Does a physical therapist-led, home-based walking exercise behavior change intervention improve walking capacity compared with usual care in adults with peripheral artery disease and intermittent claudication? FindingsIn this randomized clinical trial that included 190 participants with intermittent claudication due to peripheral artery disease, receipt of the intervention, compared with usual care, resulted in a statistically significant adjusted difference in mean six-minute walk distance at 3-months of 16.7m. MeaningAmong adults with peripheral artery disease, a home-based walking exercise behavior change intervention, compared with usual care, increased six-minute walking distance at 3-months.

Background Rheumatoid arthritis (RA) is a disabling, inflammatory joint condition affecting 0.5%-1% of the global population. Physical activity (PA) and exercise are recommended for people with RA, but uptake and adherence tend to be low. Smartphone apps could assist people with RA to achieve PA recommendations. However, it is not known whether high quality, evidence-informed PA apps that include behavior change techniques (BCTs) previously identified as effective for PA adherence are available for people with RA. Objective This study aims to systematically identify apps that include goals to facilitate PA for adults with RA and assess app quality and content for the inclusion of relevant BCTs against recommendations for cardiorespiratory, resistance, flexibility, and neuromotor PA and exercise. Methods A systematic search of the Apple App Store and Google Play Store in the United Kingdom was conducted to identify English language apps that promote PA for adults with RA. Two researchers independently assessed app quality (mobile app rating scale [MARS]; range 0-5) and content (BCT Taxonomy version 1, World Health Organization, the American College of Sports Medicine, and the European League against Rheumatism recommendations for PA). The completeness of reporting of PA prescription was evaluated using a modified version of the Consensus on Exercise Reporting Template (CERT; range 0-14). Results A total of 14,047 apps were identified. Following deduplication, 2737 apps were screened for eligibility; 6 apps were downloaded (2 on the Apple App Store and 4 on the Google Play Store), yielding 4 unique apps. App quality varied (MARS score 2.25-4.17). Only 1 app was congruent with all aspects of the PA recommendations. All apps completely or partially recommended flexibility and resistance exercises, 3 apps completely or partially advised some form of neuromotor exercise, but only 2 offered full or partial guidance on cardiorespiratory exercise. Completeness of exercise reporting was mixed (CERT scores 7-14 points) and 3-7 BCTs were identified. Two BCTs were common to all apps (information about health consequences and instruction on how to perform behavior). Higher quality apps included a greater number of BCTs and were more closely aligned to PA guidance. No published trials evaluating the effect of the included apps were identified. Conclusions This review identifies 4 PA apps of mixed quality and content for use by people with RA. Higher quality apps were more closely aligned to PA guidance and included a greater number of BCTs. One high-quality app (Rheumatoid Arthritis Information Support and Education) included 7 BCTs and was fully aligned with PA and exercise guidance. The effect of apps on PA adherence should be established before implementation.

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ObjectivesThis meta-analysis aims to (1) evaluate the efficacy of physical activity interventions in heart failure and (2) to identify intervention characteristics significantly associated with the interventions’ efficacy.MethodsRandomised controlled trials reporting intervention effects on physical activity in heart failure were combined in a meta-analysis using a random-effect model. Exploratory meta-analysis was performed by specifying the general approach (eg, cardiac rehabilitation), strategies used (eg, action planning), setting (eg, centre based), mode of delivery (eg, face to face or online), facilitator (eg, nurse), contact time and behavioural change theory use as predictors in the random-effect model.ResultsInterventions (n=21) had a significant overall effect (SMD=0.54, 95% CI (0.13 to 0.95), p<0.0005). Combining an exercise programme with behavioural change intervention was found efficacious (SMD=1.26, 95% CI (0.26 to 2.26), p<0.05). Centre-based (SMD=0.98, 95% CI (0.35 to 1.62), and group-based (SMD=0.89, 95% CI (0.29 to 1.50),) delivery by a physiotherapist (SMD=0.84, 95% CI (0.03 to 1.65),) were significantly associated with efficacy. The following strategies were identified efficacious: prompts/cues (SMD=3.29, 95% CI (1.97 to 4.62)), credible source (standardised mean difference, SMD=2.08, 95% CI (0.95;3.22)), adding objects to the environment (SMD=1.47, 95% CI (0.41 to 2.53)), generalisation of the target behaviour SMD=1.32, 95% CI (0.22 to 2.41)), monitoring of behaviour by others without feedback (SMD=1.02, 95% CI (0.05 to 1.98)), self-monitoring of outcome(s) of behaviour (SMD=0.79, 95% CI (0.06 to 1.52), graded tasks (SMD=0.73, 95% CI (0.22 to 1.24)), behavioural practice/rehearsal (SMD=0.72, 95% CI (0.26 to 1.18)), action planning (SMD=0.62, 95% CI (0.03 to 1.21)) and goal setting (behaviour) (SMD=0.56, 95% CI (0.03 to 1.08)).ConclusionThe meta-analysis suggests intervention characteristics that may be suitable for promoting physical activity in heart failure. There is moderate evidence in support of an exercise programme combined with a behavioural change intervention delivered by a physiotherapist in a group-based and centre-based settings.PROSPERO registerationCRD42015015280.

