Disclosures:
Lewey reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.
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Postpartum women who participated in a text message intervention that included gamification walked an average of 647 more steps per day compared with similar women who received daily text message feedback without gamification, data show.
Jennifer Lewey
“Preeclampsia and other hypertensive disorders of pregnancy are important risk factors for developing chronic hypertension after delivery and heart disease later in life,” Jennifer Lewey, MD, MPH, assistant professor of medicine, co-director of the Pregnancy and Heart Disease Program and director of the Penn Women’s Cardiovascular Health Program at the Hospital of the University of Pennsylvania, told Healio. “The American Heart Association and American College of Obstetrics and Gynecology recommend these women receive counseling to adopt healthy lifestyle changes to improve their cardiovascular health; however, it is not clear how to counsel postpartum women to make these healthy changes, especially while they are taking care of a newborn. We found that a digital intervention using wearable activity trackers, gamification and social incentives helped to keep participants accountable to reaching their daily step goal. As a result, at the end of 12 weeks, women in the intervention walked more than women who just received the wearable activity trackers.”
Source: Adobe Stock
Step counting and motivation
For the STEP UP Mom study, Lewey and colleagues analyzed data from 127 postpartum women who delivered at the University of Pennsylvania and had a hypertensive disorder of pregnancy from October 2019 to June 2020 (mean, 7.9 weeks postpartum). The mean age of women was 32 years; 55.1{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} were Black and 41.9{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} had Medicaid insurance. Women received a wearable activity tracker, established a baseline step count and selected a step goal greater than baseline. Researchers then randomly assigned participants to virtual “teams” of three for 12 weeks, enrolled in a game with points and levels for daily step goal achievement or to a control arm in which women received daily feedback on goal attainment.
“Each team received 70 weekly points every Monday,” the researchers wrote. “Each day, one team member was selected at random. The team kept its points if the selected member achieved their step goal on the prior day and conversely lost 10 points if the member did not meet their step goal. In addition to loss aversion, each member is accountable to other team members to reach their daily step goal.”
The primary outcome was change in mean daily step count from baseline to 12 weeks; the secondary outcome was proportion of participant-days the step goal was achieved. The study was conducted using Way to Health, an online research platform at the University of Pennsylvania that synchronizes with remote monitoring devices and automates the delivery of behavioral interventions using text messaging and email.
The findings were published in JAMA Cardiology.
For the intervention and control arms, mean baseline step count was similar at 6,175 and 6,042 daily steps, respectively.
After adjustment for baseline steps and calendar month, the intervention arm had more of an increase in mean daily steps from baseline compared with the control arm (647 steps; 95{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} CI, 169-1,124; P = .009). Participants in the intervention arm achieved their steps goals on a greater proportion of participant-days than those in the control arm (0.47 vs. 0.38; adjusted difference, 0.11; 95{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} CI, 0.04-0.19; P = .003).
Need to increase engagement
“We know that physical activity is an important part of cardiovascular health,” Lewey told Healio. “If we can help participants stay more active over a longer period of time, this could help lead to reduction in blood pressure and, over the long term, lower risk for CVD. It is also important to note that all of these participants are moms with a new baby and, in many cases, other children at home. If we can get moms to be more active, this may have downstream benefits to other family members.”
By the end of follow-up, 37.5{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} of control participants and 31.7{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} of intervention participants stopped syncing step count data for more than 6 days. Participants in the control arm were more likely to stop syncing data earlier in the study compared with the intervention arm, according to the researchers.
Lewey said more research is needed to understand what behavioral strategies are needed to maintain engagement, especially as demands at home and at work change over the first postpartum year.
“We need to understand whether an increase in physical activity levels impact the risk for developing hypertension in the months to years after delivery,” Lewey told Healio. “Postpartum depression was common in our study, and we found that many participants requested more contact with others in the study. Finding ways to facilitate social support in the postpartum period has potential benefit for physical activity, but also mental health.”
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Professor in Used Wellbeing Psychology and Physical Exercise 
Contract sort: Permanent 
Hours: Whole time 
****** 
About ARU: 
ARU is a worldwide college transforming life via modern, inclusive and entrepreneurial training and analysis. We are rated in the world’s best 350 HEIs in the 2021 Moments Greater Education and learning Environment University Rankings and in the prime 10 mainstream universities in the place for the proportion of Uk undergraduates in work 15 months after graduating. We have campuses in Cambridge, Chelmsford, London and Peterborough with about 2,500 employees and 35,000 pupils from 185 international locations. We are committed to operating with other people by way of schooling, analysis and information exchange to increase the economic, cultural and social wellbeing of neighborhood, regional and global communities. ARU at this time holds an institutional Bronze Athena Swan award in recognition of its motivation to equality, range and inclusion, and resolve to generate a community where all people can prosper.
