EXPLORING THE IMPACT OF EXERCISE IN PEOPLE EXPERIENCING SEVERE AND MULTIPLE DISADVANTAGE

Abstract

Low physical functioning and frailty are prevalent in non-geriatric at-risk populations who experience severe and multiple disadvantage such as those who are homeless. Exercise with nutritional supplementation is recommended. There is an absence of research on exercise interventions delivered to this population to target physical function and frailty specifically. It is known that people experiencing homelessness have complex health issues, yet engage poorly with healthcare services, therefore interventions require a targeted and unique approach. The aim of this PhD was to explore the feasibility and holistic impact, of a targeted low-threshold, multi-modal exercise intervention with protein supplementation, in a non-geriatric population experiencing severe and multiple disadvantage, namely a cohort of people experiencing homelessness, addiction and mental health challenges. The secondary aim was to explore its impact in a sub-population of women. A broad test battery was utilised to measure baseline physical function and frailty and evaluate pre-post intervention change. The primary outcome of feasibility was measured by recruitment and retention rates, adherence to the exercise and protein supplement, acceptability of the intervention and the occurrence of adverse events. Secondary outcomes were physical function, pain, frailty and nutritional status, self-reported health and perceptions of the intervention. The first study of this PhD was LEAP-II, a 12-week exercise intervention with protein supplementation delivered to a mixed-gender cohort. Results demonstrated feasibility through high retention in sub-groups (older people and women), adherence to the exercise and protein supplementation and safety and acceptability of the programme, and also pre-post intervention improvement in a number of physical function outcomes, namely lower limb strength [Chair Stand Test], gait speed [10m Walk Test], pain [Numerical Pain Rating Scale], nutritional status [Mini-Nutritional Assessment] and frailty [SHARE-FI]. An exploration of frailty demonstrated that 33% and 72% lived with some degree of frailty, by SHARE-FI and Clinical Frailty Scale, respectively. An exit survey demonstrated acceptability of the programme and highlighted possible reasons for the study's attrition as well as the need for further research to explore participant and stakeholder perspectives further. LEAP-W followed as a 10-week intervention based on LEAP-II and was delivered to a sub-group of women. This study used quantitative and qualitative components and 20 semi-structured interviews with study participants and key stakeholders were conducted following the intervention. Quantitative results revealed study feasibility and enhanced retention in LEAP-W (38.7% [LEAP-W] v 26% [LEAP-II]) and also improved physical function evidenced by pre-post intervention change in strength [Chair Stand Test], balance [Single Leg Stance Test], pain [Numerical Pain Rating Scale] and quality of life/mental health [Mental Component Summary of the Short Form-12] . Qualitative data identified 3 main themes of 1- `The power of exercise' as a vehicle for enhancing physical health and other health domains; 2- `Challenges to engagement' which were difficult to overcome due to participants' life course, lifestyle and legacies of trauma and disadvantage, yet, required urgent intervention and care of a targeted kind given the reported health challenges; and 3- `The LEAP approach'- the importance of delivery of trauma informed, flexible, low threshold exercise interventions to target physical function and frailty, in order to positively engage, avoid re-traumatisation and improve health outcomes. In conclusion, this important work adds to the knowledge base as a unique low threshold and person-centred exercise intervention which has important implications for education, clinical practice and policy and paves the way for future higher powered longitudinal research studies to further investigate effectiveness.