Comparison of Veteran experiences of low-cost, home-based diet and exercise interventions

Best Practices for Developing a Diabetes mHealth App

The widespread use of smartphones in the United States has led to a surge in mHealth apps designed to support people with various health issues. Yet the effectiveness and long-term impacts of these apps still need to be determined. This article presents a case study of the development of MyT1DHero, an mHealth app for people with type 1 diabetes, to identify best practices for app development. We propose four essential best practices based on the insights gained from this case study: incorporating theoretical frameworks, prioritizing user feedback, engaging key stakeholders, and establishing a robust data-collection foundation. These findings have practical implications for researchers and developers seeking to create effective mHealth interventions. Furthermore, we suggest future research directions to advance the development and implementation of innovative health technologies.

Impact of Military Affiliation on Exercise Perceptions Among Survivors of Sexual Violence

INTRODUCTION

Military service members disproportionately experience sexual violence (SV) and its related health concerns. Although recent work has shown physical activity to be an effective strategy for improving physical and mental health among trauma-exposed military populations, little of this work has focused specifically on military service members with a history of SV. To address these gaps in knowledge and practice, this study identified the most salient perceived benefits/barriers of exercise among men and women survivors of SV with military affiliations. Additionally, these analyses explore willingness to engage in exercise programs, and preferences for the structure/content of these programs, among men and women survivors of SV with military affiliations.

MATERIALS AND METHODS

An online, cross-sectional survey of women (n = 355) and men (n = 198) survivors of SV was completed using Amazon Mechanical Turk. Inclusion criteria were men and women, age between 18 and 65 years, self-reported history of SV, and located in the United States. Information on sociodemographics and post-traumatic stress disorder symptoms was collected alongside perceived barriers and benefits to exercise, willingness to engage in exercise programs, and preferences for the structure/content of these programs. Analyses were stratified by sex. Comparisons by history of military involvement (active duty military or veteran; no military involvement/civilian) were reported.

RESULTS

Both military-involved men (n = 68) and women (n = 139) were more likely to prefer at-home and online exercise options when compared to civilians (Ps < .05; Cramer's Vs 0.19-0.36). Additionally, both men and women with military involvement reported strongly favoring exercising with an instructor over no instructor and preferred that this instructor identifies with their same gender (Ps < .01; Cramer's Vs 0.28-0.36). Women with military involvement also preferred shorter program durations and exercising alone or in a group online or in person, whereas men with military involvement were open to longer program durations, when compared to their civilian counterparts (Ps < .05; Cramer's Vs 0.19-0.37). Women and men with military involvement were more likely than their civilian counterparts to perceive that exercise benefits their psychological outlook and social interactions. They were also more likely than civilians to indicate poor exercise environment, high time expenditure, and family discouragement as perceived barriers to exercise (Ps < .05; Cohen's ds 0.21-0.97). Military-involved women were also more likely than civilian women to endorse the perceived barrier of hard physical exercise (P < .05; Cohen's d = 0.25).

CONCLUSIONS

This study identified perceived benefits and barriers to exercise, along with willingness to engage in exercise programs, and exercise preferences among men and women survivors of SV with military involvement. Targeting these factors in intervention planning will be important for physical activity promotion and program engagement among veterans to reduce the disproportionate impact of SV and disease burden among U.S. service members and veterans.

Peer Support Activities for Veterans, Serving Members, and Their Families: Results of a Scoping Review

For many, including military veterans and their families, support between individuals with shared lived experiences, or peer support, has long been utilized as a way to support each other through many different challenges. Building on other reviews and guided by the seven domains of well-being in the Canadian veteran well-being framework, the objective of this paper is to describe and catalogue the nature of peer support activities and related outcomes in the veteran, serving member, and family member populations. A scoping review following the five stages outlined by Arksey and O'Malley was conducted; it was guided by the question: What is currently known about peer support activities for veterans, serving members, and their families that has been evaluated in the literature? In total, 101 publications from 6 different countries were included in this review and catalogued based on publication characteristics, participant information, peer support activity information, and peer information. Peer support activities have the potential to positively influence the well-being of veterans, serving members, and their families on a holistic level across multiple domains. This scoping review highlights the existing gaps in the literature and provides an important foundation for future research on peer support for these populations, specifically in the Canadian context.