About the Faculty of Science and Engineering: 
The School of Science and Engineering combines a potent research culture with excellence in training and finding out. The school is at present going through a time period of sustained advancement with formidable plans. We concentration on employer co-intended curricula supported by superb training and use of technologies. We support earth course interdisciplinary investigate and understanding trade in spots including sustainability (zero carbon), health & wellbeing and foreseeable future towns. We are dedicated to partnership operating with external organisations and communities to greatly enhance the social, cultural and financial areas of the areas with which we collaborate.
This is an interesting time to sign up for the College of Science and Engineering. We’re dedicated to establish a more assorted representative school of excellence in STEM analysis, teaching and scholarship. We are looking for to make a collection of strategic senior tutorial appointments across the Faculty to include things like a total-time Professor in Applied Wellness Psychology and Physical Action to even further bolster our investigate in the College of Psychology and Activity Science.
Your position will involve both of those training and analysis, and you will support the Faculty management group in enhancing and increasing the University’s intercontinental standing in your tutorial area. You will reveal tutorial management in your subject, and a willingness to guidance other folks to realize research excellence.
With a PhD and preferably a post-graduate training qualification, you will have an proven monitor history of making exploration outputs that are internationally fantastic in terms of originality, significance and rigour, as very well as a observe history in securing research funding.
You will have substantial knowledge of training and skills as an tutorial researcher and/or information trade. You’ll have great facilitation and interpersonal competencies, and the potential to deal with alter and to feel innovatively and creatively. You will have potent interaction and romance-constructing skills with a collaborative and supportive management fashion, and preferably must be ready to make a considerable contribution to one of our ARU extensive Study, Innovation and Influence Themes: Well being, General performance and Wellbeing Sustainable Futures Risk-free and Inclusive Communities. Candidates should be fully commited to equality, variety and inclusion and to nurturing a society of research integrity and open analysis.
Discover out more about this possibility and functioning with us or get hold of Laurie Butler, PVC & Dean of Faculty at [email protected] isles for an informal dialogue.
Closing day: 25 April 2022.
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On the net surveys have been executed to collect both of those longitudinal and cross-sectional details at a few time details. The 1st study was performed early on through the COVID-19 pandemic from 9th to 19th April 2020 the second from 30th July to 16th August 2020 and the third concerning 1st and 25th December 2020. Throughout the initially time position, Australian point out governments had adopted remarkable actions to reduce the rates of infection which includes social distancing, lockdowns, and travel constraints. During the second time stage, all Australian states except Victoria experienced peaceful constraints because of to minimal case numbers of the an infection. At the time of the 3rd study, most COVID-19 limits were being lifted in all States and Territories as the premiums of infection were being mostly below command [21, 22].
At each and every study, participants (together with new contributors recruited for survey 2) were requested if they would like to take part in foreseeable future data selection chances. Individuals completing at minimum two surveys turned section of a longitudinal cohort while all those who elected to entire only one survey formed the cross-sectional cohort. The surveys ended up anonymous and hosted on the Qualtrics survey system. Australian older people aged 18 years and above have been invited to complete the surveys using paid Facebook advertising, social media (e.g., Twitter) and institutional sources such as electronic mail lists. On line educated consent was provided by all members just after they experienced read the data sheet that outlined the mother nature of their participation, the challenges and gains of participation, and how the knowledge would be utilised. Ethical approval was granted by Central Queensland University’s Human Investigate Ethics Committee (Acceptance range 22332).
Actions
Demographic qualities provided age (several years), gender, several years of education, weekly household profits (< 1000 AUD, 1000 - < 2000 AUD, or ≥ 2000 AUD), and marital status (in a relationship or not). Chronic disease status (Yes/No) was identified using the question “Have you ever been told by a doctor that you have any chronic health problems?”. These included one or a combination of heart disease, high blood pressure, stroke, cancer, depressive disorder, anxiety disorder, psychotic illness, bipolar disorder, diabetes, arthritis, chronic back/neck pain, asthma, COPD, and chronic kidney/renal diseases [23].
