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Oliveira JS, Sherrington C, Rissel C, Howard K, Tong A, Merom D, Wickham J, Bauman AE, Lord SR, Lindley RI, Simpson JM, Allman-Farinelli M, Kirkham C, Ramsay E, O'Rourke S, Tiedemann A. Effect of a coaching intervention to enhance physical activity and prevent falls in community-dwelling people aged 60+ years: a cluster randomised controlled trial. Br J Sports Med 2024; 58:382-391. [PMID: 38253435 PMCID: PMC10982628 DOI: 10.1136/bjsports-2023-107027] [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] [Accepted: 12/21/2023] [Indexed: 01/24/2024]
Abstract
OBJECTIVES To evaluate the effect of a coaching intervention compared with control on physical activity and falls rate at 12 months in community-dwelling people aged 60+ years. DESIGN Cluster randomised controlled trial. SETTING Community-dwelling older people. PARTICIPANTS 72 clusters (605 participants): 37 clusters (290 participants) randomised to the intervention and 35 (315 participants) to control. INTERVENTION Intervention group received written information, fall risk assessment and prevention advice by a physiotherapist, activity tracker and telephone-based coaching from a physiotherapist focused on safe physical activity. Control group received written information and telephone-based dietary coaching. Both groups received up to 19 sessions of telephone coaching over 12 months. OUTCOMES The co-primary outcomes were device-measured physical activity expressed in counts per minute at 12 months and falls rate over 12 months. Secondary outcomes included the proportion of fallers, device-measured daily steps and moderate-to-vigorous physical activity (MVPA), self-reported hours per week of physical activity, body mass index, eating habits, goal attainment, mobility-related confidence, quality of life, fear of falling, risk-taking behaviour, mood, well-being and disability. RESULTS The mean age of participants was 74 (SD 8) years, and 70% (n=425) were women. There was no significant effect of the intervention on device-measured physical activity counts per minute (mean difference 5 counts/min/day, 95% CI -21 to 31), or falls at 12 months (0.71 falls/person/year in intervention group and 0.87 falls/person/year in control group; incidence rate ratio 0.86, 95% CI 0.65 to 1.14). The intervention had a positive significant effect on device-measured daily steps and MVPA, and self-reported hours per week of walking, well-being, quality of life, and disability. No significant between-group differences were identified in other secondary outcomes. CONCLUSION A physical activity and fall prevention programme including fall risk assessment and prevention advice, plus telephone-based health coaching, did not lead to significant differences in physical activity counts per minute or falls rate at 12 months. However, this programme improved other physical activity measures (ie, daily steps, MVPA, hours per week of walking), overall well-being, quality of life and disability. TRIAL REGISTRATION NUMBER ACTRN12615001190594.
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Affiliation(s)
- Juliana S Oliveira
- Sydney Musculoskeletal Health, The University of Sydney, Sydney, New South Wales, Australia
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Catherine Sherrington
- Sydney Musculoskeletal Health, The University of Sydney, Sydney, New South Wales, Australia
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Chris Rissel
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Kirsten Howard
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Menzies Centre for Health Policy and Economics, Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Allison Tong
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Dafna Merom
- School of Health Sciences, Western Sydney University, Sydney, New South Wales, Australia
| | - James Wickham
- School of Dentistry and Medical Sciences, Charles Sturt University, Orange, New South Wales, Australia
| | - Adrian E Bauman
- Prevention Research Collaboration, Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Stephen R Lord
- Neuroscience Research Australia, Randwick, New South Wales, Australia
| | - Richard I Lindley
- Sydney Medical School, Discipline of Medicine, The University of Sydney, Sydney, New South Wales, Australia
| | - Judy M Simpson
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Margaret Allman-Farinelli
- Nutrition and Dietetics, School of Nursing, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Catherine Kirkham
- Sydney Musculoskeletal Health, The University of Sydney, Sydney, New South Wales, Australia
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Elisabeth Ramsay
- Sydney Musculoskeletal Health, The University of Sydney, Sydney, New South Wales, Australia
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Sandra O'Rourke
- Sydney Musculoskeletal Health, The University of Sydney, Sydney, New South Wales, Australia
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Anne Tiedemann
- Sydney Musculoskeletal Health, The University of Sydney, Sydney, New South Wales, Australia
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, New South Wales, Australia
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
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Feleus A, Wevers L, Schiphof D, Verhoef J, van Hooft S, van Staa A. Content Validition and Psychometric Evaluation of the Self-efficacy and Performance in Self-management Support Instrument for Physiotherapists. Arch Phys Med Rehabil 2024; 105:49-58. [PMID: 37385365 DOI: 10.1016/j.apmr.2023.06.008] [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: 02/13/2023] [Revised: 05/05/2023] [Accepted: 06/19/2023] [Indexed: 07/01/2023]
Abstract
OBJECTIVE To develop and psychometrically test the Self-Efficacy and Performance in Self-Management Support instrument for physiotherapists (SEPSS-PT), based on the SEPSS-36, the corresponding instrument for nurses. DESIGN Instrument development including content validation and psychometric evaluation (construct validity, factor structure, and reliability). SETTING Data were collected from literature, expertmeetings, and online questionnaire PARTICIPANTS: Next to a comprehensive literature study, experts (self-management experts (n=2); physiotherapists (n=10); patients (n=6)) and physiotherapists and physiotherapy students (n=334), participated in different stages of the study. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Not applicable. A literature study (n=42 reviews) and consultations with physiotherapists and patients identified the specific content for physiotherapy. The Five-A's model and overarching competencies of "supportive partnership attitude", were used to structure the items. Psychometric evaluation of the draft questionnaire (40 items) was tested in a sample of 334 physiotherapists and physiotherapy students from the Netherlands, of whom 33 filled out the questionnaire twice to establish the test-retest reliability. RESULTS Confirmatory factor analyses revealed satisfactory fit indices for both the 6-factor model and hierarchical model, with best fit for the 6-factor model. The questionnaire discriminated between physiotherapists and physiotherapy students, and between physiotherapists who did or did not consider self-management support important. The overall internal consistency (Cronbach's alpha) was high, both for the self-efficacy and the performance items. In most of the subscales, test-retest intra-class correlation coefficients for both overall self-efficacy and performance were good, but in 3 subscales insufficient for performance. CONCLUSION The SEPSS-PT questionnaire is a 40-item, Likert-scaled instrument with good content and construct validity, good internal consistency and reliability, and sufficient test-retest reliability. Future research in a larger and more diverse sample could confirm stability and discriminating power.
