Using Technology to get
People Active
[email protected]
@troosters
Outline
• Challenges of making people active: PA is not exercise
• Key principles of behavior change
• Can technology make it happen
• In whom may it work
• Conclusions
Definition Physical activity
• Physical activity / Exercise tolerance / functional status
Physiology
Disease process
Functional capacity
Motivation
Functional Reserve
Physiology
Comorbidity
Season
Behavior
Self efficacy
Health believes
Functional Performance
Functional Capacity
Utilization
Definition Physical activity
N steps.day-1
• Physical activity / Exercise tolerance / functional status
6 minute walking distance
PA variable within a given capacity
Factors related to my PA
Steps.day-1
•
•
•
•
Weekends  (+1222 steps)
Season
Hollidays  (+614 steps)
Scientific (all day) meetings 
(-1966 steps)
Variability imposes a challenge
Troosters Breathe 2015
Barriers and enablers for PA in COPD
Internal factors (COPD related)
External factors
Network around the patient
Perceived support
Tackling PA behavior will
require more than exercise
training
Thorpe Int J COPD 2014
Principles (theory) of changing behavior
Grouping and BCTs
Grouping and BCTs
Grouping and BCTs
1. Goals and planning
6. Comparison of behaviour
12. Antecedents
1.Goal setting (behavior)
2.Problem solving
6.1. Demonstration of the behavior
6.2. Social comparison
6.3. Information about others’ approval
12.1. Restructuring the physical environment
12.2. Restructuring the social environment
12.3. Avoidance/reducing exposure to cues for the behavior
12.4. Distraction
12.5. Adding objects to the environment
12.6. Body changes
3.Goal setting (outcome)
4.Action planning
5.Review behavior goal(s)
6.Discrepancy between current behavior and goal
7.Review outcome goal(s)
8.Behavioral contract
9.Commitment
7. Associations
2.1. Monitoring of behaviour by others without feedback
7.1. Prompts/cues
7.2. Cue signalling reward
7.3. Reduce prompts/cues
7.4. Remove access to the reward
7.5. Remove aversive stimulus
7.6. Satiation
7.7. Exposure
7.8. Associative learning
2.2. Feedback on behaviour
2.3. Self-monitoring of behaviour
8. Repetition and substitution
14. Scheduled consequences
8.1. Behavioral practice/rehearsal
8.2. Behavior substitution
8.3. Habit formation
8.4. Habit reversal
8.5. Overcorrection
8.6. Generalisation of target behavior
8.7. Graded tasks
14.1. Behavior cost
14.2. Punishment
14.3. Remove reward
14.4. Reward approximation
14.5. Rewarding completion
14.6. Situation-specific reward
14.7. Reward incompatible behavior
14.8. Reward alternative behavior
14.9. Reduce reward frequency
14.10. Remove punishment
2. Feedback and monitoring
2.4. Self-monitoring of outcome(s) of behaviour
2.5. Monitoring of outcome(s) of behavior without feedback
2.6. Biofeedback
2.7. Feedback on outcome(s) of behavior
3. Social support
3.1. Social support (unspecified)
3.2. Social support (practical)
3.3. Social support (emotional)
4. Shaping knowledge
4.1. Instruction on how to perform the behavior
4.2. Information about Antecedents
4.3. Re-attribution
4.4. Behavioral experiments
5. Natural consequences
5.1. Information about health consequences
5.2. Salience of consequences
5.3. Information about social and environmental consequences
5.4. Monitoring of emotional consequences
5.5. Anticipated regret
5.6. Information about emotional consequences
13. Identity
13.1. Identification of self as role model
13.2. Framing/reframing
13.3. Incompatible beliefs
13.4. Valued self-identify
13.5. Identity associated with changed behavior
9. Comparison of outcomes
9.1. Credible source
9.2. Pros and cons
9.3. Comparative imagining of future outcomes
10. Reward and threat
10.1. Material incentive (behavior)
10.2. Material reward (behavior)
10.3. Non-specific reward
10.4. Social reward
10.5. Social incentive
10.6. Non-specific incentive
10.7. Self-incentive
10.8. Incentive (outcome)
10.9. Self-reward
10.10. Reward (outcome)
10.11. Future punishment