Resilience was assessed using the six-item Brief Resilience Scale (BRS). The BRS measures an individuals’ ability to bounce back from an adverse event and focuses on the ability to recover [24]. The BRS is a reliable measure of resilience, with Cronbach’s alpha ranging from 0.80 to 0.91 and a 1 month test-retest reliability (ICC) of 0.69 [24]. The BRS is comprised of six items with three positively worded items (1, 3, and 5) and negatively worded items (2, 4, and 6). For example, a positive item states “I tend to bounce back quickly after hard times” while a negative item states “I have a hard time making it through stressful events”. Responses were provided on a 5-point Likert scale with anchors at 1 (strongly disagree) and 5 (strongly agree). The scale was scored by reverse coding the negative items and then averaging the total score for the six items. Final scores range from 1.0–5.0 with a score of 3.0–4.3 considered a normal level of resilience [25].
Psychological distress was measured using the 21-item Depression, Anxiety and Stress Scale (DASS-21) [26]. The DASS-21 has shown acceptable construct validity and high reliability (Cronbach’s alphas were 0.88, 0.82 and 0.90 for depression, anxiety and stress respectively) in a non-clinical adult population [27]. Each domain has seven items scored on a 4-point Likert scale between 0 (did not apply to me at all) and 3 (applied to me very much, or most of the time). Example items were “I was aware of dryness of my mouth” or “I found myself getting agitated”. A score was calculated for each domain by adding the scores for the relevant items and multiplying by two. Standard cut-points were used to determine whether participants had symptom severity above normal for depression (≥10 points), anxiety (≥8 points), and stress (≥15 points) [26].
Physical activity was assessed using the Active Australia Survey (AAS), which comprises eight items identifying the duration and frequency of walking, and moderate and vigorous (MVPA) physical activities, over the past 7 days. For example, questions about walking are “In the last week, how many times have you walked continuously, for at least 10 minutes, for recreation, exercise or to get to or from places?” and “What do you estimate was the total time that you spent walking in this way in the last week?”. The AAS guidelines were used to calculate total physical activity by summing minutes of walking, minutes of moderate activity, and minutes of vigorous activity (multiplied by 2). Participants were then categorised as meeting the physical activity guidelines (≥150 min of moderate – vigorous (MVPA) per week) or not (< 150 min MVPA per week) [28]. The AAS criterion validity has been found to be acceptable for use in self-administered format, with correlations between self-reported physical activity and weekly pedometer steps, and accelerometry being 0.43 and 0.52 respectively [29].
Analyses
Statistical analysis was undertaken using SAS software v9.4. Two datasets, longitudinal and repeated cross-sectional, were analysed separately. Participants completing at least two surveys were included in the longitudinal dataset. The repeated cross-sectional dataset excluded those in the longitudinal dataset and therefore included only those completing one survey. Descriptive statistics (mean, standard deviation, and percentages) were calculated and are presented for each time point. Changes in resilience scores were examined using general linear mixed models for the longitudinal data, and general linear models for cross-sectional data. In addition to bivariate analyses, estimated changes in resilience scores were also adjusted for age, gender, years of education, weekly household income, relationship status, and chronic disease status. Multiple comparison correction was applied using the simulation option in PROC GLIMMIX.
Associations between resilience scores with physical activity and depression, anxiety, and stress were also examined using general linear mixed models for the longitudinal data and general linear models for the cross-sectional data. Three models were run for both datasets. Model 1 included resilience scores, time and either physical activity, depression, anxiety, or stress. Model 2 included the additional covariates: age, gender, years of education, weekly household income, relationship status, and chronic disease status. To examine whether the observed associations were independent, physical activity, depression, anxiety, and stress were also included in Model 3 together with time and all other covariates.
Due to missing values for the household income variable being higher than 10{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf}, analyses were conducted with and without household income as a covariate. As the results between these two analyses did not change the findings, only models including household income are presented. Crude and adjusted differences in resilience scores with 95{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} confidence intervals are reported. All p-values were two sided and considered significant if < 0.05.
From innovative smartwatches to primary conditioning trackers, electronic units are encouraging an increasing quantity of individuals continue to keep tabs on their energy burned, steps taken, and other day by day bodily action metrics to monitor actual physical exercise.
