Monica Casey

Effectiveness of a smartphone application to promote physical activity in primary care: the SMART MOVE randomised controlled trial

BACKGROUND Physical inactivity is a major, potentially modifiable, risk factor for cardiovascular disease, cancer, and other chronic diseases. Effective, simple, and generalisable interventions that will increase physical activity in populations are needed. AIM To evaluate the effectiveness of a smartphone application (app) to increase physical activity in primary care. DESIGN AND SETTING An 8-week, open-label, randomised controlled trial in rural, primary care in the west of Ireland. METHOD Android smartphone users >16 years of age were recruited. All participants were provided with similar physical activity goals and information on the benefits of exercise. The intervention group was provided with a smartphone app and detailed instructions on how to use it to achieve these goals. The primary outcome was change in physical activity, as measured by a daily step count between baseline and follow-up. RESULTS A total of 139 patients were referred by their primary care health professional or self-referred. In total, 37 (27%) were screened out and 12 (9%) declined to participate, leaving 90 (65%) patients who were randomised. Of these, 78 provided baseline data (intervention = 37; control = 41) and 77 provided outcome data (intervention = 37; control = 40). The mean daily step count at baseline for intervention and control groups was 4365 and 5138 steps per day respectively. After adjusting, there was evidence of a significant treatment effect (P = 0.009); the difference in mean improvement in daily step count from week 1 to week 8 inclusive was 1029 (95% confidence interval 214 to 1843) steps per day, favouring the intervention. Improvements in physical activity in the intervention group were sustained until the end of the trial. CONCLUSION A simple smartphone app significantly increased physical activity over 8 weeks in a primary care population.

SMART MOVE - a smartphone-based intervention to promote physical activity in primary care: study protocol for a randomized controlled trial

BackgroundSedentary lifestyles are now becoming a major concern for governments of developed and developing countries with physical inactivity related to increased all-cause mortality, lower quality of life, and increased risk of obesity, diabetes, hypertension and many other chronic diseases. The powerful onboard computing capacity of smartphones, along with the unique relationship individuals have with their mobile phones, suggests that mobile devices have the potential to influence behavior. However, no previous trials have been conducted using smartphone technology to promote physical activity. This project has the potential to provide robust evidence in this area of innovation. The aim of this study is to evaluate the effectiveness of a smartphone application as an intervention to promote physical activity in primary care.Methods/designA two-group, parallel randomized controlled trial (RCT) with a main outcome measure of mean difference in daily step count between baseline and follow up over eight weeks. A minimum of 80 active android smartphone users over 16 years of age who are able to undertake moderate physical activity are randomly assigned to the intervention group (n = 40) or to a control group (n = 40) for an eight week period. After randomization, all participants will complete a baseline period of one week during which a baseline mean daily step count will be established. The intervention group will be instructed in the usability features of the smartphone application, will be encouraged to try to achieve 10,000 steps per day as an exercise goal and will be given an exercise promotion leaflet. The control group will be encouraged to try to walk an additional 30 minutes per day along with their normal activity (the equivalent of 10,000 steps) as an exercise goal and will be given an exercise promotion leaflet. The primary outcome is mean difference in daily step count between baseline and follow-up. Secondary outcomes are systolic and diastolic blood pressure, resting heart rate, mental health score using HADS and quality of life score using Euroqol. Randomization and allocation to the intervention and groups will be carried out by an independent researcher, ensuring the allocation sequence is concealed from the study researchers until the interventions are assigned. The primary analysis is based on mean daily step count, comparing the mean difference in daily step count between the baseline and the trial periods in the intervention and control groups at follow up.Trial registrationCurrent Controlled Trials ISRCTN99944116

Patients’ experiences of using a smartphone application to increase physical activity: the SMART MOVE qualitative study in primary care

