Cost effectiveness of a mail-delivered individually tailored physical activity intervention for Latinas vs. a mailed contact control

Impact of the COVID-19 Pandemic on Physical Activity among Mostly Older, Overweight Black Women Living in the Rural Alabama Black Belt

Despite well-documented global declines in physical activity (PA) during the COVID-19 pandemic, little is known regarding the specific impact among underserved, rural Alabama counties. This is concerning as this region was already disproportionately burdened by inactivity and related chronic diseases and was among the hardest hit by COVID-19. Thus, the current study examined the effect of COVID-19 on PA in four rural Alabama counties. An ancillary survey was administered between March 2020 and August 2021 to the first cohort (N = 171) of participants enrolled in a larger PA trial. Main outcomes of this survey included the perceived impact of COVID-19 on PA, leisure-time PA, and social cognitive theory (SCT) constructs at 3 months. Almost half of the participants reported being less active during the pandemic (49.7%) and endorsed that COVID-19 made PA more difficult (47.4%), citing concerns such as getting sick from exercising outside of the home (70.4%) and discomfort wearing a face mask while exercising (58%). Perceived COVID-19 impact on PA was significantly associated with education, household dependents, and gender (p's < 0.05). More women, parents, and college graduates reported that the COVID-19 pandemic made PA more difficult. Overall, there were no significant associations between PA, SCT constructs, or perceived COVID-19 impact on PA scores at 3 months. While the pandemic made PA difficult for many participants, these barriers were not associated with leisure-time PA levels or related theoretical mechanisms of action, which bodes well for the success of our ongoing intervention efforts and the resiliency of these communities.

Cost effectiveness of a technology-enhanced physical activity intervention for Latinas

Latinas report low levels of physical activity (PA) and disproportionate risk of lifestyle-related diseases. Enhancements to evidence-based PA interventions may increase efficacy; however, uptake of interventions will likely depend on costs. To describe costs and examine the cost-effectiveness of two interventions for helping Latinas reach national aerobic PA guidelines. Adult Latinas (N = 199) were randomly assigned to an Original theory-based mail-delivered intervention or an Enhanced version with texting and additional calls and materials. Meeting PA guidelines was measured by the 7-Day PA Recall interview at baseline, 6 and 12 months. Intervention costs were estimated from a payer perspective. Incremental cost-effectiveness ratios (ICERs) were calculated as the additional cost per participant meeting guidelines in the Enhanced versus Original intervention. At baseline, no participants met guidelines. After 6 months, 57% and 44% in the Enhanced and Original arms met guidelines, respectively; at 12 months, rates fell to 46% and 36%. Cost per person of the Enhanced and Original interventions were $184 and $173 at 6 months, respectively, and $234 and $203 at 12 months. The primary additional expense in the Enhanced arm was staff time. ICERs were $87 per additional person meeting guidelines at 6 months (per sensitivity analysis, $26 if delivered by volunteers and $114 by medical assistants), and $317 at 12 months (sensitivity analysis: $57 and $434). Incremental costs per person meeting guidelines in the Enhanced arm were modest and could be warranted given the potential health benefits of meeting PA guidelines.

A multiple technology-based physical activity intervention for Latina adolescents in the USA: randomized controlled trial study protocol for Chicas Fuertes

Background

Latina adolescents in the USA report some of the lowest rates of physical activity of any demographic subgroup; this is paralleled by a markedly higher lifetime risk of obesity, type 2 diabetes, and other conditions related to inactivity. Despite this, to date, no fully powered clinical trials have tested physical activity interventions specifically for this population. High use of mobile technologies (including text messages, smartphone apps, and social media) suggests this could be an appropriate intervention channel, while also having potential for broad reach. This paper describes the protocol for Chicas Fuertes, a fully powered randomized trial of a mobile technology-based physical activity intervention for Latina adolescents.

Methods

We plan to recruit 200 Latina teens (age 13–18) in San Diego, CA, currently engaging in ≤ 150 min/week of moderate-to-vigorous physical activity (MVPA) to be assigned 1:1 to the intervention or control groups. Those randomly assigned to the intervention group receive a one-on-one goal setting session followed by 6 months of mobile technology-based intervention, including a personalized website, Fitbit activity tracker and app, individually tailored text messages based on Fitbit data, and daily intervention content on Instagram. Those randomized to the control group receive only a Fitbit activity tracker. The main outcome is change in weekly minutes of MVPA from baseline to 6 months, measured both objectively (ActiGraph accelerometers and Fitbit Inspire HR) and subjectively (7-Day Physical Activity Recall Interview). Additional outcomes are maintenance of activity change at 12 months and changes in psychosocial constructs, including social support and self-efficacy, engagement with mobile technology channels, and costs of intervention delivery. We are also examining the potential mediators and moderators of the intervention. The efficacy of the intervention is analyzed using a mixed effects regression model, adjusting for any potential confounders not balanced by randomization. All analyses of accelerometer measured MVPA are also adjusted for wear time.

