Web-based intervention to promote physical activity by sedentary older adults: randomized controlled trial

"Women and active life": An extended TPB-based multimedia software to boost and sustain physical activity and fitness of Iranian women

Inactivity is prevalent in women, although regular physical activity (PA) has significant health benefits. Health education interventions based on multimedia software and the extended theory of planned behavior (TPB) with planning may be efficacious in promoting PA. This randomized controlled trial, conducted in 2014, aimed to evaluate theory-based multimedia for increasing and maintaining PA and fitness of 130 military personnel's wives in Tehran, Iran. We randomly selected respondents by multistage cluster sampling. We designed a "Women and Active Life" self-taught DVD-Rom, based on the extended TPB model with action and coping planning. We analyzed theoretical constructs and health-related physical fitness at baseline and 3 and 6 months post-education. Administering educational software raised average developed TPB constructs, cardiorespiratory endurance, and muscular fitness (strength, endurance, and flexibility) in women in the intervention group, which was sustained at follow-up (p < .001). Also, mean body composition (body fat percentage, waist-hip ratio, and body mass index) was reduced with retained reduction at follow-up (p < .001), although no significant change was found in these variables in the control group (p > .05). Using a new communication technology in TPB-directed multimedia led to improved and maintained PA, aerobic and musculoskeletal fitness, and body composition of women.

Effectiveness of eHealth interventions for the promotion of physical activity in older adults: A systematic review

Regular physical activity (PA) is central to healthy ageing. However, only a minority of older adults currently meet the WHO-recommended PA levels. The aim of this systematic review is to compare the effectiveness of eHealth interventions promoting PA in older adults aged 55years and above with either no intervention or a non-eHealth intervention (review registration: PROSPERO CRD42015023875). Eight electronic databases were searched to identify experimental and quasi-experimental studies examining the effectiveness of eHealth interventions for PA promotion in adults aged 55years and above. Two authors independently selected and reviewed references, extracted data, and assessed study quality. In the search, 5771 records were retrieved, 20 studies met all inclusion criteria. Studies varied greatly in intervention mode, content, duration and assessed outcomes. Study quality ranged from poor to moderate. All interventions comprised tailored PA advice and the majority of interventions included goal setting and feedback, as well as PA tracking. Participation in eHealth interventions to promote PA led to increased levels of PA in adults aged 55years and above when compared to no intervention control groups, at least in the short term. However, the results were inconclusive regarding the question of whether eHealth interventions have a greater impact on PA behavior among older adults than non-eHealth interventions (e.g., print interventions). eHealth interventions can effectively promote PA in older adults aged 55years and above in the short-term, while evidence regarding long-term effects and the added benefit of eHealth compared to non-eHealth intervention components is still lacking.

Physical therapy vs internet-based exercise training for patients with knee osteoarthritis: results of a randomized controlled trial

OBJECTIVE

To compare the effectiveness of physical therapy (PT, evidence-based approach) and internet-based exercise training (IBET), each vs a wait list (WL) control, among individuals with knee osteoarthritis (OA).

DESIGN

Randomized controlled trial of 350 participants with symptomatic knee OA, allocated to standard PT, IBET and WL control in a 2:2:1 ratio, respectively. The PT group received up to eight individual visits within 4 months. The IBET program provided tailored exercises, video demonstrations, and guidance on progression. The primary outcome was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC, range 0 [no problems]-96 [extreme problems]), assessed at baseline, 4 months (primary time point) and 12 months. General linear mixed effects modeling compared changes in WOMAC among study groups, with superiority hypotheses testing differences between each intervention group and WL and non-inferiority hypotheses comparing IBET with PT.

RESULTS

At 4-months, improvements in WOMAC score did not differ significantly for either the IBET or PT group compared with WL (IBET: -2.70, 95% Confidence Interval (CI) = -6.24, 0.85, P = 0.14; PT: -3.36, 95% (CI) = -6.84, 0.12, P = 0.06). Similarly, at 12-months mean differences compared to WL were not statistically significant for either group (IBET: -2.63, 95% CI = -6.37, 1.11, P = 0.17; PT: -1.59, 95% CI = -5.26, 2.08, P = 0.39). IBET was non-inferior to PT at both time points.

CONCLUSIONS

Improvements in WOMAC score following IBET and PT did not differ significantly from the WL group. Additional research is needed to examine strategies for maximizing benefits of exercise-based interventions for patients with knee OA.

TRIAL REGISTRATION

NCT02312713.

Exploring the Specific Needs of Persons with Multiple Sclerosis for mHealth Solutions for Physical Activity: Mixed-Methods Study

Background

Multiple sclerosis (MS) is one of the world’s most common neurologic disorders, with symptoms such as fatigue, cognitive problems, and issues with mobility. Evidence suggests that physical activity (PA) helps people with MS reduce fatigue and improve quality of life. The use of mobile technologies for health has grown in recent years with little involvement from relevant stakeholders. User-centered design (UCD) is a design philosophy with the goal of creating solutions specific to the needs and tasks of the intended users. UCD involves stakeholders early and often in the design process. In a preliminary study, we assessed the landscape of commercially available MS mobile health (mHealth) apps; to our knowledge, no study has explored what persons with MS and their formal care providers think of mHealth solutions for PA.

Objective

The aim of this study was to (1) explore MS-specific needs for MS mHealth solutions for PA, (2) detect perceived obstacles and facilitators for mHealth solutions from persons with MS and health care professionals, and (3) understand the motivational aspects behind adoption of mHealth solutions for MS.

Methods

A mixed-methods design study was conducted in Kliniken Valens, Switzerland, a clinic specializing in neurological rehabilitation. We explored persons with MS and health care professionals who work with them separately. The study had a qualitative part comprising focus groups and interviews, and a quantitative part with standardized tools such as satisfaction with life scale and electronic health (eHealth) literacy.

Results

A total of 12 persons with relapsing-remitting MS and 12 health care professionals from different backgrounds participated in the study. Participants were well-educated with an even distribution between genders. Themes identified during analysis were MS-related barriers and facilitators, mHealth design considerations, and general motivational aspects. The insights generated were used to create MS personas for design purposes. Desired mHealth features were as follows: (1) activity tracking, (2) incentives for completing tasks and objectives, (3) customizable goal setting, (4) optional sociability, and (5) game-like attitude among others. Potential barriers to mHealth apps adoption were as follows: (1) rough on-boarding experiences, (2) lack of clear use benefits, and (3) disruption of the health care provider-patient relationship. Potential facilitators were identified: (1) endorsements from experts, (2) playfulness, and (3) tailored to specific persons with MS needs. A total of 4 MS personas were developed to provide designers and computer scientists means to help in the creation of future mHealth solutions for MS.

Conclusions

mHealth solutions for increasing PA in persons with MS hold promise. Allowing for realistic goal setting and positive feedback, while minimizing usability burdens, seems to be critical for the adoption of such apps. Fatigue management is especially important in this population; more attention should be brought to this area.

Health Information Technology Continues to Show Positive Effect on Medical Outcomes: Systematic Review

Background

Health information technology (HIT) has been introduced into the health care industry since the 1960s when mainframes assisted with financial transactions, but questions remained about HIT’s contribution to medical outcomes. Several systematic reviews since the 1990s have focused on this relationship. This review updates the literature.

Objective

The purpose of this review was to analyze the current literature for the impact of HIT on medical outcomes. We hypothesized that there is a positive association between the adoption of HIT and medical outcomes.

Methods

We queried the Cumulative Index of Nursing and Allied Health Literature (CINAHL) and Medical Literature Analysis and Retrieval System Online (MEDLINE) by PubMed databases for peer-reviewed publications in the last 5 years that defined an HIT intervention and an effect on medical outcomes in terms of efficiency or effectiveness. We structured the review from the Primary Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA), and we conducted the review in accordance with the Assessment for Multiple Systematic Reviews (AMSTAR).

Results

We narrowed our search from 3636 papers to 37 for final analysis. At least one improved medical outcome as a result of HIT adoption was identified in 81% (25/37) of research studies that met inclusion criteria, thus strongly supporting our hypothesis. No statistical difference in outcomes was identified as a result of HIT in 19% of included studies. Twelve categories of HIT and three categories of outcomes occurred 38 and 65 times, respectively.

Conclusions

A strong majority of the literature shows positive effects of HIT on the effectiveness of medical outcomes, which positively supports efforts that prepare for stage 3 of meaningful use. This aligns with previous reviews in other time frames.

The beneficial effects of different types of exercise interventions on motor and cognitive functions in older age: a systematic review

The decline in cognitive and motor functions with age affects the performance of the aging healthy population in many daily life activities. Physical activity appears to mitigate this decline or even improve motor and cognitive abilities in older adults. The current systematic review will focus mainly on behavioral studies that look into the dual effects of different types of physical training (e.g., balance training, aerobic training, strength training, group sports, etc.) on cognitive and motor tasks in older adults with no known cognitive or motor disabilities or disease. Our search retrieved a total of 1095 likely relevant articles, of which 41 were considered for full-text reading and 19 were included in the review after the full-text reading. Overall, observations from the 19 included studies conclude that improvements on both motor and cognitive functions were found, mainly in interventions that adopt physical-cognitive training or combined exercise training. While this finding advocates the use of multimodal exercise training paradigms or interventions to improve cognitive-motor abilities in older adults, the sizeable inconsistency among training protocols and endpoint measures complicates the generalization of this finding.