Home-based exercise for adults with overweight or obesity: A rapid review

The COVID-19 pandemic has impacted the ability of people globally to consistently engage in their typical physical activity and exercise behaviour, contributing to the rising number of people living with overweight and obesity. The imposed government lockdowns and quarantine periods saw an increase in social media influencers delivering their own home-based exercise programmes, but these are unlikely to be an evidence-based, efficacious, long-term solution to tackle sedentary behaviour and increase physical activity. This rapid review aims to conceptualise home-based exercise and physical activity programmes, by extracting relevant programme characteristics regarding the availability of evidence and effectiveness of home-based exercise programmes. Fifteen studies met the inclusion criteria, of which there were varied reports of significant positive effects of the exercise programme on weight management and related outcomes. The two most common measures were Body Mass Index and body mass, as of which almost all reported a trend of post intervention reduction. Some programmes reported qualitative data, identifying barriers to physical activity and preferred programme components, highlighting a need to consider factors outside of physiological measures. The findings provide guidance and direction for the development of future home-based physical activity and exercise programmes for adults living with overweight and obesity.

Effect of Adding Telephone-Based Brief Coaching to an mHealth App (Stay Strong) for Promoting Physical Activity Among Veterans: Randomized Controlled Trial

Background

Though maintaining physical conditioning and a healthy weight are requirements of active military duty, many US veterans lose conditioning and rapidly gain weight after discharge from active duty service. Mobile health (mHealth) interventions using wearable devices are appealing to users and can be effective especially with personalized coaching support. We developed Stay Strong, a mobile app tailored to US veterans, to promote physical activity using a wrist-worn physical activity tracker, a Bluetooth-enabled scale, and an app-based dashboard. We tested whether adding personalized coaching components (Stay Strong+Coaching) would improve physical activity compared to Stay Strong alone.

Objective

The goal of this study is to compare 12-month outcomes from Stay Strong alone versus Stay Strong+Coaching.

Methods

Participants (n=357) were recruited from a national random sample of US veterans of recent wars and randomly assigned to the Stay Strong app alone (n=179) or Stay Strong+Coaching (n=178); both programs lasted 12 months. Personalized coaching components for Stay Strong+Coaching comprised of automated in-app motivational messages (3 per week), telephone-based human health coaching (up to 3 calls), and personalized weekly goal setting. All aspects of the enrollment process and program delivery were accomplished virtually for both groups, except for the telephone-based coaching. The primary outcome was change in physical activity at 12 months postbaseline, measured by average weekly Active Minutes, captured by the Fitbit Charge 2 device. Secondary outcomes included changes in step counts, weight, and patient activation.

Results

The average age of participants was 39.8 (SD 8.7) years, and 25.2% (90/357) were female. Active Minutes decreased from baseline to 12 months for both groups (P<.001) with no between-group differences at 6 months (P=.82) or 12 months (P=.98). However, at 12 months, many participants in both groups did not record Active Minutes, leading to missing data in 67.0% (120/179) for Stay Strong and 61.8% (110/178) for Stay Strong+Coaching. Average baseline weight for participants in Stay Strong and Stay Strong+Coaching was 214 lbs and 198 lbs, respectively, with no difference at baseline (P=.54) or at 6 months (P=.28) or 12 months (P=.18) postbaseline based on administrative weights, which had lower rates of missing data. Changes in the number of steps recorded and patient activation also did not differ by arm.

Conclusions

Adding personalized health coaching comprised of in-app automated messages, up to 3 coaching calls, plus automated weekly personalized goals, did not improve levels of physical activity compared to using a smartphone app alone. Physical activity in both groups decreased over time. Sustaining long-term adherence and engagement in this mHealth intervention proved difficult; approximately two-thirds of the trial’s 357 participants failed to sync their Fitbit device at 12 months and, thus, were lost to follow-up.