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Affiliation(s)
- Anita Feleus
- Department of Physiotherapy and Research Center Innovations in Care, Rotterdam University of Applied Sciences, Rotterdam, the Netherlands.
| | - Lotte Wevers
- Department of Physiotherapy and Research Center Innovations in Care, Rotterdam University of Applied Sciences, Rotterdam, the Netherlands
| | - Dieuwke Schiphof
- Department of General Practice, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - John Verhoef
- Department of Physical Therapy & Faculty of Health University of Applied Sciences, Leiden, the Netherlands
| | - Susanne van Hooft
- Department of Nursing and Research Center Innovations in Care, Rotterdam University of Applied Sciences, Rotterdam, the Netherlands
| | - AnneLoes van Staa
- Research Center Innovations in Care, Rotterdam University of Applied Sciences, Rotterdam, the Netherlands
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Dawson R, Pinheiro M, Nagathan V, Taylor M, Delbaere K, Olivera J, Haynes A, Rayner J, Hassett L, Sherrington C. Physiotherapy-led telehealth and exercise intervention to improve mobility in older people receiving aged care services (TOP UP): protocol for a randomised controlled type 1 hybrid effectiveness-implementation trial. BMJ Nutr Prev Health 2023; 6:273-281. [PMID: 38618537 PMCID: PMC11009537 DOI: 10.1136/bmjnph-2022-000606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 10/30/2023] [Indexed: 04/16/2024] Open
Abstract
Introduction Deteriorating mobility and falls reduce independence and quality of life for older people receiving aged care services. This trial aims to establish effectiveness on the mobility of older people, and explore cost-effectiveness and implementation of a telehealth physiotherapy programme. Method and analysis This type 1 hybrid effectiveness-implementation randomised controlled trial will involve 240 people aged 65+ years receiving aged care services in community or residential settings. Participants will be randomised to either: (1) the Telehealth Physiotherapy for Older People (TOP UP) Program or (2) a wait-list control group. The 6-month intervention includes 10 physiotherapy sessions delivered by videocall (Zoom). The intervention will include the local support of an aged care worker and online exercise resources. Primary outcome is mobility at 6 months post randomisation measured by the Short Physical Performance Battery. Secondary outcomes include rate of falls, sit-to-stand, quality of life, and goal attainment at 6 months after randomisation. Regression models will assess the effect of group allocation on mobility and the other continuously scored secondary outcomes, adjusting for baseline scores. The number of falls per person over 6 months will be analysed using negative binomial regression models to estimate between-group differences. An economic analysis will explore the cost-effectiveness of the TOP UP programme compared with usual care. Implementation outcomes and determinants relating to the intervention's reach, fidelity, exercise dose delivered, adoption, feasibility, acceptability, barriers and facilitators will be explored using mixed methods. Conclusion This is the first trial to investigate the effectiveness, cost-effectiveness and implementation of a physiotherapy intervention in aged care delivered solely by telehealth internationally. The study has strong aged care co-design and governance and is guided by steering and advisory committees that include staff from aged care service providers and end-users. Trial results will be disseminated via peer-reviewed articles, conference presentations and lay summaries. Trial registration number The trial is registered with the Australian New Zealand Clinical Trials Registry (ACTRN 12621000734864).
