Identifying mechanisms of change in a magic-themed hand-arm bimanual intensive therapy programme for children with unilateral spastic cerebral palsy: a qualitative study using behaviour change theory

Background There has been much research into how to promote upper-limb skills to achieve functional independence in children with unilateral spastic cerebral palsy (USCP). One researched intervention is the Breathe Magic programme, which follows the protocol of hand-arm bimanual intensive therapy (HABIT) whilst, incorporating magic tricks to develop children's motor skills and bimanual skills. However, whilst research has found the programme to be effective, there has been little consideration of how the intervention leads to a positive outcome: what the psychological, social and physical mechanisms of action are. Methods Qualitative semi-structured interviews with 21 children with USCP who participated in the Breathe Magic HABIT intervention, and focus groups with 17 parents and/or carers were undertaken. Analysis was conducted through the lens of the COM-B behaviour change model using a combined deductive framework and inductive thematic analysis. Reliability of coding was confirmed through random extraction and double coding of a portion of responses and the calculation of inter-rater reliability. Results Breathe Magic brings about change and positive outcomes by increasing children's psychological and physical capabilities, providing social opportunities, and enhancing reflective and automatic motivation. Additionally, a number of enablers to engaging in the intervention were identified, particularly under psychological capabilities, social opportunities and both reflective and automatic motivation. Very few barriers were raised; those that were raised were of relatively low frequency of reporting. Conclusions By conducting a theory-based qualitative process evaluation, this study demonstrated the mechanisms of change behind the Breathe Magic HABIT intervention for children with USCP. Breathe Magic was found to be a well-structured combination of intended and unintended mechanisms of change. Overall, the success of Breathe Magic was observed through not only its intended mechanisms to enhance hand skills, but also through unintended psychological improvements in children's hand function, as well as social and motivational benefits resulting from interaction between children and parents.