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Ashton LM, Rayward AT, Pollock ER, Kennedy SL, Young MD, Eather N, Barnes AT, Lee DR, Morgan PJ. Twelve-month outcomes of a community-based, father-daughter physical activity program delivered by trained facilitators. Int J Behav Nutr Phys Act 2024; 21:101. [PMID: 39261926 PMCID: PMC11389107 DOI: 10.1186/s12966-024-01648-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Accepted: 08/22/2024] [Indexed: 09/13/2024] Open
Abstract
BACKGROUND Dads and Daughters Exercising and Empowered (DADEE) is a program targeting fathers/father-figures to improve their daughters' physical activity and well-being. Previous randomised controlled efficacy and effectiveness trials of DADEE demonstrated meaningful improvements in a range of holistic outcomes for both fathers and daughters in the short-term. This study aims to assess the long-term impact (12-months) of the program when delivered in the community by trained facilitators. METHODS Fathers/father-figures and their primary school-aged daughters were recruited from Newcastle, Australia into a single-arm, non-randomised, pre-post study with assessments at baseline, 10-weeks (post-intervention) and 12-months. The 9-session program included weekly 90-min educational and practical sessions, plus home-based tasks. The primary outcome was fathers' and daughters' days per week meeting national physical activity recommendations (≥ 30 min/day of MVPA for fathers, ≥ 60 min/day MVPA for daughters). Secondary outcomes included physical activity, screen time, self-esteem, father-daughter relationship, social-emotional well-being, parenting measures, and process outcomes (including recruitment, attendance, retention and program acceptability). RESULTS Twelve programs were delivered with 257 fathers (40.0 ± 9.2 years) and 285 daughters (7.7 ± 1.9 years). Mixed effects regression models revealed significant intervention effects for the primary outcome, with fathers increasing the days/week meeting physical activity recommendations by 27% at 10-weeks (p < 0.001) and by 19% at 12-months (p < 0.001) compared with baseline. Likewise, for daughters there was a significant increase by 25% at 10-weeks (p < 0.001) and by 14% at 12-months (p = 0.02) when compared to baseline. After conducting a sensitivity analysis with participants unaffected by COVID-19 lockdowns (n = 175 fathers, n = 192 daughters), the primary outcome results strengthened at both time-points for fathers and at 12-months for daughters. Additionally, the sensitivity analysis revealed significant intervention effects at post-program and 12-months for all secondary outcomes in both fathers and daughters. Furthermore, the process outcomes for recruitment capability, attendance, retention and satisfaction levels were high. CONCLUSIONS Findings provide support for a sustained effect of the DADEE program while delivered in a community setting by trained facilitators. Further investigation is required to identify optimised implementation processes and contextual factors to deliver the program at scale. TRIAL REGISTRATION ACTRN12617001450303 . Date registered: 12/10/2017.
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Affiliation(s)
- Lee M Ashton
- Centre for Active Living and Learning, College of Human and Social Futures, School of Education, University of Newcastle, University Drive, Awabakal Country, Callaghan, NSW, 2308, Australia
- Active Living and Learning Research Program, Hunter Medical Research Institute (HMRI), Lot 1 Kookaburra Circuit, New Lambton Heights, NSW, 2305, Australia
| | - Anna T Rayward
- School of Medicine and Public Health, The University of Newcastle, Newcastle, NSW, Australia
- The National Centre of Implementation Science (NCOIS), The University of Newcastle, Newcastle, NSW, Australia
- Population Health Research Program, Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
- Hunter New England Population Health, Hunter New England Local Health District, Newcastle, NSW, Australia
| | - Emma R Pollock
- School of Medicine and Public Health, The University of Newcastle, Newcastle, NSW, Australia
- The National Centre of Implementation Science (NCOIS), The University of Newcastle, Newcastle, NSW, Australia
- Population Health Research Program, Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
- Hunter New England Population Health, Hunter New England Local Health District, Newcastle, NSW, Australia
| | - Stevie-Lee Kennedy
- School of Medicine and Public Health, The University of Newcastle, Newcastle, NSW, Australia
- The National Centre of Implementation Science (NCOIS), The University of Newcastle, Newcastle, NSW, Australia
- Population Health Research Program, Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
- Hunter New England Population Health, Hunter New England Local Health District, Newcastle, NSW, Australia
| | - Myles D Young
- Active Living and Learning Research Program, Hunter Medical Research Institute (HMRI), Lot 1 Kookaburra Circuit, New Lambton Heights, NSW, 2305, Australia
- College of Engineering, Science and Environment, School of Psychology, University of Newcastle, Callaghan, NSW, Australia
| | - Narelle Eather
- Centre for Active Living and Learning, College of Human and Social Futures, School of Education, University of Newcastle, University Drive, Awabakal Country, Callaghan, NSW, 2308, Australia
- Active Living and Learning Research Program, Hunter Medical Research Institute (HMRI), Lot 1 Kookaburra Circuit, New Lambton Heights, NSW, 2305, Australia
| | - Alyce T Barnes
- School of Medicine and Public Health, The University of Newcastle, Newcastle, NSW, Australia
- The National Centre of Implementation Science (NCOIS), The University of Newcastle, Newcastle, NSW, Australia
- Population Health Research Program, Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
- Hunter New England Population Health, Hunter New England Local Health District, Newcastle, NSW, Australia
| | - Daniel R Lee
- Centre for Active Living and Learning, College of Human and Social Futures, School of Education, University of Newcastle, University Drive, Awabakal Country, Callaghan, NSW, 2308, Australia
- Active Living and Learning Research Program, Hunter Medical Research Institute (HMRI), Lot 1 Kookaburra Circuit, New Lambton Heights, NSW, 2305, Australia
| | - Philip J Morgan
- Centre for Active Living and Learning, College of Human and Social Futures, School of Education, University of Newcastle, University Drive, Awabakal Country, Callaghan, NSW, 2308, Australia.
