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Abstract Background The steep increase in knee arthroplasties in lower- and middle-income countries has increased demand for personalised rehabilitation care. Technology-based rehabilitation programs offer potential to replace or augment conventional face-to-face rehabilitation for providing continuum of care. We aimed to systematically develop a theory, evidence-driven, contextualised, and user-centred mobile health platform for people undergoing knee arthroplasty to facilitate monitoring progress during rehabilitation. Methods We followed the UK Medical Research Council’s framework and adopted a behaviour design thinking approach, consisting of five steps; (1) conduct multiple literature reviews and cross-sectional surveys to determine the needs and problems experienced during the rehabilitation phase by healthcare professionals and individuals with replaced knees, (2) identify target behaviours along with barriers and facilitators, integrated within the Capability, Opportunity, Motivation-Behaviour (COM-B) framework, (3) identify intervention functions and components, behaviour change techniques, and features for the mobile application, selected after discussions with orthopaedic surgeons, physiotherapists and behavioural experts, (4) develop a prototype application for end-users, and a web-based platform for healthcare professionals, and (5) pilot test the intervention for end-users’ feedback on usability of the application and to identify possible strategies for implementing the intervention package. Results Using the COM-B model, education, training, persuasion, enablement, and modelling were chosen as intervention functions for improving adherence to exercise protocol during early-phase of rehabilitation. The application featured five interlinked components; education, training, goal setting and self-management, communication, and a personalized therapy plan utilising 13 behaviour change techniques. An education booklet, exercise videos, text messaging, video consultation, and a digital tool for measuring range of motion were incorporated into the application. Feedback on the interactive prototype and education material was sought from ten patient volunteers and a physiotherapist. Pilot testing in a convenient sample with broad eligibility criteria (n = 30) indicated importance of digital literacy and dedicated time for remote consultation by healthcare provider within the existing clinical work. Overall, the intervention was well received and valued by the end users. Conclusion This paper demonstrates the development of a contextualised digital behavioural intervention grounded in behavioural theory and evidence from literature to improve end-user’s engagement with rehabilitation protocols after knee arthroplasty in lower- and middle-income country context. Trial registration Study registered prospectively (on 16 February 2023) at Clinical Trials Registry of India (CTRI/2023/02/049792).

Abstract BackgroundStrong evidence supports the benefits of exercise following both cardiovascular disease and cancer diagnoses. However, less than one-third of Australians who are referred to exercise rehabilitation complete a program following a cardiac diagnosis. Technological advances make it increasingly possible to embed real-time supervision, tailored exercise prescription, behavior change, and social support into home-based programs. ObjectiveThis study aimed to explore demographic and health characteristics associated with the likelihood of breast cancer survivors uptaking a digitally delivered cardiac exercise rehabilitation program and to determine whether this differed according to intervention timing (ie, offered generally, before, during, or after treatment). Secondary aims were to explore the knowledge of cardiac-related treatment side-effects, exercise behavior, additional intervention interests (eg, diet, fatigue management), and service fee capabilities. MethodsThis cross-sectional study involved a convenience sample of breast cancer survivors recruited via social media. A self-reported questionnaire was used to collect outcomes of interests, including the likelihood of uptaking a digitally delivered cardiac exercise rehabilitation program, and demographic and health characteristics. Descriptive statistics were used to summarize sample characteristics and outcomes. Ordered logistic regression models were used to examine associations between demographic and health characteristics and likelihood of intervention uptake generally, before, during, and after treatment, with odds ratios (ORs) 1.5 defined as clinically meaningful and statistical significance a priori set at P ResultsA high proportion (194/208, 93%) of the sample (mean age 57, SD 11 years; median BMI=26, IQR 23‐31 kg/m2PP ConclusionsThese findings can be used to better inform future research and the development of intervention techniques that are critical to improving the delivery of a digital service model that is effective, equitable, and accessible, specifically, by enhancing digital inclusion, addressing general exercise barriers experienced by chronic disease populations, incorporating multidisciplinary care, and developing affordable delivery models.

Background: The Global Burden of Disease (GBD) 2021 study updated methods for attributing burden to physical inactivity, to include all conditions from fasting plasma glucose (FPG) due to physical inactivity. However, physical inactivity influences several additional GBD risk factors that also effect other diseases. This study estimated effects of physical activity on high blood pressure (hypertension), FPG (as diabetes), osteoporosis, and LDL-cholesterol, to enable mediation effects modelling. Methods: MEDLINE, ProQuest Central, Scopus, EMBASE, SPORTDiscus, and Cochrane Library databases were searched from inception to 29 June 2024 for systematic reviews reporting total physical activity levels as an exposure and at least one of the above GBD risk factors or BMI as outcomes. Results: There were 25 systematic reviews that met the inclusion criteria (3 for hypertension, 5 for diabetes, 1 for osteoporosis, and 16 for LDL-cholesterol). Physical activity reduced levels of the risk factors investigated, with dose–response effects observed for blood pressure (6 % for every 600 MET-min/week; 19 % for high versus low activity level) and diabetes (14–28 % if active versus being inactive). Relative to adults not reporting any activity, approximately 600 METs/week reduced levels of LDL-cholesterol by 3.2 % (95 % CI: 1.0 % to 5.4 %) and reduced low bone mineral density by an odds ratio of 0.76 (0.64 to 0.91). No studies of high BMI were identified. Conclusion: Current risk factor models do not comprehensively assess indirect effects of physical activity through all of the relevant biomedical risk factors. Our study estimated input parameters that can be used to assess these indirect pathways.

Objective Helping people to change their health behaviours is becoming a greater feature within the role of health professionals, including through whole system initiatives such as Making Every Contact Count. Health services provide an ideal setting to routinely promote health behaviours, including physical activity. Snacktivity is a novel approach that promotes small bouts of physical activity (activity snacks) throughout the day. This study explored health professionals’ initial experiences of delivering a Snacktivity intervention to promote physical activity within routine health consultations. A further aim was to investigate health professionals’ ability/fidelity in delivering the Snacktivity intervention to their patients.Design Semistructured interviews (n=11) and audio recording of consultations (n=46).Setting and participants Healthcare professionals from a variety of specialisms who delivered the Snacktivity intervention within patient consultations.Results Analyses revealed two higher-level themes of interest: (1) health professionals’ conceptualisation of Snacktivity (subthemes: observations/reflections about patients’ understanding, engagement and enthusiasm for delivering the Snacktivity intervention) and (2) health professionals’ understanding of Snacktivity and experience in delivering the intervention (subthemes: delivering Snacktivity; limitations, challenges and possible improvements). Consultation audio recordings demonstrated health professionals delivered the Snacktivity intervention with high levels of fidelity. Health professionals were proficient and supportive of delivering the Snacktivity intervention within consultations although practical barriers to implementation such as time constraints were raised, and confidence in doing so was mixed.Conclusions Health professionals were proficient and supportive of delivering the Snacktivity intervention within consultations. The primary barrier to implementation was the time to deliver it, however, gaining greater experience in the intervention and improving behaviour change counselling skills may reduce this barrier.Trial registration number ISRCTN64851242.