Background Regular physical activity is known to help prevent and treat numerous non-communicable diseases. Smartphone applications (apps) have been shown to increase physical activity in primary care but little is known regarding the views of patients using such technology or how such technology may change behaviour. Aim To explore patients’ views and experiences of using smartphones to promote physical activity in primary care. Design and setting This qualitative study was embedded within the SMART MOVE randomised controlled trial, which used an app (Accupedo-Pro Pedometer) to promote physical activity in three primary care centres in the west of Ireland. Method Taped and transcribed semi-structured interviews with a purposeful sample of 12 participants formed the basis of the investigation. Framework analysis was used to analyse the data. Results Four themes emerged from the analysis: transforming relationships with exercise; persuasive technology tools; usability; and the cascade effect. The app appeared to facilitate a sequential and synergistic process of positive change, which occurred in the relationship between the participants and their exercise behaviour; the study has termed this the ‘Know-Check-Move’ effect. Usability challenges included increased battery consumption and adjusting to carrying the smartphone on their person. There was also evidence of a cascade effect involving the families and communities of participants. Conclusion Notwithstanding technological challenges, an app has the potential to positively transform, in a unique way, participants’ relationships with exercise. Such interventions can also have an associated cascade effect within their wider families and communities.

Implementing transnational telemedicine solutions: a connected health project in rural and remote areas of six Northern Periphery countries Series on European collaborative projects.

Abstract This is the first article in a Series on collaborative projects between European countries, relevant for general practice/family medicine and primary healthcare. Telemedicine, in particular the use of the Internet, videoconferencing and handheld devices such as smartphones, holds the potential for further strides in the application of technology for the delivery of healthcare, particularly to communities in rural and remote areas within and without the European Union where this study is taking place. The Northern Periphery Programme has funded the ‘Implementing Transnational Telemedicine Solutions’ (ITTS) project from September 2011 to December 2013, led by the Centre for Rural Health in Inverness, Scotland. Ten sustainable projects based on videoconsultation (speech therapy, renal services, emergency psychiatry, diabetes), mobile patient self-management (physical activity, diabetes, inflammatory bowel disease) and home-based health services (medical and social care emergencies, rehabilitation, multi-morbidity) are being implemented by the six partner countries: Scotland, Finland, Ireland, Northern Ireland, Norway and Sweden. In addition, an International Telemedicine Advisory Service, created for the project, provides business expertise and advice. Community panels contribute feedback on the design and implementation of services and ensure ‘user friendliness’. The project goals are to improve accessibility of healthcare in rural and remote communities, reducing unnecessary hospital visits and travel in a sustainable way. Opportunities will be provided for comparative research studies. This article provides an introduction to the ITTS project and how it aims to fulfil these needs. The ITTS team encourage all healthcare providers to at least explore possible technological solutions within their own context.

Medication adherence among patients with apparent treatment-resistant hypertension: systematic review and meta-analysis.

Objectives: Medication nonadherence is a known behavioural contributor to poor blood pressure (BP) control that puts patients with hypertension at elevated cardiovascular risk. Studies of medication adherence for apparent treatment-resistant hypertension (aTRH) vary significantly with respect to design, methods, and setting, and, as a result, have produced highly variable figures describing the prevalence of nonadherence. This review aimed to describe the prevalence and potential moderators of medication nonadherence estimates for aTRH. Methods: Systematic review and random effects meta-analysis. Results: From an initial discovery of 921 studies, we identified 24 studies that measured medication adherence for patients with uncontrolled BP despite being prescribed three or more antihypertensive medications of different classes. By using a random effects model, the pooled prevalence of nonadherence was 31.2% (95% confidence interval = 20.2–44.7, I2 = 99.50) with nonadherence rates ranging from 3.3 to 86.1%. The strongest contributor to variance in nonadherence rates was the method of adherence assessment used. Studies that relied on self-report measures of adherence and/or pharmacy data reported lower levels of nonadherence than studies using more objective methods, such as liquid chromatography–mass spectrometry in single time-point bioassays or directly observed therapy. Conclusion: Findings indicate that medication nonadherence is a significant problem among aTRH patients. Identifying the most accurate and clinically feasible adherence assessment methods is necessary to reduce BP and cardiovascular morbidity, facilitate early behavioural intervention, prevent unnecessary diagnostic testing, and limit sometimes unnecessary and expensive BP lowering procedures. Registration number: CRD42016028121.

