Using a behavior change toolkit in pediatric physical therapy to support physical activity: A feasibility study.

INTRODUCTION: Physical activity levels of children with disabilities are low, as these children and their parents face a wide variety of both personal and environmental barriers. Behavior change techniques support pediatric physical therapists to address these barriers together with parents and children. We developed the What Moves You?! intervention Toolkit (WMY Toolkit) filled with behavioral change tools for use in pediatric physical therapy practice. OBJECTIVE: To evaluate the feasibility of using the WMY Toolkit in daily pediatric physical therapy practice. METHODS: We conducted a feasibility study with a qualitative approach using semi-structured interviews with pediatric physical therapists (n = 11). After one day of training, the pediatric physical therapists used the WMY Toolkit for a period of 9 weeks, when facilitating physical activity in children with disabilities. We analyzed the transcripts using an inductive thematic analysis followed by a deductive analysis using a feasibility framework. RESULTS: For acceptability, pediatric physical therapists found that the toolkit facilitated conversation about physical activity in a creative and playful manner. The working mechanisms identified were in line with the intended working mechanisms during development of the WMY Toolkit, such as focusing on problem solving, self-efficacy and independence. For demand, the pediatric physical therapists mentioned that they were able to use the WMY Toolkit in children with and without disabilities with a broad range of physical activity goals. For implementation, education is important as pediatric physical therapists expressed the need to have sufficient knowledge and to feel confident using the toolkit. For practicality, pediatric physical therapists were positive about the ease of which tools could be adapted for individual children. Some of the design and materials of the toolkit needed attention due to fragility and hygiene. CONCLUSION: The WMY Toolkit is a promising and innovative way to integrate behavior change techniques into pediatric physical therapy practice.

The Effect of Social Networks on Active Living in Adolescents: Qualitative Focus Group Study.

BACKGROUND: Participation in organized sports and other forms of active living have important health benefits in adolescence and adulthood. Unfortunately, the transition to secondary school has been shown to be a barrier to participation. Social networks can play important roles in activating adolescents, and information and communication technology (ICT) interventions can augment this role. To date, there are few insights into what adolescents themselves think and feel about barriers to and motivators for active living, the role of their social networks in active living, and the potential of ICT for physical activity (PA). OBJECTIVE: This study aimed to gather insights into the perspectives of adolescents aged 12 to 14 years on active living and sports participation, motivators and demotivators for active living, and the potential roles of their social network and of ICT. METHODS: A total of 26 adolescents aged 12 to 14 years from different levels of Dutch secondary schools participated in 1 of 5 semistructured focus group interviews, in which they talked about sports and PA, their social networks, their ICT use, and the role of social networks and ICT in PA. All interviews were transcribed and analyzed using a thematic qualitative approach. RESULTS: The study showed that all participants were physically active, although the transition to secondary school made this difficult, mostly because of time constraints. Participants saw positive physical and mental health effects as important benefits of active living. They regarded social benefits as strong motivators for active living: being together, making friends, and having fun together. However, the social network could also demotivate through negative peer judgment and negative feedback. Participants were willing to share their own positive experiences and hear about those from close peers and friends but would not share their own (and were not interested in others') negative experiences or personal information. Participants were mainly interested in descriptive norms set by others and obtained inspiration from others for PA. With respect to using ICT for active living, participants stated a preference for social challenges among friends, personalized feedback, goals, activities, and rewards. Competition was seen as less important or even unattractive. If mentioned, participants felt that this should be with friends, or peers of a similar level, with fun being more important than the competition itself. CONCLUSIONS: This study shows that adolescents feel that their social network is and can be a strong driver of active living. They are willing to use ICT-based solutions that make use of social networks for PA as long as these solutions involve their current (close) network and use an approach based on being together and having fun together.

Perceived Use Cases, Barriers, and Requirements for a Smart Health-Tracking Toilet Seat: Qualitative Focus Group Study.