Examining Internet and eHealth Practices and Preferences: Survey Study of Australian Older Adults With Subjective Memory Complaints, Mild Cognitive Impairment, or Dementia

Background

Interest in electronic health (eHealth) technologies to screen for and treat a variety of medical and mental health problems is growing exponentially. However, no studies to date have investigated the feasibility of using such e-tools for older adults with mild cognitive impairment (MCI) or dementia.

Objective

The objective of this study was to describe patterns of Internet use, as well as interest in and preferences for eHealth technologies among older adults with varying degrees of cognitive impairment.

Methods

A total of 221 participants (mean age=67.6 years) attending the Healthy Brain Ageing Clinic at the University of Sydney, a specialist mood and memory clinic for adults ≥50 years of age, underwent comprehensive clinical and neuropsychological assessment and completed a 20-item self-report survey investigating current technology use and interest in eHealth technologies. Descriptive statistics and Fisher exact tests were used to characterize the findings, including variability in the results based on demographic and diagnostic factors, with diagnoses including subjective cognitive impairment (SCI), MCI, and dementia.

Results

The sample comprised 27.6% (61/221) SCI, 62.0% (137/221) MCI, and 10.4% (23/221) dementia (mean Mini-Mental State Examination=28.2). The majority of participants reported using mobile phones (201/220, 91.4%) and computers (167/194, 86.1%) routinely, with most respondents having access to the Internet at home (204/220, 92.6%). Variability was evident in the use of computers, mobile phones, and health-related websites in relation to sociodemographic factors, with younger, employed respondents with higher levels of education being more likely to utilize these technologies. Whereas most respondents used email (196/217, 90.3%), the use of social media websites was relatively uncommon. The eHealth intervention of most interest to the broader sample was memory strategy training, with 82.7% (172/208) of participants reporting they would utilize this form of intervention. Preferences for other eHealth interventions varied in relation to educational level, with university-educated participants expressing greater interest in interventions related to mood (P=.01), socialization (P=.02), memory (P=.01), and computer-based exercises (P=.046). eHealth preferences also varied in association, with diagnosis for interventions targeting sleep (P=.01), nutrition (P=.004), vascular risk factors (P=.03), and memory (P=.02).

Conclusions

Technology use is pervasive among older adults with cognitive impairment, though variability was noted in relation to age, education, vocational status, and diagnosis. There is also significant interest in Web-based interventions targeting cognition and memory, as well as other risk factors for cognitive decline, highlighting the urgent need for the development, implementation, and study of eHealth technologies tailored specifically to older adults, including those with MCI and early dementia. Strategies to promote eHealth use among older adults who are retired or have lower levels of education will also need to be considered.

A novel web-support intervention to promote recovery following Anterior Cruciate Ligament reconstruction: A pilot randomised controlled trial

BACKGROUND

Self-efficacy is positively associated with adherence behaviours and rehabilitation outcomes following Anterior Cruciate Ligament (ACL) reconstruction. An internet resource can be an effective way to provide information, goal setting, patient monitoring and hence support overall self-management.

PURPOSE

This study examined the feasibility of a three month 'internet-based intervention' (mobile-oriented site) to enhance recovery for patients following ACL reconstruction. The potential effect of the internet-based intervention on knee pain, function, self-efficacy and fear of pain were also assessed.

METHOD

This was a pilot randomised controlled trial (RCT) with pre and post intervention design (assessments at one week and three months following ACL reconstruction) comparing: (1) a control group and (2) an intervention group (internet-based intervention). A set of qualitative and quantitative assessments were included to evaluate potential improvements in self-efficacy, pain and function and perception of the internet intervention.

RESULTS AND CONCLUSION

Seventeen participants were available for analysis (n = 10 intervention and n = 7 control group). Participants reported the internet-based intervention to be a useful tool for information, reminder and reinforcement for performing their exercise rehabilitation with 30.3% (±35.3%) adherence to the internet-based intervention. No differences were observed between the groups over time on the outcome questionnaires (p > 0.05). Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12616001379404.

The Moderated Mediating Effect of Self-Efficacy on Exercise Among Older Adults in an Online Bone Health Intervention Study: A Parallel Process Latent Growth Curve Model

This secondary data analyses of a longitudinal study assessed whether self-efficacy for exercise (SEE) mediated online intervention effects on exercise among older adults and whether age (50-64 vs. ≥65 years) moderated the mediation. Data were from an online bone health intervention study. Eight hundred sixty-six older adults (≥50 years) were randomized to three arms: Bone Power (n = 301), Bone Power Plus (n = 302), or Control (n = 263). Parallel process latent growth curve modeling (LGCM) was used to jointly model growths in SEE and in exercise and to assess the mediating effect of SEE on the effect of intervention on exercise. SEE was a significant mediator in 50- to 64-year-old adults (0.061, 95 BCI: 0.011, 0.163) but not in the ≥65 age group (-0.004, 95% BCI: -0.047, 0.025). Promotion of SEE is critical to improve exercise among 50- to 64-year-olds.

Healthy preconception nutrition and lifestyle using personalized mobile health coaching is associated with enhanced pregnancy chance

Periconceptional nutrition and lifestyle are essential in pathogenesis and prevention of most reproductive failures, pregnancy outcome and future health. We aimed to investigate whether personalized mobile health (mHealth) coaching empowers couples contemplating pregnancy to increase healthy behaviour and chances of pregnancy. A survey was conducted among 1053 women and 332 male partners who received individual coaching using the mHealth programme 'Smarter Pregnancy' to change poor nutrition and lifestyle for 26 weeks, depending on pregnancy state and gender. Poor behaviours were translated into a total risk score (TRS) and Poisson regression analysis was performed to estimate associations with the chance of pregnancy adjusted for fertility status, age and baseline body mass index expressed as adjusted hazard ratio (aHR) and 95% confidence interval (95% CI). A lower (a)HR suggests a higher chance of achieving pregnancy. A higher TRS was significantly associated with a lower chance of pregnancy in all women (aHR 0.79, 95% CI 0.72-0.85) and (a)HR was lowest in women whose male partner participated (aHR 0.75, 95% CI 0.61-0.91). This survey shows that empowerment of couples in changing poor nutrition and lifestyle using personalized mHealth coaching is associated with an enhanced pregnancy chance in both infertile and fertile couples.

Effect of an Internet-based telehealth system on functional capacity and cognition in breast cancer survivors: a secondary analysis of a randomized controlled trial

PURPOSE

This trial determines the effect of an Internet-based tailored exercise program compared to usual care control for improving functional capacity and cognition among breast cancer survivors.

METHODS

A two-arm, assessor-blinded, parallel, randomized controlled efficacy trial was conducted. Participants were recruited from the Oncology and Breast unit at the Virgen de las Nieves Hospital (Granada, Spain) between March 2012 to November 2013 and randomized to either the experimental group (an 8-week Internet-based tailored exercise program) or control group (usual care). The outcome measures were the 6-min walk test, Auditory Consonant Trigrams, and Trail Making Test. All were assessed at baseline, post-intervention, and 6-month follow-up.

RESULTS

After intervention, the telerehabilitation group had significantly improved distances (d = 0.92, P < 0.001) as well as percentage of predicted of the 6-min walk test (d = 0.93, P < 0.001) compared with the control group. Significant improvement was also observed favoring the telerehabilitation group for the number of consonants recalled in total compared with the control group (d = 0.47, P = 0.04). These findings were maintained after 6-month follow-up (d = 0.80, P = 0.001; d = 0.76, P = 0.002; and d = 0.57, P = 0.02, respectively). Analysis was based on intention-to-treat principle.

CONCLUSIONS

These findings support the effectiveness of a telehealth system based on an 8-week physical exercise to achieve improvements and maintain them after 6-month follow-up in terms of functional and cognitive performance in breast cancer survivors. This broad-reach modality could help the growing number of cancer survivors to face their disabling side effects.

Development and evaluation of two web-based interventions for the promotion of physical activity in older adults: study protocol for a community-based controlled intervention trial

Background

Regular physical activity (PA) is a key contributor to healthy ageing. However, despite known health benefits, only one third of older adults in Germany reach the PA levels recommended for persons aged 65 years and above by the World Health Organization. The aim of the current study is to evaluate the effectiveness of two web-based interventions for the initiation and maintenance of regular PA (i.e., intervention groups 1 and 2) compared to a delayed intervention control group of older adults aged 65 to 75 years.

Methods/Design

Study participants will be randomly assigned to one of three study arms in five communities in the Bremen-Oldenburg metropolitan region: a) Participants in the first arm will receive access to a web-based intervention for 10 weeks allowing them to track their weekly PA (subjective self-monitoring, intervention group 1); b) participants in the second arm will receive access to the web-based intervention for 10 weeks and, in addition, track PA using Fitbit Zips (objective self-monitoring, intervention group 2); c) participants in the delayed intervention control group will receive access to the intervention implemented in the first study arm after completion of the 12-week follow-up in the other two groups within each community. In addition, weekly group meetings in the communities will be offered to study participants in the intervention groups providing the opportunity to address questions related to the use of the website and to practice PA in groups (e.g., neighborhood walks, strength and balance exercises). To evaluate short-term effects of the intervention on physical and psychological health, PA, physical fitness, and cognitive and psychological variables will be assessed at baseline and 12-week follow-up.