BackgroundCardiometabolic diseases (CMDs) are a group of interrelated conditions, including heart failure and diabetes, that increase the risk of cardiovascular and metabolic complications. The rising number of Australians with CMDs has necessitated new strategies for those managing these conditions, such as digital health interventions. The effectiveness of digital health interventions in supporting people with CMDs is dependent on the extent to which users engage with the tools. Augmenting digital health interventions with conversational agents, technologies that interact with people using natural language, may enhance engagement because of their human-like attributes. To date, no systematic review has compiled evidence on how design features influence the engagement of conversational agent–enabled interventions supporting people with CMDs. This review seeks to address this gap, thereby guiding developers in creating more engaging and effective tools for CMD management. ObjectiveThe aim of this systematic review is to synthesize evidence pertaining to conversational agent–enabled intervention design features and their impacts on the engagement of people managing CMD. MethodsThe review is conducted in accordance with the Cochrane Handbook for Systematic Reviews of Interventions and reported in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Searches will be conducted in the Ovid (Medline), Web of Science, and Scopus databases, which will be run again prior to manuscript submission. Inclusion criteria will consist of primary research studies reporting on conversational agent–enabled interventions, including measures of engagement, in adults with CMD. Data extraction will seek to capture the perspectives of people with CMD on the use of conversational agent–enabled interventions. Joanna Briggs Institute critical appraisal tools will be used to evaluate the overall quality of evidence collected. ResultsThis review was initiated in May 2023 and was registered with the International Prospective Register of Systematic Reviews (PROSPERO) in June 2023, prior to title and abstract screening. Full-text screening of articles was completed in July 2023 and data extraction began August 2023. Final searches were conducted in April 2024 prior to finalizing the review and the manuscript was submitted for peer review in July 2024. ConclusionsThis review will synthesize diverse observations pertaining to conversational agent–enabled intervention design features and their impacts on engagement among people with CMDs. These observations can be used to guide the development of more engaging conversational agent–enabled interventions, thereby increasing the likelihood of regular intervention use and improved CMD health outcomes. Additionally, this review will identify gaps in the literature in terms of how engagement is reported, thereby highlighting areas for future exploration and supporting researchers in advancing the understanding of conversational agent–enabled interventions. Trial RegistrationPROSPERO CRD42023431579; https://tinyurl.com/55cxkm26 International Registered Report Identifier (IRRID)DERR1-10.2196/52973

Objectives We sought to extrapolate the long-term costs and clinical impacts attributed to the rugby fans in training–New Zealand (RUFIT-NZ) trial in Aotearoa, New Zealand.Design A modelled cost-effectiveness analysis using efficacy data from RUFIT-NZ was conducted from the Aotearoa New Zealand healthcare perspective.Setting A Markov cohort model was constructed with a lifetime time horizon. The model simulated events of myocardial infarction (MI), stroke and type 2 diabetes mellitus (T2DM) occurring among a hypothetical cohort of 10 000 individuals receiving either the RUFIT-NZ intervention or no intervention. Efficacy data were based on the RUFIT-NZ trial, and the latest Global Burden of Disease study was used to extrapolate the impact of body weight reduction on clinical outcomes of T2DM, MI or stroke. Cost and utility data were drawn from the RUFIT-NZ trial and published sources.Primary outcome measures The incremental cost-effectiveness ratio (ICER).Results Over a lifetime time horizon, participants in the RUFIT-NZ intervention gained 0.02 (discounted) quality-adjusted life years (QALYs) at an additional cost of NZ$863, relative to no intervention. The estimated ICER was NZ$49 515 per QALY gained (discounted), which is above the arbitrary willingness-to-pay threshold of NZ$45 000 per QALY. Sensitivity analyses supported the robustness of these findings.Conclusions RUFIT-NZ was associated with a reduction in cardiovascular and endocrine events for overweight and obese males. However, based on conservative assumptions, RUFIT-NZ was unlikely to be cost-effective from a healthcare system perspective.Trial registration number ACTRN12619000069156.

Objective Theoretical frameworks are essential for understanding behaviour change, yet their current use is inadequate to capture the complexity of human behaviour such as physical activity. Real-time and big data analytics can assist in the development of more testable and dynamic models of current theories. To transform current behavioural theories into more dynamic models, it is recommended that researchers adopt principles such as control systems engineering. In this article, we aim to describe a control system model of capability-opportunity-motivation and behaviour (COM-B) framework for reducing sedentary behaviour (SB) and increasing physical activity (PA) in adults. Methods The COM-B model is explained in terms of control systems. Examples of effective behaviour change techniques (BCTs) (e.g. goal setting, problem-solving and social support) for reducing SB and increasing PA were mapped to the COM-B model for illustration. Result A fluid analogy of the COM-B system is presented. Conclusions The proposed integrated model will enable empirical testing of individual behaviour change components (i.e. BCTs) and contribute to the optimisation of digital behaviour change interventions.

Abstract Background Diets low in vegetables are a main contributor to the health burden experienced by Australians living in rural communities. Given the ubiquity of smartphones and access to the Internet, digital interventions may offer an accessible delivery model for a dietary intervention in rural communities. However, no digital interventions to address low vegetable intake have been co-designed with adults living in rural areas. This paper describes the co-design of a digital intervention to improve vegetable intake with rural community members and research partners. Methods Active participants in the co-design process were adults ≥ 18 years living in three rural Australian communities (total n = 57) and research partners (n = 4) representing three local rural governments and one peak non-government health organisation. An iterative co-design process was undertaken to understand the needs (pre-design phase) and ideas (generative phase) of the target population. Eight online workshops and a community survey were conducted between July and December 2021. The MoSCoW prioritisation method was used to help participants identify the ‘Must-have, Should-have, Could-have, and Won’t-have or will not have right now’ features and functions of the digital intervention. Workshops were transcribed and inductively analysed using NVivo. Convergent and divergent themes were identified between the workshops and community survey to identify how to implement the digital intervention in the community. Results Consensus was reached on a concept for a digital intervention that addressed individual and food environment barriers to vegetable intake, specific to rural communities. Implementation recommendations centred on (i) food literacy approaches to improve skills via access to vegetable-rich recipes and healthy eating resources, (ii) access to personalisation options and behaviour change support, and (iii) improving the community food environment by providing information on and access to local food initiatives. Conclusions Rural-dwelling adults expressed preferences for personalised intervention features that can enhance food literacy and engagement with community food environments. This research will inform the development of the prototyping (evaluation phase) and feasibility testing (post-design phase) of this intervention.