BACKGROUND: Smart bathroom technology offers unrivaled opportunities for the automated measurement of a range of biomarkers and other data. Unfortunately, efforts in this area are mostly driven by a technology push rather than market pull approach, which decreases the chances of successful adoption. As yet, little is known about the use cases, barriers, and desires that potential users of smart bathrooms perceive. OBJECTIVE: This study aimed to investigate how participants from the general population experience using a smart sensor-equipped toilet seat installed in their home. The study contributes to answering the following questions: What use cases do citizens see for this innovation? and What are the limitations and barriers to its everyday use that they see, including concerns regarding privacy, the lack of fit with everyday practices, and unmet expectations for user experience? METHODS: Overall, 31 participants from 30 households participated in a study consisting of 3 (partially overlapping) stages: sensitizing, in which participants filled out questionnaires to trigger their thoughts about smart bathroom use and personal health; provotyping, in which participants received a gentle provocation in the form of a smart toilet seat, which they used for 2 weeks; and discussion, in which participants took part in a web-based focus group session to discuss their experiences. RESULTS: Participants mostly found the everyday use of the toilet, including installation and dismantling when necessary, to be relatively easy and free of complications. Where complications occurred, participants mentioned issues related to the design of the prototype, technology, or mismatches with normal practices in using toilets and hygiene. A broad range of use cases were mentioned, ranging from signaling potentially detrimental health conditions or exacerbations of existing conditions to documenting physical data to measuring biomarkers to inform a diagnosis and behavioral change. Participants differed greatly in whether they let others use, or even know about, the seat. Ownership and control over their own data were essential for most participants. CONCLUSIONS: This study showed that participants felt that a smart toilet seat could be acceptable and effective, as long as it fits everyday practices concerning toilet use and hygiene. The range of potential uses for a smart toilet seat is broad, as long as privacy and control over disclosure and data are warranted.

Low- and Medium-Socioeconomic-Status Group Members' Perceived Challenges and Solutions for Healthy Nutrition: Qualitative Focus Group Study.

BACKGROUND: Although digital tools for healthy nutrition have shown great potential, their actual impact remains variable as digital solutions often do not fit users' needs and barriers. This is especially poignant for priority communities in society. Involving these groups in citizen science may have great benefits even beyond the increase in knowledge of the lives and experiences of these groups. However, this requires specialized skills. Participants from priority groups could benefit from an approach that offers sensitization and discussion to help them voice their needs regarding healthy nutrition and technology to support healthy eating. OBJECTIVE: This study aimed to gather insights into people's thoughts on everyday eating practices, self-regulation in healthy eating, and skill acquisition and on applying technological innovations to these domains. METHODS: Participants answered 3 daily questionnaires to garner their current practices regarding habits, self-regulation, skills, and technology use surrounding healthy eating and make it easier for them to collect their thoughts and experiences (sensitization). Within a week of filling out the 3 questionnaires, participants took part in a web-based focus group discussion session. All sessions were transcribed and analyzed using a thematic qualitative approach. RESULTS: A total of 42 people took part in 7 focus group interviews of 6 people each. The analysis showed that participants would like to receive support from technology for a broad range of aspects of nutrition, such as measuring the effect their personal nutrition has on their individual health, providing them with reliable product information, giving them practical guidance for healthy eating and snacking, and reducing the burden of registering food intake. Technology should be easy to use, reduce burdens, and be tailored to personal situations. Privacy and cost were major concerns for the participants. CONCLUSIONS: This study shows that people from low- and medium-socioeconomic-status groups have a need for specific support in tailoring their knowledge of healthy nutrition to their own situation and see technology as a means to achieve this.

Stressors and Destressors in Working From Home Based on Context and Physiology From Self-Reports and Smartwatch Measurements: International Observational Study Trial.

BACKGROUND: The COVID-19 pandemic has greatly boosted working from home as a way of working, which is likely to continue for most companies in the future, either in fully remote or in hybrid form. To manage stress levels in employees working from home, insights into the stressors and destressors in a home office first need to be studied. OBJECTIVE: We present an international remote study with employees working from home by making use of state-of-the-art technology (ie, smartwatches and questionnaires through smartphones) first to determine stressors and destressors in people working from home and second to identify smartwatch measurements that could represent these stressors and destressors. METHODS: Employees working from home from 3 regions of the world (the United States, the United Kingdom, and Hong Kong) were asked to wear a smartwatch continuously for 7 days and fill in 5 questionnaires each day and 2 additional questionnaires before and after the measurement week. The entire study was conducted remotely. Univariate statistical analyses comparing variable distributions between low and high stress levels were followed by multivariate analysis using logistic regression, considering multicollinearity by using variance inflation factor (VIF) filtering. RESULTS: A total of 202 people participated, with 198 (98%) participants finishing the experiment. Stressors found were other people and daily life getting in the way of work (P=.05), job intensity (P=.01), a history of burnout (P=.03), anxiety toward the pandemic (P=.04), and environmental noise (P=.01). Destressors found were access to sunlight (P=.02) and fresh air (P<.001) during the workday and going outdoors (P<.001), taking breaks (P<.001), exercising (P<.001), and having social interactions (P<.001). The smartwatch measurements positively related to stress were the number of active intensity periods (P<.001), the number of highly active intensity periods (P=.04), steps (P<.001), and the SD in the heart rate (HR; P<.001). In a multivariate setting, only a history of burnout (P<.001) and family and daily life getting in the way of work (P<.001) were positively associated with stress, while self-reports of social activities (P<.001) and going outdoors (P=.03) were negatively associated with stress. Stress prediction models based on questionnaire data had a similar performance (F1=0.51) compared to models based on automatic measurable data alone (F1=0.47). CONCLUSIONS: The results show that there are stressors and destressors when working from home that should be considered when managing stress in employees. Some of these stressors and destressors are (in)directly measurable with unobtrusive sensors, and prediction models based on these data show promising results for the future of automatic stress detection and management. TRIAL REGISTRATION: Netherlands Trial Register NL9378; https://trialsearch.who.int/Trial2.aspx?TrialID=NL9378.