ObjectivesThis study examined differences in perceived discrimination across multiple characteristics in England and the United States (US), in middle- and older-aged adults.MethodsUsing data from the English Longitudinal Study of Aging (N = 8,671) and the US-based Health and Retirement Study (N = 7,927), we assessed cross-national differences in perceived discrimination attributed to disability, financial status, sex, race, sexual orientation, and weight. We also compared how perceived discrimination varied with socioeconomic position (SEP) based on wealth.ResultsPerceived discrimination due to financial status was more common in England (6.65%) than in the US (2.14%) adjusting for age, sex, and wealth [Odds Ratio (OR) = 1.09, 95% CI (1.07; 1.10)]. This affected people of low but not high SEP. Sexual orientation discrimination was more common in England [0.72 vs. 0.15%, OR = 4.61, 95% CI (2.48; 8.57)]. Sex-based perceived discrimination was more prevalent in the US (12.42%) than England (9.07%) adjusting for age and wealth [OR = 0.87, 95% CI (0.86; 0.89)]. Cross-national differences in sex discrimination did not vary with SEP. Racism was the most common type of perceived discrimination reported in both samples (England: 17.84%, US: 19.80%), with no significant cross-national differences after adjustment for sex.DiscussionPerceived discrimination attributed to financial status and sexual orientation were more prevalent in England, while more women perceived sex discrimination in the US. This study suggests that country-specific and socioeconomic factors affect the prevalence of perceived discrimination. This may be relevant when targeting interventions aimed at reducing perceived discrimination.

In heart failure (HF), increased physical activity is associated with improved quality of life, reduced hospitalisation, and increased longevity and is an important aim of treatment. However, physical activity levels in individuals living with HF are typically extremely low. This qualitative study with one-to-one interviews systematically explores perceived clinical, environmental, and psychosocial barriers and enablers in older adults (≥70 years old) living with HF. Semi-structured interviews (N = 16) based on the Theoretical Domains Framework elicited 39 belief statements describing the barriers and enablers to physical activity. Theoretical domains containing these beliefs and corresponding constructs that were both pervasive and common were deemed most relevant. These were: concerns about physical activity (Beliefs about Consequences), self-efficacy (Beliefs about Capabilities), social support (Social Influences), major health event (Environmental Context and Resources), goal behavioural (Goal), action planning (Behavioural Regulation). This work extends the limited research on the modifiable barriers and enablers for physical activity participation by individuals living with HF. The research findings provide insights for cardiologists, HF-specialist nurses, and physiotherapists to help co-design and deliver a physical activity intervention more likely to be effective for individuals living with HF.

Structured summary Provide a structured summary including, as applicable: background; objectives; data sources; study eligibility criteria, participants, and interventions; study appraisal and synthesis methods; results; limitations; conclusions and implications of key findings; systematic review registration number.

Objectives This meta-analysis aims to 1) evaluate the efficacy of physical activity interventions in heart failure and 2) to identify intervention characteristics significantly associated with the interventions' efficacy. Methods Randomised controlled trials reporting intervention effects on physical activity in heart failure were combined in a meta-analysis using a random-effect model. Exploratory meta-analysis was performed by specifying the general approach (e.g. cardiac rehabilitation), strategies used (e.g. action planning), setting (e.g. centre-based), mode of delivery (e.g. face-to-face or online), facilitator (e.g. nurse), contact time, and behaviour change theory use as predictors in the random-effect model. Results Interventions (n=21) had a significant overall effect (SMD=0.54,95% CI:[0.13; 0.95],p<0.005). Combining an exercise programme with behaviour change intervention was found efficacious (SMD = 1.26,95% CI: [0.26;2.26],p<0.05). Centre- (SMD=0.98,95% CI: [0.35;1.62],p<0.001), and group- based (SMD=0.89,95 % CI: [0.29;1.50],p<0.001) delivery by a physiotherapist (SMD=0.84,95% CI: [0.03;1.65]],p<0.01) were significantly associated with efficacy. The following strategies were identified efficacious: prompts/cues (SMD=3.29,95% CI:[1.97;4.62]), credible source (SMD=2.08,95% CI:[0.95;3.22]), adding objects to the environment (SMD=1.47,95% CI:[0.41;2.53]), generalisation of the target behaviour (SMD=1.32,95% CI:[0.22;2.41]), monitoring of behaviour by others without feedback (SMD=1.02,95% CI:[0.05;1.98]), self-monitoring of outcome(s) of behaviour (SMD=0.79,95% CI:[0.06;1.52]), graded tasks (SMD=0.73,95% CI:[0.22;1.24]), behavioural practice/rehearsal (SMD=0.72,95% CI:[0.26;1.18]), action planning (SMD=0.62,95% CI:[0.03;1.21]), and goal setting (behaviour) (SMD=0.56,95% CI:[0.03;1.08]). Conclusion: The meta-analysis suggests intervention characteristics that may be suitable for promoting physical activity in heart failure. There is moderate evidence in support of an exercise programme combined with a behaviour change intervention delivered by a physiotherapist in a group- and centre-based settings..