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Affiliation(s)
- Rik Dawson
- Sydney Musculoskeletal Health, Faculty of Health and Medicine, School of Public Health, The University of Sydney Institute for Musculoskeletal Health, Sydney, New South Wales, Australia
- Sydney Local Health District, Sydney, New South Wales, Australia
| | - Marina Pinheiro
- Sydney Musculoskeletal Health, Faculty of Health and Medicine, School of Public Health, The University of Sydney Institute for Musculoskeletal Health, Sydney, New South Wales, Australia
- Sydney Local Health District, Sydney, New South Wales, Australia
| | - Vasikaran Nagathan
- Faculty of Health and Medicine, School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- Department of Geriatric Medicine, Sydney Local Health District, Sydney, New South Wales, Australia
| | - Morag Taylor
- Falls, Balance and Injury Research Centre, Neuroscience Research Australia, Randwick, New South Wales, Australia
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Kim Delbaere
- Falls, Balance and Injury Research Centre, Neuroscience Research Australia, Randwick, New South Wales, Australia
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Juliana Olivera
- Sydney Musculoskeletal Health, Faculty of Health and Medicine, School of Public Health, The University of Sydney Institute for Musculoskeletal Health, Sydney, New South Wales, Australia
- Sydney Local Health District, Sydney, New South Wales, Australia
| | - Abby Haynes
- Sydney Musculoskeletal Health, Faculty of Health and Medicine, School of Public Health, The University of Sydney Institute for Musculoskeletal Health, Sydney, New South Wales, Australia
- Sydney Local Health District, Sydney, New South Wales, Australia
| | - Jenny Rayner
- Sydney Local Health District, Sydney, New South Wales, Australia
| | - Leanne Hassett
- Sydney Musculoskeletal Health, Faculty of Health and Medicine, School of Public Health, The University of Sydney Institute for Musculoskeletal Health, Sydney, New South Wales, Australia
- Sydney Local Health District, Sydney, New South Wales, Australia
| | - Catherine Sherrington
- Sydney Musculoskeletal Health, Faculty of Health and Medicine, School of Public Health, The University of Sydney Institute for Musculoskeletal Health, Sydney, New South Wales, Australia
- Sydney Local Health District, Sydney, New South Wales, Australia
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Wegener EK, Kayser L. Smart health technologies used to support physical activity and nutritional intake in fall prevention among older adults: A scoping review. Exp Gerontol 2023; 181:112282. [PMID: 37660762 DOI: 10.1016/j.exger.2023.112282] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 08/24/2023] [Accepted: 08/31/2023] [Indexed: 09/05/2023]
Abstract
BACKGROUND Falls are the second leading cause of accidental injury deaths globally. Older age is a key risk factors for falls. Besides older age, physical inactivity and malnutrition are identified risk factors for falls. Smart health technologies might offer a sustainable solution to prevent falls by supporting physical activity and nutritional status. OBJECTIVE The aim is to identify, describe, and synthesize knowledge, and identify knowledge gaps on the use of existing smart health technologies to support health behaviour in relation to physical activity and nutrition, among older (65+) in risk of falling. METHODS A scoping review was conducted following the PRISMA-ScR. Searches were carried out in PubMed, Scopus, and Embase using search strings on the themes; smart health technology, physical activity, nutrition, behaviour, falls and older. Identified literature was screened. Data from the included studies was extracted and synthesized. RESULTS 2948 studies were obtained through searches. 18 studies were included. Various smart health technologies are used for fall prevention to support physical activity among older, including software and applications for smart phones, TV, and tablet. Three gaps were identified: use of smart health technologies to support nutrition in fall prevention. Inclusion of relevant stakeholders and fall prevention in low-and middle-income countries. CONCLUSIONS Smart health technology can offer sustainable and cost-effective fall prevention in the future. More knowledge is needed on the use of smart health technologies to support nutritional status for fall prevention, and studies involving older with physical and cognitive conditions, and studies on measures for fall prevention in low- and middle-income countries is needed.
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Affiliation(s)
- Emilie Kauffeldt Wegener
- Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, 1353 Copenhagen, Denmark.
| | - Lars Kayser
- Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, 1353 Copenhagen, Denmark
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Hong A, Welch-Stockton J, Kim JY, Canham SL, Greer V, Sorweid M. Age-Friendly Community Interventions for Health and Social Outcomes: A Scoping Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:2554. [PMID: 36767920 PMCID: PMC9915867 DOI: 10.3390/ijerph20032554] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 01/18/2023] [Accepted: 01/19/2023] [Indexed: 06/18/2023]
Abstract
To address the numerous challenges associated with aging, increased attention has been given to the development of age-friendly cities and communities (AFCC) to promote healthy aging and social participation. However, limited evidence exists for addressing both health and social needs through the AFCC framework. We address this gap by conducting a scoping review of the interventions that target both health and social outcomes within the purview of the AFCC framework. The results showed that many of the successful interventions used a partnership model and behavioral change theories to inform the program design and implementation. The results also indicated that social participation and engagement played a key role in making the interventions successful. However, the results revealed that the literature is dominated by person-focused approaches. Future research should focus more on evaluating environmental-focused interventions and develop a holistic framework that combines both person- and environment-based approaches to healthy aging.