BackgroundExercise rehabilitation is a promising strategy for reducing cardiovascular disease risk among patients with breast cancer. However, the evidence is primarily derived from programs based at exercise centers with in-person supervised delivery. Conversely, most patients report a preference for home-based rehabilitation. As such, there is a clear need to explore strategies that can provide real-time supervision and coaching while addressing consumer preferences. Evidence from cardiac rehabilitation has demonstrated the noninferiority of a smartphone-based telerehabilitation approach (REMOTE-CR) to improve cardiorespiratory fitness in people with cardiovascular disease compared to a center-based program. ObjectiveThis study aims to assess the feasibility, safety, and preliminary efficacy of the REMOTE-CR program adapted for patients with breast cancer at risk of cardiotoxicity (REMOTE-COR-B). We will also assess the satisfaction and usability of REMOTE-COR-B. MethodsWe will conduct a single-arm feasibility study of the REMOTE-COR-B program among patients with stage I-III breast cancer who are at risk of cardiotoxicity (taking treatment type and dose, as well as other common cardiovascular disease risk factors into account) and who are within 24 months of completing primary definitive treatment. Participants (target sample size of 40) will receive an 8-week smartphone-based telerehabilitation exercise program involving remotely delivered real-time supervision and behavior change support. The platform comprises a smartphone and wearable heart rate monitor, as well as a custom-built smartphone app and web application. Participants will be able to attend remotely monitored exercise sessions during set operating hours each week, scheduled in both the morning and evening. Adherence is the primary outcome of the trial, assessed through the number of remotely monitored exercise sessions attended compared to the trial target (ie, 3 sessions per week). Secondary outcomes include additional trial feasibility indicators (eg, recruitment and retention), safety, satisfaction, and usability, and objective and patient-reported efficacy outcomes (cardiovascular fitness, quality of life, fatigue, self-reported exercise, self-efficacy, habit strength, and motivation). Adherence, feasibility, and safety outcomes will be assessed during the intervention period; intervention satisfaction and usability will be assessed post intervention; and objective and patient-reported efficacy outcomes will be assessed at baseline, post intervention (2-month postbaseline assessment), and at follow-up (5-month postbaseline assessment). ResultsRecruitment for this trial commenced in March 2023, and 7 participants had been recruited as of the submission of the manuscript. The estimated completion date for the project is October 2024, with results expected to be published in mid-2025. ConclusionsThe REMOTE-COR-B intervention is a novel and promising approach to providing exercise therapy to patients with breast cancer at risk of cardiotoxicity who have unique needs and heightened safety risks. This project will provide important information on the extent to which this approach is satisfactory to patients with breast cancer, safe, and potentially effective, which is necessary before larger-scale research or clinical projects. Trial RegistrationAustralian New Zealand Clinical Trials Registry ACTRN12621001557820; www.anzctr.org.au/ACTRN12621001557820.aspx International Registered Report Identifier (IRRID)DERR1-10.2196/53301

BackgroundGlobally, heart failure (HF) affects more than 64 million people, and attempts to reduce its social and economic burden are a public health priority. Interventions to support people with HF to self-manage have been shown to reduce hospitalizations, improve quality of life, and reduce mortality rates. Understanding how people self-manage is imperative to improve future interventions; however, most approaches to date, have used self-report methods to achieve this. Wearable cameras provide a unique tool to understand the lived experiences of people with HF and the daily activities they undertake, which could lead to more effective interventions. However, their potential for understanding chronic conditions such as HF is unclear. ObjectiveThis study aimed to determine the potential utility of wearable cameras to better understand the activities of daily living in people living with HF. MethodsThe “Seeing is Believing (SIB)” study involved 30 patients with HF who wore wearable cameras for a maximum of 30 days. We used the E-Myscéal web-based lifelog retrieval system to process and analyze the wearable camera image data set. Search terms for 7 daily activities (physical activity, gardening, shopping, screen time, drinking, eating, and medication intake) were developed and used for image retrieval. Sensitivity analysis was conducted to compare the number of images retrieved using different search terms. Temporal patterns in daily activities were examined, and differences before and after hospitalization were assessed. ResultsE-Myscéal exhibited sensitivity to specific search terms, leading to significant variations in the number of images retrieved for each activity. The highest number of images returned were related to eating and drinking, with fewer images for physical activity, screen time, and taking medication. The majority of captured activities occurred before midday. Notably, temporal differences in daily activity patterns were observed for participants hospitalized during this study. The number of medication images increased after hospital discharge, while screen time images decreased. ConclusionsWearable cameras offer valuable insights into daily activities and self-management in people living with HF. E-Myscéal efficiently retrieves relevant images, but search term sensitivity underscores the need for careful selection.

Abstract Background Fussy eating is most often a developmentally typical behaviour, generally presenting during toddlerhood. However, up to half of parents of young children are concerned about fussy eating, and this concern may mediate the use of nonresponsive feeding practises, such as coercive or unstructured feeding and using food to reward eating. Despite the high prevalence of parental concern for fussy eating and the negative impacts nonresponsive feeding practises have on children’s health and diets, no previous digital intervention to improve the feeding practises of parents of toddlers concerned about fussy eating has been evaluated. Aim This article describes the protocol of a randomised controlled feasibility pilot aiming to evaluate Fussy Eating Rescue, a purely web app based intervention for parents of toddlers. The primary aim is to investigate feasibility and acceptability; secondary aims are to explore indications of intervention effect on parents’ feeding practises or children’s eating behaviours. Methods Fussy Eating Rescue features include: (1) a Tracker, that allows parents to track repeated offers of food, (2) Topics, providing information on fussy eating, effective feeding strategies, and general nutrition, (3) Rescues, containing quick references to material supporting Topics contents, (4) Recipes, and (5) SMS notifications. Parents of toddlers (12–36 months old, n = 50) who have concerns about fussy eating will be recruited via Facebook. Parents will be randomised to an intervention group, which receives access to the app for 6 weeks, or to wait-listed control. Outcomes will be assessed at baseline and 6 weeks after app use, using online questionnaires and app usage statistics. Primary outcomes include participant retention rate, intervention engagement, app usability, perceived ease in using the app, perceived usefulness of the app, and user satisfaction. Secondary outcome measures include parents’ feeding practises and children’s eating behaviours. Discussion Results will inform whether Fussy Eating Rescue is a feasible way to engage parents concerned for their toddler’s fussy eating behaviours. If feasible and acceptable to users, a larger trial will further examine the efficacy of the Fussy Eating app in improving parents’ feeding practises and children’s eating behaviours. Trial registration Prospectively registered with the Australian New Zealand Clinical Trials Registry on 15 July, 2021 (ACTRN12621000925842).

BackgroundThis study assesses the accuracy of a Bluetooth-enabled prototype activity tracker called the Sedentary behaviOR Detector (SORD) device in identifying sedentary, standing, and walking behaviors in a group of adult participants. ObjectiveThe primary objective of this study was to determine the criterion and convergent validity of SORD against direct observation and activPAL. MethodsA total of 15 healthy adults wore SORD and activPAL devices on their thighs while engaging in activities (lying, reclining, sitting, standing, and walking). Direct observation was facilitated with cameras. Algorithms were developed using the Python programming language. The Bland-Altman method was used to assess the level of agreement. ResultsOverall, 1 model generated a low level of bias and high precision for SORD. In this model, accuracy, sensitivity, and specificity were all above 0.95 for detecting sitting, reclining, standing, and walking. Bland-Altman results showed that mean biases between SORD and direct observation were 0.3% for sitting and reclining (limits of agreement [LoA]=–0.3% to 0.9%), 1.19% for standing (LoA=–1.5% to 3.42%), and –4.71% for walking (LoA=–9.26% to –0.16%). The mean biases between SORD and activPAL were –3.45% for sitting and reclining (LoA=–11.59% to 4.68%), 7.45% for standing (LoA=–5.04% to 19.95%), and –5.40% for walking (LoA=–11.44% to 0.64%). ConclusionsResults suggest that SORD is a valid device for detecting sitting, standing, and walking, which was demonstrated by excellent accuracy compared to direct observation. SORD offers promise for future inclusion in theory-based, real-time, and adaptive interventions to encourage physical activity and reduce sedentary behavior.