Bassett
Nonetheless, a 25-calendar year study finds that whilst exercise monitoring is on the increase, our exercise degrees have been declining.
The multidecade examine was led by David Bassett Jr., professor and head of the Department of Kinesiology, Recreation, and Activity Experiments in the University of Tennessee, Knoxville’s School of Education, Health and fitness, and Human Sciences, and Scott Conger, associate professor of kinesiology at Boise Condition College. It was published in this month’s difficulty of Medicine & Science in Sports & Training.
Scientists tracked bodily action in older people, adolescents, and little ones by examining the results of 16 peer-reviewed scientific tests conducted prior to the beginning of the COVID-19 pandemic in locations like the United States, Canada, Japan, Norway, Denmark, Sweden, Greece, and the Czech Republic. Making use of details from accelerometers and pedometers, the study confirmed major declines for each adult men and girls, with an specially pronounced decrease for younger people.
The experiments calculated populations of a specified age and sex on at least two instances, and they made use of a assortment of various sampling tactics to identify the individuals.
“The most stunning acquiring was the steep price of decline in adolescents. The study indicates that physical activity in adolescents has declined by approximately 4,000 actions for every day in the span of a one technology,” claimed Bassett.
The examine reveals an regular lower of just more than 1,100 measures for each day for grown ups in the protected time span. On the other hand, when it came to adolescents, the lower was a lot a lot more major, at just about 2,300 much less measures for every day. In truth, adolescents showed the steepest price of drop around time, dropping 1,500 techniques a working day for each decade.
So what are some of the variables guiding this craze? The study acknowledges that an increase in smartphones, social media, and digital entertainment may possibly have performed a major position in a fewer active life style. “Decreases in physical instruction and strolling to college may possibly have also contributed to the decrease seen in youngsters,” said Bassett.
Basset set the finds within just the drop of bodily activity more than a a lot longer time span as work have moved from the agricultural and manufacturing sectors to workplace-centered work and the use of labor-preserving equipment has developed. A substantial drop in action possible took put over a span of 150 yrs, commencing in the mid-1800s. It should really also be noted that greater leisure time did not automatically translate to enhanced physical action.
Findings from our systematic review [16] were used to design a theoretical framework for the qualitative study [17]. Notable determinants identified in the systematic review were financial and time limitations, health/beauty paradox (= overweight/obesity as a sign of beauty and wealth), and lack of knowledge, self-efficacy, and skills. Qualitative study findings re-affirmed the systematic review findings concerning health/beauty paradox, knowledge, self-efficacy, and skills gaps. In addition, the qualitative study showed socio-cultural misconceptions around lifestyle PA, fruits, vegetables, and habitual orientation towards carbohydrate foods. We also found that there is a high trust in nutrition information shared on social and mass media, yet skills to evaluate this nutrition information are limited. Figure 1 below shows the logical model of needs assessment, summarises the determinants of dietary and PA in urban Uganda [16, 17].
Fig. 1
Logical model of needs assessment, summarizing the personal and environmental determinants of dietary and PA behavior in urban Uganda. Adapted from Yiga et al., [16] and Yiga et al., [17]
Step II: Formulation of behavioral intervention, performance, and change objectives
We hypothesised that changing the overall existing behaviours towards WHO healthy lifestyle guidelines in one intervention may meet strong resistance and thus may not be effective. For example, the planning group hypothesised that due to the existing health/beauty paradox and habitual orientation towards carbohydrate rich foods, interventions focusing directly on weight loss and reduction of portion sizes of foods rich in carbohydrates may meet strong resistance. Therefore, we decided to go for more feasible gradual changes able to enact clinically relevant metabolic improvements. We hypothesised that increased consumption of vegetables and fruits will indirectly translate into reduction of portion sizes of carbohydrate rich foods. In line with WHO health recommendations, the intervention aims to stimulate WRA to consume at least 400 g fruits and vegetables [13]. Moderate intensity PA that can be incorporated in daily life activities may be the achievable type of PA among WRA compared to structural high intensity PA [26]. Non-factual nutrition information influences dietary and PA behaviors in urban Uganda [17]. Thus, we decided to supplement the intervention with a component on information evaluation; to enact ability to distinguish evidence-based information from nonfactual information.
Accordingly, three behavioural intervention objectives were formulated.
1.
Women evaluate the accuracy of food, nutrition, and PA information.
2.
