A qualitative evaluation of a physician-delivered pedometer-based step count prescription strategy with insight from participants and treating physicians

Physical activity among pregnant inpatients and outpatients and associations with anxiety

OBJECTIVE

Physical activity is linked to lower anxiety, but little is known about the association during pregnancy. This is especially important for antepartum inpatients, who are known to have increased anxiety yet may not be able to achieve target levels of physical activity during hospitalization. We compared physical activity metrics between pregnant inpatients and outpatients and explored correlations with anxiety.

MATERIALS AND METHODS

This was a prospective cohort between 2021 and 2022 of pregnant people aged 18-55 years carrying singleton gestations ≥ 16 weeks. Three exposure groups were matched for gestational age: 1) outpatients from general obstetric clinics; 2) outpatients from high-risk Maternal-Fetal Medicine obstetric clinics; and 3) antepartum inpatients. Participants wore Actigraph GT9X Link accelerometer watches for up to 7 days to measure physical activity. The primary outcome was mean daily step count. Secondary outcomes were metabolic equivalent tasks (METs), hourly kilocalories (kcals), moderate to vigorous physical activity (MVPA) bursts, and anxiety (State-Trait Anxiety Inventory [STAI]). Step counts were compared using multivariable generalized estimating equations adjusting for maternal age, body-mass index, and insurance type as a socioeconomic construct, accounting for within-group clustering by gestational age. Spearman correlations were used to correlate anxiety scores with step counts.

RESULTS

58 participants were analyzed. Compared to outpatients, inpatients had significantly lower mean daily steps (primary outcome, adjusted beta -2185, 95 % confidence interval [CI] -3146, -1224, p < 0.01), METs (adjusted beta -0.18, 95 % CI -0.23, -0.13, p < 0.01), MVPAs (adjusted beta -38.2, 95 % CI -52.3, -24.1, p < 0.01), and kcals (adjusted beta -222.9, 95 % CI -438.0, -7.8, p = 0.04). Over the course of the week, steps progressively decreased for inpatients (p-interaction 0.01) but not for either of the outpatient groups. Among the entire cohort, lower step counts correlated with higher anxiety scores (r = 0.30, p = 0.02).

CONCLUSION

We present antenatal population norms and variance for step counts, metabolic equivalent tasks, moderate to vigorous physical activity bursts, and kcals, as well as correlations with anxiety. Antepartum inpatients had significantly lower physical activity than outpatients, and lower step counts correlated with higher anxiety levels. These results highlight the need for physical activity interventions, particularly for hospitalized pregnant people.

Implementing an Activity Tracker to Increase Motivation for Physical Activity in Patients With Diabetes in Primary Care: Strengths, Weaknesses, Opportunities and Threats (SWOT) Analysis

BACKGROUND

Many projects related to technology implementation in the context of chronic diseases have been developed over the years to better manage lifestyle medicine interventions and improve patient care. However, technology implementation in primary care settings remains challenging.

OBJECTIVE

The aim is to carry out a strengths, weaknesses, opportunities, and threats (SWOT) analysis (1) to assess satisfaction among patients with type 2 diabetes using an activity tracker to increase motivation for physical activity (PA) and (2) to explore the research and health care team's perceptions of this technology's implementation in a primary care setting.

METHODS

A 3-month hybrid type 1 study, which included 2 stages, was conducted in an academic primary health center in Quebec City, Quebec, Canada. In stage 1, a total of 30 patients with type 2 diabetes were randomized to the intervention (activity tracker) group or the control group. In stage 2, a SWOT analysis was performed on both patients and health care professionals to determine the components of successful technology implementation. Two questionnaires were used to gather feedback: a satisfaction and acceptability questionnaire concerning an activity tracker (15 patients in the intervention group) and a questionnaire based on the SWOT elements (15 patients in the intervention group and 7 health care professionals). Both questionnaires contained quantitative and qualitative questions. Qualitative variables from open questions were synthesized in a matrix and ranked according to apparition frequency and global importance. A thematic analysis was performed by the first author and validated by 2 coauthors separately. The information gathered was triangulated to propose recommendations that were then approved by the team. Both quantitative (randomized controlled trial participants) and qualitative (randomized controlled trial participants and team) results were combined for recommendations.