Discussion

This study will provide answers regarding acceptance and effectiveness of web-based interventions promoting uptake and maintenance of regular PA in persons aged 65–75 years. Study findings will contribute to a growing body of evidence in Germany concerning the role of community-based interventions for the promotion of PA and healthy ageing in older adults.

Trial registration

German Clinical Trials Register DRKS00010052 (Date of registration 07–11-2016).

Effects of online group exercises for older adults on physical, psychological and social wellbeing: a randomized pilot trial

BACKGROUND

Intervention programs to promote physical activity in older adults, either in group or home settings, have shown equivalent health outcomes but different results when considering adherence. Group-based interventions seem to achieve higher participation in the long-term. However, there are many factors that can make of group exercises a challenging setting for older adults. A major one, due to the heterogeneity of this particular population, is the difference in the level of skills. In this paper we report on the physical, psychological and social wellbeing outcomes of a technology-based intervention that enable online group exercises in older adults with different levels of skills.

METHODS

A total of 37 older adults between 65 and 87 years old followed a personalized exercise program based on the OTAGO program for fall prevention, for a period of eight weeks. Participants could join online group exercises using a tablet-based application. Participants were assigned either to the Control group, representing the traditional individual home-based training program, or the Social group, representing the online group exercising. Pre- and post- measurements were taken to analyze the physical, psychological and social wellbeing outcomes.

RESULTS

After the eight-weeks training program there were improvements in both the Social and Control groups in terms of physical outcomes, given the high level of adherence of both groups. Considering the baseline measures, however, the results suggest that while in the Control group fitter individuals tended to adhere more to the training, this was not the case for the Social group, where the initial level had no effect on adherence. For psychological outcomes there were improvements on both groups, regardless of the application used. There was no significant difference between groups in social wellbeing outcomes, both groups seeing a decrease in loneliness despite the presence of social features in the Social group. However, online social interactions have shown to be correlated to the decrease in loneliness in the Social group.

CONCLUSION

The results indicate that technology-supported online group-exercising which conceals individual differences in physical skills is effective in motivating and enabling individuals who are less fit to train as much as fitter individuals. This not only indicates the feasibility of training together despite differences in physical skills but also suggests that online exercise might reduce the effect of skills on adherence in a social context. However, results from this pilot are limited to a small sample size and therefore are not conclusive. Longer term interventions with more participants are instead recommended to assess impacts on wellbeing and behavior change.

Viewing Telehealth Through the Lens of a Community Benefit Mission

INTRODUCTION

This article reviews the intersection of common objectives between telehealth initiatives launched by health systems and community health (specifically community benefit). Telehealth initiatives can benefit communities and play a potential role in improving population health. There is great opportunity to better integrate telehealth activities into community health strategies and community benefit reporting (for nonprofit hospitals) while building the case for telehealth service expansion.

METHODS

Through descriptive, hypothetical cases, we demonstrate the intersection of the triple aim, specifically improving population-level health, and three common objectives between telehealth and community benefit: (1) improving access to care, (2) enhancing community health, and (3) advancing medical or healthcare knowledge.

CONCLUSIONS

This article is intended to spur inspiration for possible telehealth and community health/community benefit connections.

Mobile Health Physical Activity Intervention Preferences in Cancer Survivors: A Qualitative Study

BACKGROUND

Cancer survivors are at an elevated risk for several negative health outcomes, but physical activity (PA) can decrease those risks. Unfortunately, adherence to PA recommendations among survivors is low. Fitness mobile apps have been shown to facilitate the adoption of PA in the general population, but there are limited apps specifically designed for cancer survivors. This population has unique needs and barriers to PA, and most existing PA apps do not address these issues. Moreover, incorporating user preferences has been identified as an important priority for technology-based PA interventions, but at present there is limited literature that serves to establish these preferences in cancer survivors. This is especially problematic given the high cost of app development and because the majority of downloaded apps fail to engage users over the long term.

OBJECTIVE

The aim of this study was to take a qualitative approach to provide practical insight regarding this population's preferences for the features and messages of an app to increase PA.

METHODS

A total of 35 cancer survivors each attended 2 focus groups; a moderator presented slide shows on potential app features and messages and asked open-ended questions to elicit participant preferences. All sessions were audio recorded and transcribed verbatim. Three reviewers independently conducted thematic content analysis on all transcripts, then organized and consolidated findings to identify salient themes.

RESULTS

Participants (mean age 63.7, SD 10.8, years) were mostly female (24/35, 69%) and mostly white (25/35, 71%). Participants generally had access to technology and were receptive to engaging with an app to increase PA. Themes identified included preferences for (1) a casual, concise, and positive tone, (2) tools for personal goal attainment, (3) a prescription for PA, and (4) an experience that is tailored to the user. Participants reported wanting extensive background data collection with low data entry burden and to have a trustworthy source translate their personal data into individualized PA recommendations. They expressed a desire for app functions that could facilitate goal achievement and articulated a preference for a more private social experience. Finally, results indicated that PA goals might be best established in the context of personally held priorities and values.

CONCLUSIONS

Many of the desired features identified are compatible with both empirically supported methods of behavior change and the relative strengths of an app as a delivery vehicle for behavioral intervention. Participating cancer survivors' preferences contrasted with many current standard practices for mobile app development, including value-based rather than numeric goals, private socialization in small groups rather than sharing with broader social networks, and interpretation of PA data rather than merely providing numerical data. Taken together, these insights may help increase the acceptability of theory-based mHealth PA interventions in cancer survivors.

The conceptualization of a Just-In-Time Adaptive Intervention (JITAI) for the reduction of sedentary behavior in older adults

Low physical activity and high sedentary behavior in older adults can be addressed with interventions that are delivered through modern technology. Just-In-Time Adaptive Interventions (JITAIs) are an emerging technology-driven behavior-change intervention type and capitalize on data that is collected via mobile sensing technology (e.g., smartphones) to trigger appropriate support in real-life. In this paper we integrated behavior change and aging theory and research as well as knowledge around older adult's technology use to conceptualize a JITAI targeting the reduction of sedentary behavior in older adults. The JITAIs ultimate goal is to encourage older adults to take regular activity breaks from prolonged sitting. As a proximal outcome, we suggest the number of daily activity breaks from sitting. Support provided to interrupt sitting time can be based on tailoring variables: (I) the current accumulated sitting time; (II) the location of the individual; (III) the time of the day; (IV) the frequency of daily support prompts; and (V) the response to previous support prompts. Data on these variables can be collected using sensors that are commonly inbuilt into smartphones (e.g., accelerometer, GPS). Support prompts might be best delivered via traditional text messages as older adults are usually familiar and comfortable with this function. The content of the prompts should encourage breaks from prolonged sitting by highlighting immediate benefits of sitting time interruptions. Additionally, light physical activities that could be done during the breaks should also be presented (e.g., walking into the kitchen to prepare a cup of tea). Although the conceptualized JITAI can be developed and implemented to test its efficacy, more work is required to identify ways to collect, aggregate, organize and immediately use dense data on the proposed and other potentially important tailoring variables. Machine learning and other computational modelling techniques commonly used by computer scientists and engineers appear promising. With this, to develop powerful JITAIs and to actualize the full potential of modern sensing technologies transdisciplinary approaches are required.

Population Health Management for Older Adults: Review of Interventions for Promoting Successful Aging Across the Health Continuum

Background: The older adult population is expanding, living longer, with multiple chronic conditions. Understanding and managing their needs over time is an integral part of defining successful aging. Population health is used to describe the measurement and health outcomes of a population. Objectives: To define population health as applied to older adults, summarize lessons learned from current research, and identify potential interventions designed to promote successful aging and improved health for this population. Method: Online search engines were utilized to identify research on population health and health interventions for older adults. Results: Population health management (PHM) is one strategy to promote the health and well-being of target populations. Interventions promoting health across a continuum tend to be disease, risk, or health behavior specific rather than encompassing a global concept of health. Conclusion: Many existing interventions for older adults are simply research based with limited generalizability; as such, further work in this area is warranted.

Impact of a randomized possible selves experiment on new retirees' physical activity and identity

BACKGROUND

Retirement is not always associated with greater engagement in physical activity. Previous interventions informed by possible selves, a type of future-oriented self-representation, proved useful to increase physical activity in young adults. We thus wanted to explore if a similar intervention would yield favorable outcomes in new retirees. We also examined whether possible selves could help increase identity relative to the physical activity context. Identity circumscribes the meanings which help individuals define who they are in a given role (i.e., what it means to be a physically active person). The strength of identification as a physically active person increases when individuals endorse these meanings more strongly. Possible selves may be tied to identity as they allow individuals to imagine themselves as physically active, which has been argued to incite changes to one's sense of self. Hence, the overall aim of this study was to determine whether a possible selves intervention would increase physical activity behaviour and physical activity identity in a group of newly-retired individuals.