Concurrent validation of an index to estimate fall risk in community dwelling seniors through a wireless sensor insole system: A pilot study

Falls are a major health problem for older adults with immediate effects, such as fractures and head injuries, and longer term effects including fear of falling, loss of independence, and disability. The goals of the WIISEL project were to develop an unobtrusive, self-learning and wearable system aimed at assessing gait impairments and fall risk of older adults in the home setting; assessing activity and mobility in daily living conditions; identifying decline in mobility performance and detecting falls in the home setting. The WIISEL system was based on a pair of electronic insoles, able to transfer data to a commercially available smartphone, which was used to wirelessly collect data in real time from the insoles and transfer it to a backend computer server via mobile internet connection and then onwards to a gait analysis tool. Risk of falls was calculated by the system using a novel Fall Risk Index (FRI) based on multiple gait parameters and gait pattern recognition. The system was tested by twenty-nine older users and data collected by the insoles were compared with standardized functional tests with a concurrent validity approach. The results showed that the FRI captures the risk of falls with accuracy that is similar to that of conventional performance-based tests of fall risk. These preliminary findings support the idea that theWIISEL system can be a useful research tool and may have clinical utility for long-term monitoring of fall risk at home and in the community setting.

Smartphone apps for improving medication adherence in hypertension: patients’ perspectives

Purpose Digital interventions, such as smartphone applications (apps), are becoming an increasingly common way to support medication adherence and self-management in chronic conditions. It is important to investigate how patients feel about and engage with these technologies. The aim of this study was to explore patients’ perspectives on smartphone apps to improve medication adherence in hypertension. Methods This was a qualitative study based in the West of Ireland. Twenty-four patients with hypertension were purposively sampled and engaged in focus groups. Thematic analysis on the data was carried out. Results Participants ranged in age from 50 to 83 years (M=65 years) with an equal split between men and women. Three major themes were identified in relation to patients’ perspectives on smartphone apps to improve medication adherence in hypertension: “development of digital competence,” “rules of engagement,” and “sustainability” of these technologies. Conclusion These data showed that patients can identify the benefits of a medication reminder and recognize that self-monitoring their blood pressure could be empowering in terms of their understanding of the condition and interactions with their general practitioners. However, the data also revealed that there are concerns about increasing health-related anxiety and doubts about the sustainability of this technology over time. This suggests that the current patient perspective of smartphone apps might be best characterized by “ambivalence.”

Does culture affect usability? A trans-European usability and user experience assessment of a falls-risk connected health system following a user-centred design methodology carried out in a single European country.

BACKGROUND User-centred design (UCD) is a process whereby the end-user is placed at the centre of the design process. The WIISEL (Wireless Insole for Independent and Safe Elderly Living) system is designed to monitor fall risk and to detect falls, and consists of a pair of instrumented insoles and a smartphone app. The system was designed using a three-phase UCD process carried out in Ireland, which incorporated the input of Irish end-users and multidisciplinary experts throughout. OBJECTIVE In this paper we report the results of a usability and user experience (UX) assessment of the WIISEL system in multiple countries and thus establish whether the UCD process carried out in Ireland produced positive usability and UX results outside of Ireland. METHODS 15 older adults across three centres (Ireland, Italy and Israel) were recruited for a three-day trial of the system in their home. Usability and UX data were captured using observations, interviews and usability questionnaires. RESULTS The system was satisfactory in terms of the usability and UX feedback from the participants in all three countries. There was no statistically significant difference in the usability scores for the three countries tested, with the exception of comfort. CONCLUSIONS A connected health system designed using a UCD process in a single country resulted in positive usability and UX for users in other European countries.

