting advice from health care professionals (Source 7) • Knowledge of benefits of exercise required to enable behavior (Source 3) • Knowledge of research evidence required to enable behavior (Source 3) • Knowledge of the types of exercises for varying PA and mobility levels (Source 3)  Education  • Information about health consequences • Information about social and environmental consequences • Information about emotional consequences • Vicarious consequences • Credible source.      Memory, attention, and decision processes  • Fatigue as a barrier to PA/exercise (Source 7)  Education  • Information about health consequences • Information about emotional consequences • Vicarious consequences    Physical  Skills  • Appropriate exercises for PA level and mobility level need to be provided (Sources 3 and 7)  Enablement  • Problem solving • Graded tasks • Action planning • Goal setting (behavior) • Review behavioral goal • Focus on past success  Opportunity  Social  Social influences  • Peer support as a facilitator to exercise/PA (Sources 3 and 7)  Environmental restructuring  • Restructuring the social environment    Physical  Environmental context and resources  • No accessibility or disability facilities act as barriers to exercise/PA (Source 7) • Exercise modality choice facilitator to exercise/PA (Source 3 and 7)  Enablement  • Action planning • Problem solving • Goal-setting (behavior) • Review behavioral goals • Focus on past success  Motivation  Reflective  Beliefs about capabilities  • Self-efficacy has a moderately strong association with PA (Source 4 and 6)  Enablement persuasion  • Verbal persuasion about capability • Mental rehearsal of successful performance • Focus on past success • Self-talk      Beliefs about consequences  • Outcome expectancies has a moderate association with PA (Source 4)  Education  • Information about health consequences • Information about social and environmental consequences • Information about emotional consequences      Goals  • Goal-setting has mediated change in PA in previous interventions (Source 2) • Goal-setting has a moderately strong association with PA (Sources 4 and 6)  Enablement  • Goal-setting (behavior) • Goal-setting (outcome) • Action planning • Review behavioral goals • Review outcome goals    Automatic  Emotion  • Fear/apprehension as a barrier to exercise/PA (Source 7) • Feelings of accomplishment (Source 7) • Anxiety/depression/fatigue triad has associations with exercise self-efficacy (Source 5)  Incentivization enablement  • Social support (unspecified/practical) • Reduce negative emotions • Action planning • Problem solving • Social incentive • Self-incentive  TDF theoretical domains framework; BCT behavior change technique; PA physical activity. View Large Table 3 Mapping of results from data sources on to the COM-B and TDF with appropriate intervention functions and proposed BCTs highlighted. COM-B component  TDF domain  Results  Intervention function  Proposed BCTs  Capability  Psychological  Knowledge  • Conflicting advice from health care professionals (Source 7) • Knowledge of benefits of exercise required to enable behavior (Source 3) • Knowledge of research evidence required to enable behavior (Source 3) • Knowledge of the types of exercises for varying PA and mobility levels (Source 3)  Education  • Information about health consequences • Information about social and environmental consequences • Information about emotional consequences • Vicarious consequences • Credible source.      Memory, attention, and decision processes  • Fatigue as a barrier to PA/exercise (Source 7)  Education  • Information about health consequences • Information about emotional consequences • Vicarious consequences    Physical  Skills  • Appropriate exercises for PA level and mobility level need to be provided (Sources 3 and 7)  Enablement  • Problem solving • Graded tasks • Action planning • Goal setting (behavior) • Review behavioral goal • Focus on past success  Opportunity  Social  Social influences  • Peer support as a facilitator to exercise/PA (Sources 3 and 7)  Environmental restructuring  • Restructuring the social environment    Physical  Environmental context and resources  • No accessibility or disability facilities act as barriers to exercise/PA (Source 7) • Exercise modality choice facilitator to exercise/PA (Source 3 and 7)  Enablement  • Action planning • Problem solving • Goal-setting (behavior) • Review behavioral goals • Focus on past success  Motivation  Reflective  Beliefs about capabilities  • Self-efficacy has a moderately strong association with PA (Source 4 and 6)  Enablement persuasion  • Verbal persuasion about capability • Mental rehearsal of successful performance • Focus on past success • Self-talk      Beliefs about consequences  • Outcome expectancies has a moderate association with PA (Source 4)  Education  • Information about health consequences • Information about social and environmental consequences • Information about emotional consequences      Goals  • Goal-setting has mediated change in PA in previous interventions (Source 2) • Goal-setting has a moderately strong association with PA (Sources 4 and 6)  Enablement  • Goal-setting (behavior) • Goal-setting (outcome) • Action planning • Review behavioral goals • Review outcome goals    Automatic  Emotion  • Fear/apprehension as a barrier to exercise/PA (Source 7) • Feelings of accomplishment (Source 7) • Anxiety/depression/fatigue triad has associations with exercise self-efficacy (Source 5)  Incentivization enablement  • Social support (unspecified/practical) • Reduce negative emotions • Action planning • Problem solving • Social incentive • Self-incentive  COM-B component  TDF domain  Results  Intervention function  Proposed BCTs  Capability  Psychological  Knowledge  • Conflicting advice from health care professionals (Source 7) • Knowledge of benefits of exercise required to enable behavior (Source 3) • Knowledge of research evidence required to enable behavior (Source 3) • Knowledge of the types of exercises for varying PA and mobility levels (Source 3)  Education  • Information about health consequences • Information about social and environmental consequences • Information about emotional consequences • Vicarious consequences • Credible source.      