METHODS

A total of 294 participants were randomized into one of three groups: (a) a repeated group with three possible selves image generation exposures, (b) a one-time group with one possible selves image generation exposure, or (c) a control group. Participants completed self-report measures at baseline and follow-up assessments were taken at weeks 4, 8, and 12 of the study. The measures for the outcomes of interest were the Godin Leisure Time Exercise Questionnaire and the modified Exercise Identity Scale.

RESULTS

Repeated measures mixed-effects models analyses with maximum likelihood estimation revealed no significant differences between groups on physical activity behaviour (p = 0.34) or physical activity identity (p = 0.97) at follow-up time points. However, a time effect was found for physical activity (p <.01) and physical activity identity (p <.01), which increased across time (baseline-to-12-week follow-up) in all three groups. Such a time effect (inconsequential to group assignment) suggests that the observed increases in physical activity and identity cannot be attributed to an exposure to a possible selves intervention.

CONCLUSIONS

While the intervention failed to significantly increase physical activity identity and physical activity in newly retired individuals, we suggest future research directions for interventions targeting new retired individuals.

Gamification and Adherence to Web-Based Mental Health Interventions: A Systematic Review

BACKGROUND

Adherence to effective Web-based interventions for common mental disorders (CMDs) and well-being remains a critical issue, with clear potential to increase effectiveness. Continued identification and examination of "active" technological components within Web-based interventions has been called for. Gamification is the use of game design elements and features in nongame contexts. Health and lifestyle interventions have implemented a variety of game features in their design in an effort to encourage engagement and increase program adherence. The potential influence of gamification on program adherence has not been examined in the context of Web-based interventions designed to manage CMDs and well-being.

OBJECTIVE

This study seeks to review the literature to examine whether gaming features predict or influence reported rates of program adherence in Web-based interventions designed to manage CMDs and well-being.

METHODS

A systematic review was conducted of peer-reviewed randomized controlled trials (RCTs) designed to manage CMDs or well-being and incorporated gamification features. Seven electronic databases were searched.

RESULTS

A total of 61 RCTs met the inclusion criteria and 47 different intervention programs were identified. The majority were designed to manage depression using cognitive behavioral therapy. Eight of 10 popular gamification features reviewed were in use. The majority of studies utilized only one gamification feature (n=58) with a maximum of three features. The most commonly used feature was story/theme. Levels and game leaders were not used in this context. No studies explicitly examined the role of gamification features on program adherence. Usage data were not commonly reported. Interventions intended to be 10 weeks in duration had higher mean adherence than those intended to be 6 or 8 weeks in duration.

CONCLUSIONS

Gamification features have been incorporated into the design of interventions designed to treat CMD and well-being. Further research is needed to improve understanding of gamification features on adherence and engagement in order to inform the design of future Web-based health interventions in which adherence to treatment is of concern. Conclusions were limited by varied reporting of adherence and usage data.

Integrating Evidence From Systematic Reviews, Qualitative Research, and Expert Knowledge Using Co-Design Techniques to Develop a Web-Based Intervention for People in the Retirement Transition

Background

Integrating stakeholder involvement in complex health intervention design maximizes acceptability and potential effectiveness. However, there is little methodological guidance about how to integrate evidence systematically from various sources in this process. Scientific evidence derived from different approaches can be difficult to integrate and the problem is compounded when attempting to include diverse, subjective input from stakeholders.

Objective

The intent of the study was to describe and appraise a systematic, sequential approach to integrate scientific evidence, expert knowledge and experience, and stakeholder involvement in the co-design and development of a complex health intervention. The development of a Web-based lifestyle intervention for people in retirement is used as an example.

Methods

Evidence from three systematic reviews, qualitative research findings, and expert knowledge was compiled to produce evidence statements (stage 1). Face validity of these statements was assessed by key stakeholders in a co-design workshop resulting in a set of intervention principles (stage 2). These principles were assessed for face validity in a second workshop, resulting in core intervention concepts and hand-drawn prototypes (stage 3). The outputs from stages 1-3 were translated into a design brief and specification (stage 4), which guided the building of a functioning prototype, Web-based intervention (stage 5). This prototype was de-risked resulting in an optimized functioning prototype (stage 6), which was subject to iterative testing and optimization (stage 7), prior to formal pilot evaluation.

Results

The evidence statements (stage 1) highlighted the effectiveness of physical activity, dietary and social role interventions in retirement; the idiosyncratic nature of retirement and well-being; the value of using specific behavior change techniques including those derived from the Health Action Process Approach; and the need for signposting to local resources. The intervention principles (stage 2) included the need to facilitate self-reflection on available resources, personalization, and promotion of links between key lifestyle behaviors. The core concepts and hand-drawn prototypes (stage 3) had embedded in them the importance of time use and work exit planning, personalized goal setting, and acceptance of a Web-based intervention. The design brief detailed the features and modules required (stage 4), guiding the development of wireframes, module content and functionality, virtual mentors, and intervention branding (stage 5). Following an iterative process of intervention testing and optimization (stage 6), the final Web-based intervention prototype of LEAP (Living, Eating, Activity, and Planning in retirement) was produced (stage 7). The approach was resource intensive and required a multidisciplinary team. The design expert made an invaluable contribution throughout the process.

Conclusions

Our sequential approach fills an important methodological gap in the literature, describing the stages and techniques useful in developing an evidence-based complex health intervention. The systematic and rigorous integration of scientific evidence, expert knowledge and experience, and stakeholder input has resulted in an intervention likely to be acceptable and feasible.

State of the Art Review: Physical Activity and Older Adults

Physical activity is an important component of a healthy lifestyle for all adults and especially for older adults. Using information from the updated 2008 Physical Activity Guidelines, 3 dimensions of physical activity are identified for older adults. These include increasing aerobic activity, increasing muscle-strengthening activity, and reducing sedentary or sitting behavior. Although the overall goal of the physical activity recommendations is to prevent chronic diseases and conditions from developing, many older adults are already affected. Therefore, suggested types of physical activity are described for specific diseases and conditions that are designed to mediate the condition or prevent additional disability. Finally, barriers to participation in physical activity specific to older adults are described, and possible solutions offered. Encouraging older adults to continue or even start a physical activity program can result in major health benefits for these individuals.

Quality and accuracy of publicly accessible cancer-related physical activity information on the Internet: a cross-sectional assessment

In this study, we assessed the quality of publicly available cancer-related physical activity (PA) information appearing on reputable sites from Canada and other English-speaking countries. A cross-sectional Internet search was conducted on select countries (Canada, USA, Australia, New Zealand, UK) using Google to generate top 50 results per country for the keywords "'physical activity' AND 'cancer'". Top results were assessed for quality of PA information based on a coding frame. Additional searches were performed for Canadian-based sites to produce an exhaustive list. Results found that many sites offered cancer-related PA information (94.5%), but rarely defined PA (25.2%). Top 50 results from each country did not differ on any indicator examined. The exhaustive list of Canadian sites found that many sites gave information about PA for survivorship (78.3%) and prevention (70.0%), but rarely defined (6.7%) or referenced PA guidelines (28.3%). Cancer-related PA information is plentiful on the Internet but the quality needs improvement. Sites should do more than mention PA; they should provide definitions, examples and guidelines. With improvements, these websites would enable healthcare providers to effectively educate their patients about PA, and serve as a valuable resource to the general public who may be seeking cancer-related PA information.

Interventions to promote or maintain physical activity during and after the transition to retirement: an evidence synthesis

Background

It has been argued that transition points in life, such as the approach towards and early years of retirement, present key opportunities for interventions to improve the health of the population. Interventions that may change or preserve activity levels around the time of retirement have the potential to provide benefits in terms of increased health and well-being for people in later life. Research has highlighted health inequalities in health statuses in the retired population and in response to interventions.

Objective

We aimed to conduct a systematic review and meta-synthesis of the types and effectiveness of interventions to increase physical activity among people around the time of retirement. We also aimed to identify factors that may underpin the effectiveness or acceptability of interventions, and how issues of health inequalities may be addressed.

Data sources

The following electronic databases were searched: (1) MEDLINE; (2) Applied Social Sciences Index and Abstracts; (3) The Cochrane Library (including The Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effects, Health Technology Assessment Database); (4) Cumulative Index to Nursing and Allied Health Literature; (5) Science Citation Index; (6) Social Science Citation Index; (7) PsycINFO; (8) Evidence for Policy and Practice Information and Co-ordinating Centre; (9) SPORTDiscus; (10) Social Policy and Practice; (11) Health Management Information Consortium; and (12) Sociological Abstracts. We also searched for grey literature, checked reference lists of included papers and screened other reviews.

Review methods

A systematic review of quantitative and qualitative literature was carried out between February 2014 and April 2015. The searches aimed to identify, first, evidence of effectiveness of interventions for older adults at the point of transition to retirement and, second, data relating to perceptions of barriers and facilitators to intervention effectiveness. A meta-synthesis of the two types of evidence was also carried out to provide further interpretation of the review findings.