RESULTS

In total, 86% (12/14) of the participants were satisfied with their activity tracker use and 75% (9/12) felt that it incited them to stick to their PA program. The main strengths of the team members' perspectives were the project initiation and involvement of a patient partner, the study design, the team, and the device. The weaknesses were the budgetary constraints, the turnover, and the technical issues. The opportunities were the primary care setting, the loan of equipment, and common technology. The threats were recruitment issues, administrative challenges, technological difficulties, and a single research site.

CONCLUSIONS

Patients with type 2 diabetes were satisfied with their activity tracker used to improve motivation for PA. Health care team members agreed that implementation can be done in primary care, but some challenges remain in using this technological tool in clinical practice regularly.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03709966; https://clinicaltrials.gov/ct2/show/NCT03709966.

Barriers and facilitators to diet, physical activity and lifestyle behavior intervention adherence: a qualitative systematic review of the literature

BACKGROUND

Consuming a balanced diet and regular activity have health benefits. However, many adults have a difficult time adhering to diet and activity recommendations, especially in lifestyle interventions. Adherence to recommendations could be improved if common facilitators and barriers are accounted for in intervention design. The aim of this systematic review was to understand perceived barriers and facilitators to lifestyle (diet and/or activity) intervention guidelines.

METHODS

This review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Studies included relied on qualitative methods to explore the barriers and facilitators healthy adults ([Formula: see text] 18 years) experienced in lifestyle interventions. Google Scholar, Cochrane Reviews, Medline, PubMed, and Web of Science were searched from January 2005 to October 2021. Main themes from each paper were thematically analyzed and reported as a barrier or facilitator to adherence at the individual, environment or intervention level using inductively derived themes. Study quality was assessed using the Critical Appraisal Skills Programme.

RESULTS

Thirty-five papers were included. Of these, 46% were conducted in North America and the majority had more female participants (86% in mixed-sex studies, 26% females only). Similar themes emerged across all three levels as facilitators and barriers. At the individual level, attitudes, concern for health and physical changes. At the environmental level, social support, social accountability, changeable and unchangeable aspects of the community. Finally, delivery and design and content at the intervention level. An additional facilitator at the intervention level included fostering self-regulation through Behavior Change Taxonomies (BCT).

CONCLUSIONS

Lifestyle interventions that foster self-regulatory skills, opportunities for social engagement and personalization of goals may improve behaviour adherence. This can be achieved through inclusion of BCT, tapering off of intervention supports, identification of meaningful goals and anticipated barriers with participants.

Cost-Comparison Analysis of a Physician-Delivered Step-Count Prescription Strategy

Background

Increments of 1000 steps/d predict cardiovascular disease (CVD) event reductions. In adults with type 2 diabetes and/or hypertension, our Step Monitoring to Improve Arterial Health (SMARTER) trial demonstrated a physician-delivered step-count prescription strategy to increase steps by more than this amount over 1 year, compared to usual care. In the present analysis, we aimed to determine the costs of the intervention compared to usual care, incorporating 1-year intervention costs and projected savings from lower CVD hospitalizations over the subsequent 5 years.

Methods

We considered Canadians aged 55 to 74 years with type 2 diabetes and/or hypertension. Using time estimates from our trial, we computed nursing costs corresponding to patient support time over 1 year, and pedometer costs for an anticipated 50% of patients without a smartphone. We estimated the number of CVD hospitalizations, the reduction expected with a mean 1000 steps/d increase, and the associated savings. We calculated the net cost (savings), the proportion of patients with their own device required for cost neutrality, and costs (savings) if all patients needed to be provided with a device.

Results

At an average intervention cost of $51.28/patient, the total cost would be $168 million. With an estimated 8875 CVD events prevented, $208 million would be saved. This savings would result in ~$40 million in net savings with 50% device ownership, cost neutrality with 25% device ownership, and ~$42 million in net costs if all patients required the healthcare system to provide a device.

Conclusions

At current levels of smartphone ownership, adoption of the SMARTER strategy is cost-saving to cost-neutral from the healthcare system perspective.