Discussion

The Chicas Fuertes trial uses widely available mobile technologies to target critical health behavior, physical activity, in Latina teens, a population with a high lifetime risk of lifestyle-related diseases. The results will speak to the efficacy and acceptability of the intervention, which has the potential for broad dissemination.

Trial registration

ClinicalTrials.govNCT04190225. Registered on November 20, 2019

Physical activity outcomes from a randomized trial of a theory- and technology-enhanced intervention for Latinas: the Seamos Activas II study

Latina women report disproportionately high and increasing prevalence of chronic health conditions (obesity, diabetes) related to low physical activity levels. Efforts to date at addressing high rates of physical inactivity in this at-risk population have shown modest success. The original Seamos Saludables (sample size N = 266) was a culturally and linguistically adapted, print-based physical activity intervention that showed significant increases in moderate to vigorous physical activity (MVPA) from baseline to 6 months. However, only 11% of intervention participants reached the national PA guidelines of ≥ 150 min/week of aerobic MVPA. The current study tests the original Seamos Saludables intervention (Original Intervention) against an enhanced iteration Seamos Activas II (Enhanced Intervention). Study aims and intervention refinements focus on increasing the percentage of Latinas meeting national aerobic PA guidelines. For the current study (Seamos Activas II), a randomized controlled trial with (N = 199 participants) of two PA interventions (original intervention, N = 102; vs. enhanced intervention, N = 97) was conducted. Intervention refinements involved further targeting key constructs of the Social Cognitive Theory and incorporating text-message-based strategies for self-monitoring, in response to participant feedback for greater interactivity and accountability. PA assessments were conducted at baseline and 6 months. The sample was predominantly Mexican American (89%) with average age of 43.8 years (SD = 10.11) and mean BMI at baseline was 30.6 (SD = 7.56). There were significant within group increases in MVPA from baseline to 6 months (p < .05) in both Original and Enhanced Intervention arms. However, quantile regression models did not indicate significant differences in 6-month outcomes between conditions controlling for baseline, p = 0.73. There were significant differences between conditions with respect to meeting national guidelines for aerobic MVPA at 6 months, with 57% of Enhanced Intervention participants meeting guidelines compared to 44% of Original Intervention participants, OR = 1.66, 95% CI: 1.09 -2.89. Models suggest trends favoring the enhanced condition for improvements in biomarkers over 6 months. Findings indicate that the intervention enhancements likely helped more Latinas achieve nationally recommended, health enhancing PA levels than the original intervention and showed promise for improving physiological response to exercise.Trial Registration ClinicalTrials.Gov; NCT02630953. Registered 14 December 2015. https://clinicaltrials.gov/ct2/show/NCT02630953 .

Design and Rationale for the Deep South Interactive Voice Response System-Supported Active Lifestyle Study: Protocol for a Randomized Controlled Trial

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.

Systematic review of the methods used in economic evaluations of targeted physical activity and sedentary behaviour interventions

The burden of noncommunicable diseases (NCD) on health systems worldwide is substantial. Physical inactivity and sedentary behaviour are major risk factors for NCD. Previous attempts to understand the value for money of preventative interventions targeting physically inactive individuals have proved to be challenging due to key methodological challenges associated with the conduct of economic evaluations in public health. A systematic review was carried out across six databases (Medline, SPORTSDiscus, EconLit, PsychINFO, NHS EED, HTA) along with supplementary searches. The review examines how economic evaluations published between 2009-March 2017 have addressed methodological challenges with the aim of bringing to light examples of good practice for future studies. Fifteen economic evaluations from four high-income countries were retrieved; there is a dearth of studies targeting sedentary behaviour as an independent risk factor from physical activity. Comparability of studies from the healthcare and societal perspectives were limited due to analysts' choice in cost categories, valuation technique and time horizon differing substantially. The scarcity of and inconsistencies across economic evaluations for these two behaviours have exposed a mismatch between calls for more preventative action to tackle NCD and the lack of information available on how resources may be optimally allocated in practice. Consequently, this paper offers a table of recommendations on how future studies can be improved.

Using Behavioral Analytics to Increase Exercise: A Randomized N-of-1 Study

INTRODUCTION

This intervention study used mobile technologies to investigate whether those randomized to receive a personalized "activity fingerprint" (i.e., a one-time tailored message about personal predictors of exercise developed from 6 months of observational data) increased their physical activity levels relative to those not receiving the fingerprint.