"At least someone thinks I'm doing well": a real-world evaluation of the quit-smoking app StopCoach for lower socio-economic status smokers.

BACKGROUND: Smoking is more prevalent and persistent among lower socio-economic status (SES) compared with higher-SES groups, and contributes greatly to SES-based health inequities. Few interventions exist that effectively help lower-SES smokers quit. This study evaluated "De StopCoach", a mobile phone delivered eHealth intervention targeted at lower-SES smokers based on the evidence-based StopAdvisor, in a real-world setting (five municipalities) in The Netherlands in 2019-2020. METHOD: We conducted individual semi-structured interviews with project leaders, healthcare professionals, and participating smokers (N = 22), and examined log data from the app (N = 235). For practical reasons, SES of app users was not measured. Qualitative data were analysed using the Framework Approach, with the Consolidated Framework for Implementation Research (CFIR) and Unified Theory of Acceptance and Use of Technology (UTAUT) as theoretical models. RESULTS: Qualitative data showed that factors from the Intervention and Setting domains were most important for the implementation. StopCoach seemed suitable for lower-SES smokers in terms of performance and effort expectancy, especially when integrated with regular smoking cessation counseling (SCC). Key barriers to implementation of the app were limited integration of the app in SCC programs in practice, difficulty experienced by project leaders and healthcare professionals to engage the local community, and barriers to SCC more generally (e.g., perceived resistance to quitting in patients) that prevented healthcare professionals from offering the app to smokers. Quantitative data showed that 48% of app users continued using the app after the preparation phase and pre-quit day, and that 33% of app users had attempted to quit. Both app adherence and quit attempts were more likely if smokers also received SCC from a professional coach. Posthoc analyses suggest that adherence is related to higher likelihood of a quit attempt among participants with and without a professional coach. CONCLUSIONS: Smokers, healthcare professionals and project leaders indicated in the interviews that the StopCoach app would work best when combined with SCC. It also appears from app log that app adherence and quit attempts by app users can be facilitated by combining the app with face-to-face SCC. As such, blended care appears promising for helping individual smokers quit, as it combines the best of regular SCC and eHealth. Further research on blended care for lower-SES smokers is needed.

Innovation in Pain Rehabilitation Using Co-Design Methods During the Development of a Relapse Prevention Intervention: Case Study.

BACKGROUND: Many intervention development projects fail to bridge the gap from basic research to clinical practice. Instead of theory-based approaches to intervention development, co-design prioritizes the end users' perspective as well as continuous collaboration between stakeholders, designers, and researchers throughout the project. This alternative approach to the development of interventions is expected to promote the adaptation to existing treatment activities and to be responsive to the requirements of end users. OBJECTIVE: The first objective was to provide an overview of all activities that were employed during the course of a research project to develop a relapse prevention intervention for interdisciplinary pain treatment programs. The second objective was to examine how co-design may contribute to stakeholder involvement, generation of relevant insights and ideas, and incorporation of stakeholder input into the intervention design. METHODS: We performed an embedded single case study and used the double diamond model to describe the process of intervention development. Using all available data sources, we also performed deductive content analysis to reflect on this process. RESULTS: By critically reviewing the value and function of a co-design project with respect to idea generation, stakeholder involvement, and incorporation of stakeholder input into the intervention design, we demonstrated how co-design shaped the transition from ideas, via concepts, to a prototype for a relapse prevention intervention. CONCLUSIONS: Structural use of co-design throughout the project resulted in many different participating stakeholders and stimulating design activities. As a consequence, the majority of the components of the final prototype can be traced back to the information that stakeholders provided during the project. Although this illustrates how co-design facilitates the integration of contextual information into the intervention design, further experimental testing is required to evaluate to what extent this approach ultimately leads to improved usability as well as patient outcomes in the context of clinical practice.