Results

A systematic search of the literature identified a large number of potentially relevant studies. Of these, 103 studies examining the effectiveness of interventions and 55 qualitative papers met the criteria for inclusion. A review of the effectiveness literature indicated a dearth of studies that investigate interventions that specifically examine the transition to retirement. More general studies in older adults indicated that a range of interventions might be effective for people around retirement age. The qualitative literature indicated the importance of considering the appeal and enjoyment, and social aspects, of interventions. Although there were a range of different measures in use, many were self-reported and few studies included an evaluation of sedentary time. A meta-synthesis across the data types indicated that elements reported as significant by participants did not always feature in the interventions.

Limitations

Owing to the lack of evidence relating to the retirement transition, we examined the literature relating to older adults. The applicability of these data to people around retirement age may need consideration.

Conclusions

Although the retirement transition is considered a significant point of life change, only a small volume of literature has reported interventions specifically in this period. The included literature suggests that interventions should take account of views and preferences of the target population and evaluate effectiveness by measuring meaningful outcomes and using a control group design.

Study registration

This study is registered as PROSPERO CRD42014007446.

Funding

The National Institute for Health Research Public Health Research programme.

Web-Based Interventions Targeting Cardiovascular Risk Factors in Middle-Aged and Older People: A Systematic Review and Meta-Analysis

Background

Web-based interventions can improve single cardiovascular risk factors in adult populations. In view of global aging and the associated increasing burden of cardiovascular disease, older people form an important target population as well.

Objective

In this systematic review and meta-analysis, we evaluated whether Web-based interventions for cardiovascular risk factor management reduce the risk of cardiovascular disease in older people.

Methods

Embase, Medline, Cochrane and CINAHL were systematically searched from January 1995 to November 2014. Search terms included cardiovascular risk factors and diseases (specified), Web-based interventions (and synonyms) and randomized controlled trial. Two authors independently performed study selection, data-extraction and risk of bias assessment. In a meta-analysis, outcomes regarding treatment effects on cardiovascular risk factors (blood pressure, glycated hemoglobin A1c (HbA1C), low-density lipoprotein (LDL) cholesterol, smoking status, weight and physical inactivity) and incident cardiovascular disease were pooled with random effects models.

Results

A total of 57 studies (N=19,862) fulfilled eligibility criteria and 47 studies contributed to the meta-analysis. A significant reduction in systolic blood pressure (mean difference –2.66 mmHg, 95% CI –3.81 to –1.52), diastolic blood pressure (mean difference –1.26 mmHg, 95% CI –1.92 to –0.60), HbA1c level (mean difference –0.13%, 95% CI –0.22 to –0.05), LDL cholesterol level (mean difference –2.18 mg/dL, 95% CI –3.96 to –0.41), weight (mean difference –1.34 kg, 95% CI –1.91 to –0.77), and an increase of physical activity (standardized mean difference 0.25, 95% CI 0.10-0.39) in the Web-based intervention group was found. The observed effects were more pronounced in studies with short (<12 months) follow-up and studies that combined the Internet application with human support (blended care). No difference in incident cardiovascular disease was found between groups (6 studies).

Conclusions

Web-based interventions have the potential to improve the cardiovascular risk profile of older people, but the effects are modest and decline with time. Currently, there is insufficient evidence for an effect on incident cardiovascular disease. A focus on long-term effects, clinical endpoints, and strategies to increase sustainability of treatment effects is recommended for future studies.

Promoting and maintaining physical activity in the transition to retirement: a systematic review of interventions for adults around retirement age

It has been argued that transition points in life, such as the approach towards, and early years of retirement present key opportunities for interventions to improve the health of the population. Research has also highlighted inequalities in health status in the retired population and in response to interventions which should be addressed. We aimed to conduct a systematic review to synthesise international evidence on the types and effectiveness of interventions to increase physical activity among people around the time of retirement. A systematic review of literature was carried out between February 2014 and April 2015. Searches were not limited by language or location, but were restricted by date to studies published from 1990 onwards. Methods for identification of relevant studies included electronic database searching, reference list checking, and citation searching. Systematic search of the literature identified 104 papers which described study populations as being older adults. However, we found only one paper which specifically referred to their participants as being around the time of retirement. The intervention approaches for older adults encompassed: training of health care professionals; counselling and advice giving; group sessions; individual training sessions; in-home exercise programmes; in-home computer-delivered programmes; in-home telephone support; in-home diet and exercise programmes; and community-wide initiatives. The majority of papers reported some intervention effect, with evidence of positive outcomes for all types of programmes. A wide range of different measures were used to evaluate effectiveness, many were self-reported and few studies included evaluation of sedentary time. While the retirement transition is considered a significant point of life change, little research has been conducted to assess whether physical activity interventions at this time may be effective in promoting or maintaining activity, or reducing health inequalities. We were unable to find any evidence that the transition to retirement period was, or was not a significant point for intervention. Studies in older adults more generally indicated that a range of interventions might be effective for people around retirement age.

The Impact of Information Technology on Patient Engagement and Health Behavior Change: A Systematic Review of the Literature

Background

Advancements in information technology (IT) and its increasingly ubiquitous nature expand the ability to engage patients in the health care process and motivate health behavior change.

Objective

Our aim was to systematically review the (1) impact of IT platforms used to promote patients’ engagement and to effect change in health behaviors and health outcomes, (2) behavior theories or models applied as bases for developing these interventions and their impact on health outcomes, (3) different ways of measuring health outcomes, (4) usability, feasibility, and acceptability of these technologies among patients, and (5) challenges and research directions for implementing IT platforms to meaningfully impact patient engagement and health outcomes.

Methods

PubMed, Web of Science, PsycINFO, and Google Scholar were searched for studies published from 2000 to December 2014. Two reviewers assessed the quality of the included papers, and potentially relevant studies were retrieved and assessed for eligibility based on predetermined inclusion criteria.

Results

A total of 170 articles met the inclusion criteria and were reviewed in detail. Overall, 88.8% (151/170) of studies showed positive impact on patient behavior and 82.9% (141/170) reported high levels of improvement in patient engagement. Only 47.1% (80/170) referenced specific behavior theories and only 33.5% (57/170) assessed the usability of IT platforms. The majority of studies used indirect ways to measure health outcomes (65.9%, 112/170).

Conclusions

In general, the review has shown that IT platforms can enhance patient engagement and improve health outcomes. Few studies addressed usability of these interventions, and the reason for not using specific behavior theories remains unclear. Further research is needed to clarify these important questions. In addition, an assessment of these types of interventions should be conducted based on a common framework using a large variety of measurements; these measurements should include those related to motivation for health behavior change, long-standing adherence, expenditure, satisfaction, and health outcomes.

The Effects of an Online Theory-Based Bone Health Program for Older Adults

An estimated 10 million Americans age 50 and older have osteoporosis, and many experience associated fractures. Although several interventions have been shown to be effective in preventing osteoporosis, their impact on bone health among older adults was limited. The aim of this study was, therefore, to examine the effects of a theory-based online bone health program (Bone Power program) for a large number of older adults. The 8-week program included learning modules, discussion boards, and other resources. Participants ( N = 866; M age = 62.5 years) were recruited online and randomized into a Bone Power or control group. At the end of the intervention, the Bone Power group showed significantly greater improvement over the control group in osteoporosis knowledge, self-efficacy/outcome expectations for calcium intake and exercise, and calcium intake and exercise behaviors. This study's findings suggest that online health programs can be effective in improving older adults' knowledge, beliefs, and health behaviors.

mActive: A Randomized Clinical Trial of an Automated mHealth Intervention for Physical Activity Promotion

BACKGROUND

We hypothesized that a fully automated mobile health (mHealth) intervention with tracking and texting components would increase physical activity.

METHODS AND RESULTS

mActive enrolled smartphone users aged 18 to 69 years at an ambulatory cardiology center in Baltimore, Maryland. We used sequential randomization to evaluate the intervention's 2 core components. After establishing baseline activity during a blinded run-in (week 1), in phase I (weeks 2 to 3), we randomized 2:1 to unblinded versus blinded tracking. Unblinding allowed continuous access to activity data through a smartphone interface. In phase II (weeks 4 to 5), we randomized unblinded participants 1:1 to smart texts versus no texts. Smart texts provided smartphone-delivered coaching 3 times/day aimed at individual encouragement and fostering feedback loops by a fully automated, physician-written, theory-based algorithm using real-time activity data and 16 personal factors with a 10 000 steps/day goal. Forty-eight outpatients (46% women, 21% nonwhite) enrolled with a mean±SD age of 58±8 years, body mass index of 31±6 kg/m(2), and baseline activity of 9670±4350 steps/day. Daily activity data capture was 97.4%. The phase I change in activity was nonsignificantly higher in unblinded participants versus blinded controls by 1024 daily steps (95% confidence interval [CI], -580 to 2628; P=0.21). In phase II, participants receiving texts increased their daily steps over those not receiving texts by 2534 (95% CI, 1318 to 3750; P<0.001) and over blinded controls by 3376 (95% CI, 1951 to 4801; P<0.001).

CONCLUSIONS

An automated tracking-texting intervention increased physical activity with, but not without, the texting component. These results support new mHealth tracking technologies as facilitators in need of behavior change drivers.