Women engage in moderate intensity PA for at least 150 min a week.
3.
Women consume at least one portion of vegetables and one portion of fruit every day.
Table 1 shows the behavioral intervention objectives, subdivided into POs providing the answer to the question; “what do the participants of the intervention need to do to achieve the behavioural objectives”. The model of food literacy [27] guided the formulation of POs. Food literacy is the interrelated combination of knowledge, skills and self-efficacy to (i) plan, (ii) select, (iii) prepare, (iv) eat food with the ultimate goal of developing a lifelong healthy, sustainable and gastronomic relationship with food within the prevailing environment [27, 28]. The POs were based on the above mentioned four components of food literacy (plan, select, prepare, and eat). For PA, a similar model was adopted, where “eat” was replaced with “do”, that is; plan, select, prepare, and do. The model of food literacy was chosen as it is a holistic behavior change model focusing on a “how to do approach” to initiate and sustain healthy eating habits [27, 28]. Evidence shows a positive association between food literacy and healthy dietary behaviors, particularly increased intake of vegetables and fruits [29, 30]. Table 2 shows the determinants considered to have a strong influence on accomplishing the created POs. Matrices of change objectives are presented in Additional file 3.
Table 1 Behavioural intervention objectives subdivided into performance objectives
Table 2 Determinants of performance objectives for behavior intervention objectives
Step III: Selection of theory-based methods and practical strategies
We aimed to create an intervention capable of initiating and sustaining behaviour change. Eleven BCTs scientifically shown to enact changes in knowledge, skills, self-efficacy, subjective norms, and social support were selected, Additional file 4. The selected BCTs are supported by the self-regulation theory and self-determination theory which specifies the need for autonomy, competence, and relatedness to attain a positive behaviour change [33, 34]. Accordingly, our intervention aims to create behavioural change through enacting autonomy, competence, and relatedness. Providing information coupled with motivation interviewing creates a positive intention [35]. Implementation intentions can be achieved through goal setting [24, 34, 35]. Goal setting necessitates competence, which we hypothesised to be attained through a combination of (i) action planning; (ii) guided practice; ii) self-monitoring; iv) feedback on performance and v) planning of coping plans [24, 26, 34,35,36]. To sustain the behavioural goals requires relatedness, which can be achieved using a combination of social support, role modelling, feedback, planning coping responses and motivation interviewing [20, 24, 34].
The selected BCTs were then operationalised into practical strategies. BCTs; motivational interviewing, role modelling, feedback, guided practice, social support through exchanging ideas and planning coping responses were translated into interactive group-based sessions. Brainstorming workshops with planning group II and FGDs with target group revealed that group sessions may be the best strategy to deliver the intervention in this setting.
“Through education sessions, like you come in this group and give us a health talk, like the way you have come, you teach us and then us we can go and teach our other friends out there. Like for us every Tuesday we be meeting here, very many of us, so if you say you will give us one Tuesday in a week or month, or the last Tuesday of a month and you come and teach us”. “It would be very nice, because literally I share the information with others, so it will move, it moves much faster, because these groups are not only here, but also have these groups in other dioceses, so we can go visit them, and the teach them, but in health centers you only visit when you’re sick”. “Yes it helps, what I know is good, I wish it for my friends and we act as a support for each, and we as well spread it to other groups, example of myself, I used to never eat pumpkin, but I got it from these ladies, that this pumpkin is good and with time I gradually started to eat it until it become part of my diet”, participants in FGD 4 and 6.
Additionally, a recent systematic review shows that diet and PA interventions delivered through group sessions are effective in promoting clinically relevant weight loss [34]. These groups provide opportunities for social support, experience sharing, and may create a motivating atmosphere [22, 34]. Our needs assessment as well revealed that the community and church small groups are an opportunity to share dietary and PA counselling [16, 17]. Our environmental asset assessment revealed existence of women groups within religious structures. Existing groups boosts social cohesion, a facilitator for behavioural change [22].
The reading culture of Ugandans is low.
“We need more of practical, and also the pamphlet, some of us don’t really understand so much, but if it brings out the picture very well, even I can pick interest in it”. “Pamphlets, some people are lazy to read”, participants in FGD 5.
So, the BCT of “providing information through imagery” was translated into infographics with less text and more locally recognisable visuals. Evidence as well shows that visuals increase attention, interest, and credibility of the messages [20].