STUDY DESIGN

A 12-month randomized intervention study.

SETTING/PARTICIPANTS

From 2014 to 2015, 79 intermittent exercisers had their daily physical activity assessed by accelerometry (Fitbit Flex) and daily stress experience, a potential predictor of exercise behavior, was assessed by smartphone.

INTERVENTION

Data collected during the first 6 months of observation were used to develop a person-specific "activity fingerprint" (i.e., N-of-1) that was subsequently sent via email on a single occasion to randomized participants.

MAIN OUTCOME MEASURES

Pre-post changes in the percentage of days exercised were analyzed within and between control and intervention groups.

RESULTS

The control group significantly decreased their proportion of days exercised (10.5% decrease, p<0.0001) following randomization. By contrast, the intervention group showed a nonsignificant decrease in the proportion of days exercised (4.0% decrease, p=0.14). Relative to the decrease observed in the control group, receipt of the activity fingerprint significantly increased the likelihood of exercising in the intervention group (6.5%, p=0.04).

CONCLUSIONS

This N-of-1 intervention study demonstrates that a one-time brief message conveying personalized exercise predictors had a beneficial effect on exercise behavior among urban adults.

A Web-Based Physical Activity Intervention for Spanish-Speaking Latinas: A Costs and Cost-Effectiveness Analysis

Background

Latinas report particularly low levels of physical activity and suffer from greater rates of lifestyle-related conditions such as obesity and diabetes. Interventions are needed that can increase physical activity in this growing population in a large-scale, cost-effective manner. Web-based interventions may have potential given the increase in Internet use among Latinas and the scalability of Web-based programs.

Objective

To examine the costs and cost-effectiveness of a Web-based, Spanish-language physical activity intervention for Latinas compared to a wellness contact control.

Methods

Healthy adult Latina women (N=205) were recruited from the community and randomly assigned to receive a Spanish-language, Web-based, individually tailored physical activity intervention (intervention group) or were given access to a website with content on wellness topics other than physical activity (control group). Physical activity was measured using the 7-Day Physical Activity Recall interview and ActiGraph accelerometers at baseline, 6 months (ie, postintervention), and 12 months (ie, maintenance phase). Costs were estimated from a payer perspective and included all features necessary to implement the intervention in a community setting, including staff time (ie, wages, benefits, and overhead), materials, hardware, website hosting, and routine website maintenance.

Results

At 6 months, the costs of running the intervention and control groups were US $17 and US $8 per person per month, respectively. These costs fell to US $12 and US $6 per person per month at 12 months, respectively. Linear interpolation showed that intervention participants increased their physical activity by 1362 total minutes at 6 months (523 minutes by accelerometer) compared to 715 minutes for control participants (186 minutes by accelerometer). At 6 months, each minute increase in physical activity for the intervention group cost US $0.08 (US $0.20 by accelerometer) compared to US $0.07 for control participants (US $0.26 by accelerometer). Incremental cost-per-minute increases associated with the intervention were US $0.08 at 6 months and US $0.04 at 12 months (US $0.16 and US $0.08 by accelerometer, respectively). Sensitivity analyses showed variations in staffing costs or intervention effectiveness yielded only modest changes in incremental costs.

Conclusions

While the Web-based physical activity intervention was more expensive than the wellness control, both were quite low cost compared to face-to-face or mail-delivered interventions. Cost-effectiveness ranged markedly based on physical activity measure and was similar between the two conditions. Overall, the Web-based intervention was effective and low cost, suggesting a promising channel for increasing physical activity on a large scale in this at-risk population.

ClinicalTrial

Clinicaltrials.gov NCT01834287; https://clinicaltrials.gov/ct2/show/NCT01834287 (Archived by WebCite at http://www.webcitation.org/6nyjX9Jrh)

IJBNPA in 2016: Strategy for advancing the science of behavior change in nutrition and physical activity, and associated editorial priorities

The goal of the International Journal of Behavioral Nutrition and Physical Activity (IJBNPA) is to be the leading diet and physical activity journal. To achieve this aim we embrace and publish a number of different research designs from small, but in depth, qualitative studies to large scale cohort studies. IJBNPA prioritises research based on randomised controlled trials (RCTs), systematic reviews (with or without meta-analyses, as appropriate), and well conducted observational studies that expand knowledge and understanding of the area. IJBNPA will also consider and publish other study designs that are of sufficient quality such as strong or ground-breaking methodological papers, rigorous qualitative studies, debate papers and commentaries. However, due to the demands on the journal, we publish pilot studies only in exceptional circumstances and we do not publish protocol papers or letters to the editors. The goal of this editorial is to highlight to our readers and authors the process by which we identify which papers to review and publish along with our editorial priorities.