Memory, attention, and decision processes  • Fatigue as a barrier to PA/exercise (Source 7)  Education  • Information about health consequences • Information about emotional consequences • Vicarious consequences    Physical  Skills  • Appropriate exercises for PA level and mobility level need to be provided (Sources 3 and 7)  Enablement  • Problem solving • Graded tasks • Action planning • Goal setting (behavior) • Review behavioral goal • Focus on past success  Opportunity  Social  Social influences  • Peer support as a facilitator to exercise/PA (Sources 3 and 7)  Environmental restructuring  • Restructuring the social environment    Physical  Environmental context and resources  • No accessibility or disability facilities act as barriers to exercise/PA (Source 7) • Exercise modality choice facilitator to exercise/PA (Source 3 and 7)  Enablement  • Action planning • Problem solving • Goal-setting (behavior) • Review behavioral goals • Focus on past success  Motivation  Reflective  Beliefs about capabilities  • Self-efficacy has a moderately strong association with PA (Source 4 and 6)  Enablement persuasion  • Verbal persuasion about capability • Mental rehearsal of successful performance • Focus on past success • Self-talk      Beliefs about consequences  • Outcome expectancies has a moderate association with PA (Source 4)  Education  • Information about health consequences • Information about social and environmental consequences • Information about emotional consequences      Goals  • Goal-setting has mediated change in PA in previous interventions (Source 2) • Goal-setting has a moderately strong association with PA (Sources 4 and 6)  Enablement  • Goal-setting (behavior) • Goal-setting (outcome) • Action planning • Review behavioral goals • Review outcome goals    Automatic  Emotion  • Fear/apprehension as a barrier to exercise/PA (Source 7) • Feelings of accomplishment (Source 7) • Anxiety/depression/fatigue triad has associations with exercise self-efficacy (Source 5)  Incentivization enablement  • Social support (unspecified/practical) • Reduce negative emotions • Action planning • Problem solving • Social incentive • Self-incentive  TDF theoretical domains framework; BCT behavior change technique; PA physical activity. View Large MRC Development Stage 3—model process and outcomes Proposed BCTs were matched to the intervention functions (Table 3). The final list of BCTs employed in “Activity Matters” is outlined in Table 4 along with the website functions. Not all proposed BCTs were included in the final list of BCTs after using the APEASE criteria and results of the original qualitative data source [25]. Table 4 Mapping of results to BCTs and mapping of BCTs to website functions for “Activity Matters.” Findings  BCT(s)  Website function  • Conflicting advice from health care professionals  • Credible source  • Verbal and visual communication from a health care professional/researcher/person with MS in favor of the benefits of PA for people with MS.  • Knowledge of benefits of exercise required to enable behavior  • Information about health consequences • Information about social and environmental consequences • Information about emotional consequences • Vicarious consequences • Credible source  • Text on the benefits of PA across a range of outcomes for people with MS. This text will be supplemented with videos of people with MS and health care professionals/researchers discussing the benefits of PA.  • Knowledge of research evidence required to enable behavior  • Information about health consequences • Information about social and environmental consequences • Information about emotional consequences • Credible source  • Verbal and visual communication of the range of benefits of PA from a credible researcher in the area of MS and PA.  • Fatigue as a barrier to PA  • Information about health consequences • Information about emotional consequences • Vicarious consequences • Action planning  • Text-based information on the benefits of PA in terms of improving fatigue. Additional text information on how to overcome barriers to PA such as fatigue. This is supplemented by videos of people with MS discussing overcoming barriers to PA.  • Appropriate exercises need to be given  • Problem solving • Focus on past success  • Prompt the person with MS to focus on past success with PA and provide the evidence for varying exercise options through text. The patient will then problem solve which exercise to choose by completing an action plan.  • Peer support as a facilitator to PA  • Restructuring the social environment  • Prompt to find an exercise buddy for the chosen exercise behavior. Also, provide links on the website to the local MS society and exercise classes happening there. Also the intervention will have a designated Facebook page to discuss exercise and MS with other individuals on activity matters.  • No accessibility or disability facilities act as barriers to PA  • Action planning • Problem solving  • Set an action plan for the time and place the chosen exercise behavior will occur. Provide list of potential barriers with regard to accessibility and disability for this time and place. Problem-solve the solution through this action plan.  • Exercise modality choice is a facilitator to PA  • Action planning • Focus on past success  • Prompt the person with MS to focus on past success with PA and provide the evidence for varying exercise options through text. The exercise options will be linked to one’s PA ability and mobility level. • Set an action plan for the chosen exercise.  • Self-efficacy has a moderately strong association with PA  • Verbal persuasion about capability • Mental rehearsal of successful performance • Focus on past success • Self-talk  • Provide text and video content from people with MS and their success with exercise. Also provide text encouraging the person with MS that they are capable of exercise. Do this by having information on exercise for varying mobility/PA levels. • Prompt the person with MS to focus on past success with exercise behaviors. Tell them to talk aloud and rehearse mentally successful performance of the behavior. • Complete weekly exercise logs and promote use of self-regulatory techniques such as pedometers to enhance self-efficacy.  • Outcome expectancies has a moderate association with PA  • Information about health consequences • Information about social and environmental consequences • Information about emotional consequences  • Provide text and visual information on the benefits of PA for people with MS on a range of outcomes.  • Goal-setting has mediated change in PA in previous interventions and has a moderately strong association with PA  • Goal-setting (behavior) • Goal-setting (outcome) • Action planning • Review behavioral goals • Review outcome goals  • Set an action plan of the desired behavior. Within this action plan, set goals for the exercise behavior and also for the outcomes of this behavior. For example, goal to walk 20 minutes, three times a week with a goal to improve walking speed. These goals will also be reviewed weekly for the period of the intervention.  • Fear/apprehension as a barrier to PA  • Social support (unspecified/practical) • Reduce negative emotions • Action planning • Problem solving  • Set action plan and list barriers to PA acknowledged by the person with MS. Problem-solve how to reduce this barrier(s). • Reduce negative emotions by providing text and video of people with MS discussing positive experiences with PA. Provide direction to social media page to discuss fears with other people with MS through open discussion forum.  • Feelings of accomplishment a facilitator to PA  • Social incentive • Self-incentive  • Inform the person with MS that if goals are met they should reward themselves with a small reward of their choosing (e.g., go to cinema) • Inform the person with MS that if goals are met they will be provided a verbal reward (congratulated on reaching exercise goals)  • Anxiety/depression/fatigue triad has associations with exercise self-efficacy  • Social support (unspecified/practical) • Reduce negative emotions • Action planning • Problem solving  • Set action plan and provide person with MS with a list of potential barriers (including anxiety, depression, and fatigue). Suggest problem-solving ideas of how to overcome these barriers if present. • Provide link to social media page where people with MS can discuss experiences with anxiety/depression/fatigue as a barrier to PA. • Provide link to support channels for depression/anxiety.  Findings  BCT(s)  Website function  • Conflicting advice from health care professionals  • Credible source  • Verbal and visual communication from a health care professional/researcher/person with MS in favor of the benefits of PA for people with MS.  • Knowledge of benefits of exercise required to enable behavior  • Information about health consequences • Information about social and environmental consequences • Information about emotional consequences • Vicarious consequences • Credible source  • Text on the benefits of PA across a range of outcomes for people with MS. This text will be supplemented with videos of people with MS and health care professionals/researchers discussing the benefits of PA.  • Knowledge of research evidence required to enable behavior  • Information about health consequences • Information about social and environmental consequences • Information about emotional consequences • Credible source  • Verbal and visual communication of the range of benefits of PA from a credible researcher in the area of MS and PA.  • Fatigue as a barrier to PA  • Information about health consequences • Information about emotional consequences • Vicarious consequences • Action planning  • Text-based information on the benefits of PA in terms of improving fatigue. Additional text information on how to overcome barriers to PA such as fatigue. This is supplemented by videos of people with MS discussing overcoming barriers to PA.  • Appropriate exercises need to be given  • Problem solving • Focus on past success  • Prompt the person with MS to focus on past success with PA and provide the evidence for varying exercise options through text. The patient will then problem solve which exercise to choose by completing an action plan.  • Peer support as a facilitator to PA  • Restructuring the social environment  • Prompt to find an exercise buddy for the chosen exercise behavior. Also, provide links on the website to the local MS society and exercise classes happening there. Also the intervention will have a designated Facebook page to discuss exercise and MS with other individuals on activity matters.  • No accessibility or disability facilities act as barriers to PA  • Action planning • Problem solving  • Set an action plan for the time and place the chosen exercise behavior will occur. Provide list of potential barriers with regard to accessibility and disability for this time and place. Problem-solve the solution through this action plan.  • Exercise modality choice is a facilitator to PA  • Action planning • Focus on past success  • Prompt the person with MS to focus on past success with PA and provide the evidence for varying exercise options through text. The exercise options will be linked to one’s PA ability and mobility level. • Set an action plan for the chosen exercise.  • Self-efficacy has a moderately strong association with PA  • Verbal persuasion about capability • Mental rehearsal of successful performance • Focus on past success • Self-talk  • Provide text and video content from people with MS and their success with exercise. Also provide text encouraging the person with MS that they are capable of exercise. Do this by having information on exercise for varying mobility/PA levels. • Prompt the person with MS to focus on past success with exercise behaviors. Tell them to talk aloud and rehearse mentally successful performance of the behavior. • Complete weekly exercise logs and promote use of self-regulatory techniques such as pedometers to enhance self-efficacy.  • Outcome expectancies has a moderate association with PA  • Information about health consequences • Information about social and environmental consequences • Information about emotional consequences  • Provide text and visual information on the benefits of PA for people with MS on a range of outcomes.  • Goal-setting has mediated change in PA in previous interventions and has a moderately strong association with PA  • Goal-setting (behavior) • Goal-setting (outcome) • Action planning • Review behavioral goals • Review outcome goals  • Set an action plan of the desired behavior. Within this action plan, set goals for the exercise behavior and also for the outcomes of this behavior. For example, goal to walk 20 minutes, three times a week with a goal to improve walking speed. These goals will also be reviewed weekly for the period of the intervention.  • Fear/apprehension as a barrier to PA  • Social support (unspecified/practical) • Reduce negative emotions • Action planning • Problem solving  • Set action plan and list barriers to PA acknowledged by the person with MS. Problem-solve how to reduce this barrier(s). • Reduce negative emotions by providing text and video of people with MS discussing positive experiences with PA. Provide direction to social media page to discuss fears with other people with MS through open discussion forum.  • Feelings of accomplishment a facilitator to PA  • Social incentive • Self-incentive  • Inform the person with MS that if goals are met they should reward themselves with a small reward of their choosing (e.g., go to cinema) • Inform the person with MS that if goals are met they will be provided a verbal reward (congratulated on reaching exercise goals)  • Anxiety/depression/fatigue triad has associations with exercise self-efficacy  • Social support (unspecified/practical) • Reduce negative emotions • Action planning • Problem solving  • Set action plan and provide person with MS with a list of potential barriers (including anxiety, depression, and fatigue). Suggest problem-solving ideas of how to overcome these barriers if present. • Provide link to social media page where people with MS can discuss experiences with anxiety/depression/fatigue as a barrier to PA. • Provide link to support channels for depression/anxiety.  BCT behavior change technique; MS multiple sclerosis; PA physical activity. View Large Table 4 Mapping of results to BCTs and mapping of BCTs to website functions for “Activity Matters.” Findings  BCT(s)  Website function  • Conflicting advice from health care professionals  • Credible source  • Verbal and visual communication from a health care professional/researcher/person with MS in favor of the benefits of PA for people with MS.  • Knowledge of benefits of exercise required to enable behavior  • Information about health consequences • Information about social and environmental consequences • Information about emotional consequences • Vicarious consequences • Credible source  • Text on the benefits of PA across a range of outcomes for people with MS. This text will be supplemented with videos of people with MS and health care professionals/researchers discussing the benefits of PA.  • Knowledge of research evidence required to enable behavior  • Information about health consequences • Information about social and environmental consequences • Information about emotional consequences • Credible source  • Verbal and visual communication of the range of benefits of PA from a credible researcher in the area of MS and PA.  • Fatigue as a barrier to PA  • Information about health consequences • Information about emotional consequences • Vicarious consequences • Action planning  • Text-based information on the benefits of PA in terms of improving fatigue. Additional text information on how to overcome barriers to PA such as fatigue. This is supplemented by videos of people with MS discussing overcoming barriers to PA.  • Appropriate exercises need to be given  • Problem solving • Focus on past success  • Prompt the person with MS to focus on past success with PA and provide the evidence for varying exercise options through text. The patient will then problem solve which exercise to choose by completing an action plan.  • Peer support as a facilitator to PA  • Restructuring the social environment  • Prompt to find an exercise buddy for the chosen exercise behavior. Also, provide links on the website to the local MS society and exercise classes happening there. Also the intervention will have a designated Facebook page to discuss exercise and MS with other individuals on activity matters.  • No accessibility or disability facilities act as barriers to PA  • Action planning • Problem solving  • Set an action plan for the time and place the chosen exercise behavior will occur. Provide list of potential barriers with regard to accessibility and disability for this time and place. Problem-solve the solution through this action plan.  • Exercise modality choice is a facilitator to PA  • Action planning • Focus on past success  • Prompt the person with MS to focus on past success with PA and provide the evidence for varying exercise options through text. The exercise options will be linked to one’s PA ability and mobility level. • Set an action plan for the chosen exercise.  • Self-efficacy has a moderately strong association with PA  • Verbal persuasion about capability • Mental rehearsal of successful performance • Focus on past success • Self-talk  • Provide text and video content from people with MS and their success with exercise. Also provide text encouraging the person with MS that they are capable of exercise. Do this by having information on exercise for varying mobility/PA levels. • Prompt the person with MS to focus on past success with exercise behaviors. Tell them to talk aloud and rehearse mentally successful performance of the behavior. • Complete weekly exercise logs and promote use of self-regulatory techniques such as pedometers to enhance self-efficacy.  • Outcome expectancies has a moderate association with PA  • Information about health consequences • Information about social and environmental consequences • Information about emotional consequences  • Provide text and visual information on the benefits of PA for people with MS on a range of outcomes.  • Goal-setting has mediated change in PA in previous interventions and has a moderately strong association with PA  • Goal-setting (behavior) • Goal-setting (outcome) • Action planning • Review behavioral goals • Review outcome goals  • Set an action plan of the desired behavior. Within this action plan, set goals for the exercise behavior and also for the outcomes of this behavior. For example, goal to walk 20 minutes, three times a week with a goal to improve walking speed. These goals will also be reviewed weekly for the period of the intervention.  • Fear/apprehension as a barrier to PA  • Social support (unspecified/practical) • Reduce negative emotions • Action planning • Problem solving  • Set action plan and list barriers to PA acknowledged by the person with MS. Problem-solve how to reduce this barrier(s). • Reduce negative emotions by providing text and video of people with MS discussing positive experiences with PA. Provide direction to social media page to discuss fears with other people with MS through open discussion forum.  • Feelings of accomplishment a facilitator to PA  • Social incentive • Self-incentive  • Inform the person with MS that if goals are met they should reward themselves with a small reward of their choosing (e.g., go to cinema) • Inform the person with MS that if goals are met they will be provided a verbal reward (congratulated on reaching exercise goals)  • Anxiety/depression/fatigue triad has associations with exercise self-efficacy  • Social support (unspecified/practical) • Reduce negative emotions • Action planning • Problem solving  • Set action plan and provide person with MS with a list of potential barriers (including anxiety, depression, and fatigue). Suggest problem-solving ideas of how to overcome these barriers if present. • Provide link to social media page where people with MS can discuss experiences with anxiety/depression/fatigue as a barrier to PA. • Provide link to support channels for depression/anxiety.  Findings  BCT(s)  Website function  • Conflicting advice from health care professionals  • Credible source  • Verbal and visual communication from a health care professional/researcher/person with MS in favor of the benefits of PA for people with MS.  • Knowledge of benefits of exercise required to enable behavior  • Information about health consequences • Information about social and environmental consequences • Information about emotional consequences • Vicarious consequences • Credible source  • Text on the benefits of PA across a range of outcomes for people with MS. This text will be supplemented with videos of people with MS and health care professionals/researchers discussing the benefits of PA.  • Knowledge of research evidence required to enable behavior  • Information about health consequences • Information about social and environmental consequences • Information about emotional consequences • Credible source  • Verbal and visual communication of the range of benefits of PA from a credible researcher in the area of MS and PA.  • Fatigue as a barrier to PA  • Information about health consequences • Information about emotional consequences • Vicarious consequences • Action planning  • Text-based information on the benefits of PA in terms of improving fatigue. Additional text information on how to overcome barriers to PA such as fatigue. This is supplemented by videos of people with MS discussing overcoming barriers to PA.  • Appropriate exercises need to be given  • Problem solving • Focus on past success  • Prompt the person with MS to focus on past success with PA and provide the evidence for varying exercise options through text. The patient will then problem solve which exercise to choose by completing an action plan.  • Peer support as a facilitator to PA  • Restructuring the social environment  • Prompt to find an exercise buddy for the chosen exercise behavior. Also, provide links on the website to the local MS society and exercise classes happening there. Also the intervention will have a designated Facebook page to discuss exercise and MS with other individuals on activity matters.  • No accessibility or disability facilities act as barriers to PA  • Action planning • Problem solving  • Set an action plan for the time and place the chosen exercise behavior will occur. Provide list of potential barriers with regard to accessibility and disability for this time and place. Problem-solve the solution through this action plan.  • Exercise modality choice is a facilitator to PA  • Action planning • Focus on past success  • Prompt the person with MS to focus on past success with PA and provide the evidence for varying exercise options through text. The exercise options will be linked to one’s PA ability and mobility level. • Set an action plan for the chosen exercise.  • Self-efficacy has a moderately strong association with PA  • Verbal persuasion about capability • Mental rehearsal of successful performance • Focus on past success • Self-talk  • Provide text and video content from people with MS and their success with exercise. Also provide text encouraging the person with MS that they are capable of exercise. Do this by having information on exercise for varying mobility/PA levels. • Prompt the person with MS to focus on past success with exercise behaviors. Tell them to talk aloud and rehearse mentally successful performance of the behavior. • Complete weekly exercise logs and promote use of self-regulatory techniques such as pedometers to enhance self-efficacy.  • Outcome expectancies has a moderate association with PA  • Information about health consequences • Information about social and environmental consequences • Information about emotional consequences  • Provide text and visual information on the benefits of PA for people with MS on a range of outcomes.  • Goal-setting has mediated change in PA in previous interventions and has a moderately strong association with PA  • Goal-setting (behavior) • Goal-setting (outcome) • Action planning • Review behavioral goals • Review outcome goals  • Set an action plan of the desired behavior. Within this action plan, set goals for the exercise behavior and also for the outcomes of this behavior. For example, goal to walk 20 minutes, three times a week with a goal to improve walking speed. These goals will also be reviewed weekly for the period of the intervention.  • Fear/apprehension as a barrier to PA  • Social support (unspecified/practical) • Reduce negative emotions • Action planning • Problem solving  • Set action plan and list barriers to PA acknowledged by the person with MS. Problem-solve how to reduce this barrier(s). • Reduce negative emotions by providing text and video of people with MS discussing positive experiences with PA. Provide direction to social media page to discuss fears with other people with MS through open discussion forum.  • Feelings of accomplishment a facilitator to PA  • Social incentive • Self-incentive  • Inform the person with MS that if goals are met they should reward themselves with a small reward of their choosing (e.g., go to cinema) • Inform the person with MS that if goals are met they will be provided a verbal reward (congratulated on reaching exercise goals)  • Anxiety/depression/fatigue triad has associations with exercise self-efficacy  • Social support (unspecified/practical) • Reduce negative emotions • Action planning • Problem solving  • Set action plan and provide person with MS with a list of potential barriers (including anxiety, depression, and fatigue). Suggest problem-solving ideas of how to overcome these barriers if present. • Provide link to social media page where people with MS can discuss experiences with anxiety/depression/fatigue as a barrier to PA. • Provide link to support channels for depression/anxiety.  