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Affiliation(s)
- Andy Hong
- Healthy Aging and Resilient Places (HARP) Lab, College of Architecture + Planning, University of Utah, Salt Lake City, UT 84112, USA
- Department of City & Metropolitan Planning, College of Architecture + Planning, University of Utah, Salt Lake City, UT 84112, USA
| | - Jessie Welch-Stockton
- Healthy Aging and Resilient Places (HARP) Lab, College of Architecture + Planning, University of Utah, Salt Lake City, UT 84112, USA
- College of Social Work, University of Utah, Salt Lake City, UT 84112, USA
| | - Ja Young Kim
- Healthy Aging and Resilient Places (HARP) Lab, College of Architecture + Planning, University of Utah, Salt Lake City, UT 84112, USA
- Department of City & Metropolitan Planning, College of Architecture + Planning, University of Utah, Salt Lake City, UT 84112, USA
| | - Sarah L. Canham
- Healthy Aging and Resilient Places (HARP) Lab, College of Architecture + Planning, University of Utah, Salt Lake City, UT 84112, USA
- Department of City & Metropolitan Planning, College of Architecture + Planning, University of Utah, Salt Lake City, UT 84112, USA
- College of Social Work, University of Utah, Salt Lake City, UT 84112, USA
| | - Valerie Greer
- Healthy Aging and Resilient Places (HARP) Lab, College of Architecture + Planning, University of Utah, Salt Lake City, UT 84112, USA
- School of Architecture, College of Architecture + Planning, University of Utah, Salt Lake City, UT 84112, USA
| | - Michelle Sorweid
- Healthy Aging and Resilient Places (HARP) Lab, College of Architecture + Planning, University of Utah, Salt Lake City, UT 84112, USA
- Aging Brain Care Program, University of Utah Health, Salt Lake City, UT 84132, USA
- Division of Geriatrics, Department of Internal Medicine, University of Utah Health, Salt Lake City, UT 84132, USA
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Kukafka R, Gupta A, Gilbert C, Huggins CE, Browning C, Chapman W, Haines T, Peeters A. Virtual Care Initiatives for Older Adults in Australia: Scoping Review. J Med Internet Res 2023; 25:e38081. [PMID: 36652291 PMCID: PMC9892987 DOI: 10.2196/38081] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 05/03/2022] [Accepted: 09/26/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND There has been a rapid shift toward the adoption of virtual health care services in Australia. It is unknown how widely virtual care has been implemented or evaluated for the care of older adults in Australia. OBJECTIVE We aimed to review the literature evaluating virtual care initiatives for older adults across a wide range of health conditions and modalities and identify key challenges and opportunities for wider adoption at both patient and system levels in Australia. METHODS A scoping review of the literature was conducted. We searched MEDLINE, Embase, PsycINFO, CINAHL, AgeLine, and gray literature (January 1, 2011, to March 8, 2021) to identify virtual care initiatives for older Australians (aged ≥65 years). The results were reported according to the World Health Organization's digital health evaluation framework. RESULTS Among the 6296 documents in the search results, we identified 94 that reported 80 unique virtual care initiatives. Most (69/80, 89%) were at the pilot stage and targeted community-dwelling older adults (64/79, 81%) with chronic diseases (52/80, 65%). The modes of delivery included videoconference, telephone, apps, device or monitoring systems, and web-based technologies. Most initiatives showed either similar or better health and behavioral outcomes compared with in-person care. The key barriers for wider adoption were physical, cognitive, or sensory impairment in older adults and staffing issues, legislative issues, and a lack of motivation among providers. CONCLUSIONS Virtual care is a viable model of care to address a wide range of health conditions among older adults in Australia. More embedded and integrative evaluations are needed to ensure that virtually enabled care can be used more widely by older Australians and health care providers.
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Affiliation(s)
| | - Adyya Gupta
- Global Centre for Preventive Health and Nutrition, Institute for Health Transformation, Deakin University, Geelong, Australia
| | - Cecily Gilbert
- Centre for Digital Transformation of Health, University of Melbourne, Melbourne, Australia
| | - Catherine E Huggins
- Global Centre for Preventive Health and Nutrition, Institute for Health Transformation, Deakin University, Geelong, Australia
| | - Colette Browning
- Health Innovation and Transformation Centre, Federation University, Ballarat, Australia.,Institute of Health and Wellbeing, Federation University, Ballarat, Australia
| | - Wendy Chapman
- Centre for Digital Transformation of Health, University of Melbourne, Melbourne, Australia
| | - Terry Haines
- National Centre for Healthy Ageing, Monash University, Frankston, Australia.,School of Primary and Allied Health Care, Monash University, Frankston, Australia
| | - Anna Peeters
- Institute for Health Transformation, Deakin University, Geelong, Australia
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Haynes A, Gilchrist H, Oliveira JS, Sherrington C, Tiedemann A. "I wouldn't have joined if it wasn't online": understanding older people's engagement with teleyoga classes for fall prevention. BMC Complement Med Ther 2022; 22:283. [PMID: 36324148 PMCID: PMC9628174 DOI: 10.1186/s12906-022-03756-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 10/10/2022] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Yoga-based exercise is a promising strategy for promoting healthy ageing, with the potential to reduce falls and increase physical, cognitive and psychological wellbeing. Teleyoga (real-time yoga provided via interactive videoconferencing) can deliver yoga programs at scale, potentially reducing costs, increasing convenience, and reaching people who cannot attend studio-based classes. But better understanding of how older people perceive and engage with teleyoga is needed to optimise its design, implementation and promotion. METHODS This study built on a previous realist process evaluation of the SAGE yoga trial which is testing the effect of a yoga-based exercise program on falls among 700 community-dwelling people aged 60 + years. In this second phase of evaluation we conducted focus groups with participants who had completed the SAGE program online and with the yoga instructors who were delivering it. We also conducted interviews with participants who had withdrawn from the trial. Six program theories developed in the earlier evaluation provided a framework for data analysis, supplemented by inductive coding and an analytical workshop. RESULTS Participants described physical and psychological benefits from the SAGE teleyoga program. While noting that teleyoga cannot facilitate hands-on correction or the same quality of observation or interaction as studio classes, participants were highly appreciative of their yoga instructors' strategies for optimising visibility, instruction, social connection and therapeutic alliance, and for adapting to constrained home environments. Some participants argued that teleyoga was superior to studio classes due to its accessibility and convenience, its lower exposure to potential embarrassment about physical appearance or capabilities, and a reduced sense of peer competition and distraction. Our program theories applied across studio and online modes of delivery. CONCLUSION Teleyoga increases accessibility for people in diverse locations and circumstances; it provides a psychologically safer space which combats self-consciousness and unwanted competitiveness; it may enhance embodiment and mindfulness for some; and it has the potential to be offered relatively cheaply at scale which could support free or reduced price classes for people on low incomes and pensions, thereby encouraging a wider population to engage in yoga for healthy ageing and fall prevention.
