Exercise as it relates to Disease/Physical activity intervention for people living with HIV and AIDS of low socioeconomic status

This is a review on the research article titled: ‘Development of a context-sensitive physical activity intervention for persons living with HIV and AIDS of low socioeconomic status using the behaviour change wheel’ BMC Public Health. 2019, Article number: 774.

Background to research
People living with HIV and AIDS (PLWHA) have been prescribed and recommended physical activity (PA) in order to cope and improve overall quality of life. This context sensitive PA intervention was developed for people living with HIV and AIDS of low socioeconomic status. The overall aim was to enhance PA within this population along with a secondary aim of behavioural theories being used to further increase PA.

Research
Designing a context-sensitive PA intervention was done by using other studies that were performed in order to assist in creating and developing the interventions.

The studies used: 1.	A systematic review for information of creation of PA interventions for people of low income. Previous successful behavioural change techniques (BCT) and theoretical frameworks were used to increase PA to control chronic disease. Results:
 * The most commonly used BCTs were ‘plan social support/social change, provide feedback on performance and goal setting.

2.	A cross sectional study with participants of low socioeconomic status (SES) who were positive in HIV. In order to determine PA levels, 978 subjects were used to find out their; body mass index (BMI), body weight, gender, height, waist-to-hip ratio, educational attainment, employment status and CD4+ cell count. Results:
 * Gender, employment status and educational attainment showed the biggest results in predicting PA. The greatest impact on PA was gender (PA in women was lower than men).

3.	A cross sectional study based on PA domains and PA intensity with 978 HIV positive participants of low SES. A secondary aim is to determine whether there is a correlation between employment status and level of education with predicting PA levels of PLWHA of low SES. Results:
 * PA mostly in a work environment, then transport related PA, and leisure related PA. Working environment PA was most common and therefore unemployment resulted in lower levels of PA.

4.	A concurrent mixed method study. 21 HIV positive females of low SES were tested using the exercise benefits/barriers scale (EBBS) Two group discussions about PA were also used to seek results in the participants thoughts about PA. Results include- Low/limited levels of PA were due to HIV symptoms including medications, lack of motivation, lack of knowledge on PA, aging, economic status, time and home environment.

Methods of Study
The design and characterisations of interventions play a significant role in results. Models and frameworks are important to use for this. This includes the Behaviour Change Wheel.

Behaviour Change Wheel (BCW) This study was based on the Behaviour Change Wheel (BCW) which is a method used to design behaviour change interventions. The wheel utilises the COM-B model (capability, opportunity, motivation and behaviour). (2)

As demonstrated in the image. it is divided into three sections. The sources of behaviour are the COM-B model of capability, opportunity, motivation and behaviour. The sources are required in order for behavioural change to not just occur, but also for the person to want them to occur. The intervention part of the wheel are nine interventions consisting of; restrictions, education, etc. The policy category of the wheel includes guidelines, environmental/social planning, communication/marketing, legislation, service provision, regulation and fiscal measures.

BCW Eight Steps 1.	Understanding the behavioural problem. 2.	Choosing a target behaviour; behaviours that need to change in order to solve the behavioural problems. 3.	Specify the target behaviour 4.	Identify what needs to change to achieve the desired behaviour; the COM-B model can be utilised in this step. 5.	Select intervention functions to achieve the desired behaviour; e.g. training and restrictions. 6.	Policy categories; select them based on APEASE criteria.

APEASE Criteria Descriptions
 * Affordability: Can patients afford the intervention when it is delivered at the level it is intended to be.
 * Practicability: Procedure can be delivered as designed targeted at the certain population (PLWHA of low SES).
 * Effectiveness: Effectiveness when the objectives of the intervention are met by the patients.
 * Acceptability: How acceptable the intervention is to stakeholders.
 * Safety/side effects: The level of unintentional and unexpected results and side effects coming from the intervention.
 * Equity: Is there a reduction in patient variability after as a cause of the intervention? How much?

7.	Identify behavioural change techniques (based on APEASE criteria). 8.	Identify mode of delivery (based on APEASE criteria).

Results
The results of the intervention were based on the eight steps of the BCW.

The first step was to define the problem in behavioural terms. Women had lower PA levels than men, which is why HIV positive women of low SES were the target population. Selecting the target behaviour phase showed that PLWHA enjoyed activities such as chair exercises, light logging, aerobics, etc. Specifying target behaviours included encouraging and improving health of all HIV/AIDS positive women with a low SES. Step four; (identifying what needs to change), demonstrated that physical capability, psychological capability, physical opportunity, social opportunity and more were aspects were in need of change.

Identifying interventions: APEASE was successful with the interventions chosen. Interventions such as incentivisation, training, modelling, enablement and education were selected. APEASE criteria did not approve of interventions such as persuasion, coercion and restrictions. As for identifying policy categories; based on the APEASE criteria, service provision was the only one policy to be used for the intervention. The rest did not meet the criteria.

Behaviour Change Techniques (BCT) selected:
 * Informing the patient on the effects on health
 * Honest feedback on patient behaviour
 * Review of goal results
 * Individual self-observations of outcomes/behaviour
 * Model of the behaviour
 * Direction on behaviour
 * Goal setting behaviour
 * Analysis of behavioural goals
 * Action planning

While the BCW clearly is a strong intervention design method, there are also some negatives. Some limitations of the BCW include; low effect rates of older patients as well as limited evidence of the effectiveness of the BCTs.

Conclusions
Physical activity has a big impact on the body and builds up resilience to fight against HIV/AIDS. PA and exercise in general will strengthen immunity, increase appetite, combat fatigue, etc. It is important as PLWHA have difficulties completing any type of PA. Interventions are the best way to get optimal results for overall health of PLWHA of low SES. The BCW is an innovative method to design interventions specific for all goals. Therefore, intervention methods aiming to cause higher PA levels (and also health levels) for this population using the wheel, would be a successful option.

Practical Advice
More specific client-based studies on a patient’s experience, process, methods and results. This would demonstrate clearer results on a personal level of how the BCW works for each individual (how it varies with people). This would also make it easier for readers to understand each step of the intervention design process as well as the results themselves. Further studies on intervention designs and studies are recommended and should be done extensively in order to compare studies. This will create more accurate and clearer results in future.

Further Readings/Sources

 * Behaviour Change Theory
 * An application of the COM‐B model and behaviour‐change wheel