BackgroundSuccessful post-knee replacement rehabilitation requires adequate access to health information, social support, and periodic monitoring by a health professional. Mobile health (mHealth) and computer-based technologies are used for rehabilitation and remote monitoring. The extent of technology use and its function in post-knee replacement rehabilitation care in low and middle-income settings are unknown. ObjectiveTo inform future mHealth intervention development, we conducted a scoping review to map the features and functionality of existing technologies and determine users’ perspectives on telerehabilitation and technology for self-management. MethodsWe followed the Joanna Briggs Institute methodology for scoping reviews. We searched the Embase, Medline, PsycINFO via OVID, and Cochrane Central Register of Controlled Trials databases for manuscripts published from 2001 onward. We included original research articles reporting the use of mobile or computer-based technologies by patients, health care providers, researchers, or family members. Studies were divided into the following 3 categories based on the purpose: validation studies, clinical evaluation, and end user feedback. We extracted general information on study design, technology features, proposed function, and perspectives of health care providers and patients. The protocol for this review is accessible in the Open Science Framework. ResultsOf the 5960 articles, 158 that reported from high-income settings contributed to the qualitative summary (64 studies on mHealth or telerehabilitation programs, 28 validation studies, 38 studies describing users’ perceptions). The highest numbers of studies were from Europe or the United Kingdom and North America regarding the use of a mobile app with or without wearables and reported mainly in the last decade. No studies were from low and middle-income settings. The primary functions of technology for remote rehabilitation were education to aid recovery and enable regular, appropriate exercises; monitoring progress of pain (n=19), activity (n=20), and exercise adherence (n=30); 1 or 2-way communication with health care professionals to facilitate the continuum of care (n=51); and goal setting (n=23). Assessment of range of motion (n=16) and gait analysis (n=10) were the commonly validated technologies developed to incorporate into a future rehabilitation program. Few studies (n=14) reported end user involvement during the development stage. We summarized the reasons for satisfaction and dissatisfaction among users across various technologies. ConclusionsSeveral existing mobile and computer-based technologies facilitate post-knee replacement rehabilitation care for patients and health care providers. However, they are limited to high-income settings and may not be extrapolated to low-income settings. A systematic needs assessment of patients undergoing knee replacement and health care providers involved in rehabilitation, involving end users at all stages of development and evaluation, with clear reporting of the development and clinical evaluation can make post-knee replacement rehabilitation care in resource-poor settings accessible and cost-effective.

Introduction Diets low in vegetables are a main contributor to the health burden experienced by young adults in rural communities. Digital health interventions provide an accessible delivery model that can be personalised to meet the diverse preferences of young adults. A personalisable digital vegetable intake intervention (Veg4Me) was codesigned to meet the needs of young adults living in rural communities. This study will determine the feasibility of delivering a personalised Veg4Me programme and compare preliminary effects with a non-personalised Veg4Me (control).Methods and analysis A 12-week assessor-blinded, two-arm, parallel randomised controlled trial will be undertaken from August 2023 until April 2024. A total of 150 eligible and consenting young adults (18–35 years; eat

The effective management of chronic conditions requires an approach that promotes a shift in care from the clinic to the home, improves the efficiency of health care systems, and benefits all users irrespective of their needs and preferences. Digital health can provide a solution to this challenge, and in this paper, we provide our vision for a smart health ecosystem. A smart health ecosystem leverages the interoperability of digital health technologies and advancements in big data and artificial intelligence for data collection and analysis and the provision of support. We envisage that this approach will allow a comprehensive picture of health, personalization, and tailoring of behavioral and clinical support; drive theoretical advancements; and empower people to manage their own health with support from health care professionals. We illustrate the concept with 2 use cases and discuss topics for further consideration and research, concluding with a message to encourage people with chronic conditions, their caregivers, health care professionals, policy and decision makers, and technology experts to join their efforts and work toward adopting a smart health ecosystem.

BackgroundThe COVID-19 pandemic led to changes in the delivery of exercise physiology services. The lived experience of those who continued to provide or receive exercise physiology services during the heightened public health restrictions of the inaugural year of the COVID-19 pandemic has received little attention to date. Acquiring this knowledge will be fundamental in addressing whether telehealth is a viable option for service delivery in exercise care, research, and policy. This is especially pertinent in the wake of the COVID-19 pandemic and subsequent global interest in digital health delivery of health care services. ObjectiveThis study aims to explore the clinician and client experiences and perspectives of exercise physiology services delivered in person or via telehealth during the inaugural year of the COVID-19 pandemic (after January 25, 2020; the date of the first confirmed case in Australia). MethodsEligible participants for this study were adult (aged 18 years or older; capable of understanding and writing in English) clients who received and clinicians who delivered 1 or more exercise physiology sessions in Australia during the first year of the COVID-19 pandemic (June 2020 to June 2021). The data collection period spanned from January 20, 2021, to September 24, 2021. A total of 18 semistructured individual interviews were conducted with accredited exercise physiologists (n=7) and clients (n=11) who engaged with exercise physiology services during this period. All interviews were digitally recorded and transcribed verbatim. Thematic analysis was conducted with themes and subthemes derived using deductive and inductive approaches. ResultsA total of 3 dominant themes, each with 2 subthemes, were identified. The first theme was that telehealth enables access to services but limits the use of some clinical tools. Remote access to services was valued by both clinicians and clients, but the exercise clinical environment could not be replicated over telehealth. This was especially true regarding access to exercise equipment. Second, engagement and the “relational space” are limited by telehealth. Perceived challenges regarding social interactions and a sense of community were a limitation for clients, and difficulties fostering clinician-client report were noted by clinicians. Finally, technological challenges are pervasive in the telehealth delivery of exercise services. Both clinicians and clients noted that systems necessary to facilitate telehealth frequently disrupted delivery, and client-based technical issues were influenced by digital health literacy. ConclusionsShared client and accredited exercise physiologist experiences highlight key considerations for the ongoing implementation of telehealth to facilitate the uptake and effectiveness of exercise physiology services. These findings imply that the co-design of solutions to client-perceived limitations of telehealth delivery is warranted.

