Background The sequential multiple assignment randomized trial (SMART) design allows for changes in the intervention during the trial period. Despite its potential and feasibility for defining the best sequence of interventions, so far, it has not been utilized in a smartphone/gamified intervention for physical activity. Objective We aimed to investigate the feasibility of the SMART design for assessing the effects of a smartphone app intervention to improve physical activity in adults. We also aimed to describe the participants’ perception regarding the protocol and the use of the app for physical activity qualitatively. Methods We conducted a feasibility 24-week/two-stage SMART in which 18 insufficiently active participants (<10,000 steps/day) were first randomized to group 1 (smartphone app only), group 2 (smartphone app + tailored messages), and a control group (usual routine during the protocol). Participants were motivated to increase their step count by at least 2000 steps/day each week. Based on the 12-week intermediate outcome, responders continued the intervention and nonresponders were rerandomized to subsequent treatment, including a new group 3 (smartphone app + tailored messages + gamification) in which they were instructed to form groups to use several game elements available in the chosen app (Pacer). We considered responders as those with any positive slope in the linear relationship between weeks and steps per day at the end of the first stage of the intervention. We compared the accelerometer-based steps per day before and after the intervention, as well as the slopes of the app-based steps per day between the first and second stages of the intervention. Results Twelve participants, including five controls, finished the intervention. We identified two responders in group 1. We did not observe relevant changes in the steps per day either throughout the intervention or compared with the control group. However, the rerandomization of five nonresponders led to a change in the slope of the steps per day (median −198 steps/day [IQR −279 to −103] to 20 steps/day [IQR −204 to 145]; P=.08). Finally, in three participants from group 2, we observed an increase in the number of steps per day up to the sixth week, followed by an inflection to baseline values or even lower (ie, a quadratic relationship). The qualitative analysis showed that participants’ reports could be classified into the following: (1) difficulty in managing the app and technology or problems with the device, (2) suitable response to the app, and (3) difficulties to achieve the goals. Conclusions The SMART design was feasible and changed the behavior of steps per day after rerandomization. Rerandomization should be implemented earlier to take advantage of tailored messages. Additionally, difficulties with technology and realistic and individualized goals should be considered in interventions for physical activity using smartphones. Trial Registration Brazilian Registry of Clinical Trials RBR-8xtc9c; http://www.ensaiosclinicos.gov.br/rg/RBR-8xtc9c/.

BackgroundThere is scientific evidence suggesting that app-based interventions targeted to increase the level of physical activity might be effective, although multicomponent interventions appear to be more effective than app-based interventions alone. Despite the motivating results, it remains unclear whether or not app-based interventions can increase the level of physical activity and cardiovascular health. Our study aims to investigate the effect of a smartphone app combined with gamification on the level of physical activity of adults and older adults. The specific aims are (1) to verify the effects of the intervention on cardiometabolic and cardiovascular health, lung function, and cardiorespiratory fitness; and (2) to verify the relationship between age group and the response rate.Methods/designWe will conduct a sequential multiple assignment randomized trial (SMART). The adaptive intervention protocol will last 6 months. After baseline assessments, participants will be randomized into one of three groups (group 1: app + tailored messages; group 2: app + tailored messages + gamification I; control group: physical activity counseling). For 12 weeks, we will record the average number of steps per day of participants from groups 1 and 2. At 6 weeks from initiation of recording, participants will be classified into responders and non-responders according to their increase in the average number of daily steps; all those considered as non-responders will be re-randomized, with the chance to participate in a third group – group 3: app + tailored messages + gamification II. Finally, at 12 weeks, participants will continue using the app but will no longer receive direct intervention from investigators. All participants will be reassessed at 3 and 6 months from baseline. Our pilot SMART will require 42 participants (14 per arm). Following the SMART pilot, we will calculate the sample size for the trial based on the variation of the average number of steps/day, including an up to 40% loss to follow-up and a less optimistic nonresponse rate of 65%.DiscussionTo our knowledge, this will be the first trial with adaptive intervention to test the effectiveness of using a smartphone app to increase the level of physical activity of adults and older adults.Trial registrationBrazilian Clinical Trials Registry: RBR-8xtc9c. Registered on 3 August 2018, http://www.ensaiosclinicos.gov.br; UTN number: U1111–1218-1092.