- Active Living and Learning Research Program, Hunter Medical Research Institute (HMRI), Lot 1 Kookaburra Circuit, New Lambton Heights, NSW, 2305, Australia.
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Ashton LM, Grounds JA, Barnes AT, Pollock ER, Young MD, Kennedy SL, Rayward AT, Lee DR, Morgan PJ. Replicability, adaptability and long-term impact of the 'Healthy Youngsters, Healthy Dads' program in Newcastle, Australia. Health Promot Int 2024; 39:daae095. [PMID: 39129343 PMCID: PMC11317530 DOI: 10.1093/heapro/daae095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/13/2024] Open
Abstract
'Healthy Youngsters, Healthy Dads' (HYHD) targets fathers to improve the health of their preschool-aged children. In a previous randomized trial, fathers and children experienced meaningful improvements in physical activity and eating behaviours. The next phase is to test the replicability and adaptability of HYHD when delivered in the community by trained facilitators. Fathers/father-figures and children aged 3-5 years were recruited from Newcastle, Australia into a 9-week, non-randomized trial with assessments at baseline, 10 weeks, and 12 months. The primary outcome was achievement of pre-registered targets for recruitment (≥ 96 dyads), attendance (≥ 70%), compliance (completing ≥ 70% of home-based tasks), fidelity (≥ 80% of content delivered as intended) and program satisfaction (≥ 4/5). Secondary outcomes included physical activity, nutrition, screen time and parenting measures. Process targets were surpassed for recruitment (140 fathers, 141 children), attendance (79% for fathers-only workshops, 81% for father-child sessions), compliance (80% of home-tasks completed), fidelity (99% for education, ≥ 97% for practical) and program satisfaction (4.8/5). Mixed effects regression models revealed significant effects in fathers for moderate-to-vigorous physical activity, co-physical activity, dietary intake and parenting practises, which were maintained at 12 months. Significant effects were also established for screen time at 10 weeks only. For children, significant effects were observed for screen time and dietary intake at 10 weeks, while effects on energy-dense, nutrient-poor foods and healthy, nutrient-dense core food intake were maintained at 12 months. Findings demonstrate the replicability and adaptability of HYHD when delivered in the community by local trained facilitators. Further investigation into how to optimally scale-up HYHD is warranted.