BCT behavior change technique; MS multiple sclerosis; PA physical activity. View Large Using the information in Table 4, the authors have developed an outline of the proposed “Activity Matters” intervention. This is illustrated in Table 5. The intervention is 12 weeks in duration and aims to increase objective PA levels among ambulatory pwMS. Outcome measurements will be taken at baseline, post-intervention, 6 months, and 12 months. These will include but are not yet limited to, objective PA measurement, exercise self-efficacy, goal-setting, social support, fatigue, depression and anxiety, and a range of symptom outcomes. The intervention will use a web-based learning management system. It will include 11 structured modules and four phonecalls with a facilitator while also incorporating a designated social media page to enhance social support. Participants will also receive booster phonecalls after the 12-week program, once monthly for 3 months. The content of the modules, phonecalls, and social media page will be based upon the findings in Table 4. Table 5 Outline of the “Activity Matters” intervention. Activity matters  Weekly outline  Week number    Phonecall from facilitator  1  Module 1: Benefits of physical activity  1  Module 2: Goal-setting  1  Module 3: Choosing the right activity  2  Module 4: Action planning  2  Module 5: Self-monitoring  3  Module 6: Barriers and symptom management  4  Module 7: Social support  5  Module 8: Feedback and keeping an exercise diary  6  No Modules–Phonecall  7  Module 9: Having a bad day and goal revision  8  No Modules–Phonecall  9  Module 10: Maintaining the behavior  10  No Modules–Phonecall  11  Module 11: Feedback and keeping it going.  12    Additional features      Weekly completion of an exercise “action plan” for the week ahead    Weekly completion of an exercise log for the week past      Participants followed for 3 months post intervention with phonecall from facilitator each month post-trial    Activity matters  Weekly outline  Week number    Phonecall from facilitator  1  Module 1: Benefits of physical activity  1  Module 2: Goal-setting  1  Module 3: Choosing the right activity  2  Module 4: Action planning  2  Module 5: Self-monitoring  3  Module 6: Barriers and symptom management  4  Module 7: Social support  5  Module 8: Feedback and keeping an exercise diary  6  No Modules–Phonecall  7  Module 9: Having a bad day and goal revision  8  No Modules–Phonecall  9  Module 10: Maintaining the behavior  10  No Modules–Phonecall  11  Module 11: Feedback and keeping it going.  12    Additional features      Weekly completion of an exercise “action plan” for the week ahead    Weekly completion of an exercise log for the week past      Participants followed for 3 months post intervention with phonecall from facilitator each month post-trial    View Large Table 5 Outline of the “Activity Matters” intervention. Activity matters  Weekly outline  Week number    Phonecall from facilitator  1  Module 1: Benefits of physical activity  1  Module 2: Goal-setting  1  Module 3: Choosing the right activity  2  Module 4: Action planning  2  Module 5: Self-monitoring  3  Module 6: Barriers and symptom management  4  Module 7: Social support  5  Module 8: Feedback and keeping an exercise diary  6  No Modules–Phonecall  7  Module 9: Having a bad day and goal revision  8  No Modules–Phonecall  9  Module 10: Maintaining the behavior  10  No Modules–Phonecall  11  Module 11: Feedback and keeping it going.  12    Additional features      Weekly completion of an exercise “action plan” for the week ahead    Weekly completion of an exercise log for the week past      Participants followed for 3 months post intervention with phonecall from facilitator each month post-trial    Activity matters  Weekly outline  Week number    Phonecall from facilitator  1  Module 1: Benefits of physical activity  1  Module 2: Goal-setting  1  Module 3: Choosing the right activity  2  Module 4: Action planning  2  Module 5: Self-monitoring  3  Module 6: Barriers and symptom management  4  Module 7: Social support  5  Module 8: Feedback and keeping an exercise diary  6  No Modules–Phonecall  7  Module 9: Having a bad day and goal revision  8  No Modules–Phonecall  9  Module 10: Maintaining the behavior  10  No Modules–Phonecall  11  Module 11: Feedback and keeping it going.  12    Additional features      Weekly completion of an exercise “action plan” for the week ahead    Weekly completion of an exercise log for the week past      Participants followed for 3 months post intervention with phonecall from facilitator each month post-trial    View Large DISCUSSION The aim of this paper was to describe the development process of an Internet-based intervention that aims to change PA behavior among pwMS. The intervention is called “Activity Matters.” To our knowledge, this is the first MS PA intervention that has been developed using the MRC complex interventions and BCW frameworks. Using a range of data sources and following the steps of the BCW, the “Activity Matters” intervention has been developed. The intervention is theoretically based and TDF domains including, knowledge, memory, attention and decision processes, skills, social influences, environmental context and resources, beliefs about capabilities, beliefs about consequences, goals, and emotions were recognized as important and included in the intervention. Intervention functions that will be used include: education, enablement, environmental restructuring, persuasion, and incentivization. Strengths and challenges This is the first MS PA intervention to use the MRC complex interventions framework and the BCW approach. Although other MS PA interventions have used theory, including the SCT and TTM [13–15], these intervention developers have adopted a top-down approach and often do not detail the development process of the intervention using these theories. The BCW and MRC complex interventions framework use a bottom-up approach and provide increased transparency for future replication. In addition, the COM-B and the TDF provide a wide array of theoretical constructs upon which to draw upon which one singular model could not. Another strength of this paper includes the use of a large number of data sources. This paper includes the seven data sources of which five are original research produced by the authors. In addition, the data sources used include qualitative and quantitative research methods. Although the BCW process is both systematic and transparent, there are challenges associated with its use. The researcher must make subjective and pragmatic decisions. The use of the APEASE criteria reduces this subjectivity. For example, when aiming to choose one intervention function versus