Exercise as it relates to Disease/Mobile monitoring and feedback to stimulate physical activity in people with chronic disease

What is the background to this research?
Individuals who are sedentary put themselves in risk of acquiring cardiovascular disease such as: diabetes, obesity, some cancers and COPD. Currently the Australian physical activity guidelines recommend at least 150 minutes of moderate intensity exercise every week. Not only has physical activity been proven in multiple studies with examples being Paul D et al and Judith Garcia-Aymerich that having an active lifestyle prevents these cardiovascular diseases. But by carrying out an active lifestyle it will improve overall quality of life as well as the mental status of people in regards to health who currently live with chronic disease. A group of researchers from Maastricht University set out to establish if they could change the behavior of people living with chronic disease by a device worn at the hip to help encourage these participants to do physical activity.

Where is the research from?
The chosen article from JMIR Mhealth Uhealth was published online in 2013. The paper was published by a reputable peer reviewed publication which gives us the indication that it will likely be of good quality. The research was conducted at Maastricht University in the Netherlands as well as in the comfort of the participants own home by the following departments:

•	CAPHRI School for Public Health and Primary Care, Department of Health Services Research, Maastricht University, Maastricht, Netherlands

•	Research Centre Technology in Care, Zuyd University of Applied Sciences, Heerlen, Netherlands

•	CAPHRI School for Public Health and Primary Care, Department of General Practice, Maastricht University, Maastricht, Netherlands

What kind of research was this?
Participants were recruited by snowball sampling which is a non random sampling technique by accessing contacts in the national patient associations. Snowball sampling is where research participants recruit other people for a test/study which consists of two steps. First step involves identifying subjects in the specific population. Second step involves the selected people to recruit other people and those people then recruit others. The use of snowball sampling for this kind of research was good as it allows the discoveries of characteristics about the population that the researches weren't previously aware of. Even though these discoveries can be made using this method it is impossible to determine the sampling error of populations on the obtained sample.

What did the research involve?
This study focused on people who were diagnosed with COPD and type 2 diabetes aged between 40-70. This category represents a large proportion of people who currently have a chronic disease and could benefit from doing exercise. Participants in the study were treated in a primary care setting which allowed for qualitative data to be collected from the 15 patients, 16 care professionals and 7 experts. Three stages were set to make the prototype. Stage 1: researchers determined how the monitoring and feedback tool should be used in relation to the participants. Stage 2: was primarily about concept development which involved studying behavior change strategies as well as technologies that stimulate physical activity. Stage 2 was the main focus for the researches as this was where they were going to see if their aim was met (changing behavior to increase physical activity). Stage 3 included interviews with the participants with the purpose being identifying the pros and cons about the product. There were a number of limitations associated to this study with the main factors being contextual restraints such as budget and time of the nurse (which wasn’t available between the consultations). Another limitation was the depth of the technology isn’t quite there for example: the device is worn at the hip but wasn’t able register cycling as well as not being water proof so participants weren’t able to do swimming.

What were the basic results?
The main aim of this tool was to change the participants behavior through self moderating and goal setting which included personalized feedback based on how close the participant is to their goal. In order to do this the research team connected three different kinds of technology (accelerometer, app and an Internet application). By having different technologies available to them, participants could receive feedback in three loops: direct feedback though daily activity, periodic feedback by accessing their prior performances and lastly personal feedback given by the nurse. This provided the participant with a combination of behavior change techniques which included an increase in knowledge, awareness (due to self monitoring) and self efficacy. Throughout the duration of the study this aim was met and the participants did change their behavior towards exercise, given that this was the aim of the research team I think that this study was successful as already another version of the tool will be used in a randomised control trial meaning that the results so far are promising enough to go the length of another study.

What conclusions can we take from this research?
One thing that has become obvious when reading about similar studies using pedometers or accelerometers from Bravata DM et al, Lindberg R and Tudor-Locke C, Lutes L is that they're effective short term but we don’t know if they are still as effective over a long period. So it would be interesting if there was a study that followed participants for a long duration of time to see if their behavior would relapse to how it was before. If it didn't this prototype could be a great tool to not only combat cardiovascular disease and diabetes but for the general population changing their overall behavior towards physical activity.

Practical advice
This tool has the potential to create healthier lifestyles for people not only living with chronic disease but for the general population and promote change in how their behaviour and attitude towards physical activity. So long as improvements are made to the device such as being water poof, being able to wear anywhere for example like a watch making people incorporate it more if it provides multiple benefits and cost effective. Obviously if made accessible to the public a nurse won’t be able to make consultations with everyone so the device would need to incorporate an alternative to combat this which more study would need to be done to make sure people’s behaviour still changed. I think is participants should still seek consultations with a professional but not necessarily a nurse, as long as they had someone to talk about their personal results.

Here are some further readings which may interest the reader and provide information about prevention/ management strategies of chronic diseases.

Preventing chronic disease: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3992293/

Patients managing chronic disease: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1117581/