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Affiliation(s)
- Lee M Ashton
- Centre for Active Living and Learning, College of Human and Social Futures, School of Education, University of Newcastle, Awabakal Country, Callaghan, New South Wales, 2308, Australia
- Active Living and Learning Research Program, Hunter Medical Research Institute (HMRI), Lot 1 Kookaburra Circuit, Awabakal Country, New Lambton Heights, New South Wales 2305, Australia
| | - Jacqueline A Grounds
- Centre for Active Living and Learning, College of Human and Social Futures, School of Education, University of Newcastle, Awabakal Country, Callaghan, New South Wales, 2308, Australia
- Active Living and Learning Research Program, Hunter Medical Research Institute (HMRI), Lot 1 Kookaburra Circuit, Awabakal Country, New Lambton Heights, New South Wales 2305, Australia
| | - Alyce T Barnes
- College of Health, Medicine and Wellbeing, School of Medicine and Public Health, The University of Newcastle, Awabakal Country, Newcastle, New South Wales, 2308, Australia
- The National Centre of Implementation Science (NCOIS), The University of Newcastle, Awabakal Country, Newcastle, New South Wales, 2308, Australia
- Population Health Research Program, Hunter Medical Research Institute, Awabakal Country, New Lambton Heights, New South Wales, 2305, Australia
- Hunter New England Population Health, Hunter New England Local Health District, Awabakal Country, Newcastle, New South Wales, 2287, Australia
| | - Emma R Pollock
- College of Health, Medicine and Wellbeing, School of Medicine and Public Health, The University of Newcastle, Awabakal Country, Newcastle, New South Wales, 2308, Australia
- The National Centre of Implementation Science (NCOIS), The University of Newcastle, Awabakal Country, Newcastle, New South Wales, 2308, Australia
- Population Health Research Program, Hunter Medical Research Institute, Awabakal Country, New Lambton Heights, New South Wales, 2305, Australia
- Hunter New England Population Health, Hunter New England Local Health District, Awabakal Country, Newcastle, New South Wales, 2287, Australia
| | - Myles D Young
- Active Living and Learning Research Program, Hunter Medical Research Institute (HMRI), Lot 1 Kookaburra Circuit, Awabakal Country, New Lambton Heights, New South Wales 2305, Australia
- College of Engineering, Science and Environment, School of Psychology, University of Newcastle, Awabakal Country, Callaghan, New South Wales, 2308, Australia
| | - Stevie-Lee Kennedy
- Centre for Active Living and Learning, College of Human and Social Futures, School of Education, University of Newcastle, Awabakal Country, Callaghan, New South Wales, 2308, Australia
- Active Living and Learning Research Program, Hunter Medical Research Institute (HMRI), Lot 1 Kookaburra Circuit, Awabakal Country, New Lambton Heights, New South Wales 2305, Australia
| | - Anna T Rayward
- College of Health, Medicine and Wellbeing, School of Medicine and Public Health, The University of Newcastle, Awabakal Country, Newcastle, New South Wales, 2308, Australia
- The National Centre of Implementation Science (NCOIS), The University of Newcastle, Awabakal Country, Newcastle, New South Wales, 2308, Australia
- Population Health Research Program, Hunter Medical Research Institute, Awabakal Country, New Lambton Heights, New South Wales, 2305, Australia
- Hunter New England Population Health, Hunter New England Local Health District, Awabakal Country, Newcastle, New South Wales, 2287, Australia
| | - Daniel R Lee
- Centre for Active Living and Learning, College of Human and Social Futures, School of Education, University of Newcastle, Awabakal Country, Callaghan, New South Wales, 2308, Australia
- Active Living and Learning Research Program, Hunter Medical Research Institute (HMRI), Lot 1 Kookaburra Circuit, Awabakal Country, New Lambton Heights, New South Wales 2305, Australia
| | - Philip J Morgan
- Centre for Active Living and Learning, College of Human and Social Futures, School of Education, University of Newcastle, Awabakal Country, Callaghan, New South Wales, 2308, Australia
- Active Living and Learning Research Program, Hunter Medical Research Institute (HMRI), Lot 1 Kookaburra Circuit, Awabakal Country, New Lambton Heights, New South Wales 2305, Australia
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Hutto B, Saunders RP, Wilcox S, Jake-Schoffman DE, Bernhart JA, Dunn CG, Kaczynski AT, James KL. Pathways of influences leading to adoption of the Faith, Activity and Nutrition (FAN) program in a statewide initiative. EVALUATION AND PROGRAM PLANNING 2021; 87:101941. [PMID: 33773182 DOI: 10.1016/j.evalprogplan.2021.101941] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 09/15/2020] [Accepted: 03/08/2021] [Indexed: 06/12/2023]
Abstract
RE-AIM (Reach, effectiveness, Adoption, Implementation, Maintenance) and CFIR (Consolidated Framework for Implementation Research) are complementary frameworks guiding research on dissemination and implementation of evidence-based interventions and factors influencing this process. Faith, Activity, and Nutrition (FAN) is an evidence-based program that increased physical activity and fruit and vegetable intake in faith-based settings. The aims of this adoption study were to quantify state-wide church level adoption rates and congregant reach of FAN in accordance with RE-AIM guidelines, and to explore the association of CFIR-derived constructs of the church inner setting and pastor characteristics with FAN adoption. Church recruitment was documented, and data were collected via telephone-administered surveys from 93 pastors in adopting churches and 60 pastors in non-adopting churches. Qualitative Comparative Analysis (QCA) identified combinations of CFIR-derived church and pastor characteristics sufficient for FAN adoption. As defined by RE-AIM, church-level FAN adoption was 11.7 % and congregant-level reach was 20.0 %. Fourteen pathways to adoption were identified; seven of these featured the presence of a culture of concern for congregant health along with openness to new ideas. Results suggest early assessment of these two CFIR-derived inner setting constructs may help identify faith-based organizations predisposed to undertake a comprehensive, environmental intervention to promote congregant health.