CLINICAL TRIAL REGISTRATION

URL: http://ClinicalTrials.gov/. Unique identifier: NCT01917812.

Physical therapy vs. internet-based exercise training (PATH-IN) for patients with knee osteoarthritis: study protocol of a randomized controlled trial

Background

Physical activity improves pain and function among individuals with knee osteoarthritis (OA), but most people with this condition are inactive. Physical therapists play a key role in helping people with knee OA to increase appropriate physical activity. However, health care access issues, financial constraints, and other factors impede some patients from receiving physical therapy (PT) for knee OA. A need exists to develop and evaluate other methods to provide physical activity instruction and support to people with knee OA. This study is examining the effectiveness of an internet-based exercise training (IBET) program designed for knee OA, designed by physical therapists and other clinicians.

Methods/Design

This is a randomized controlled trial of 350 participants with symptomatic knee OA, allocated to three groups: IBET, standard PT, and a wait list (WL) control group (in a 2:2:1 ratio, respectively). The study was funded by the Patient Centered Outcomes Research Institute, which conducted a peer review of the proposal. The IBET program provides patients with a tailored exercise program (based on functional level, symptoms, and current activity), video demonstrations of exercises, and guidance for appropriate exercise progression. The PT group receives up to 8 individual visits with a physical therapist, mirroring standard practice for knee OA and with an emphasis on a home exercise program. Outcomes are assessed at baseline, 4 months (primary time point) and 12 months (to assess maintenance of treatment effects). The primary outcome is the Western Ontario and McMaster Universities Osteoarthritis Index, and secondary outcomes include objective physical function, satisfaction with physical function, physical activity, depressive symptoms and global assessment of change. Linear mixed models will be used to compare both the IBET and standard PT groups to the WL control group, examine whether IBET is non-inferior to PT (a treatment that has an established evidence base for knee OA), and explore whether participant characteristics are associated with differential effects of IBET and/or standard PT. This research is in compliance with the Helsinki Declaration and was approved by the Institutional Review Board of the University of North Carolina at Chapel Hill.

Discussion

The IBET program could be disseminated widely at relatively low cost and could be an important resource for helping patients with knee OA to adopt and maintain appropriate physical activity. This trial will provide an important evaluation of the effectiveness of this IBET program for knee OA.

Trial registration

NCT02312713

From Foucault to Freire Through Facebook: Toward an Integrated Theory of mHealth

OBJECTIVE

To document the integration of social science theory in literature on mHealth (mobile health) and consider opportunities for integration of classic theory, health communication theory, and social networking to generate a relevant theory for mHealth program design.

METHOD

A secondary review of research syntheses and meta-analyses published between 2005 and 2014 related to mHealth, using the AMSTAR (A Measurement Tool to Assess Systematic Reviews) methodology for assessment of the quality of each review. High-quality articles from those reviews using a randomized controlled design and integrating social science theory in program design, implementation, or evaluation were reviewed. Results There were 1,749 articles among the 170 reviews with a high AMSTAR score (≥30). Only 13 were published from 2005 to 2014, used a randomized controlled design and made explicit mention of theory in any aspect of their mHealth program. All 13 included theoretical perspectives focused on psychological and/or psychosocial theories and constructs. Conclusions There is a very limited use of social science theory in mHealth despite demonstrated benefits in doing so. We propose an integrated theory of mHealth that incorporates classic theory, health communication theory, and social networking to guide development and evaluation of mHealth programs.

Which behaviour change techniques are most effective at increasing older adults' self-efficacy and physical activity behaviour? A systematic review

BACKGROUND

Increasing self-efficacy is an effective mechanism for increasing physical activity, especially for older people.

PURPOSE

The aim of this review was to identify behaviour change techniques (BCTs) that increase self-efficacy and physical activity behaviour in non-clinical community-dwelling adults 60 years or over.

METHODS

A systematic search identified 24 eligible studies reporting change in self-efficacy for physical activity following an intervention. Moderator analyses examined whether the inclusion of specific BCTs (as defined by CALO-RE taxonomy) was associated with changes in self-efficacy and physical activity behaviour.

RESULTS

Overall, interventions increased self-efficacy (d = 0.37) and physical activity (d = 0.14). Self-regulatory techniques such as setting behavioural goals, prompting self-monitoring of behaviour, planning for relapses, providing normative information and providing feedback on performance were associated with lower levels of both self-efficacy and physical activity.

CONCLUSIONS

Many commonly used self-regulation intervention techniques that are effective for younger adults may not be effective for older adults.

Health behavior change counseling in surgery for degenerative lumbar spinal stenosis. Part II: patient activation mediates the effects of health behavior change counseling on rehabilitation engagement

OBJECTIVE

To determine the effect of health behavior change counseling (HBCC) on patient activation and the influence of patient activation on rehabilitation engagement, and to identify common barriers to engagement among individuals undergoing surgery for degenerative lumbar spinal stenosis.

DESIGN

Prospective clinical trial.

SETTING

Academic medical center.

PARTICIPANTS

Consecutive lumbar spine surgery patients (N=122) defined in our companion article (Part I) were assigned to a control group (did not receive HBCC, n=59) or HBCC group (received HBCC, n=63).

INTERVENTION

Brief motivational interviewing-based HBCC versus control (significance, P<.05).

MAIN OUTCOME MEASURES

We assessed patient activation before and after intervention. Rehabilitation engagement was assessed using the physical therapist-reported Hopkins Rehabilitation Engagement Rating Scale and by a ratio of self-reported physical therapy and home exercise completion. Common barriers to rehabilitation engagement were identified through thematic analysis.

RESULTS

Patient activation predicted engagement (standardized regression weight, .682; P<.001). Postintervention patient activation was predicted by baseline patient activation (standardized regression weight, .808; P<.001) and receipt of HBCC (standardized regression weight, .444; P<.001). The effect of HBCC on rehabilitation engagement was mediated by patient activation (standardized regression weight, .079; P=.395). One-third of the HBCC group did not show improvement compared with the control group. Thematic analysis identified 3 common barriers to engagement: (1) low self-efficacy because of lack of knowledge and support (62%); (2) anxiety related to fear of movement (57%); and (3) concern about pain management (48%).

CONCLUSIONS

The influence of HBCC on rehabilitation engagement was mediated by patient activation. Despite improvements in patient activation, one-third of patients reported low rehabilitation engagement. Addressing these barriers should lead to greater improvements in rehabilitation engagement.

Efficacy of a web-based, center-based or combined physical activity intervention among older adults

With more social support and environment-centered interventions being recommended in web-based interventions, this study examined the efficacy of three intervention conditions aimed at promoting physical activity (PA) in older adults. The efficacy analyses included the self-reported PA level, stage of change for PA and awareness about PA among participants. Eligible participants (N = 149; M = 65 years old, SD = 6), recruited in a unique Belgian French-speaking municipality, were randomized in four research arms for a 3-month intervention: (i) web-based; (ii) center-based; (iii) mixed (combination of web- and center-based); and (iv) control (no intervention). Web-based condition included a PA website and monthly tailored emails whereas center-based condition comprised 12 sessions (1 per week) of group exercising. With a significant increase in PA, the PA stage of change and the PA awareness at 12 months, the mixed intervention condition seemed to include the key social and motivating elements for sustainable behavior change. Center-based intervention was more likely to produce significant improvements of the PA level and the stage of change for PA change whereas web-based intervention was more likely to extend the awareness about PA.

Changes in physical activity during the retirement transition: a theory-based, qualitative interview study

Background

There are considerable inter-individual differences in the direction and degree of change in physical activity (PA) levels during the retirement transition. There is currently a limited theoretical understanding of how these differences can be explained. This study aimed to explore and compare perceptions about how theory-based factors influence PA change during the transition from employment to retirement among individuals approaching retirement and recently retired.

Methods

Theory-based, one-to-one, semi-structured interviews were conducted with a purposive sample of 28 adults (15 retired) within 24 months of retirement. Participants were sampled to reflect a diverse range of socio-economic and occupational backgrounds. The interview was based on the 12 domains within the Theory Domain Framework and designed to elicit anticipated or experienced retirement-related changes in PA behaviour and perceived determinants. Interview transcripts were analysed using Framework analysis to explore intra- and inter-individual perceptions of how PA changes after retirement and the factors which may influence this change.

Results

The majority of participants perceived retirement to be related to an increase in PA levels. Four themes emerged from the data regarding factors perceived to influence changes in PA behaviour after retirement: (1) resources for PA; (2) structure of daily life in retirement; (3) opportunities for PA; and (4) transitional PA phases after retirement. Retirement is associated with a number of inter-related changes and opportunities which can have a positive or negative impact on PA behaviour. The influence of these factors does not appear to be static and may change over time. A number of different transitional phases may be experienced after leaving work and each phase may have a differential impact on PA behaviour.

Conclusions

The findings of this qualitative study contribute to the theoretical understanding of PA change during the retirement transition. Each post-retirement PA trajectory is highly individual and personalised intervention approaches to increase PA during the retirement transition may be most successful. Future research should focus on the maintenance of PA change during the retirement transition and should develop and evaluate interventions to promote and maintain PA during retirement.