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Affiliation(s)
- Abby Haynes
- grid.1013.30000 0004 1936 834XInstitute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Gadigal Country, NSW Australia ,grid.1013.30000 0004 1936 834XSchool of Public Health, Faculty of Medicine and Health, The University of Sydney, Gadigal Country, Sydney, NSW Australia
| | - Heidi Gilchrist
- grid.1013.30000 0004 1936 834XInstitute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Gadigal Country, NSW Australia ,grid.1013.30000 0004 1936 834XSchool of Public Health, Faculty of Medicine and Health, The University of Sydney, Gadigal Country, Sydney, NSW Australia
| | - Juliana S Oliveira
- grid.1013.30000 0004 1936 834XInstitute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Gadigal Country, NSW Australia ,grid.1013.30000 0004 1936 834XSchool of Public Health, Faculty of Medicine and Health, The University of Sydney, Gadigal Country, Sydney, NSW Australia
| | - Catherine Sherrington
- grid.1013.30000 0004 1936 834XInstitute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Gadigal Country, NSW Australia ,grid.1013.30000 0004 1936 834XSchool of Public Health, Faculty of Medicine and Health, The University of Sydney, Gadigal Country, Sydney, NSW Australia
| | - Anne Tiedemann
- grid.1013.30000 0004 1936 834XInstitute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Gadigal Country, NSW Australia ,grid.1013.30000 0004 1936 834XSchool of Public Health, Faculty of Medicine and Health, The University of Sydney, Gadigal Country, Sydney, NSW Australia
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Therapeutic Alliance and Its Potential Application to Physical Activity Interventions for Older Adults: A Narrative Review. J Aging Phys Act 2022; 30:739-743. [PMID: 34808599 DOI: 10.1123/japa.2021-0379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 10/06/2021] [Indexed: 01/12/2023]
Abstract
Increasing the physical activity (PA) levels of inactive older adults to promote healthy aging and to reduce preventable health conditions is a public health priority. However, there remains uncertainty on what constitutes the most important components and characteristics of effective PA interventions for older adults, and previous research has largely focused on the cognitive and behavioral strategies they adopt to increase uptake and adherence to PA. This narrative review puts forward the novel idea, with supporting evidence, that the strength, quality, and collaborative nature of the professional-client relationship, a concept drawn from the field of psychotherapy and known as therapeutic alliance, may be a vital and foundational element of effective PA interventions. This article will offer a new understanding, and a new direction of research to aid the future conceptualization, design, and development of interventions that aim to increase the PA levels of older adults.
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Wong S, Hassett L, Koorts H, Grunseit A, Tong A, Tiedemann A, Greaves CJ, Haynes A, Milat A, Harvey LA, Taylor NF, Hinman RS, Pinherio MDB, Jennings M, Treacy D, O'Rourke S, West C, Ramsay E, Kirkham C, Morris C, Sherrington C. Planning implementation and scale-up of physical activity interventions for people with walking difficulties: study protocol for the process evaluation of the ComeBACK trial. Trials 2022; 23:40. [PMID: 35033165 PMCID: PMC8760869 DOI: 10.1186/s13063-021-05990-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 12/29/2021] [Indexed: 11/16/2022] Open
Abstract
Background There is currently little evidence of planning for real-world implementation of physical activity interventions. We are undertaking the ComeBACK (Coaching and Exercise for Better Walking) study, a 3-arm hybrid Type 1 randomised controlled trial evaluating a health coaching intervention and a text messaging intervention. We used an implementation planning framework, the PRACTical planning for Implementation and Scale-up (PRACTIS), to guide the process evaluation for the trial. The aim of this paper is to describe the protocol for the process evaluation of the ComeBACK trial using the framework of the PRACTIS guide. Methods A mixed methods process evaluation protocol was developed informed by the Medical Research Council (MRC) guidance on process evaluations for complex interventions and the PRACTIS guide. Quantitative data, including participant questionnaires, health coach and administrative logbooks, and website and text message usage data, is being collected over the trial period. Semi-structured interviews and focus groups with trial participants, health coaches and health service stakeholders will explore expectations, factors influencing the delivery of the ComeBACK interventions and potential scalability within existing health services. These data will be mapped against the steps of the PRACTIS guide, with reporting at the level of the individual, provider, organisational and community/systems. Quantitative and qualitative data will elicit potential contextual barriers and facilitators to implementation and scale-up. Quantitative data will be reported descriptively, and qualitative data analysed thematically. Discussion This process evaluation integrates an evaluation of prospective implementation and scale-up. It is envisaged this will inform barriers and enablers to future delivery, implementation and scale-up of physical activity interventions. To our knowledge, this is the first paper to describe the application of PRACTIS to guide the process evaluation of physical activity interventions. Trial registration Australian and New Zealand Clinical Trials Registry (ANZCTR) Registration date: 10/12/2018. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-021-05990-3.