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Affiliation(s)
- Brent Hutto
- Prevention Research Center, Arnold School of Public Health, University of South Carolina, Columbia, SC, 29208, USA.
| | - Ruth P Saunders
- Prevention Research Center, Arnold School of Public Health, University of South Carolina, Columbia, SC, 29208, USA; Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina, Columbia, SC, 29208, USA
| | - Sara Wilcox
- Prevention Research Center, Arnold School of Public Health, University of South Carolina, Columbia, SC, 29208, USA; Department of Exercise Science, Arnold School of Public Health, University of South Carolina, Columbia, SC, 29208, USA
| | - Danielle E Jake-Schoffman
- Department of Health Education and Behavior, College of Health and Human Performance, University of Florida, Gainesville, FL, 32611, USA
| | - John A Bernhart
- Prevention Research Center, Arnold School of Public Health, University of South Carolina, Columbia, SC, 29208, USA; Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina, Columbia, SC, 29208, USA
| | - Caroline G Dunn
- Department of Health Policy Management, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Andrew T Kaczynski
- Prevention Research Center, Arnold School of Public Health, University of South Carolina, Columbia, SC, 29208, USA; Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina, Columbia, SC, 29208, USA
| | - Katherine L James
- South Carolina Conference of the United Methodist Church, Columbia, SC, 29203, USA
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Brown NI, Powell MA, Baskin M, Oster R, Demark-Wahnefried W, Hardy C, Pisu M, Thirumalai M, Townsend S, Neal WN, Rogers LQ, Pekmezi D. Design and Rationale for the Deep South Interactive Voice Response System-Supported Active Lifestyle Study: Protocol for a Randomized Controlled Trial. JMIR Res Protoc 2021; 10:e29245. [PMID: 34032575 PMCID: PMC8188314 DOI: 10.2196/29245] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 04/14/2021] [Accepted: 04/15/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND The rates of physical inactivity and related cancer incidence and mortality are disproportionately high in the Deep South region in the United States, a rural, medically underserved region with a large African American population compared with the rest of the nation. Given this region's lower rates of literacy and internet access, interactive voice response (IVR) system-automated telephone-based interventions have the potential to help overcome physical activity intervention barriers (literacy, internet access, costs, and transportation) but have yet to be extended to rural, underserved populations, such as in the Deep South. Thus, extensive formative research is being conducted to develop and beta test the Deep South IVR System-Supported Active Lifestyle intervention in preparation for dissemination in rural Alabama counties. OBJECTIVE This paper aims to describe the design and rationale of an ongoing efficacy trial of the Deep South IVR System-Supported Active Lifestyle intervention. METHODS A two-arm randomized controlled trial will be conducted to compare a 12-month physical activity intervention versus a wait-list control condition in 240 underactive adults from 6 rural Alabama counties. The Deep South IVR System-Supported Active Lifestyle intervention is based on the Social Cognitive Theory and includes IVR-automated physical activity-related phone counseling (daily in months 0-3, twice weekly in months 4-6, and weekly in months 7-12) and support from local rural county coordinators with the University of Alabama O'Neal Comprehensive Cancer Center Community Outreach and Engagement Office. The primary outcome is weekly minutes of moderate- to vigorous-intensity physical activity (7-day physical activity recall; accelerometry) at baseline, 6 months, 12 months, and 18 months. Rural Active Living Assessments will be conducted in each rural county to assess walkability, assess recreational amenities, and inform future environment and policy efforts. RESULTS This study was funded in March 2019 and approved by the institutional review board of the University of Alabama at Birmingham in April 2019. As of February 2020, start-up activities (hiring and training staff and purchasing supplies) were completed. Study recruitment and assessments began in September 2020 and are ongoing. As of February 2021, a total of 43 participants have been enrolled in Dallas County, 42 in Sumter County, and 51 in Greene County. CONCLUSIONS IVR-supported phone counseling has great potential for addressing physical activity barriers (eg, culture, literacy, cost, or transportation) and reducing related rural health disparities in this region. TRIAL REGISTRATION ClinicalTrials.gov NCT03903874; https://clinicaltrials.gov/ct2/show/NCT03903874. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/29245.
