title: Whole home exercise intervention for depression in older care home residents (the OPERA study): a process evaluation.
abstract: BACKGROUND
  The 'Older People's Exercise intervention in Residential and nursing Accommodation' (OPERA) cluster randomised trial evaluated the impact of training for care home staff together with twice-weekly, physiotherapist-led exercise classes on depressive symptoms in care home residents, but found no effect. We report a process evaluation exploring potential explanations for the lack of effect.
  
  
  METHODS
  The OPERA trial included over 1,000 residents in 78 care homes in the UK. We used a mixed methods approach including quantitative data collected from all homes. In eight case study homes, we carried out repeated periods of observation and interviews with residents, care staff and managers. At the end of the intervention, we held focus groups with OPERA research staff. We reported our first findings before the trial outcome was known.
  
  
  RESULTS
  Homes showed large variations in activity at baseline and throughout the trial. Overall attendance rate at the group exercise sessions was low (50%). We considered two issues that might explain the negative outcome: whether the intervention changed the culture of the homes, and whether the residents engaged with the intervention. We found low levels of staff training, few home champions for the intervention and a culture that prioritised protecting residents from harm over encouraging activity. The trial team delivered 3,191 exercise groups but only 36% of participants attended at least 1 group per week and depressed residents attended significantly fewer groups than those who were not depressed. Residents were very frail and therefore most groups only included seated exercises.
  
  
  CONCLUSIONS
  The intervention did not change the culture of the homes and, in the case study homes, activity levels did not change outside the exercise groups. Residents did not engage in the exercise groups at a sufficient level, and this was particularly true for those with depressive symptoms at baseline. The physical and mental frailty of care home residents may make it impossible to deliver a sufficiently intense exercise intervention to impact on depressive symptoms.
authors.affiliation: Warwick Clinical Trials Unit, Division of Health Sciences, Warwick Medical School, The University of Warwick, Coventry CV4 7AL, UK. d.r.ellard@warwick.ac.uk.
authors.forename: David R
authors.initials: DR
authors.lastname: Ellard
authors.forename: Margaret
authors.initials: M
authors.lastname: Thorogood
authors.forename: Martin
authors.initials: M
authors.lastname: Underwood
authors.forename: Clive
authors.initials: C
authors.lastname: Seale
authors.forename: Stephanie J C
authors.initials: SJ
authors.lastname: Taylor
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D003863:Depression / Q000453:epidemiology* / Q000523:psychology / Q000628:therapy*; D061345:Early Medical Intervention / Q000379:methods / Q000592:standards*; D004739:England / Q000453:epidemiology; D005081:Exercise Therapy / Q000379:methods / Q000523:psychology / Q000592:standards*; D005260:Female; D005500:Follow-Up Studies; D006699:Home Care Services / Q000592:standards*; D006801:Humans; D008297:Male; D010358:Patient Participation / Q000379:methods / Q000523:psychology; D017064:Process Assessment, Health Care / Q000379:methods / Q000592:standards*; D016896:Treatment Outcome