Trial Registration

ClinicalTrials.gov NCT02360293; https://clinicaltrials.gov/ct2/show/NCT02360293

International Registered Report Identifier (IRRID)

RR2-10.2196/12526

Antidepressant Effect of the VA Weight Management Program (MOVE) Among Veterans With Severe Obesity

INTRODUCTION

Obesity is prevalent among users of Veteran's Health Administration services, where it is comorbid with depression, post-traumatic stress disorder, type 2 diabetes, cardiovascular disease, colon, and breast cancer. Among obese subjects, severe obesity represents a subpopulation with the highest risk of depression. We investigate the antidepressant effect of a local VA weight management program (Managing Overweight Veterans Everywhere - MOVE) among depressed veterans with severe obesity.

MATERIAL AND METHODS

In a 10-week prospective pilot study, 14 clinically depressed veterans with severe obesity were recruited from: (1) the 2-week residential based intense MOVE program (IMP) (N = 7) and (2) the 10-week educational module of self-management MOVE program (SMP) (N = 7). Subjects had a Beck Depression Inventory, 2nd edition (BDI-II) score > 12 and BMI > 40 or BMI > 35 with associated to comorbid conditions. Concurrent treatment for depression such as medications or psychotherapy was excluded. The primary efficacy endpoint was the change in BDI-II score form baseline to week 10. Analysis consisted of linear mixed model with baseline BDI-II score as a covariate, and level of MOVE intervention (IMP vs. SMP), time, and time by treatment interaction as fixed effects, and random patient effect. Pearson's correlation examined the relationships between clinical and demographic variables and change in severity of depression by BDI-II scores. Secondary outcomes include weight loss and energy expenditure.

RESULTS

The sample was composed by 14 subjects (IMP = 7; SMP = 7) mostly unemployed (N = 9), married (N = 10), mid-aged (mean = 58.2, SD = 8.4), Caucasian (N = 13), male (N = 12), with recurrent depression (N = 11), and a mean overall duration of current depressive episode of 13.5 months (SD = 10.2). Out of 14 participants; seven had a family history of mood disorder, two had previous psychiatric hospitalization, three had a previous suicidal attempt, and eight had a history of substance use disorder. There was a significant decrease in severity of depression among all 14 (F3,36.77 = 5.28; P < 0.01); antidepressant effect favored the IMP compared to SMP at day 12 (F1,15.10 = 9.37, P = 0.01) and week 6 (F2,27.34 = 4.26, P = 0.03), but effect fell short of significance at week 10. The change in severity of depression measured by BDI-II score significantly correlated with total weight loss (r = -0.60; P = 0.04) and daily energy expenditure at 12 days (r = -0.67; P = 0.01), week 6 (r = -0.59; P = 0.03), and week 10 (r = -0.71; P = 0.01).

CONCLUSIONS

Depressed veterans with severe obesity improved their depressive symptoms by participating in the MOVE program. Veterans in the IMP had greater but short-term antidepressant effect as compared to educational intervention for obesity. Future studies with larger sample size may elucidate the underlying mechanisms of weight reduction to improve depression and, more importantly, sustain response among veterans with severe obesity.

Adapting the "Resist Diabetes" Resistance Training Intervention for Veterans

PURPOSE

The Resist Diabetes trial demonstrated that twice-per-week resistance training reduced prediabetes prevalence and improved strength among older adults with prediabetes. Our objective was to determine initial perceptions of patients and care providers in a Veterans Affairs Medical Center (VAMC) regarding Resist Diabetes (RD), and ultimately, inform adaptations to improve uptake of RD in the Veterans Health Administration.

METHODS

A mixed-methods approach was utilized. Care providers (n=20) and veterans with prediabetes (n=12) were recruited to gauge perceptions of the RD program and identify barriers and facilitators to the program referral process and program implementation. Care provider perceptions of the acceptability, appropriateness and feasibility were determined using a validated survey. Open-ended questionnaires and interview guides, based upon the Consolidated Framework for Implementation Research, were utilized to determine major and minor themes within the provider and veteran responses. To identify the dissemination potential of RD, the availability of onsite fitness facilities at VAMC facilities nationally (n=159) was assessed.