Using a Co-design Approach to Create Tools to Facilitate Physical Activity in Children With Physical Disabilities.

Introduction: There is a lack of effective interventions available for Pediatric Physical Therapists (PPTs) to promote a physically active lifestyle in children with physical disabilities. Participatory design methods (co-design) may be helpful in generating insights and developing intervention prototypes for facilitating a physically active lifestyle in children with physical disabilities (6-12 years). Materials and methods: A multidisciplinary development team of designers, developers, and researchers engaged in a co-design process-together with parents, PPTs, and other relevant stakeholders (such as the Dutch Association of PPTs and care sports connectors). In this design process, the team developed prototypes for interventions during three co-creation sessions, four one-week design sprint, living-lab testing and two triangulation sessions. All available co-design data was structured and analyzed by three researchers independently resulting in themes for facilitating physical activity. Results: The data rendered two specific outcomes, (1) knowledge cards containing the insights collected during the co-design process, and (2) eleven intervention prototypes. Based on the generated insights, the following factors seem important when facilitating a physically active lifestyle: a) stimulating self-efficacy; b) stimulating autonomy; c) focusing on possibilities; d) focusing on the needs of the individual child; e) collaborating with stakeholders; f) connecting with a child's environment; and g) meaningful goal setting. Conclusion: This study shows how a co-design process can be successfully applied to generate insights and develop interventions in pediatric rehabilitation. The designed prototypes facilitate the incorporation of behavioral change techniques into pediatric rehabilitation and offer new opportunities to facilitate a physically active lifestyle in children with physical disabilities by PPTs. While promising, further studies should examine the feasibility and effectivity of these prototypes.

User-Centered Design of a Mobile Health Intervention to Enhance Exacerbation-Related Self-Management in Patients With Chronic Obstructive Pulmonary Disease (Copilot): Mixed Methods Study.

BACKGROUND: Adequate self-management skills are of great importance for patients with chronic obstructive pulmonary disease (COPD) to reduce the impact of COPD exacerbations. Using mobile health (mHealth) to support exacerbation-related self-management could be promising in engaging patients in their own health and changing health behaviors. However, there is limited knowledge on how to design mHealth interventions that are effective, meet the needs of end users, and are perceived as useful. By following an iterative user-centered design (UCD) process, an evidence-driven and usable mHealth intervention was developed to enhance exacerbation-related self-management in patients with COPD. OBJECTIVE: This study aimed to describe in detail the full UCD and development process of an evidence-driven and usable mHealth intervention to enhance exacerbation-related self-management in patients with COPD. METHODS: The UCD process consisted of four iterative phases: (1) background analysis and design conceptualization, (2) alpha usability testing, (3) iterative software development, and (4) field usability testing. Patients with COPD, health care providers, COPD experts, designers, software developers, and a behavioral scientist were involved throughout the design and development process. The intervention was developed using the behavior change wheel (BCW), a theoretically based approach for designing behavior change interventions, and logic modeling was used to map out the potential working mechanism of the intervention. Furthermore, the principles of design thinking were used for the creative design of the intervention. Qualitative and quantitative research methods were used throughout the design and development process. RESULTS: The background analysis and design conceptualization phase resulted in final guiding principles for the intervention, a logic model to underpin the working mechanism of the intervention, and design requirements. Usability requirements were obtained from the usability testing phases. The iterative software development resulted in an evidence-driven and usable mHealth intervention-Copilot, a mobile app consisting of a symptom-monitoring module, and a personalized COPD action plan. CONCLUSIONS: By following a UCD process, an mHealth intervention was developed that meets the needs and preferences of patients with COPD, is likely to be used by patients with COPD, and has a high potential to be effective in reducing exacerbation impact. This extensive report of the intervention development process contributes to more transparency in the development of complex interventions in health care and can be used by researchers and designers as guidance for the development of future mHealth interventions.

Effects of eating with an augmented fork with vibrotactile feedback on eating rate and body weight: a randomized controlled trial.