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Affiliation(s)
- Siobhan Wong
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia.
| | - Leanne Hassett
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia.,Sydney School of Health Sciences, Faculty of Medicine & Health, University of Sydney, Sydney, Australia
| | - Harriet Koorts
- School of Exercise and Nutrition Sciences, Deakin University, Burwood, Victoria, Australia
| | - Anne Grunseit
- Prevention Research Collaboration, Sydney Medical School, Sydney School of Public Health, The University of Sydney, Sydney, Australia
| | - Allison Tong
- Sydney School of Public Health, The University of Sydney, Sydney, Australia.,Centre for Kidney Research, The Children's Hospital, Westmead, Sydney, Australia
| | - Anne Tiedemann
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
| | - Colin J Greaves
- Psychology Applied to Health, School of Sport, Exercise & Rehabilitation Sciences, University of Birmingham, Birmingham, UK
| | - Abby Haynes
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
| | - Andrew Milat
- Sydney Medical School, School of Public Health, The University of Sydney, Sydney, Australia
| | - Lisa A Harvey
- John Walsh Centre for Rehabilitation Research, Northern Clinical School, The University of Sydney, Sydney, Australia
| | - Nicholas F Taylor
- Centre for Sport and Exercise Medicine Research, La Trobe University, Melbourne, Australia.,Eastern Health, Alfred Health, Box Hill, Victoria, Australia
| | - Rana S Hinman
- Centre for Health, Exercise and Sports Medicine, Department of Physiotherapy, The University of Melbourne, Melbourne, Australia
| | - Marina De Barros Pinherio
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
| | | | - Daniel Treacy
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia.,South Eastern Sydney Local Health District, Sydney, Australia
| | - Sandra O'Rourke
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
| | - Courtney West
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
| | - Elizabeth Ramsay
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
| | - Catherine Kirkham
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
| | | | - Catherine Sherrington
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, Australia
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Haynes A, Sherrington C, Wallbank G, Wickham J, Tong A, Kirkham C, Manning S, Ramsay E, Tiedemann A. Using self-determination theory to understand and improve recruitment for the Coaching for Healthy Ageing (CHAnGE) trial. PLoS One 2021; 16:e0259873. [PMID: 34797820 PMCID: PMC8604286 DOI: 10.1371/journal.pone.0259873] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 10/28/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Intervention trials promoting physical activity among older people frequently report low and unrepresentative recruitment. Better understanding of reasons for participation can help improve recruitment. This study explored why participants enrolled in the Coaching for Healthy Ageing (CHAnGE) trial, including how their decision was influenced by recruitment strategies. CHAnGE was a cluster randomised controlled trial testing the effectiveness of a healthy ageing program targeting inactivity and falls. Seventy-two groups of people aged 60+ were recruited from community organisations via informal presentations by the health coaches. METHODS We conducted a secondary thematic analysis of interview data from our wider qualitative evaluation in which 32 purposively sampled trial participants took part in semi-structured interviews about their experiences of CHAnGE. Data relating to recruitment and participation were analysed inductively to identify themes, then a coding framework comprising the core constructs from self-determination theory-autonomy, competence and relatedness-was used to explore if and how this theory fit with and helped to explain our data. RESULTS Recruitment presentations promoted the CHAnGE intervention well in terms of addressing value expectations of structured support, different forms of accountability, credibility, achievability and, for some, a potential to enhance social relationships. Participation was motivated by the desire for improved health and decelerated ageing, altruism and curiosity. These factors related strongly to self-determination concepts of autonomy, competence and relatedness, but the intervention's demonstrated potential to support self-determination needs could be conveyed more effectively. CONCLUSIONS Findings suggest that recruitment could have greater reach using: 1. Strengths-based messaging focusing on holistic gains, 2. Participant stories that highlight positive experiences, and 3. Peer support and information sharing to leverage altruism and curiosity. These theory-informed improvements will be used to increase participation in future trials, including people in hard-to-recruit groups. They may also inform other physical activity trials and community programs.