Abstract Background Many people do not regularly participate in physical activity, which may negatively impact their health. Current physical activity guidelines are focused on promoting weekly accumulation of at least 150 min of moderate to vigorous intensity physical activity (MVPA). Whilst revised guidance now recognises the importance of making small changes to physical activity behaviour, guidance still focuses on adults needing to achieve at least 150 min of MVPA per week. An alternative ‘whole day’ approach that could motivate the public to be more physically active, is a concept called Snacktivity™. Instead of focusing on achieving 150 min per week of physical activity, for example 30 min of MVPA over 5 days, Snacktivity™ encourages the public to achieve this through small, but frequent, 2–5 min ‘snacks’ of MVPA throughout the whole day. Methods The primary aim is to undertake a feasibility trial with nested qualitative interviews to assess the feasibility and acceptability of the Snacktivity™ intervention to inform the design of a subsequent phase III randomised trial. A two-arm randomised controlled feasibility trial aiming to recruit 80 inactive adults will be conducted. Recruitment will be from health and community settings and social media. Participants will be individually randomised (1:1 ratio) to receive either the Snacktivity™ intervention or usual care. The intervention will last 12 weeks with assessment of outcomes completed before and after the intervention in all participants. We are interested in whether the Snacktivity™ trial is appealing to participants (assessed by the recruitment rate) and if the Snacktivity™ intervention and trial methods are acceptable to participants (assessed by Snacktivity™/physical activity adherence and retention rates). The intervention will be delivered by health care providers within health care consultations or by researchers. Participants’ experiences of the trial and intervention, and health care providers’ views of delivering the intervention within health consultations will be explored. Discussion The development of physical activity interventions that can be delivered at scale are needed. The findings from this study will inform the viability and design of a phase III trial to assess the effectiveness and cost-effectiveness of Snacktivity™ to increase physical activity. Trial registration ISRCTN: 64851242.

Abstract Non-alcoholic fatty liver disease (NAFLD) is the most common chronic liver disease, which can progress from simple steatosis to advanced cirrhosis and hepatocellular carcinoma. Clinical diagnosis of NAFLD is crucial in the early stages of the disease. The main aim of this study was to apply machine learning (ML) methods to identify significant classifiers of NAFLD using body composition and anthropometric variables. A cross-sectional study was carried out among 513 individuals aged 13 years old or above in Iran. Anthropometric and body composition measurements were performed manually using body composition analyzer InBody 270. Hepatic steatosis and fibrosis were determined using a Fibroscan. ML methods including k-Nearest Neighbor (kNN), Support Vector Machine (SVM), Radial Basis Function (RBF) SVM, Gaussian Process (GP), Random Forest (RF), Neural Network (NN), Adaboost and Naïve Bayes were examined for model performance and to identify anthropometric and body composition predictors of fatty liver disease. RF generated the most accurate model for fatty liver (presence of any stage), steatosis stages and fibrosis stages with 82%, 52% and 57% accuracy, respectively. Abdomen circumference, waist circumference, chest circumference, trunk fat and body mass index were among the most important variables contributing to fatty liver disease. ML-based prediction of NAFLD using anthropometric and body composition data can assist clinicians in decision making. ML-based systems provide opportunities for NAFLD screening and early diagnosis, especially in population-level and remote areas.

Abstract Background A healthy lifestyle program that appeals to, and supports, overweight and obese New Zealand (NZ) European, Māori (indigenous) and Pasifika men to achieve weight loss is urgently needed. A pilot program inspired by the successful Football Fans in Training program but delivered via professional rugby clubs in NZ (n = 96) was shown to be effective in weight loss, adherence to healthy lifestyle behaviors, and cardiorespiratory fitness in overweight and obese men. A full effectiveness trial is now needed. Aims To determine the effectiveness and cost effectiveness of Rugby Fans In Training-NZ (RUFIT-NZ) on weight loss, fitness, blood pressure, lifestyle change, and health related quality of life (HRQoL) at 12- and 52-weeks. Methods We conducted a pragmatic, two-arm, multi-center, randomized controlled trial in NZ with 378 (target 308) overweight and obese men aged 30–65 years, randomized to an intervention group or wait-list control group. The 12-week RUFIT-NZ program was a gender-sensitised, healthy lifestyle intervention delivered through professional rugby clubs. Each intervention session included: i) a 1-h workshop-based education component focused on nutrition, physical activity, sleep, sedentary behavior, and learning evidence-based behavior change strategies for sustaining a healthier lifestyle; and 2) a 1-h group-based, but individually tailored, exercise training session. The control group were offered RUFIT-NZ after 52-weeks. The primary outcome was change in body weight from baseline to 52-weeks. Secondary outcomes included change in body weight at 12-weeks, waist circumference, blood pressure, fitness (cardiorespiratory and musculoskeletal), lifestyle behaviors (leisure-time physical activity, sleep, smoking status, and alcohol and dietary quality), and health-related quality of life at 12- and 52-weeks. Results Our final analysis included 200 participants (intervention n = 103; control n = 97) who were able to complete the RUFIT-NZ intervention prior to COVID-19 restrictions. At 52-weeks, the adjusted mean group difference in weight change (primary outcome) was -2.77 kg (95% CI -4.92 to -0.61), which favored the intervention group. The intervention also resulted in favorable significant differences in weight change and fruit and vegetable consumption at 12-weeks; and waist circumference, fitness outcomes, physical activity levels, and health-related quality of life at both 12 and 52 weeks. No significant intervention effects were observed for blood pressure, or sleep. Incremental cost-effective ratios estimated were $259 per kg lost, or $40,269 per quality adjusted life year (QALY) gained. Conclusion RUFIT-NZ resulted in sustained positive changes in weight, waist circumference, physical fitness, self-reported physical activity, selected dietary outcomes, and health-related quality of life in overweight/obese men. As such, the program should be recommended for sustained delivery beyond this trial, involving other rugby clubs across NZ. Trial registration Australia New Zealand Clinical Trials Registry, ACTRN12619000069156. Registered 18 January 2019, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=376740 Universal Trial Number, U1111-1245–0645.

Abstract Background Digital interventions may help address low vegetable intake in adults, however there is limited understanding of the features that make them effective. We systematically reviewed digital interventions to increase vegetable intake to 1) describe the effectiveness of the interventions; 2) examine links between effectiveness and use of co-design, personalisation, behavioural theories, and/or a policy framework; and 3) identify other features that contribute to effectiveness. Methods A systematic search strategy was used to identify eligible studies from MEDLINE, Embase, PsycINFO, Scopus, CINAHL, Cochrane Library, INFORMIT, IEEE Xplore and Clinical Trial Registries, published between January 2000 and August 2022. Digital interventions to increase vegetable intake were included, with effective interventions identified based on statistically significant improvement in vegetable intake. To identify policy-action gaps, studies were mapped across the three domains of the NOURISHING framework (i.e., behaviour change communication, food environment, and food system). Risk of bias was assessed using Cochrane tools for randomized, cluster randomized and non-randomized trials. Results Of the 1,347 records identified, 30 studies were included. Risk of bias was high or serious in most studies (n = 25/30; 83%). Approximately one quarter of the included interventions (n = 8) were effective at improving vegetable intake. While the features of effective and ineffective interventions were similar, embedding of behaviour change theories (89% vs 61%) and inclusion of stakeholders in the design of the intervention (50% vs 38%) were more common among effective interventions. Only one (ineffective) intervention used true co-design. Although fewer effective interventions included personalisation (67% vs 81%), the degree of personalisation varied considerably between studies. All interventions mapped across the NOURISHING framework behaviour change communication domain, with one ineffective intervention also mapping across the food environment domain. Conclusion Few digital interventions identified in this review were effective for increasing vegetable intake. Embedding behaviour change theories and involving stakeholders in intervention design may increase the likelihood of success. The under-utilisation of comprehensive co-design methods presents an opportunity to ensure that personalisation approaches better meet the needs of target populations. Moreover, future digital interventions should address both behaviour change and food environment influences on vegetable intake.