During FGDs with the target group, participants emphasised the need for practical vegetable preparation skills.
“like we are trying to reduce cooking oil and other stuff from our daily life, so maybe we meet in a group, there is a demonstration whereby some food stuffs are prepared in the best possible way which is to the taste, and people learn how to prepare them, because most of us, do not know how to cook, that is the truth, but somebody may not even fry food, but it tastes so good, if you know how to mix the ingredients and so on. Yes, include cooking demonstrations”, participants in FGD 2.
Hence, BCT of “guided practice” was specifically translated into a practical vegetable group cooking session. We also included vegetable recipes based on locally available vegetables in the intervention infographics. Intervention strategies linked to personal metabolic health and lifestyle needs, and environmental opportunities may help drive behaviour change and positively influence health outcomes [37]. Thus, BCT of; implementation intentions, goal setting and action planning were translated in to; (i) creating “if then plans” in line with metabolic health, (ii) SMART fruit/vegetable/PA goals, detailed action plans to achieve set SMART goals drawn considering environmental opportunities. Figure 2 below shows the hypothesised intervention logical model (conceptual framework) of behavioural change. Practical strategies built from BCT are hypothesized to effect changes in the change objectives, which in turn translate in changes in the determinants. Changes in the determinants in turn result in attainment of POs and corresponding behavioural intervention objectives.
Fig. 2
hypothesised intervention logical model for behavioural change (conceptual framework for the intervention)
Step IV: Development of the intervention programme
The practical strategies were built into the intervention scope and sequence, Additional file 5. The intervention consists of five interactive group sessions, 150 min each, Fig. 3. A booklet (infographics); on benefits/recommendations, local vegetable recipes, and practical tips to eat more fruits, vegetables and do more PA is included as a guide, Additional file 6. Tools to assess PA and food environment for opportunities were included, Additional file 7. As well a self-monitoring tool for PA, fruit and vegetable intake was included for participants to track their behaviour daily goals for use in the feedback sessions, Additional file 8. The infographics were designed with locally recognisable images as cultural relevance of health promotion materials is vital for the success of an intervention [20]. Messages on the infographics were framed in a positive and active tone as evidence shows that positively framed messages are more acceptable [20].
Fig. 3
Showing delivery timeline of the intervention sessions, intervention content (organised practical strategies from step III), role of participants, and anticipated outcome per session
Brain storming workshop with planning group I and FGDs with the target group identified religious institution women group structures as an appropriate potential delivery channel. The women group structures boosts established social networks, community reach (85{e4f787673fbda589a16c4acddca5ba6fa1cbf0bc0eb53f36e5f8309f6ee846cf} Ugandans are Christians) and trust. The channel offers an opportunity for assessing the intervention effectiveness in an unrestricted real-life community setting.
“Religious institutions because they are transparent, religious organizations because they reach out to a bigger community and then they are transparent. The health centers, there is that rudeness, and still for health centers will only meet those people who come to them, but the church, you get a bigger audience”, “Come to churches like this, people really belong to this communities, then you say every third Saturday or Sunday of the month, from 4 to 5 pm, there will always be a nutritional class, for the first-time people may not come, but eventually they come, if it is a free class”, participants in FGD 4.
STEP V: Adoption and implementation plan
The intervention will be delivered through institutional religious women groups (results of environmental asset assessment framework – see step IV). Through meetings with the strategic community leaders, a collaboration was established with Our Lady of Africa Catholic Parish, Mbuya. Mbuya Catholic Parish has six sub parishes. Within these sub parishes they are existing women groups, and these groups will be utilized for face-to-face intervention group sessions. FGDs with target group and meetings with planning group II pointed at the importance of opinion peer leaders being part of the implementation team.
“Our women group leader has helped us a lot, she taught us the dangers of cooking in polyethene bags and taught us the use of banana leaves, us we had got so much used to using the polyethene bags, she can’t eat the food you have prepared in polyethene bags, even if she visits you and if you have cooked like that, she can’t eat that food. “We have musawo (village health team) in our group, she usually brings for us education sessions on how to eat, she goes a lot for these education sessions and what she learns she brings them back to us”, participants in FGD 6.