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Affiliation(s)
- Abby Haynes
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, NSW, Australia
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Catherine Sherrington
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, NSW, Australia
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Geraldine Wallbank
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, NSW, Australia
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - James Wickham
- School of Biomedical Sciences, Charles Sturt University, Orange, NSW, Australia
| | - Allison Tong
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, NSW, Australia
| | - Catherine Kirkham
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, NSW, Australia
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Shona Manning
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, NSW, Australia
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Christian Homes Tasmania Inc, Kingston, TAS, Australia
| | - Elisabeth Ramsay
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, NSW, Australia
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Anne Tiedemann
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney, NSW, Australia
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
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Haynes A, Sherrington C, Ramsay E, Kirkham C, Manning S, Wallbank G, Hassett L, Tiedemann A. "Sharing Success with Someone": Building therapeutic alliance in physiotherapist-delivered physical activity coaching for healthy aging. Physiother Theory Pract 2021; 38:2771-2787. [PMID: 34324406 DOI: 10.1080/09593985.2021.1946872] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Therapeutic alliance, a goal-orientated partnership between clients and practitioners, can enhance program engagement and adherence, and improve treatment outcomes and satisfaction. OBJECTIVES To develop an empirical model that describes how therapeutic alliances can be operationalized in clinical and research settings and use this in our evaluation of the Coaching for Healthy Ageing (CHAnGE) trial. METHODS Secondary analysis of interviews with participants in the CHAnGE trial (n = 32) and a focus group with the physiotherapists who delivered health coaching in that trial (n = 3). Analysis was inductive (thematic) and deductive (using a therapeutic alliance model derived from a literature review and informed by earlier analyses). RESULTS Data from participants and physiotherapists indicated that health coaching in CHAnGE built effective therapeutic alliances (i.e. it facilitated collaborative decision-making and trusting person-centered relationships) which were underpinned by professional skills and structural supports. Components of the intervention that strengthened therapeutic alliance were health coaching training, home visits, the coaching format, and provision of free activity monitors. CONCLUSION This study identifies key concepts and practical 'building blocks' of therapeutic alliance, showing how these were operationalized within an intervention. This may help those in clinical and research settings to recognize the importance and characteristics of therapeutic alliance and put it into practice.
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Affiliation(s)
- Abby Haynes
- Institute for Musculoskeletal Health, University of Sydney and Sydney Local Health District, Level 10N King George V Building Royal Prince Alfred Hospital, Camperdown, NSW, Australia.,School of Public Health, Faculty of Medicine and Health, University of Sydney, NSW, Australia
| | - Catherine Sherrington
- Institute for Musculoskeletal Health, University of Sydney and Sydney Local Health District, Level 10N King George V Building Royal Prince Alfred Hospital, Camperdown, NSW, Australia.,School of Public Health, Faculty of Medicine and Health, University of Sydney, NSW, Australia
| | - Elisabeth Ramsay
- Institute for Musculoskeletal Health, University of Sydney and Sydney Local Health District, Level 10N King George V Building Royal Prince Alfred Hospital, Camperdown, NSW, Australia.,School of Public Health, Faculty of Medicine and Health, University of Sydney, NSW, Australia
| | - Catherine Kirkham
- Institute for Musculoskeletal Health, University of Sydney and Sydney Local Health District, Level 10N King George V Building Royal Prince Alfred Hospital, Camperdown, NSW, Australia.,School of Public Health, Faculty of Medicine and Health, University of Sydney, NSW, Australia
| | - Shona Manning
- Institute for Musculoskeletal Health, University of Sydney and Sydney Local Health District, Level 10N King George V Building Royal Prince Alfred Hospital, Camperdown, NSW, Australia.,School of Public Health, Faculty of Medicine and Health, University of Sydney, NSW, Australia.,Christian Homes Tasmania Inc, Kingston, TAS, Australia
| | - Geraldine Wallbank
- Institute for Musculoskeletal Health, University of Sydney and Sydney Local Health District, Level 10N King George V Building Royal Prince Alfred Hospital, Camperdown, NSW, Australia.,School of Public Health, Faculty of Medicine and Health, University of Sydney, NSW, Australia
| | - Leanne Hassett
- Institute for Musculoskeletal Health, University of Sydney and Sydney Local Health District, Level 10N King George V Building Royal Prince Alfred Hospital, Camperdown, NSW, Australia.,School of Public Health, Faculty of Medicine and Health, University of Sydney, NSW, Australia.,School of Health Sciences, University of Sydney, Lidcombe, NSW, Australia
| | - Anne Tiedemann
- Institute for Musculoskeletal Health, University of Sydney and Sydney Local Health District, Level 10N King George V Building Royal Prince Alfred Hospital, Camperdown, NSW, Australia.,School of Public Health, Faculty of Medicine and Health, University of Sydney, NSW, Australia