another, the answer is often determined by the practicality or affordability and not always effectiveness. Using the BCW process to develop an intervention and increase transparency of intervention design is a lengthy process. The authors began working on the development of “Activity Matters,” almost 4 years ago. This included the time to complete each of the included data sources and the mapping stages of the BCW. At this point, the intervention has yet to be assessed for usability, practicality, and therefore effectiveness. This timeframe should be taken into account for future funding applications in which the BCW framework is proposed. Implications for future research Despite the large number of data sources used, it is possible there is more we do not know about PA behavior among pwMS. There are possibly other known correlates of PA that have not been studied and therefore are not known. As the development of PA interventions for pwMS continues, researchers should be aware of new publications arising on correlates and predictors of PA behavior among pwMS that could be added to the theoretical model underpinning “Activity Matters” and described in this paper. In addition, among all seven data sources used, the sample of pwMS used were largely ambulatory people living with the disease. Little is known about those with higher disability caused by MS including those who use wheelchairs. Future research should include these participants. This paper provides a detailed outline of the theoretical development of a web-based intervention to change PA behavior among pwMS. Future research by the authors will include the clinical evaluation of the “Activity Matters.” The website functions outlined in this paper will be created with assistance from a software developer and web designer. Once developed, before testing for effectiveness, the authors will test the usability and acceptability of the web intervention for pwMS. The authors will also conduct qualitative research with health care professionals and policy makers who work with pwMS and can influence change. The aim will be to understand how health care professionals can use “Activity Matters” routinely in their practice to ensure adoption. In addition, these interviews will explore whether health care professionals discuss PA with their MS and if not how to overcome this. It is hoped these findings will lead to the inclusion of specific health care professional content on the “Activity Matters” web resource. CONCLUSION This paper describes the development of an Internet intervention to change PA behavior among pwMS called “Activity Matters.” It is the first MS PA intervention to use the theoretical approach outlined by the MRC complex interventions framework and the BCW. “Activity Matters” will use intervention functions including education, enablement, environmental restructuring, persuasion, and incentivization. These intervention functions have been linked to a number of BCTs including action planning, goal-setting, and problem-solving. The next phase of this work is to test the usability, acceptability, and preliminary effectiveness of “Activity Matters” among pwMS. Acknowledgments: B. Casey was funded for this work by MS Ireland through the ‘Ireland Fund’. Compliance with Ethical Standards Primary Data: The findings reported in this paper have not been previously published, and the manuscript has not being simultaneously submitted elsewhere. Also, the authors have full control of all primary data, and they agree to allow the journal to review their data if requested. Conflict of Interest: None declared Ethical Approval: This article does not contain any studies with human participants performed by any of the authors. This article does not contain any studies with animals performed by any of the authors. Informed Consent: This study does not involve human participants and informed consent was therefore not required. References 1. Trapp BD, Nave KA. Multiple sclerosis: an immune or neurodegenerative disorder? Annu Rev Neurosci . 2008; 31: 247– 269. Google Scholar CrossRef Search ADS PubMed  2. Dilokthornsakul P, Valuck RJ, Nair KV, Corboy JR, Allen RR, Campbell JD. Multiple sclerosis prevalence in the United States commercially insured population. Neurology . 2016; 86( 11): 1014– 1021. Google Scholar CrossRef Search ADS PubMed  3. Ma VY, Chan L, Carruthers KJ. Incidence, prevalence, costs, and impact on disability of common conditions requiring rehabilitation in the United States: stroke, spinal cord injury, traumatic brain injury, multiple sclerosis, osteoarthritis, rheumatoid arthritis, limb loss, and back pain. Arch Phys Med Rehabil . 2014; 95( 5): 986– 995.e1. Google Scholar CrossRef Search ADS PubMed  4. Lublin FD. Clinical features and diagnosis of multiple sclerosis. Neurol Clin . 2005; 23( 1): 1– 15. Google Scholar CrossRef Search ADS PubMed  5. Kjølhede T, Vissing K, Dalgas U. Multiple sclerosis and progressive resistance training: a systematic review. Mult Scler J . 2012: 18( 9): 1215– 1228. Google Scholar CrossRef Search ADS   6. Pilutti LA, Greenlee TA, Motl RW, Nickrent MS, Petruzzello SJ. Effects of exercise training on fatigue in multiple sclerosis: a meta-analysis. Psychosom Med . 2013; 75( 6): 575– 580. Google Scholar CrossRef Search ADS PubMed  7. Gunn H, Markevics S, Haas B, Marsden J, Freeman J. Systematic Review: The Effectiveness of Interventions to Reduce Falls and Improve Balance in Adults With Multiple Sclerosis. Arch Phys Med Rehabil . 2015; 96( 10): 1898– 1912. Google Scholar CrossRef Search ADS PubMed  8. Snook EM, Motl RW, Gliottoni RC. The effect of walking mobility on the measurement of physical activity using accelerometry in multiple sclerosis. Clin Rehabil . 2009; 23( 3): 248– 258. Google Scholar CrossRef Search ADS PubMed  9. Motl RW, Gosney JL. Effect of exercise training on quality of life in multiple sclerosis: a meta-analysis. Mult Scler . 2008; 14( 1): 129– 135. Google Scholar CrossRef Search ADS PubMed  10. Kinnett-Hopkins D, Adamson B, Rougeau K, Motl RW. People with MS are less physically active than healthy controls but as active as those with other chronic diseases: An updated meta-analysis. Mult Scler Relat Disord . 2017; 13: 38– 43. Google Scholar CrossRef Search ADS PubMed  11. Sangelaji B, Smith CM, Paul L, Sampath KK, Treharne GJ, Hale LA. The effectiveness of behaviour change interventions to increase physical activity participation in people with multiple sclerosis: a systematic review and meta-analysis. Clin Rehabil . 