RESULTS

Providers rated (scaled 1-5; 1=completely disagree, 5=completely agree) the RD program as appealing (4.8+/-0.1), appropriate (4.8+/-0.0), and feasible (4.6+/-0.2). Providers reported that prediabetes/diabetes is a significant problem in the VAMC, and that different prevention programs will appeal to different types of VAMC patients. Patients (n=12; 58% female; aged 65+/-10yrs; BMI 34+/-6 kg/m²; HbA1c 5.7+/-1.8%) expressed interest in an exercise-focused diabetes prevention program and defined key barriers: travel, transportation, and time constraints. Among the responding national VAMC sites, 85% (97/114) reported having an onsite fitness facility.

CONCLUSION

Salem VAMC care providers and veteran patients demonstrated positive perceptions of the Resist Diabetes program. Program adaptations are needed to address barriers to patient participation including travel, transportation and time constraints.

Understanding the Effect of Adding Automated and Human Coaching to a Mobile Health Physical Activity App for Afghanistan and Iraq Veterans: Protocol for a Randomized Controlled Trial of the Stay Strong Intervention

Background

Although maintaining a healthy weight and physical conditioning are requirements of active military duty, many US veterans rapidly gain weight and lose conditioning when they separate from active-duty service. Mobile health (mHealth) interventions that incorporate wearables for activity monitoring have become common, but it is unclear how to optimize engagement over time. Personalized health coaching, either through tailored automated messaging or by individual health coaches, has the potential to increase the efficacy of mHealth programs. In an attempt to preserve conditioning and ward off weight gain, we developed Stay Strong, a mobile app that is tailored to veterans of recent conflicts and tracks physical activity monitored by Fitbit Charge 2 devices and weight measured on a Bluetooth-enabled scale.

Objective

The goal of this study is to determine the effect of activity monitoring plus health coaching compared with activity monitoring alone.

Methods

In this randomized controlled trial, with Stay Strong, a mobile app designed specifically for veterans, we plan to enroll 350 veterans to engage in an mHealth lifestyle intervention that combines the use of a wearable physical activity tracker and a Bluetooth-enabled weight scale. The Stay Strong app displays physical activity and weight data trends over time. Enrolled participants are randomized to receive the Stay Strong app (active comparator arm) or Stay Strong + Coaching, an enhanced version of the program that adds coaching features (automated tailored messaging with weekly physical activity goals and up to 3 telephone calls with a health coach—intervention arm) for 1 year. Our primary outcome is change in physical activity at 12 months, with weight, pain, patient activation, and depression serving as secondary outcome measures. All processes related to recruitment, eligibility screening, informed consent, Health Insurance Portability and Accountability Act authorization, baseline assessment, randomization, the bulk of intervention delivery, and outcome assessment will be accomplished via the internet or smartphone app.

Results

The study recruitment began in September 2017, and data collection is expected to conclude in 2019. A total of 465 participants consented to participate and 357 (357/465, 77%) provided baseline levels of physical activity and were randomized to 1 of the 2 interventions.

Conclusions

This novel randomized controlled trial will provide much-needed findings about whether the addition of telephone-based human coaching and other automated supportive-coaching features will improve physical activity compared with using a smartphone app linked to a wearable device alone.

Trial Registration

ClinicalTrials.gov NCT02360293; https://clinicaltrials.gov/ct2/show/NCT02360293 (Archived by WebCite at http://www.webcitation.org/75KQeIFwh)

International Registered Report Identifier (IRRID)

DERR1-10.2196/12526

Health Care Provider Perceptions of Consumer-Grade Devices and Apps for Tracking Health: A Pilot Study

Background

The use of Web- or mobile phone–based apps for tracking health indicators has increased greatly. However, provider perceptions of consumer-grade devices have not been widely explored.

Objective

The purpose of this study was to determine primary care physicians’ and advanced practice registered nurses’ perceptions of consumer-grade sensor devices and Web- or mobile phone–based apps that allow patients to track physical activity, diet, and sleep.

Methods

We conducted a cross-sectional mailed survey with a random sample of 300 primary care physicians and 300 advanced practice registered nurses from Michigan, USA. Providers’ use and recommendation of these types of technologies, and their perceptions of the benefits of and barriers to patients’ use of the technologies for physical activity, diet, and sleep tracking were key outcomes assessed.