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Hassett L, Tiedemann A, Hinman RS, Crotty M, Hoffmann T, Harvey L, Taylor NF, Greaves C, Treacy D, Jennings M, Milat A, Bennell KL, Howard K, van den Berg M, Pinheiro M, Wong S, Kirkham C, Ramsay E, O'Rourke S, Sherrington C. Physical activity coaching for adults with mobility limitations: protocol for the ComeBACK pragmatic hybrid effectiveness-implementation type 1 randomised controlled trial. BMJ Open 2020; 10:e034696. [PMID: 33148720 PMCID: PMC7640503 DOI: 10.1136/bmjopen-2019-034696] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION Mobility limitation is common and often results from neurological and musculoskeletal health conditions, ageing and/or physical inactivity. In consultation with consumers, clinicians and policymakers, we have developed two affordable and scalable intervention packages designed to enhance physical activity for adults with self-reported mobility limitations. Both are based on behaviour change theories and involve tailored advice from physiotherapists. METHODS AND ANALYSIS This pragmatic hybrid effectiveness-implementation type 1 randomised control trial (n=600) will be undertaken among adults with self-reported mobility limitations. It aims to estimate the effects on physical activity of: (1) an enhanced 6-month intervention package (one face-to-face physiotherapy assessment, tailored physical activity plan, physical activity phone coaching from a physiotherapist, informational/motivational resources and activity monitors) compared with a less intensive 6-month intervention package (single session of tailored phone advice from a physiotherapist, tailored physical activity plan, unidirectional text messages, informational/motivational resources); (2) the enhanced intervention package compared with no intervention (6-month waiting list control group); and (3) the less intensive intervention package compared with no intervention (waiting list control group). The primary outcome will be average steps per day, measured with the StepWatch Activity Monitor over a 1-week period, 6 months after randomisation. Secondary outcomes include other physical activity measures, measures of health and functioning, individualised mobility goal attainment, mental well-being, quality of life, rate of falls, health utilisation and intervention evaluation. The hybrid effectiveness-implementation design (type 1) will be used to enable the collection of secondary implementation outcomes at the same time as the primary effectiveness outcome. An economic analysis will estimate the cost-effectiveness and cost-utility of the interventions compared with no intervention and to each other. ETHICS AND DISSEMINATION Ethical approval has been obtained by Sydney Local Health District, Royal Prince Alfred Zone. Dissemination will be via publications, conferences, newsletters, talks and meetings with health managers. TRIAL REGISTRATION NUMBER ACTRN12618001983291.
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Affiliation(s)
- Leanne Hassett
- Institute for Musculoskeletal Health, University of Sydney/ Sydney Local Health District, Sydney, New South Wales, Australia
- Discipline of Physiotherapy, Sydney School of Health Sciences, University of Sydney, Sydney, New South Wales, Australia
- School of Public Health, University of Sydney, Camperdown, New South Wales, Australia
| | - Anne Tiedemann
- Institute for Musculoskeletal Health, University of Sydney/ Sydney Local Health District, Sydney, New South Wales, Australia
- School of Public Health, University of Sydney, Camperdown, New South Wales, Australia
| | - Rana S Hinman
- Centre for Health, Exercise and Sports Medicine, Department of Physiotherapy, The University of Melbourne, Melbourne, Victoria, Australia
| | - Maria Crotty
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Tammy Hoffmann
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Queensland, Australia
| | - Lisa Harvey
- John Walsh Centre for Rehabilitation Research, Northern Clinical School, The University of Sydney, St Leonards, New South Wales, Australia
| | - Nicholas F Taylor
- School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, New South Wales, Australia
| | - Colin Greaves
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, UK
| | - Daniel Treacy
- Institute for Musculoskeletal Health, University of Sydney/ Sydney Local Health District, Sydney, New South Wales, Australia
- School of Public Health, University of Sydney, Camperdown, New South Wales, Australia
- Prince of Wales Hospital, South Eastern Sydney Local Health District, Sydney, New South Wales, Australia
| | - Matthew Jennings
- Liverpool Hospital, South Western Sydney Local Health District, Sydney, New South Wales, Australia
| | - Andrew Milat
- School of Public Health, University of Sydney, Camperdown, New South Wales, Australia
- NSW Ministry of Health, Liverpool, New South Wales, Australia
| | - Kim L Bennell
- Centre for Health, Exercise and Sports Medicine, Department of Physiotherapy, The University of Melbourne, Melbourne, Victoria, Australia
| | - Kirsten Howard
- School of Public Health, University of Sydney, Camperdown, New South Wales, Australia
| | - Maayken van den Berg
- College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - Marina Pinheiro
- Institute for Musculoskeletal Health, University of Sydney/ Sydney Local Health District, Sydney, New South Wales, Australia
- Discipline of Physiotherapy, Sydney School of Health Sciences, University of Sydney, Sydney, New South Wales, Australia
- School of Public Health, University of Sydney, Camperdown, New South Wales, Australia
| | - Siobhan Wong
- Institute for Musculoskeletal Health, University of Sydney/ Sydney Local Health District, Sydney, New South Wales, Australia
- School of Public Health, University of Sydney, Camperdown, New South Wales, Australia
| | - Catherine Kirkham
- Institute for Musculoskeletal Health, University of Sydney/ Sydney Local Health District, Sydney, New South Wales, Australia
- School of Public Health, University of Sydney, Camperdown, New South Wales, Australia
| | - Elizabeth Ramsay
- Institute for Musculoskeletal Health, University of Sydney/ Sydney Local Health District, Sydney, New South Wales, Australia
- School of Public Health, University of Sydney, Camperdown, New South Wales, Australia
| | - Sandra O'Rourke
- Institute for Musculoskeletal Health, University of Sydney/ Sydney Local Health District, Sydney, New South Wales, Australia
- School of Public Health, University of Sydney, Camperdown, New South Wales, Australia
| | - Catherine Sherrington
- Institute for Musculoskeletal Health, University of Sydney/ Sydney Local Health District, Sydney, New South Wales, Australia
- School of Public Health, University of Sydney, Camperdown, New South Wales, Australia
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