Electronic supplementary material

The online version of this article (doi:10.1186/s12966-015-0186-4) contains supplementary material, which is available to authorized users.

Feasibility and Acceptability of an Internet-Based, African Dance-Modified Yoga Program for African-American Women with or at Risk for Metabolic Syndrome

African-American (AA) women are the segment of the population that experiences the highest mortality from metabolic syndrome (MetS). Yoga decreases risk of MetS, yet there have been no yoga studies of AA women with or at risk for MetS. The purpose of this 4-week study was to test the feasibility and acceptability of a culturally tailored, Internet-based intervention, yogic dance (YD), using digital videos in a sample of AA women (ages 35-64) at risk for or with MetS. The investigators examined the rates of accrual, attrition, and reasons for attrition; the feasibility of using the Internet to deliver the intervention; the acceptability of the intervention as structured; and any other benefits and/or limitations of YD. The study used a single-group, mixed-methods design underpinned by social constructivist theory and Pender's Health Promotion Model. Twenty-four women provided consent to enroll in the study. After completing in-person semi-structured interviews and Internet-based measures, including the Physical Activity Readiness Questionnaire, and the modified International Physical Activity Questionnaire, consented participants engaged in 4-weeks of the yogic dance intervention via daily video-based instructions located on the study Web site. After the intervention, four women participated in focus groups to voice their perceptions of barriers to and benefits from YD and the acceptability of using the YD intervention. The investigators analyzed focus group data using content/thematic analysis and validated themes with baseline semi-structured interviews. The majority of the women (79%) found YD acceptable. Themes that emerged from the descriptive data include: (1) Culture is an important aspect of yogic dance; and (2) Increased social support would enhance yogic dance participation. The integrated results from this feasibility study will inform research exploring the complex correlates that influence health behaviors in AA women.

Mobile-Web app to self-manage low back pain: randomized controlled trial

BACKGROUND

Nonspecific low back pain (NLBP) is the diagnosis for individuals with back pain that has no underlying medical cause (eg, tumor, infection, fracture, herniated disc, spinal stenosis). The American College of Physicians (ACP) and American Pain Society (APS) recommend multidisciplinary treatments for NLBP that lasts more than 4 weeks. This approach, however, is impractical for many physicians to implement, and relatively few providers offer NLBP treatment that meets the joint ACP-APS guidelines.

OBJECTIVE

This study evaluated the efficacy of a mobile-Web intervention called "FitBack" to help users implement self-tailored strategies to manage and prevent NLBP occurrences.

METHODS

A total of 597 adults were recruited, screened, consented, and assessed online at baseline, at 2 months (T2), and at 4 months (T3). After baseline assessments, participants were randomized into three groups: FitBack intervention, alternative care group that received 8 emails urging participants to link to six Internet resources for NLBP, and control group. The FitBack group also received weekly email reminder prompts for 8 weeks plus emails to do assessments. The control group was only contacted to do assessments.

RESULTS

Users of the FitBack program showed greater improvement compared to the control group in every comparison of the critical physical, behavioral, and worksite outcome measures at 4-month follow-up. In addition, users of the FitBack program performed better than the alternative care group on current back pain, behavioral, and worksite outcomes at 4-month follow-up. For example, subjects in the control group were 1.7 times more likely to report current back pain than subjects in the FitBack group; subjects in the alternative care group were 1.6 times more likely to report current back pain at 4-month follow-up. Further, the users of the FitBack program showed greater improvement compared to both the control and alternative care groups at 4-month follow-up on patient activation, constructs of the Theory of Planned Behavior, and attitudes toward pain.

CONCLUSIONS

This research demonstrated that a theoretically based stand-alone mobile-Web intervention that tailors content to users' preferences and interests can be an effective tool in self-management of low back pain. When viewed from the RE-AIM perspective (ie, reach, efficacy/effectiveness, adoption, implementation fidelity, and maintenance), this study supports the notion that there is considerable value in this type of intervention as a potentially cost-effective tool that can reach large numbers of people. The results are promising considering that the FitBack intervention was neither supported by professional caregivers nor integrated within a health promotion campaign, which might have provided additional support for participants. Still, more research is needed on how self-guided mobile-Web interventions will be used over time and to understand factors associated with continuing user engagement.

TRIAL REGISTRATION

Clinicaltrials.gov NCT01950091; http://clinicaltrials.gov/ct2/show/NCT01950091 (Archived by WebCite at http://www.webcitation.org/6TwZucX77).

Social work practice with LGBT seniors

The Los Angeles Gay & Lesbian Center began providing services to LGBT seniors in 2008. Since then, the Center's seniors program has grown to over 3,300 clients. It provides a variety of enrichment and support services with the overarching goal of empowering seniors to successfully age in place. This article outlines the service delivery program of the Center's Seniors Services Department and describes its successes and challenges in meeting the needs of diverse LGBT seniors. It offers future directions for social work practice, policy, and research with LGBT older adults.

Intervention use and action planning in a web-based computer-tailored weight management program for overweight adults: randomized controlled trial

BACKGROUND

There are many online interventions aiming for health behavior change but it is unclear how such interventions and specific planning tools are being used.

OBJECTIVE

The aim of this study is to identify which user characteristics were associated with use of an online, computer-tailored self-regulation intervention aimed at prevention of weight gain; and to examine the quality of the goals and action plans that were generated using the online planning tools.

METHODS

Data were obtained with a randomized controlled effect evaluation trial in which the online computer-tailored intervention was compared to a website containing generic information about prevention of weight gain. The tailored intervention included self-regulation techniques such as personalized feedback, goal setting, action planning, monitoring, and other techniques aimed at weight management. Participants included 539 overweight adults (mean age 46.9 years, mean body mass index [BMI] 28.03 kg/m(2), 31.2% male, 11% low education level) recruited from the general population. Use of the intervention and its planning tools were derived from server registration data. Physical activity, fat intake, motivational factors, and self-regulation skills were self-reported at baseline. Descriptive analyses and logistic regression analyses were used to analyze the results.

RESULTS

Use of the tailored intervention decreased sharply after the first modules. Visiting the first tailored intervention module was more likely among participants with low levels of fat intake (OR 0.77, 95% CI 0.62-0.95) or planning for change in PA (OR 0.23, 95% CI 0.05-0.97). Revisiting the intervention was more likely among participants high in restrained eating (OR 2.45, 95% CI 1.12-5.43) or low in proactive coping skills for weight control (OR 0.28, 95% CI 0.10-0.76). The planning tools were used by 5%-55% of the participants, but only 20%-75% of the plans were of good quality.

CONCLUSIONS

This study showed that psychological factors such as self-regulation skills and action planning were associated with repeated use of an online, computer-tailored self-regulation intervention aimed at prevention of weight gain among adults being overweight. Use of the intervention was not optimal, with a limited number of participants who visited all the intervention modules. The use of the action and coping planning components of the intervention was mediocre and the quality of the generated plans was low, especially for the coping plans. It is important to identify how the use of action planning and coping planning components in online interventions can be promoted and how the quality of plans generated through these tools can be improved.

TRIAL REGISTRATION

Netherlands Trial Register: NTR1862; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=1862 (Archived by WebCite at http://www.webcitation.org/6QG1ZPIzZ).

Online social networks that connect users to physical activity partners: a review and descriptive analysis

BACKGROUND

The US Centers for Disease Control and Prevention have identified a lack of encouragement, support, or companionship from family and friends as a major barrier to physical activity. To overcome this barrier, online social networks are now actively leveraging principles of companion social support in novel ways.

OBJECTIVE

The aim was to evaluate the functionality, features, and usability of existing online social networks which seek to increase physical activity and fitness among users by connecting them to physical activity partners, not just online, but also face-to-face.

METHODS

In September 2012, we used 3 major databases to identify the website addresses for relevant online social networks. We conducted a Google search using 8 unique keyword combinations: the common keyword "find" coupled with 1 of 4 prefix terms "health," "fitness," "workout," or "physical" coupled with 1 of 2 stem terms "activity partners" or "activity buddies." We also searched 2 prominent technology start-up news sites, TechCrunch and Y Combinator, using 2 unique keyword combinations: the common keyword "find" coupled with 1 of 2 stem terms "activity partners" and "activity buddies." Sites were defined as online social health activity networks if they had the ability to (1) actively find physical activity partners or activities for the user, (2) offer dynamic, real-time tracking or sharing of social activities, and (3) provide virtual profiles to users. We excluded from our analysis sites that were not Web-based, publicly available, in English, or free.

RESULTS

Of the 360 initial search results, we identified 13 websites that met our complete criteria of an online social health activity network. Features such as physical activity creation (13/13, 100%) and private messaging (12/13, 92%) appeared almost universally among these websites. However, integration with Web 2.0 technologies such as Facebook and Twitter (9/13, 69%) and the option of direct event joining (8/13, 62%) were not as universally present. Largely absent were more sophisticated features that would enable greater usability, such as interactive engagement prompts (3/13, 23%) and system-created best fit activities (3/13, 23%).