BACKGROUND: Eating rate is a basic determinant of appetite regulation: people who eat more slowly feel sated earlier and eat less. A high eating rate contributes to overeating and potentially to weight gain. Previous studies showed that an augmented fork that delivers real-time feedback on eating rate is a potentially effective intervention to decrease eating rate in naturalistic settings. This study assessed the impact of using the augmented fork during a 15-week period on eating rate and body weight. METHODS: In a parallel randomized controlled trial, 141 participants with overweight (age: 49.2 ± 12.3 y; BMI: 31.5 ± 4.48 kg/m2) were randomized to intervention groups (VFC, n = 51 or VFC+, n = 44) or control group (NFC, n = 46). First, we measured bite rate and success ratio on five consecutive days with the augmented fork without feedback (T1). The intervention groups (VFC, VFC+) then used the same fork, but now received vibrotactile feedback when they ate more than one bite per 10 s. Participants in VFC+ had additional access to a web portal with visual feedback. In the control group (NFC), participants ate with the fork without either feedback. The intervention period lasted four weeks, followed by a week of measurements only (T2) and another measurement week after eight weeks (T3). Body weight was assessed at T1, T2, and T3. RESULTS: Participants in VFC and VFC+ had a lower bite rate (p < .01) and higher success ratio (p < .0001) than those in NFC at T2. This effect persisted at T3. In both intervention groups participants lost more weight than those in the control group at T2 (p < .02), with no rebound at T3. CONCLUSIONS: The findings of this study indicate that an augmented fork with vibrotactile feedback is a viable tool to reduce eating rate in naturalistic settings. Further investigation may confirm that the augmented fork could support long-term weight loss strategies. TRIAL REGISTRATION: The research reported in this manuscript was registered on 4 November 2015 in the Netherlands Trial Register with number NL5432 ( https://www.trialregister.nl/trial/5432 ).

Determinants for Sustained Use of an Activity Tracker: Observational Study.

BACKGROUND: A lack of physical activity is considered to cause 6% of deaths globally. Feedback from wearables such as activity trackers has the potential to encourage daily physical activity. To date, little research is available on the natural development of adherence to activity trackers or on potential factors that predict which users manage to keep using their activity tracker during the first year (and thereby increasing the chance of healthy behavior change) and which users discontinue using their trackers after a short time. OBJECTIVE: The aim of this study was to identify the determinants for sustained use in the first year after purchase. Specifically, we look at the relative importance of demographic and socioeconomic, psychological, health-related, goal-related, technological, user experience-related, and social predictors of feedback device use. Furthermore, this study tests the effect of these predictors on physical activity. METHODS: A total of 711 participants from four urban areas in France received an activity tracker (Fitbit Zip) and gave permission to use their logged data. Participants filled out three Web-based questionnaires: at start, after 98 days, and after 232 days to measure the aforementioned determinants. Furthermore, for each participant, we collected activity data tracked by their Fitbit tracker for 320 days. We determined the relative importance of all included predictors by using Random Forest, a machine learning analysis technique. RESULTS: The data showed a slow exponential decay in Fitbit use, with 73.9% (526/711) of participants still tracking after 100 days and 16.0% (114/711) of participants tracking after 320 days. On average, participants used the tracker for 129 days. Most important reasons to quit tracking were technical issues such as empty batteries and broken trackers or lost trackers (21.5% of all Q3 respondents, 130/601). Random Forest analysis of predictors revealed that the most influential determinants were age, user experience-related factors, mobile phone type, household type, perceived effect of the Fitbit tracker, and goal-related factors. We explore the role of those predictors that show meaningful differences in the number of days the tracker was worn. CONCLUSIONS: This study offers an overview of the natural development of the use of an activity tracker, as well as the relative importance of a range of determinants from literature. Decay is exponential but slower than may be expected from existing literature. Many factors have a small contribution to sustained use. The most important determinants are technical condition, age, user experience, and goal-related factors. This finding suggests that activity tracking is potentially beneficial for a broad range of target groups, but more attention should be paid to technical and user experience-related aspects of activity trackers.

The effect of real-time vibrotactile feedback delivered through an augmented fork on eating rate, satiation, and food intake.

Eating rate is a basic determinant of appetite regulation, as people who eat more slowly feel sated earlier and eat less. Without assistance, eating rate is difficult to modify due to its automatic nature. In the current study, participants used an augmented fork that aimed to decelerate their rate of eating. A total of 114 participants were randomly assigned to the Feedback Condition (FC), in which they received vibrotactile feedback from their fork when eating too fast (i.e., taking more than one bite per 10 s), or a Non-Feedback Condition (NFC). Participants in the FC took fewer bites per minute than did those in the NFC. Participants in the FC also had a higher success ratio, indicating that they had significantly more bites outside the designated time interval of 10 s than did participants in the NFC. A slower eating rate, however, did not lead to a significant reduction in the amount of food consumed or level of satiation. These findings indicate that real-time vibrotactile feedback delivered through an augmented fork is capable of reducing eating rate, but there is no evidence from this study that this reduction in eating rate is translated into an increase in satiation or reduction in food consumption. Overall, this study shows that real-time vibrotactile feedback may be a viable tool in interventions that aim to reduce eating rate. The long-term effectiveness of this form of feedback on satiation and food consumption, however, awaits further investigation.