!"#$%&#$'()*+,#($&+$-&.(**/$#.+,#($ ,0.1$(2(%3&,(&)0-/.0&"#,,#$%&+$-&#$.)0+"0& 413"#.+2&+.,#5#,3&#$&(''#.0&6()70)" A/-#,&B(),&C(#%&D&EFGH !"#$"%&'($)*+,+ 8/40)5#"0-&93: !-.(&//0(12(3456(%578-0(0/9(!-.(:5;<=>0?(!.(@5>?=/ ;&,10"#"&"/9*#,,0-&'()&,10&-0%)00&('&<(.,()&('&=1#2("(413&#$: A8>B0-8C()80>D<(0/9(E40>5DF(=B('5B8 & !$#50)"#,+,&-0&>#.?!$#50)"#,+,&@0$,)+2&-0&@+,+2/$3+ DOCTORAL THESIS Using information and communication technology to reduce sitting and increase physical activity in office workers Judit Bort Roig Supervised by: Dr Anna Mª Puig Ribera and Dr Nicholas D. Gilson A thesis submitted for the degree of Doctor of Philosophy in: Welfare, Health and Quality of Life Centre d’Estudis Sanitaris i Socials Facultat d’Educació, Traducció i Ciències Humanes Universitat de Vic - Universitat Central de Catalunya 2015 2 If we can now develop and implement effective policies and programs to encourage and enable more people be more active more of the time, this will truly be a “Triumph of Epidemiology” Steven M. Blair and Jeremy N. Morris (2009, p.256) 3 4 Abstract Background. Sitting too much and moving too little affects the development of many chronic diseases. Office workplaces are key settings to reduce and break up occupational sitting by replacing sedentary time with step counts. A better understanding of which strategies can encourage office workers to ‘sit less and move more’, and the role technology can play in delivering these strategies is needed. Aims. The overarching aim of the thesis was to investigate the impact of an intervention to reduce occupational sitting time and increase physical activity in Spanish office workers. Assessment of technology based strategies and the role of web and mobile-based behaviour change platforms were a focus of the thesis, and were examined through three specific studies that: (a) evaluated the effectiveness of an automated web-based workplace program (Walk@WorkSpain-W@WS) on reducing occupational sitting, increasing step counts and improving physical risk factors among office Spanish workers (Study One); (b) investigated the uptake of W@WS strategies that reduced sitting time and increased walking, and explored factors that enabled or limited uptake of these strategies (Study Two); and (c) systematically reviewed evidence on measuring and influencing physical activity using smartphone technology (Study Three). Methods. Study One used a quasi-experimental pre-post design. Administrative and academic workers at six Spanish university campuses (n=264; 42±10 years; 171 women) were randomly assigned by workplace and campus to an intervention (used W@WS; 19 weeks; n=129; 87 women) or a comparison group (maintained normal behaviour; n=135; 84 female). The intervention consisted of (a) a ramping phase (8 weeks) to progressively increase baseline step counts through incidental movement, short and long walks, and higher step count frequency and intensity; and (b) a 5 maintenance phase (11 weeks) with automated guidance. Changes in outcome measures (step counts, self-reported sitting time, body mass index, waist circumference and blood pressure) were assessed between baseline, ramping, maintenance and follow-up (two months) phases for intervention versus comparison groups, using linear mixed model analyses. Study Two conducted semi-structured interviews with 12 W@WS participants (44±12 years; 6 women) at three points across the intervention. Workers (n=88; 42±8 years; 51 women) who finished the intervention completed a survey (generated from the interview thematic analysis) rating the extent to which ‘sit less, move more’ strategies were used (never [1] to usually [4]) and those factors that enabled or limited strategy uptake (no influence [1] to very strong influence [4]). Survey score distributions and averages were calculated and findings triangulated with interview data. Progressing the learning of the previous two studies, Study Three systematically reviewed evidence on smartphones and their viability for measuring and influencing physical activity. The databases Web of Knowledge, PubMed, PsycINFO, EBSCO, ScienceDirect, and Scopus were searched for relevant articles up to September 2013. The search strategy used the keywords (physical activity OR exercise OR fitness) AND (smartphone* OR mobile phone* OR cell phone*) AND (intervention OR measurement). Reviewed articles were required to be published in international academic peer-reviewed journals or in full text from international scientific conferences. Data on study characteristics, technologies used, strategies applied, and the main study findings were extracted and reported. Results. Study One identified a significant 2 (group) ! 