CONCLUSIONS

Several major online social networks that connect users to physical activity partners currently exist and use standardized features to achieve their goals. Future research is needed to better understand how users utilize these features and how helpful they truly are.

Community-based recreational football: a novel approach to promote physical activity and quality of life in prostate cancer survivors

As the number of cancer survivors continues to increase, there is an increasing focus on management of the long-term consequences of cancer including health promotion and prevention of co-morbidity. Prostate cancer is the most frequent type of cancer type in men and causes increased risk of heart disease, diabetes and osteoporosis. Epidemiological evidence points to a positive effect of regular physical activity on all-cause and prostate cancer mortality and current clinical evidence supports the use of exercise in cancer rehabilitation. However, the external validity of existing exercise studies is limited and the majority of prostate cancer survivors remain sedentary. Hence, novel approaches to evaluate and promote physical activity are warranted. This paper presents the rationale behind the delivery and evaluation of community-based recreational football offered in existing football clubs under the Danish Football Association to promote quality of life and physical activity adherence in prostate cancer survivors. The RE-AIM framework will be applied to evaluate the impact of the intervention including outcomes both at the individual and organizational level. By introducing community-based sport environments, the study offers a novel approach in the strive towards sustained physical activity adherence and accessibility in prostate cancer survivors.

Non-face-to-face physical activity interventions in older adults: a systematic review

Physical activity is effective in preventing chronic diseases, increasing quality of life and promoting general health in older adults, but most older adults are not sufficiently active to gain those benefits. A novel and economically viable way to promote physical activity in older adults is through non-face-to-face interventions. These are conducted with reduced or no in-person interaction between intervention provider and program participants. The aim of this review was to summarize the scientific literature on non-face-to-face physical activity interventions targeting healthy, community dwelling older adults (≥ 50 years). A systematic search in six databases was conducted by combining multiple key words of the three main search categories "physical activity", "media" and "older adults". The search was restricted to English language articles published between 1st January 2000 and 31st May 2013. Reference lists of relevant articles were screened for additional publications. Seventeen articles describing sixteen non-face-to-face physical activity interventions were included in the review. All studies were conducted in developed countries, and eleven were randomized controlled trials. Sample size ranged from 31 to 2503 participants, and 13 studies included 60% or more women. Interventions were most frequently delivered via print materials and phone (n=11), compared to internet (n=3) and other media (n=2). Every intervention was theoretically framed with the Social Cognitive Theory (n=10) and the Transtheoretical Model of Behavior Change (n=6) applied mostly. Individual tailoring was reported in 15 studies. Physical activity levels were self-assessed in all studies. Fourteen studies reported significant increase in physical activity. Eight out of nine studies conducted post-intervention follow-up analysis found that physical activity was maintained over a longer time. In the six studies where intervention dose was assessed the results varied considerably. One study reported that 98% of the sample read the respective intervention newsletters, whereas another study found that only 4% of its participants visited the intervention website more than once. From this review, non-face-to-face physical activity interventions effectively promote physical activity in older adults. Future research should target diverse older adult populations in multiple regions while also exploring the potential of emerging technologies.

Effectiveness of a web-based physical activity intervention for adults with Type 2 diabetes-a randomised controlled trial

OBJECTIVE

This study examined the effectiveness of a fully automated web-based programme to increase physical activity in adults with Type 2 diabetes.

METHODS

Between May and July 2010, participants were randomly allocated into either a 12-week intervention (n=195) or a control (n=202) group. Participants were adults diagnosed with Type 2 diabetes, residing in Australia. Participants were assessed at baseline, 12 and 36weeks. The primary physical activity outcome was self-reported minutes of total physical activity. Secondary physical activity outcomes included minutes spent walking, and engaged in moderate, and vigorous physical activity. Additional measures included website satisfaction and website usage. The intervention consisted of a 12-week web-based physical activity intervention developed based on the Theory of Planned Behavior and self-management framework. Data were analysed from 2011 to 2012.

RESULTS

There was a significant group-by-time interaction (X(2) (df=1)=6.37, p<.05) for total physical activity favouring the intervention group d=0.11, for those who completed the intervention, however this was not significant in the intention-to-treat analysis d=0.01. The intervention yielded high website satisfaction and usage.

CONCLUSIONS

In general, there is some evidence for the effectiveness of web-based interventions for improving physical activity levels; however it is clear that maintaining improvements remains an issue.

Systematic literature review of Internet interventions across health behaviors

Purpose: This review examines Internet interventions aiming to change health behaviors in the general population. Methods: Internet health interventions in the USA published between January 2005 and December 2013 were identified through Medline and CINAHL. Keywords used were (Internet or e-health or social media or web) paired with (intervention or program*). A total of 38 articles met all criteria and were reviewed. Results: Studies were analyzed by targeted health behavior interventions: tobacco (5), alcohol (4), weight loss (7), physical activity (PA) (7), nutrition (2), PA and nutrition combined (5), HIV or sexual health (4), and chronic diseases (4). Interventions ranged from one session to 24  weeks (average 6-12 weeks). Common strategies used, including web-based information, tailored feedback, weekly e-mails, goal setting, and self-assessment. Social cognitive theory and the transtheoretical models were the most commonly used frameworks. Recruitment strategies were typically media based varied by settings and populations. Except for the tobacco interventions, the majority studies yielded significant outcomes. Conclusion: This review provides updates and synthesized knowledge on the design and consistent effectiveness of Internet interventions across health behaviors. Results have implications for public health and healthcare professionals, as they play a key role in developing and delivering health promotion interventions as well as in assisting the communities and clients serviced obtaining evidence-based health information.

Effects of a behavioral program on exercise adherence and exercise self-efficacy in community-dwelling older persons

Background. This study determines the effects of a behavioral program on exercise adherence (step counts) and level of exercise self-efficacy (ESE) in community-dwelling older persons. Methods. Sixty-three participants (age = 63.8 ± 4.5 years) were enrolled in this controlled quasi-experimental study. They were divided into 3 groups: (1) EBG performed a 6-week exercise intervention followed by a 5-week behavioral program, (2) EG performed exercise intervention similar to EBG, and (3) control group (CG) did not receive any interventions. Step counts were measured based on the scores recorded by a pedometer while ESE was measured by a self-reported ESE scale. Results. Data analysis showed significant differences due to time effect (F(1,2) = 39.884, P < 0.01, and η = .399); time and group interactions (F(2,60) = 112.683, P < 0.01, and η = .790); and between-group effect (F(2,60) = 12.524, P < 0.01, and η = .295) for step counts. As for ESE, significant differences were also found for time effect (F(2,4) = 66.628, P < 0.05, and η = .526); time and group interactions (F(2,60) = 4.562, P = 0.014, and η = .132); and between-group effect (F(2,60) = 13.632, P < 0.05, and η = .312). EBG presented with significantly higher mean changes for both step counts and ESE compared to other groups (all P < 0.05). Conclusion. This study suggests that the addition of a behavioral program is superior as compared to exercising alone on increasing exercise adherence and level of self-efficacy in older persons.

Effects of a web-based intervention on physical activity and metabolism in older adults: randomized controlled trial

Background

Lack of physical activity leads to detrimental changes in body composition and metabolism, functional decline, and increased risk of disease in old age. The potential of Web-assisted interventions for increasing physical activity and improving metabolism in older individuals holds great promise but to our knowledge it has not been studied.

Objective

The goal of our study was to assess whether a Web-based intervention increases physical activity and improves metabolic health in inactive older adults.

Methods

We conducted a 3-month randomized, waitlist-controlled trial in a volunteer sample of 235 inactive adults aged 60-70 years without diabetes. The intervention group received the Internet program Philips DirectLife, which was directed at increasing physical activity using monitoring and feedback by accelerometer and digital coaching. The primary outcome was relative increase in physical activity measured objectively using ankle- and wrist-worn accelerometers. Secondary outcomes of metabolic health included anthropometric measures and parameters of glucose metabolism.

Results

In total, 226 participants (97%) completed the study. At the ankle, activity counts increased by 46% (standard error [SE] 7%) in the intervention group, compared to 12% (SE 3%) in the control group (P_difference<.001). Measured at the wrist, activity counts increased by 11% (SE 3%) in the intervention group and 5% (SE 2%) in the control group (P_difference=.11). After processing of the data, this corresponded to a daily increase of 11 minutes in moderate-to-vigorous activity in the intervention group versus 0 minutes in the control group (P_difference=.001). Weight decreased significantly more in the intervention group compared to controls (−1.5 kg vs −0.8 kg respectively, P=.046), as did waist circumference (−2.3 cm vs −1.3 cm respectively, P=.036) and fat mass (−0.6% vs 0.07% respectively, P=.025). Furthermore, insulin and HbA1c levels were significantly more reduced in the intervention group compared to controls (both P<.05).

Conclusions

This was the first study to show that in inactive older adults, a 3-month Web-based physical activity intervention was effective in increasing objectively measured daily physical activity and improving metabolic health. Such Web-based interventions provide novel opportunities for large scale prevention of metabolic deregulation in our rapidly aging population.

Trial Registration

Dutch Trial Registry: NTR 3045; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=3045 (Archived by WebCite at http://www.webcitation.org/6KPw52dCc).