15. Self-belief
15.1. Verbal persuasion about capability
15.2. Mental rehearsal of successful performance
15.3. Focus on past success
15.4. Self-talk
16. Covert learning
16.1. Imaginary punishment
16.2. Imaginary reward
16.3. Vicarious consequences
Michie The Behavior Change Technique Taxonomy
Annals Behavioral Med 2013
Can technology make it happen
Step couters with
real time feedback
Computer apps
Smartphone apps
Exergaming
 Consumer market (no third party interface)
 Consumer market (with coach interface)
 Medical market (with HCP interface)
Can technology make it happen
D a ily a m o u n t o f s t e p s ( n .d a y
-1
)
•
•
•
8000
Goal setting
<6000 increase by 3000 steps
<9000 reach 9000 steps
>9000 maintain or increase
Feedback
7000
6000
5000
4000
3000
0m
Mendoza Eur Respir J 2015
3m
Pedometer
∆3080±3255
Control
∆138±1950
+2942 st.day-1 **
Can technology make it happen
Telecoaching
Control
4500
M e a n s te p s .d a y
-1
+ 4 4 71 8 1 7
4000
779 st.day-1 **
3500
3000
-3 4 6  1 9 4 9
2500
Goal setting
B a s e lin e
4m
S G R Q t o ta l s c o r e ( p o in t s )
Motivation
Social support
Feedback
Moy Chest 2015
50
- 0 .8  1 0 . 9
45
40
-2.3 points
- 3 .2  1 1 . 1
35
B a s e lin e
4m
Can technology make it happen
Primary-tertiary care and rehabilitation centers
Motivation
Action planning
Goal setting
Feedback
Education
Mon
Tue
Wed
Thu
Fri
Weekly feedback
Sat
Sun
 Problem Solving
New goal if desired
Group Text Message
Demeyer & PROactive consortium Submitted 2016
Can technology make it happen
Telecoaching
7000
-1
+ 870 2 5 3 0
1469 st.day-1 **
5000
-6 7 8 1 6 7 5
4000
3000
B a s e lin e
3m
)
35
M P A (m in .d a y
Coaching happened semi-automated
M e a n s te p s .d a y
This increase is clinically relevant
Control
6000
-1
Physical activity was succesfully increased
30
+ 8 2 1
10min.day-1 **
25
-3 1 7
20
15
B a s e lin e
3m
The patient experience
S c o r e ( 0 -1 0 )
10
5
0
Step counter with goal
Demeyer & PROactive consortium Submitted 2016
Possibility to contact a HCP
The patient experience
Important increase (≥1000 steps) Demeyer, PLoS ONE, 2016
100
Odds
4.44 [2.38-8.29]
% o f p a t ie n t s
 < 1 0 0 0 s te p s
  1 0 0 0 s te p s
80
60
40
20
11%
0
C o n tro l g ro u p
36%
C o a c h in g g r o u p
m M R C 2
More
Symptoms
m M RC<2
p = 0 .0 0 1
Less
6M W D<450
Low
6M W D 450
Capacity
p = 0 .0 0 1
High
G O L D C CD
D
AB
GOLD
GOLD
AB
p = 0 .0 5 0
C o m o rb  2
More
p = 0 .3 0
Comorbidity
C o m o rb < 2
Less
< 5 0 Low
00
Steps 5 0 0 0
Higher
p = 0 .4 8
0
1000
2000
3000
C h a n g e in s t e p s ( n .d a y
4000
-1
0
)
Better patients benefit more...
1000
2000
3000
C h a n g e in s t e p s ( n .d a y
-1
4000
)
The patient experience
Problems with software updates
Compatibility with the mobile phone
Discontinuation of a product (consumer devices)
Inaccuracy of some step counters
McMahon JMIR 2016
50
1600
45
1400
 Steps (n.day-1)
 6MWD (m)
The physical activity paradox
40
35
30
25
20
15
1200
1000
800
600
400
10
200
5
0
0
Exercise
training
Telecoaching
Exercise
training
Telecoaching
PA programs are no substitute to exercise training.
Patients with poor exercise capacity should be referred to pulmonary rehabilitation
The physical activity paradox
N steps.day-1
+HCP Coach
+TRAINING
Conclusions
• Enhancing (maintaining) physical activity is a key
objective in COPD care.
• Several behavioural strategies can be implemented in
patient oriented, technology supported interventions.
• Technology supported (simple) interventions improve PA
in the short term. Patients enjoy using step counters,
but also HCP contacts.
• Better patients seem better candidates for PA
interventions.
• PA enhancing interventions should not be used as an
alternative to PR, but they can be integrated.
Thanks to
PROactive study group
PhD students
Matthias Loeckx, Fernanda Rodriguez, Carlos Camillo
Post Doc
Heleen Demeyer
Pulmonary Rehabilitation group
Prof Wim Janssens, Prof Rik Gosselink, Prof Marc Decramer
Funders: FWO Vlaanderen, EU