Abstract Background The COVID-19 pandemic markedly changed how healthcare services are delivered and telehealth delivery has increased worldwide. Whether changes in healthcare delivery borne from the COVID-19 pandemic impact effectiveness is unknown. Therefore, we examined the effectiveness of exercise physiology services provided during the COVID-19 pandemic. Methods This prospective cohort study included 138 clients who received exercise physiology services during the initial COVID-19 pandemic. Outcome measures of interest were EQ-5D-5L, EQ-VAS, patient-specific functional scale, numeric pain rating scale and goal attainment scaling. Results Most (59%, n = 82) clients received in-person delivery only, whereas 8% (n = 11) received telehealth delivery only and 33% (n = 45) received a combination of delivery modes. Mean (SD) treatment duration was 11 (7) weeks and included 12 (6) sessions lasting 48 (9) minutes. The majority (73%, n = 101) of clients completed > 80% of exercise sessions. Exercise physiology improved mobility by 14% (β = 0.23, P = 0.003), capacity to complete usual activities by 18% (β = 0.29, P 0.087). Conclusions Exercise physiology services provided during the COVID-19 pandemic improved a range of client-reported outcomes regardless of delivery mode. Further exploration of cost-effectiveness is warranted.

Background/Objective: This article reports the methods and findings for Aotearoa New Zealand's 2022 Report Card on Physical Activity for Children and Youth indicators, and on inequities within these indicators. Methods: Grades were assigned to indicators using the Active Healthy Kids Global Alliance criteria depending on data availability, and inequities reported based on gender, ethnicity, disability status, area-level socioeconomic deprivation, urbanicity, and school year. Two additional indicators were included in this report card: Sleep, and Physical literacy. Results: Grades were assigned to indicators as follows: Overall physical activity: C+, Organised sport and physical activity: B-, Physical literacy: B, Active transportation: D, Sedentary behaviours: C-, Sleep: B+, Whānau (family) and peers: D, School: C+, Government: A. Inequities across all socio-demographic variables were observed. An ‘inconclusive’ grade was assigned to the Active play, Physical fitness, and Community and Environment indicators due to insufficient data. Conclusion: It is imperative that targeted, comprehensive, and population-specific approaches are implemented to support health-promoting physical activity behaviours and reduce inequities among children and youth in Aotearoa. There is a need to promote all dimensions of physical activity (overall activity, active play, recreation, organised sport, active transportation) and the reduction of screen time through policy, research, evidence-based social marketing campaigns, and urban design. Regular, nationally representative surveys that enable the consistent and regular measurement of key Report Card indicators are needed.

Abstract Background Insufficient physical activity (PA) is a risk factor for the development of many non-communicable diseases. Electric bicycles (e-bikes) offer considerable potential to support people to be physically active, however, no previous e-bike intervention studies have supported e-bike use with behavioural support. The aim of this study was to co-develop theory-based intervention components which can be used to increase physical activity through e-cycling among people who are overweight or obese and physically inactive. Methods We conducted a mixed-methods study using an online survey and virtual co-design workshops. We utilised the Behaviour Change Wheel (BCW) to inform the development of the behavioural support intervention to facilitate day-to-day e-cycling. Results One hundred participants completed an online survey and seven participated in the online co-design workshops. The development of the intervention identified five intervention functions (enablement, training, environmental restructuring, education, and persuasion) and 16 behaviour change techniques (BCTs) from 11 BCT groups (goals and planning, feedback and monitoring, social support, shaping knowledge, natural consequences, comparison of behaviour, associations, repetition and substitution, comparison of outcomes, antecedents, and self-belief). Conclusion To our knowledge, this is the first study to combine co-design and the BCW to develop a comprehensive behavioural support intervention for e-bike use. Theory based intervention options should be considered when providing e-bikes to individuals to help them increase their habitual PA levels.

BackgroundPeople with cardiovascular disease (CVD) need to engage in healthy lifestyle behaviours. However, there is a gap in identifying longitudinal patterns of change in lifestyle behaviours among people with CVD. This study aimed to identify clustering of lifestyle risk behaviours and their 4 ± year changes among UK adults with CVD, and to determine the associated factors.MethodsWe used the UK Biobank data collected at two time points (2006–2010/baseline data = T0 and 2014+/third visit data = T4). Six key lifestyle risk behaviours were assessed: smoking, high alcohol intake, poor fruit and vegetable consumption, physical inactivity, poor sleep balance (8 h/night) and prolonged sitting. A random intercept latent transition analysis was performed to identify patterns of lifestyle risk behaviours at T0 and their changes from T0 to T4.ResultsWe included 5,304 participants with CVD whose data on lifestyle risk behaviours were collected at two-time points. Alcohol intake and current smoking were 75.7% and 5.4% at baseline, respectively, and 67.4% and 3.0% at follow-up. Three latent classes emerged: Latent class (LC) 1—“high alcohol intake, poor sleep balance and poor fruit and vegetable intake”, LC2—“high alcohol intake and poor fruit and vegetable intake”, and LC3—“high alcohol intake”. Most adults remained in the same LC over the 4 + years (range: 83.9%–100.0%). After 4 + years, 3.5% from LC3 and 10.4% from LC2 at baseline moved into LC1. The odds of transitioning to LC2 relative to staying in LC1 and LC3 were 2.22 and 4.13 times higher for males than for females, respectively. A single-year increase in participants' age was associated with a 1.16 times increase in the odds of moving to LC1 relative to staying in LC2.ConclusionPeople with CVD did not show improvement in lifestyle risk behaviours, and interventions targeting multiple lifestyle risk behaviours are needed to improve CVD.

BackgroundReducing sedentary behavior and increasing physical activity in people with type 2 diabetes (T2D) are associated with various positive health benefits. Just-in-time adaptive interventions offer the potential to target both of these behaviors through more contextually aware, tailored, and personalized support. We have developed a just-in-time adaptive intervention to promote sitting less and moving more in people with T2D. ObjectiveThis paper presents the study protocol for a microrandomized trial to investigate whether motivational messages are effective in reducing time spent sitting in people with T2D and to determine what behavior change techniques are effective and in which context (eg, location, etc). MethodsWe will use a 6-week microrandomized trial design. A total of 22 adults with T2D will be recruited. The intervention aims to reduce sitting time and increase time spent standing and walking and comprises a mobile app (iMove), a bespoke activity sensor called Sedentary Behavior Detector (SORD), a messaging system, and a secured database. Depending on the randomization sequence, participants will potentially receive motivational messages 5 times a day. ResultsRecruitment was initiated in October 2022. As of now, 6 participants (2 female and 4 male) have consented and enrolled in the study. Their baseline measurements have been completed, and they have started using iMove. The mean age of 6 participants is 56.8 years, and they were diagnosed with T2D for 9.4 years on average. ConclusionsThis study will inform the optimization of digital behavior change interventions to support people with T2D Sit Less and Move More to increase daily physical activity. This study will generate new evidence about the immediate effectiveness of sedentary behavior interventions, their active ingredients, and associated factors. Trial RegistrationAustralian New Zealand Clinical Trial Registry ACTRN12622000426785; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=383664 International Registered Report Identifier (IRRID)DERR1-10.2196/41502