2016; 30( 6): 559– 576. Google Scholar CrossRef Search ADS PubMed  12. Michie S, Johnston M, Abraham C, Lawton R, Parker D, Walker A; “Psychological Theory” Group. Making psychological theory useful for implementing evidence based practice: a consensus approach. Qual Saf Health Care . 2005; 14( 1): 26– 33. Google Scholar CrossRef Search ADS PubMed  13. Dlugonski D, Motl RW, Mohr DC, Sandroff BM. Internet-delivered behavioral intervention to increase physical activity in persons with multiple sclerosis: sustainability and secondary outcomes. Psychol Health Med . 2012; 17( 6): 636– 651. Google Scholar CrossRef Search ADS PubMed  14. Motl RW, Dlugonski D, Wójcicki TR, McAuley E, Mohr DC. Internet intervention for increasing physical activity in persons with multiple sclerosis. Mult Scler . 2011; 17( 1): 116– 128. Google Scholar CrossRef Search ADS PubMed  15. Pilutti LA, Dlugonski D, Sandroff BM, Klaren RE, Motl RW. Internet-delivered lifestyle physical activity intervention improves body composition in multiple sclerosis: preliminary evidence from a randomized controlled trial. Arch Phys Med Rehabil . 2014; 95( 7): 1283– 1288. Google Scholar CrossRef Search ADS PubMed  16. Carter A, Daley A, Humphreys Let al.   Pragmatic intervention for increasing self-directed exercise behaviour and improving important health outcomes in people with multiple sclerosis: a randomised controlled trial. Mult Scler . 2014; 20( 8): 1112– 1122. Google Scholar CrossRef Search ADS PubMed  17. Craig P, Dieppe P, Macintyre S, Michie S, Nazareth I, Petticrew M; Medical Research Council Guidance. Developing and evaluating complex interventions: the new Medical Research Council guidance. Bmj . 2008; 337: a1655. Google Scholar CrossRef Search ADS PubMed  18. Michie S, van Stralen MM, West R. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement Sci . 2011; 6: 42. Google Scholar CrossRef Search ADS PubMed  19. Sinnott C, Mercer SW, Payne RA, Duerden M, Bradley CP, Byrne M. Improving medication management in multimorbidity: development of the MultimorbiditY COllaborative Medication Review And DEcision Making (MY COMRADE) intervention using the Behaviour Change Wheel. Implement Sci . 2015; 10: 132. Google Scholar CrossRef Search ADS PubMed  20. Cane J, O’Connor D, Michie S. Validation of the theoretical domains framework for use in behaviour change and implementation research. Implement Sci . 2012; 7: 37. Google Scholar CrossRef Search ADS PubMed  21. Michie S, Richardson M, Johnston Met al.   The behavior change technique taxonomy (v1) of 93 hierarchically clustered techniques: building an international consensus for the reporting of behavior change interventions. Ann Behav Med . 2013; 46( 1): 81– 95. Google Scholar CrossRef Search ADS PubMed  22. Webster R, Bailey JV. Development of a theory-based interactive digital intervention to improve condom use in men in sexual health clinics: an application of qualitative methods using the behaviour change wheel. Lancet . 2013; 382: S102. Google Scholar CrossRef Search ADS   23. Fulton EA, Brown KE, Kwah KL, Wild S. StopApp: using the behaviour change wheel to develop an app to increase uptake and attendance at NHS Stop Smoking Services. Healthcare . 2016; 4 (2):31. 24. Casey B, Coote S, Donnelly A. Objective physical activity measurement in people with multiple sclerosis: a review of the literature. Disabil Rehabil Assist Technol . 2017; 13 (2): 1– 8. Google Scholar PubMed  25. Casey B, Hayes S, Browne C, Coote S. What do people with MS want from a web-based resource to encourage increased physical activity behaviour? Disabil Rehabil . 2016; 38( 16): 1557– 1566. Google Scholar CrossRef Search ADS PubMed  26. Casey B, Coote S, Shirazipour Cet al.   Modifiable Psychosocial Constructs Associated With Physical Activity Participation in People With Multiple Sclerosis: A Systematic Review and Meta-Analysis. Arch Phys Med Rehabil . 2017; 98( 7): 1453– 1475. Google Scholar CrossRef Search ADS PubMed  27. Streber R, Peters S, Pfeifer K. Systematic Review of Correlates and Determinants of Physical Activity in Persons with Multiple Sclerosis. Arch Phys Med Rehabil . 2016; 97( 4): 633– 645.e29. Google Scholar CrossRef Search ADS PubMed  28. Learmonth YC, Motl RW. Physical activity and exercise training in multiple sclerosis: a review and content analysis of qualitative research identifying perceived determinants and consequences. Disabil Rehabil . 2016; 38( 13): 1227– 1242. Google Scholar CrossRef Search ADS PubMed  29. Michie S, Atkins L, West R. The Behaviour Change Wheel: A Guide to Designing Interventions . London, United Kingdom: Silverback Publishing; 2014. 30. Dlugonski D, Wójcicki TR, McAuley E, Motl RW. Social cognitive correlates of physical activity in inactive adults with multiple sclerosis. Int j Rehabil Res . 2011; 34( 2): 115– 120. Google Scholar CrossRef Search ADS PubMed  31. Wardell L, Hum S, Laizner AM, Lapierre Y. Multiple sclerosis patients’ interest in and likelihood of using online health-care services. Int J MS Care . 2009; 11( 2): 79– 89. Google Scholar CrossRef Search ADS   © Society of Behavioral Medicine 2018. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Journal

Translational Behavioral MedicineOxford University Press

Published: Mar 27, 2018

There are no references for this article.

You’re reading a free preview. Subscribe to read the entire article.


DeepDyve is your
personal research library

It’s your single place to instantly
discover and read the research
that matters to you.

Enjoy affordable access to
over 18 million articles from more than
15,000 peer-reviewed journals.

All for just $49/month

Explore the DeepDyve Library

Search

Query the DeepDyve database, plus search all of PubMed and Google Scholar seamlessly

Organize

Save any article or search result from DeepDyve, PubMed, and Google Scholar... all in one place.

Access

Get unlimited, online access to over 18 million full-text articles from more than 15,000 scientific journals.

Your journals are on DeepDyve

Read from thousands of the leading scholarly journals from SpringerNature, Elsevier, Wiley-Blackwell, Oxford University Press and more.

All the latest content is available, no embargo periods.

See the journals in your area

DeepDyve

Freelancer

DeepDyve

Pro

Price

FREE

$49/month
$360/year

Save searches from
Google Scholar,
PubMed

Create lists to
organize your research

Export lists, citations

Read DeepDyve articles

Abstract access only

Unlimited access to over
18 million full-text articles

Print

20 pages / month

PDF Discount

20% off