Implementation of the SMART MOVE intervention in primary care: a qualitative study using normalisation process theory

BackgroundProblematic translational gaps continue to exist between demonstrating the positive impact of healthcare interventions in research settings and their implementation into routine daily practice. The aim of this qualitative evaluation of the SMART MOVE trial was to conduct a theoretically informed analysis, using normalisation process theory, of the potential barriers and levers to the implementation of a mhealth intervention to promote physical activity in primary care.MethodsThe study took place in the West of Ireland with recruitment in the community from the Clare Primary Care Network. SMART MOVE trial participants and the staff from four primary care centres were invited to take part and all agreed to do so. A qualitative methodology with a combination of focus groups (general practitioners, practice nurses and non-clinical staff from four separate primary care centres, n = 14) and individual semi-structured interviews (intervention and control SMART MOVE trial participants, n = 4) with purposeful sampling utilising the principles of Framework Analysis was utilised. The Normalisation Process Theory was used to develop the topic guide for the interviews and also informed the data analysis process.ResultsFour themes emerged from the analysis: personal and professional exercise strategies; roles and responsibilities to support active engagement; utilisation challenges; and evaluation, adoption and adherence. It was evident that introducing a new healthcare intervention demands a comprehensive evaluation of the intervention itself and also the environment in which it is to operate. Despite certain obstacles, the opportunity exists for the successful implementation of a novel healthcare intervention that addresses a hitherto unresolved healthcare need, provided that the intervention has strong usability attributes for both disseminators and target users and coheres strongly with the core objectives and culture of the health care environment in which it is to operate.ConclusionWe carried out a theoretical analysis of stakeholder informed barriers and levers to the implementation of a novel exercise promotion tool in the Irish primary care setting. We believe that this process amplifies the implementation potential of such an intervention in primary care. The SMART MOVE trial is registered at Current Controlled Trials (ISRCTN99944116; Date of registration: 1st August 2012).

[LB.02.06] APPARENT AND TRUE TREATMENT RESISTANT HYPERTENSION IN GP: A CROSS SECTIONAL STUDY OF PREVALENCE WITH CONSIDERATION OF MORBIDITY, WHITE COAT HYPERTENSION, DOSING AND ADHERENCE

Objective: Treatment Resistant Hypertension (TRH) is defined as high blood pressure in patients taking three or more groups of anti-hypertensive medications (one must be a diuretic) or those taking four or more medications regardless of type and BP level. Target BP levels need to be adapted to specific morbidity (e.g. diabetes), ambulatory blood pressure measurement (ABPM) should be used to exclude white coat hypertension, doses should be the optimal tolerated, and both non-adherence and lifestyle should be examined. Most previous studies have not accounted for these considerations. We conducted a cross sectional study of the prevalence of apparent TRH in general practice, utilizing the appropriate definition, and then considered these issues. Design and method: Forty university-research affiliated practices were invited to participate. We ran a standard ATC drug search identifying patients on any possible hypertensive medications. Two researchers reviewed individual patients records. The World Health Organisation-Defined Daily Dosing guidelines determined adequate dosing. A measure of adherence was whether patients were printed greater than nine repeat prescriptions within the last year. Results: Sixteen practices participated (N = 50, 878). 2, 807 patients had been prescribed three or more medications previously and of these 646 were deemed to have aTRH. They were largely elderly, male and had co-morbidities (Diabetes 36.7% and Chronic Kidney Disease 40%). 19.0% had adequate medication dosing for each medication and 79.9% were deemed adherent by printed prescription record. Using a BP cut-off of 140/90 mm Hg, the prevalence of aTRH was 6.4% (95%CI 5.8–7.0),130/80 mm Hg for patients with diabetes or CKD, the prevalence was 10.0% (95%CI 9.3–10.8), reducing to 9.0% (95%CI 8.3–9.7) when a threshold BP of 150/80 mm Hg was applied for over eighties. Considering adequate dosing and adherence reduces prevalence rates even further. Conclusions: Reviewing individual patient records results in a lower estimate of the prevalence of aTRH than has been generally previously reported. Consideration for individual patients of criteria such as morbidity, dosing, white coat hypertension and adherence additionally lowers these estimates, and may be all that is required for the management of the vast majority of cases.