Abstract Lifestyle risk behaviours such as smoking, physical inactivity, and unhealthy diet account for a considerable disease burden globally. These risk behaviours tend to cluster within an individual, which could have detrimental health effects. In this study, we aimed to examine the clustering effect of lifestyle risk behaviours on cardiovascular disease (CVD) and CVD risk among adults in the United Kingdom (UK). We performed a latent class (LC) analysis with distal outcomes using the UK Biobank baseline (2006–2010) data. First, we estimated LC measurement models, followed by an auxiliary model conditional on LC variables. We reported continuous (mean difference—MD) and binary (odds ratio—OR) outcomes with 95% confidence intervals. We included 283,172 and 174,030 UK adults who had data on CVD and CVD risk, respectively. Multiple lifestyle risk behaviour clustering (physically inactive, poor fruit & vegetable intake, high alcohol intake, and prolonged sitting) had a 3.29 mean increase in CVD risk compared to high alcohol intake. In addition, adults with three risk behaviours (physically inactive, poor fruit & vegetable intake, and high alcohol intake) had 25.18 higher odds of having CVD than those with two risk behaviours (physically inactive, and poor fruit and vegetable intake). Social deprivation, gender and age were also associated with CVD. Individuals' LC membership with two or more lifestyle risk behaviours negatively affects CVD. Interventions targeting multiple lifestyle behaviours and social circumstances should be prioritized to reduce the CVD burden.

Abstract Although user engagement is generally considered important for the effectiveness of digital behavior change interventions, there is a lack of such data in pregnancy. The aim of this study was therefore to examine the associations of user engagement with the HealthyMoms app with gestational weight gain, diet quality and physical activity in pregnancy. The study involved secondary analyses of participant data from the intervention group (n = 134) in a randomized controlled trial to determine the effectiveness of a 6-month mHealth intervention (the HealthyMoms app) on gestational weight gain, diet quality and physical activity. In adjusted regression models, the total number of registrations from three self-monitoring features (i.e., for weight-, diet- and physical activity) was associated with lower gestational weight gain (β = − 0.18, P = 0.043) and improved diet quality (β = 0.17, P = 0.019). These findings were mainly attributable to the associations of physical activity registrations with lower gestational weight gain (β = − 0.20, P = 0.026) and improved diet quality (β = 0.20, P = 0.006). However, the number of app sessions and page views were not associated with any of the outcomes. Our results may motivate efforts to increase user engagement in digital lifestyle interventions in pregnancy. However, additional studies are needed to further elucidate the influence of different types of user engagement in digital pregnancy interventions on their effectiveness. Trial registration: ClinicalTrials.gov (NCT03298555); https://clinicaltrials.gov/ct2/show/NCT03298555 (date of registration: October 2, 2017; date of first enrolled participant: October 24, 2017).

Abstract Background Little is known about girls’ use of a broad range of digital technologies to support a healthy lifestyle, particularly during the later adolescent years when they are expected to take greater responsibility for individually managing their health and wellbeing. The present study was designed to gain an in-depth understanding of adolescent girls’, 15 to 17 years of age, use of a broad range of digital technologies to support multiple healthy lifestyle purposes. Methods This study used a mixed-methods sequential research design (i.e. quantitative and qualitative data in two consecutive phases). A quantitative online survey was conducted to determine the use of digital technologies for healthy lifestyle purposes. Qualitative semi-structured interviews were conducted with a subset of survey respondents to explore factors influencing their technology use and preferences. Results Descriptive analysis of survey data (online survey, n = 336) demonstrated the popularity of social media and online video sharing platforms, with evidence that the use of digital technologies does not occur in isolation and girls draw on several resources simultaneously to achieve their desired healthy lifestyle outcomes. Thematic analysis of interview data (semi-structured interviews, n = 29) revealed seven interrelated themes around factors influencing girls’ use of, and satisfaction with, different digital technologies: accessibility, social connectivity, credibility, relatability, inspiration, safety, and customisability. Conclusions The findings reiterate that one size doesn’t fit all girls, and often one size might not even fit one girl, and thus highlight the challenge of catering to such varied use cases. Overall, it appears that current digital technology offerings meet the needs and preferences of adolescent girls for healthy lifestyle purposes, however there may be benefit in allowing greater customisation of use, and consumer driven tailoring of content, according to personal preferences and changing circumstances.

BackgroundDespite the unequivocal evidence demonstrating the benefits of being physically active, many people do not meet the recommended guidelines of at least 150 minutes of moderate- to vigorous-intensity physical activity per week. This can be changed with the development and implementation of innovative interventions. The use of mobile health (mHealth) technologies has been suggested as a mechanism to offer people innovative health behavior change interventions. ObjectiveThis study aims to outline the systematic, theory-driven processes and user testing applied to the development of a smartphone-based physical activity app (SnackApp) to promote participation in a novel physical activity intervention called Snacktivity. The acceptability of the app was explored and reported. MethodsIntervention mapping involves a 6-step process, the first 4 of which were presented in this study. These steps were used to develop the SnackApp for use within the Snacktivity intervention. The first step involved a needs assessment, which included composing an expert planning group, patient and public involvement group, and gathering the views of the public on Snacktivity and the public perception of the use of wearable technology to support Snacktivity. This first step aimed to determine the overall purpose of the Snacktivity intervention. Steps 2 to 4 involved determining the intervention objectives, the behavior change theory and techniques on which the intervention is based, and the development of the intervention resources (ie, SnackApp). After the completion of steps 1 to 3 of the intervention mapping process, the SnackApp was developed and linked to a commercial physical activity tracker (Fitbit Versa Lite) for the automated capture of physical activity. SnackApp includes provisions for goal setting, activity planning, and social support. Stage 4 involved users (inactive adults, N=15) testing the SnackApp for 28 days. App engagement (mobile app use analytics) was analyzed to determine app use and to inform the further development of SnackApp. ResultsOver the study period (step 4), participants engaged with SnackApp an average of 77 (SD 80) times. On average, participants used the SnackApp for 12.6 (SD 47) minutes per week, with most of the time spent on the SnackApp dashboard and engaging, on average, 14 (SD 12.1) times, lasting 7 to 8 minutes per week. Overall, male participants used the SnackApp more than female participants did. The app rating score was 3.5 (SD 0.6) out of 5, suggesting that SnackApp was rated as fair to good. ConclusionsThis study outlines and reports data regarding the development of an innovative mHealth app using a systematic, theory-driven framework. This approach can guide the development of future mHealth programs. User testing of the SnackApp suggested that physically inactive adults will engage with the SnackApp, indicating its applicability of use in the Snacktivity physical activity intervention.