Background: The 6-min walk test (6MWT) is a simple, inexpensive, reliable, and reproducible test that provides a reasonable estimate of the cardiorespiratory fitness (CRF). We aimed to assess the reliability and reproducibility of a self-administered 6MWT in asymptomatic adults using a free smartphone app. Methods: In the 1st phase, 93 participants underwent a supervised 6MWT (6MWTsup) in a 30 m indoor corridor, using a triaxial accelerometer and their smartphones to compare the total step counts and to develop a 6-min walk distance (6MWD) prediction equation. In the 2nd phase, 25 participants performed the 6MWTsup and two self-administered 6MWTs outdoors (6MWTsa1 and 6MWTsa2, at least 48 h apart) using a free smartphone app. Results: The agreement between accelerometer- and app-based total step counts was limited (mean difference, −58.7 steps (−8.7%): 95% confidence interval, −326.5 (−46.8%) to 209.1 (29.3%)). The best algorithm for predicting the 6MWTsupm included: 795.456 + (0.815 heightm app-steps) − (1.620 ageyears) − (3.005 weightkg) − (1.155 app-steps), R2 = 0.609). The intraclass correlation coefficient between 6MWTsa2 and 6MWTsa1 was excellent (0.91: 0.81–0.96). The coefficient of variation was 6.4%. The agreement between the two self-administered tests was narrow (−1.9 (0.2%) meters: −57.4 (−9.5%) to 61.3 (9.9%)). Conclusions: The self-administered 6MWT has excellent reliability and reproducibility in asymptomatic adults, being a valuable tool for assessing CRF in community-based interventions.

BackgroundThere are currently more than 200 million smartphones in Brazil. The potential of mobile technologies for favorable changes in health behavior such as physical activity has been previously described in the literature. Results of surveys in developed countries indicate that applications (APPs) are developed for people who are better educated, younger, and with higher incomes compared to non-users. However, the profile of users in developing countries like Brazil is not well-known. Understanding the profile of APP users might ease the development turned to physically inactive people and those at higher cardiovascular risk. Furthermore, the physiological and functional factors associated with the use of such APP are unknown.ObjectivesTo characterize the profile of APP users to monitor the physical activity level (PAL) and assess the demographic, socioeconomic, clinical, physiological, and functional characteristics associated with the use of smartphone APPs to monitor physical activity in Brazilian adults.MethodsWe assessed 176 asymptomatic men and 178 women (43 ± 12 years; 27 ± 5 kg/m2). We initially asked participants about their current use of a smartphone APP containing PAL monitoring functionality, such as exercise session logs and/or step counts. In a cross-sectional design, we investigated schooling, socioeconomic status (Critério Brasil), and classic self-reported cardiovascular risk factors. We evaluated several physiological and functional variables such as maximum O2 consumption on a treadmill (VO2 max), blood pressure, body composition (bioelectrical impedance), handgrip strength, and isokinetic muscle strength of the dominant lower limb. Participants used a triaxial accelerometer for 7 days to quantify daily physical activity. We also assessed health-related quality of life (WHOQOL BREF), perceived stress (PSS14 Scale), and the built environment (NEWS Scale). We compared continuous variables using the Student's t-test and categorical variables using the χ2 test, between APP users and non-users. After univariate analysis, we included the main variables associated with the use of APP in a multiple logistic regression model.ResultsOne hundred and two participants (28.3%), unrelated to gender, reported using a smartphone APP for physical activity at the time of assessment. Except for perceived stress and the built environment that were not associated with the use of APP, users of APP were younger and had higher education, lower cardiovascular risk, better socioeconomic status, a better quality of life, better cardiorespiratory function, better body composition, greater physical fitness and more moderate to vigorous physical activity in daily life. The results of the multiple logistic regression showed that age, hypertension, VO2 max, socioeconomic status (Critério Brasil), and quality of life (WHOQOL BREF total score) were the variables most significantly associated with the use of the APP.ConclusionsOur results indicate that smartphone APPs to monitor physical activity are developed for younger adults with better socioeconomic status, lower cardiovascular risk, higher quality of life, and greater cardiorespiratory fitness. Greater efforts are needed to develop a science-based APP for people who most need this technology, enabling greater potential to prevent undesirable health outcomes in asymptomatic adults.