Prescription of Physical Activity by General Practitioners in Type 2 Diabetes: Practice and Barriers in French Guiana

BACKGROUND

General practitioners (GPs) are the major primary healthcare players in the management of type 2 diabetes. In addition to a well-balanced diet, physical activity (PA) appears as a necessary non-medicinal therapy in the management of diabetic patients. However, GPs emphasize several obstacles to its prescription. The aim of this study is to evaluate the practices, barriers, and factors favoring the prescription of PA in type 2 diabetic patients by GPs in French Guiana.

METHOD

We conducted a cross-sectional descriptive study using a questionnaire, designed to interview 152 French Guiana GPs and describe their practice in prescribing PA in type 2 diabetic patients.

RESULTS

Our results revealed that the prescription of PA as a non-medicinal therapeutic choice in the management of type 2 diabetes was practiced by 74% of the French Guiana GPs. However, only 37% of GPs responded that they implemented the recommendations; indeed, only one-third knew about them. The majority of GPs were interested in PA training, but only 11% were actually trained in this practice. The lack of structure adapted to the practice of PA and the lack of awareness of the benefits of PA in metabolic pathology appeared as the main obstacles to PA prescription.

CONCLUSION

This study highlights the importance of improving the training of GPs in the prescription of PA, the development of adapted PA structures, and collaboration between the different actors within the framework of the sport-health system in type 2 diabetes in French Guiana.

REGO-ACT: assessment of physical activity during treatment with regorafenib for metastatic colorectal cancer

BACKGROUND

A frequent side effect of the multikinase inhibitor regorafenib is fatigue. Physical activity has shown potential in reducing cancer-related fatigue.

METHODS

This non-interventional pilot study assessed physical activity levels of metastatic colorectal cancer (mCRC) patients treated with regorafenib based on median daily step counts measured at 1‑week intervals using a pedometer. The study further evaluated relations between physical activity levels and fatigue, quality of life (QoL) and progression-free survival.

RESULTS

Pedometer data were available for 22 out of 25 enrolled patients. The numbers of days with available pedometer data ranged from 6 to 100 days. The overall median daily step count was 2357 (range 10-14,931), with substantial interindividual and intraindividual variations. Interindividual median weekly step counts were in the range of 5000-7000 in some, 2000-3000 in others, and several hundreds or less in a few patients. Intraindividual daily step counts also varied by several thousands of steps. Step counts in weeks in which patients reported fatigue were well within the range of or even higher than step counts in adjacent weeks, indicating a lack of correlation. The risk of disease progression was also independent of median weekly step counts; however, significant correlations were seen between QoL and step counts.

CONCLUSION

Despite the severity of their disease patients showed remarkable levels of walking activity. In view of the highly individual activity levels, exercise prescriptions for seriously ill patient populations should be personalized to the specific needs and preferences of each individual patient.

A trajectory analysis of daily step counts during a physician-delivered intervention

OBJECTIVES

Higher steps are associated with lower mortality and cardiovascular event rates. We previously demonstrated that tailored physician-delivered step count prescriptions successfully increased steps/day in adults with type 2 diabetes mellitus (T2DM) and/or hypertension. In the present analysis, we examined patterns of step count change and the factors that influence different responses.

DESIGN

Longitudinal observational study METHODS: Active arm participants (n=118) recorded steps/day. They received a step count prescription from their physician every 3-4 months. We computed mean steps/day and changes from baseline for sequential 30-day periods. Group-based trajectory modeling was applied.

RESULTS

Four distinct trajectories of mean steps/day emerged, distinguishable by differences in baseline steps/day: sedentary (19%), low active (40%), somewhat active (30%) and active (11%). All four demonstrated similar upward slopes. Three patterns emerged for the change in steps from baseline: gradual decrease (30%), gradual increase with late decline (56%), and rapid increase with midpoint decline (14%); thus 70% had an increase from baseline. T2DM (odd ratios [OR]: 3.7, 95% CI 1.7, 7.7) and age (OR per 10-year increment: 2, 95% CI 1.3, 2.8) were both associated with starting at a lower baseline but participants from these groups were no less likely than others to increase steps/day.

CONCLUSIONS

T2DM and older age were associated with lower baseline values but were not indicators of likelihood of step count increases. A physician-delivered step count prescription and monitoring strategy has strong potential to be effective in increasing steps irrespective of baseline counts and other clinical and demographic characteristics.