2 (program phases) interaction for self-reported occupational sitting (F[3]=7.97, p=0.046), daily step counts (F[3]=15.68, p=0.0013) and waist circumference (F[3]=11.67, p=0.0086). The intervention group decreased minutes of daily occupational sitting while also increasing 6 step counts from baseline (446±126 minutes/day; 8,862±2,475 steps/day) through ramping (-21 minutes/day; +483 steps/day), maintenance (-24 minutes/day; +776 steps/day) and follow-up (-32 minutes/day; +924 steps/day). In the comparison group, compared to baseline (404±106), sitting time remained unchanged through ramping and maintenance, but decreased at follow-up (-16 minutes/day), while step counts diminished across all phases. Larger reductions in waist circumference were observed in the intervention (-2.1±0.3 cm) compared with the comparison group (-1.3±0.3 cm). Study Two survey data indicated that ‘active work tasks’ (e.g. moving around the office while talking on the phone or reading documents) and ‘increases in walking intensity’ (e.g. using the stairs instead of lifts or escalators) were the strategies most frequently used by W@WS participants (89% and 94% sometimes or usually utilised these strategies respectively). ‘Walk-talk meetings’ and ‘lunchtime walking groups’ were the least used (80% and 96% hardly ever or never utilised these strategies respectively)!" Thematic analyses of interview data" highlighted that inherent time pressures and existing cultural norms limited the use of these W@WS strategies. ‘Sitting time and step count logging’ (mean survey score of 3.1±0.8) was the most important enabler of behaviour change while ‘screen based work’ (mean survey score of 3.2±0.8) was the most significant barrier limiting the uptake of strategies. Study Three identified 26 articles that met inclusion criteria. Studies measured physical activity using native mobile features, and/or an external device linked to an application. Measurement accuracy ranged from 52 to 100% (n=10 studies). Smartphone strategies to influence physical activity tended to be ad hoc, rather than theory-based approaches. Only five studies assessed physical activity intervention effects; all used step counts as the outcome measure. Four studies (three pre–post and one comparative) reported physical activity increases (12–42 participants, 800–1,104 steps/day, 2 weeks–6 months), and one case-control study reported physical activity maintenance (n=200 participants; 10,000 steps/day) over 3 months. 7 Strengths and limitations. Thesis findings provide important and original contributions to the evidence base on workplace physical activity interventions to reduce occupational sitting through ICTs. The studies included are the first to use a parallel mixed methods design targeting a combined range of occupational sitting and moving strategies, and undertake a systematic review synthesising the role of smartphones in physical activity promotion. The thesis responds to a growing need to develop, test and evaluate programs that have the potential to be easily implemented and translated into the day-to-day life of busy office based organisations and workers. A number of limitations and learning for future research are also apparent. The heterogeneity of W@WS participants highlights the need for on-going research with other office-based workers. Adherence to behaviour change was measured two months post intervention, and provides short to mid-term evidence on impact. Future studies need to extend assessment duration to better evaluate program sustainability. Finally, although the use of web-based approaches can be considered valuable to promote behavioural change in workplaces at low cost, smartphone technology provides new and more accessible solutions in this regard. Conclusions. W@WS was effective in achieving small but sustained changes in occupational sitting and step counts by facilitating the uptake of a menu of ‘sit less and move more’ strategies, that can overcome office work environmental barriers. The thesis findings provide practical information that can guide managers and occupational health services on promoting ecological and cost-effective interventions to elicit positive changes in energy expenditure. New smartphone technology needs to be a central feature of ICT based interventions that target occupational sitting and physical activity given the novel and engaging capabilities these devices provide for measuring and influencing behaviour change in real time. 8 Resum (Catalan version) Introducció. Passar-se moltes hores assegut i moure’s poc està associat al desenvolupament de malalties cròniques. Els llocs de treball d'oficina han estat considerats entorns clau per reduir aquests comportaments sedentaris amb substitució d’activitats que impliquen una major despesa energètica. Tot i això, es necessita una millor comprensió de les estratègies que millor