Results

Most of the respondents (189/562, 33.6% response rate) were advanced practice registered nurses (107/189, 56.6%). Almost half of the sample (93/189, 49.2%) owned or used behavioral tracking technologies. Providers found these technologies to be helpful in clinical encounters, trusted the data, perceived their patients to be interested in them, and did not have concerns over the privacy of the data. However, the providers did perceive patient barriers to using these technologies. Additionally, those who owned or used these technologies were up to 6.5 times more likely to recommend them to their patients.

Conclusions

Our study demonstrated that many providers perceived benefits for their patients to use these technologies, including improved communication. Providers’ concerns included their patients’ access and the usability of these technologies. Providers who encountered data from these technologies during patient visits generally perceive this to be helpful. We additionally discuss the barriers perceived by the providers and offer suggestions and future research to realize the potential benefits to using these data in clinical encounters.

Peer-Based Social Media Features in Behavior Change Interventions: Systematic Review

Background

Incorporating social media features into digital behavior change interventions (DBCIs) has the potential to contribute positively to their success. However, the lack of clear design principles to describe and guide the use of these features in behavioral interventions limits cross-study comparisons of their uses and effects.

Objective

The aim of this study was to provide a systematic review of DBCIs targeting modifiable behavioral risk factors that have included social media features as part of their intervention infrastructure. A taxonomy of social media features is presented to inform the development, description, and evaluation of behavioral interventions.

Methods

Search terms were used in 8 databases to identify DBCIs that incorporated social media features and targeted tobacco smoking, diet and nutrition, physical activities, or alcohol consumption. The screening and review process was performed by 2 independent researchers.

Results

A total of 5264 articles were screened, and 143 articles describing a total of 134 studies were retained for full review. The majority of studies (70%) reported positive outcomes, followed by 28% finding no effects with regard to their respective objectives and hypothesis, and 2% of the studies found that their interventions had negative outcomes. Few studies reported on the association between the inclusion of social media features and intervention effect. A taxonomy of social media features used in behavioral interventions has been presented with 36 social media features organized under 7 high-level categories. The taxonomy has been used to guide the analysis of this review.

Conclusions

Although social media features are commonly included in DBCIs, there is an acute lack of information with respect to their effect on outcomes and a lack of clear guidance to inform the selection process based on the features’ suitability for the different behaviors. The proposed taxonomy along with the set of recommendations included in this review will support future research aimed at isolating and reporting the effects of social media features on DBCIs, cross-study comparisons, and evaluations.

Iraq and Afghanistan veterans with PTSD participate less in VA's weight loss program than those without PTSD

BACKGROUND

Three-quarters of Iraq and Afghanistan veterans enrolled in Veterans Health Administration (VHA) care are overweight or obese. The VHA MOVE!® weight management program can mitigate the risks of obesity-related morbidity. However, many Iraq and Afghanistan veterans experience barriers to VHA services, which may affect participation, especially among those with posttraumatic stress disorder (PTSD) and/or depression. Little is known about MOVE! engagement among recent veterans. We describe a retrospective evaluation of MOVE! participation among Iraq and Afghanistan veterans with and without mental health problems.

METHODS

As part of a national VHA mental health evaluation study, we accessed VHA patient care databases to identify Iraq and Afghanistan veterans receiving care from 2008-2013 who had ≥1 MOVE! visit(s) and ≥1 weight measurements (N=24,899). We used logistic regression to determine whether mental health conditions were associated with having 12 visits/year (desirable dose of care), adjusting for demographic, health, and utilization factors.

RESULTS

Among Iraq and Afghanistan veterans enrolled in MOVE!, 4% had a desirable dose of participation. In adjusted models, desirable MOVE! participation was more likely among those without PTSD; those who were older, female, and unmarried; and those who had higher baseline weight, more medical comorbidities, no pain, psychotropic medication use, higher disability ratings, and more mental health visits.

LIMITATIONS

We used administrative ICD-9 codes. Sample only included veterans in VHA care.

CONCLUSIONS

Iraq and Afghanistan veterans, particularly those with PTSD, had low participation in VHA weight management programming. Correlates of MOVE! participation were identified, highlighting opportunities to tailor MOVE! to improve participation for these veterans.

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

Background

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

Objective

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

Methods

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

Results

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

Conclusions

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