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UNSTRUCTURED Background: The SMART design allows for changes in the intervention during the randomized controlled trial period. Despite its potential and feasibility for defining the best sequence of interventions, so far, it has never been utilized in a smartphone/gamified intervention for physical activity. Objectives: To investigate the feasibility of a SMART design for assessing the effects of a smartphone app intervention to improve physical activity in adults. We also aimed to describe the participants’ perception regarding the protocol and the use of the app for physical activity qualitatively. Secondarily, we aimed to analyze the participants’ response to the intervention. Methods: We conducted a feasibility 24-week/2-stage SMART [ReBEC #RBR-8xtc9c] in which 18 insufficiently active participants (< 10,000 steps per day) were first randomized to Group 1 (smartphone app only), Group 2 (smartphone app + tailored messages) and a Control Group. Participants were motivated to increase at least 2,000 steps/day on average each week. Based on the 12-week intermediate outcome, responders kept their interventions and non-responders were re-randomized to subsequent treatment, including a new group 3 (Smartphone app + gamification) in which participants were instructed to form groups to use several game elements available in the chosen application (Pacer®). Participants in the Control group were instructed to maintain their usual routine during all protocol. We fit linear regressions for each participant with the relationship between weeks and steps per day. We considered responders those with any positive slope at the end of the 1st stage intervention. We compared the accelerometer-based steps per day before and after the intervention as well as the slopes of the app-based steps per day between the first and second stages of treatment. Results: Twelve participants, including five controls, finished the intervention. We identified two responders in Group 1. We did not observe significant changes in the steps per day, neither throughout the intervention nor compared to the control Group. However, the re-randomization of the five non-responders led to a change in the slope of the steps per day of a median, -198 steps per day (interquartile range, -279 to -103) to 20 steps/day (-204 to 145), P = .079. Finally, we observed in three participants in the Group 2 an increase in the number of steps per day up to the sixth week followed by an inflection to baseline values or even lower (i.e., a quadratic relationship). The qualitative analysis showed that participants’ reports could be classified into three categories: (1) difficulty in managing the app and technology or problems with the device, (2) suitable response to the app, and (3) difficulties to achieve the goals. Conclusions: The SMART design was feasible and changed the behavior of the steps per day after re-randomization. Our results suggest that the re-randomization should be implemented earlier to take advantage of the tailored messages. Also, difficulties with technology and a realistic and individualized goal should be considered in interventions for physical activity using smartphones. Brazilian Clinical Trials Registry (ReBEC #RBR-8xtc9c)

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BACKGROUND Physical inactivity is the fourth leading risk factor for mortality worldwide. Currently, we count on technologies’ vertiginous advances, mostly in smartphone applications (apps), which showed to be useful in the introduction or expansion of physical activity. However, little attention has been paid to understanding the viewpoint of researchers from human movement sciences. OBJECTIVE To understand the perception of researchers from human movement sciences about using a smartphone app to promote physical activity behavior change. METHODS Ten physically active researchers (8 men and 2 women, mean [SD] age 32.4 [5.21] years), users of the Pacer smartphone app participated in a focus group. The focus group lasted two hours and was mediated by the first author using guiding questions grouped into three categories: app features, barriers and facilitators to physical activity and challenges to behavior change. We performed a qualitative analysis, using the content analysis approach based on the audio records, using participants' verbal reports as a unit of analysis. RESULTS The focus group revealed that physical activity has always been present in the participants' lives. Participants identified changes in their patterns of physical activity over time, incorporating technologies during their exercise sessions. They realized that throughout life the goal in physical activity changed from improving performance to improving health. Participants' life history of physical activity was associated with their preference for the app that stimulated competitiveness. The possibility of competing and being rewarded by their achievements are essential motivational tools. In this way, participants appreciated the possibility of creating groups and ranking among them. As facilitators for physical activity, the group pointed to the adequate city infrastructure and the possibilities of exercising with someone and being challenged by colleagues. As barriers, participants listed a lack of safety and the need to take the smartphone for the app using. CONCLUSIONS Our study reporting challenges and possibilities to drive changes in physical activity behavior by using smartphone apps. The focus group provided important resources and characteristics that had a positive impact on the behavior change and should be considered, such as: the participants’ challenge of overcoming themselves, the opportunity to compete with their peers to achieve personal goals, and the possibility to measure the amount of physical activity. These finds can contribute to improving app development and user acceptability, especially regarding features based on behavior change techniques. Additionally, although this is a descriptive qualitative study with a limited sample, using a smartphone app seems to contribute to physical activity behavior change, even among participants with adequate levels of physical activity.