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Affiliation(s)
- Nashira I Brown
- Department of Health Behavior, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Mary Anne Powell
- Department of Health Behavior, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Monica Baskin
- Department of Medicine, Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
- O'Neal Comprehensive Cancer Center at UAB, Birmingham, AL, United States
| | - Robert Oster
- Department of Medicine, Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
- O'Neal Comprehensive Cancer Center at UAB, Birmingham, AL, United States
| | - Wendy Demark-Wahnefried
- O'Neal Comprehensive Cancer Center at UAB, Birmingham, AL, United States
- Department of Nutrition Sciences, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Claudia Hardy
- O'Neal Comprehensive Cancer Center at UAB, Birmingham, AL, United States
| | - Maria Pisu
- Department of Medicine, Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
- O'Neal Comprehensive Cancer Center at UAB, Birmingham, AL, United States
| | - Mohanraj Thirumalai
- Health Services Administration, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Sh'Nese Townsend
- Department of Health Behavior, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Whitney N Neal
- Department of Health Behavior, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Laura Q Rogers
- Department of Medicine, Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
- O'Neal Comprehensive Cancer Center at UAB, Birmingham, AL, United States
| | - Dori Pekmezi
- Department of Health Behavior, University of Alabama at Birmingham, Birmingham, AL, United States
- O'Neal Comprehensive Cancer Center at UAB, Birmingham, AL, United States
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Kelechi TJ, Prentice MA, Mueller M, Madisetti M, Vertegel A. A Lower Leg Physical Activity Intervention for Individuals With Chronic Venous Leg Ulcers: Randomized Controlled Trial. JMIR Mhealth Uhealth 2020; 8:e15015. [PMID: 32412419 PMCID: PMC7260657 DOI: 10.2196/15015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 12/04/2019] [Accepted: 02/02/2020] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Individuals with venous leg ulcers (VLUs) suffer disproportionately with multiple chronic conditions, are often physically deconditioned, and demonstrate high levels of physical inactivity. OBJECTIVE The primary objective of this randomized controlled trial was to establish the feasibility of a mobile health (mHealth) physical activity exercise app for individuals with VLUs to improve lower leg function. METHODS In a 6-week study, adults with VLUs were recruited from 2 wound centers in South Carolina, United States, and enrolled if they were aged 18 years or older with impaired functional mobility and an ankle-brachial index between 0.8 and 1.3. Participants were randomized 1:1 to receive evidence-based, phased, nonexertive physical conditioning activities for lower leg function (FOOTFIT) or FOOTFIT+ with an added patient-provider communication feature. The mHealth Conditioning Activities for Lower Leg Function app also provided automated educational and motivational messages and user reports. Foot movement on the VLU-affected leg was tracked by a Bluetooth-enabled triaxial accelerometer. The study was guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework to assess the feasibility of reach, adherence, acceptability, implementation, and maintenance. RESULTS A total of 24 patients were recruited, enrolled, and randomized in the study. Most patients reported difficulty following the protocol for exercising and using the accelerometer and mobile phone and did not use the provider contact feature. However, all patients were adherent to the 6-week exercise program more than 85% of the time for duration, whereas 33% (8/24) of patients adhered more than 85% for the frequency of performing the exercises. Across the three exercise levels, adherence did not differ between the two groups. Confidence limits around the difference in proportions ranged from -0.4 to 0.7. Providers in FOOTFIT+ were inconsistent in checking participant progress reports because of lack of time from competing work commitments. The technology became outdated quickly, making maintenance problematic. Participants said they would continue to exercise their foot and legs and liked being able to follow along with the demonstrations of each level of exercise provided through the app. CONCLUSIONS The findings of this study suggest that despite initial interest in using the app, several components of the program as originally designed had limited acceptability and feasibility. Future refinements should include the use of more modern technology including smaller wearable accelerometers, mobile phones or tablets with larger screens, an app designed with larger graphics, automated reporting for providers, and more engaging user features. TRIAL REGISTRATION ClinicalTrials.gov NTC02632695; https://clinicaltrials.gov/ct2/show/NCT02632695.
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Affiliation(s)
- Teresa J Kelechi
- College of Nursing, Medical University of South Carolina, Charleston, SC, United States
| | - Margaret A Prentice
- College of Nursing, Medical University of South Carolina, Charleston, SC, United States
| | - Martina Mueller
- College of Nursing, Medical University of South Carolina, Charleston, SC, United States.,Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, United States
| | - Mohan Madisetti
- College of Nursing, Medical University of South Carolina, Charleston, SC, United States
| | - Alexey Vertegel
- Department of Bioengineering, Clemson University, Clemson, SC, United States
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