Scientific evidence shows that the efficacy and acceptability of health promotion interventions increases if peer opinion leaders within the target group are part of the implementation team [38]. Peer opinion leaders provide entry and legitimacy to the external change agents and may help drive changes in social norms. Selection of peer opinion leaders: the intervention will be delivered within existing women groups. Leaders of these existing groups will be selected to work as peer opinion leaders on the implementation team. The main role and responsibilities peer opinion leaders will be to (i) mobilize fellow women to participate in the intervention, (ii) follow up and (iii) give social support to participating women to attain set intervention goals. Women leaders will be given a two – day refresher training on mobilization and leadership skills, as mobilization is the routine responsibility for women leaders in their usual group meetings. The planning group I designed the sessions to be moderated by health behavior coach (PhD researcher) following the techniques of motivational interviewing [39]. A general guide (scope & sequence) will ensure consistency during the group sessions.
Step VI: Development of an evaluation plan
Study design, setting and timing
The effectiveness of the intervention will be evaluated through a cluster-randomized controlled trial. The intervention will be evaluated in Kampala, the capital city of Uganda. The six sub parishes of Mbuya catholic parish will be randomized to treatment and control arms, Fig. 4. The treatment arm will be exposed to both the developed intervention infographics and face to face group sessions while the control arm will only receive the developed intervention infographics. An awareness session will be organized to distribute the infographics to the control arm. Within the sub parishes, there are existing women groups. These existing groups will be utilized for face-to-face intervention group sessions. For the intervention purposes, each group will be limited to a maximum of 14 members. The study period is divided into two phases: a three-month intervention and a three-month post-intervention follow-up phase.
Fig. 4
Recruitment
The PhD researcher and women leaders of existing groups will make presentations about the intervention during one of the routine meetings. Flyers with details of the intervention will be distributed for sharing with members who are absent during the briefing. At the end of the presentations, interested participants will be invited for the first session to test their eligibility to participate in the study. Eligible participants will be provided with an informed consent form to endorse.
Inclusion criteria
i)
Sex (women),
ii)
Age (18 to 45 years),
iii)
Central obesity [waist circumference ≥ 80 cm]),
iv)
Fluent in either Luganda or English (sessions will be conducted in Luganda/English).
v)
Willingness to follow the three-months intervention and three months follow-up,
vi)
Willingness to sign the informed consent.
Exclusion criteria
i.
Being treated for diabetes Mellitus Type 1 or Type 2, hypertension, high cholesterol, or any other cardio-metabolic related disease.
ii.
Pregnancy.
Outcomes
Primary outcome is reduction in waist circumference. Decreases in waist circumference are recommended as critically important treatment target for reducing adverse cardiometabolic health risks [15]. Secondary outcomes include optimisation of, fasting blood glucose, total cholesterol, HDL, LDL, triglycerides, body composition, food literacy, PA, and fruit and vegetable intake.
Sample size calculation
Sample size calculation is based on waist circumference.
To calculate the sample size, we used the formula described by Rutterford, Copas [40], Table 3.
Table 3 Description of sample size calculation
Randomization
The six sub parishes (clusters) will be listed alphabetically. A cluster randomization with a 1:1 allocation will then be applied to randomize the sub parishes to either the treatment or control arm. In the sub parishes, women group leaders and participants will be blinded about the study arms.
Data collection
Table 4 gives an overview of the different measurements and time points during the study.
Table 4 Measurements and time points
Data analysis
Data will be analysed using R software. To evaluate the effects of the intervention, multilevel analysis will be used. Using this technique, regression coefficients will be adjusted for the clustering of observations within sub parishes. We will define two levels in our multi-level analysis: (1) participant and (2) sub parishes. Linear mixed effect models will be used to examine the effect of the intervention on each of the outcome values. All analyses will be performed according to the intention-to treat-principle [42]. To assess changes in metabolic health between the intervention and control groups, a linear mixed effect model will be built where “time” (end line measurement (M2) will be compared with base-line measurement (M1) and post-follow up measurement (M3)), treatment (and interaction of time and treatment) as well as age will be specified as fixed effects, and sub parishes and participants as random factors. For all linear mixed models, compatibility with mixed-model assumptions will be checked by inspection of residual plots and Q-Q plots. In the case of heteroscedastic residuals, data will be log transformed. Tukey or Benjamini–Hochberg procedures will be applied when performing post hoc analyses to further identify differences within treatments as well as between time points. Statistical outliers will be defined as any observation which has an absolute residual exceeding 3 times the residual standard deviation. p < 0.05 will be considered significant in all analyses.