BackgroundSeveral research studies have demonstrated the potential of mobile health apps in supporting health management. However, the design and development process of these apps are rarely presented.ObjectiveWe present the design and development of a smartphone-based lifestyle app integrating a wearable device for hypertension management.MethodsWe used an intervention mapping approach for the development of theory- and evidence-based intervention in hypertension management. This consisted of six fundamental steps: needs assessment, matrices, theoretical methods and practical strategies, program design, adoption and implementation plan, and evaluation plan. To design the contents of the intervention, we performed a literature review to determine the preferences of people with hypertension (Step 1) and necessary objectives toward the promotion of self-management behaviors (Step 2). Based on these findings, we implemented theoretical and practical strategies in consultation with stakeholders and researchers (Steps 3), which was used to identify the functionality and develop an mHealth app (Step 4). The adoption (Step 5) and evaluation (Step 6) of the mHealth app will be conducted in a future study.ResultsThrough the needs analysis, we identified that people with hypertension preferred having education, medication or treatment adherence, lifestyle modification, alcohol and smoking cessation and blood pressure monitoring support. We utilized MoSCoW analysis to consider four key elements, i.e., education, medication or treatment adherence, lifestyle modification and blood pressure support based on past experiences, and its potential benefits in hypertension management. Theoretical models such as (i) the information, motivation, and behavior skills model, and (ii) the patient health engagement model was implemented in the intervention development to ensure positive engagement and health behavior. Our app provides health education to people with hypertension related to their condition, while utilizing wearable devices to promote lifestyle modification and blood pressure management. The app also contains a clinician portal with rules and medication lists titrated by the clinician to ensure treatment adherence, with regular push notifications to prompt behavioral change. In addition, the app data can be reviewed by patients and clinicians as needed.ConclusionsThis is the first study describing the design and development of an app that integrates a wearable blood pressure device and provides lifestyle support and hypertension management. Our theory-driven intervention for hypertension management is founded on the critical needs of people with hypertension to ensure treatment adherence and supports medication review and titration by clinicians. The intervention will be clinically evaluated in future studies to determine its effectiveness and usability.

BackgroundHeart failure (HF) is a common chronic condition that affects over 26 million people worldwide. It is a progressive and debilitating disease with a broad symptom profile, intermittently marked by periods of acute decompensation. People with HF generally do not self-manage their condition well (eg, monitoring symptoms, taking medications regularly, physical activity, etc). A better understanding of self-care activities and what factors may indicate deterioration is warranted. ObjectiveThe aim of this study was to determine the feasibility and acceptability of using wearable cameras to assess self-care activities in people with HF. The study objectives were to (1) explore whether changes in self-care activities could be identified prior to hospitalization and (2) determine the acceptability of wearable cameras to people with HF. MethodsA total of 30 people recently diagnosed with HF wore a camera for a maximum of 30 days; the camera took a photo every 30 seconds in the forward-facing direction. At the end of the study, all 30 participants were presented with 8 statements of acceptability, scored on a 5-point Likert scale. To determine whether camera images could identify changes in self-care activities and lifestyle risk factors before hospitalization, we analyzed images from participants (n=8) who were hospitalized during the 30-day study period. Images from the period immediately prior to hospitalization and a comparison were selected for each participant. Images were manually coded according to 9 different event categories relating to self-care and lifestyle risk factors, and events were compared between the 2 periods. ResultsThe participants reported high acceptability for wearing the cameras, as most strongly agreed or agreed that they were comfortable to wear (28/30, 93%) and easy to use (30/30, 100%). The results of the camera image analysis showed that participants undertook fewer activities of daily living (P=.008) and were more sedentary (P=.02) prior to being hospitalized, compared to a period nonadjacent to hospitalization. ConclusionsAdults with HF were accepting of using a wearable camera for periods within a 30-day time frame. Wearable cameras were a feasible approach for providing data on selected self-care activities and lifestyle risk factors for HF and offer the potential to be a valuable tool for improving our understanding of self-care.

Abstract Background The use of antihypertensive medications is critical for controlling high blood pressure. We aimed to investigate associations between socio-demographic factors and antihypertensive medications use, and antihypertensive medications use with different types of drugs use with levels of systolic blood pressure (SBP) and diastolic blood pressure (DBP). Methods For the present report we derived data from the baseline measurements of a cluster randomised control trial on 307 participants with previously diagnosed hypertension from the rural district of Narial in Bangladesh. We measured the participant’s current blood pressure levels and recorded antihypertensive medications uses. Associated factors included socio-economic status, diabetes, antihypertensive medications use, and types of drugs and doses used for controlling blood pressure. We applied analysis of variance and logistic regression techniques to identify factors associated with blood pressure. Results Of the total participants, 144 (46.9%) were on antihypertensive medications. After multivariate adjustment, binary logistic regression revealed that employees (odds ratio, (95% confidence interval (CI)) (OR 3.58, 95%CI 1.38-9.28) compared to farmers, and people with diabetes (OR 2.43, 95%CI 1.13-5.26) compared to people without diabetes were associated with a higher proportion of antihypertensive medications use. Of 144 participants on antihypertensive medications, 7 (5%) had taken two doses, 114 (79%) had taken one dose per day and the rest were irregular in medication use. The mean (standard deviation) [min, max] SBP and DBP were 149 (19) mmHg [114, 217] and 90 (10) mmHg [75, 126], respectively. Overall, there was no significant difference in SBP (p = 0.10) or DBP (p = 0.67) between participants with or without antihypertensive medications or using any type of medications (p = 0.54 for SBP and 0.76 for DBP). There was no significant association between antihypertensive medications use and elevated BP levels SBP/DBP≥140/90 mmHg (p = 0.42) Conclusion Less than half of the people with hypertension were on medication. Irrespective of the antihypertensive medications use, most of the participant’s blood pressure was high. Further study is needed with a large sample to understand the factors and aetiology of unmanaged hypertension in rural areas of Bangladesh where the prevalence of hypertension is very high.

Abstract Background Diabetes mellitus represents a substantial global health challenge, with prevalence rising in low- and middle-income countries (LMICs). Although diabetes is known to follow a socioeconomic gradient, patterns in LMICs are unclear. This study examined associations between education and diabetes, and diabetes self-management behaviours, in six LMICs. Methods Cross-sectional data for 31,780 participants from China, Ghana, India, Mexico, Russia, and South Africa from the World Health Organization Study on Global AGEing and adult health (SAGE) study were used. Participants aged ≥50 years completed face-to-face interviews between 2007 and 2010. Participants self-reported diabetes diagnosis, physical activity, sedentary time, fruit and vegetable consumption, any special diet/program for diabetes, whether they were taking insulin for diabetes and number of years of education. Height, weight, waist, and hip circumference were measured. Country-specific survey-weighted log-binomial regression models were fitted to examine associations between the number of years of education and self-reported diabetes diagnosis (primary analysis). In secondary analyses, among those with a self-reported diabetes diagnosis, generalised linear regression models were fitted to examine associations between education and i) physical activity, ii) sedentary time, iii) fruit and vegetable consumption, iv) special diet for diabetes, v) taking insulin, vi) BMI, vii) waist circumference and viii) hip circumference. Results There was strong evidence of an association between years of education and diabetes diagnosis in Ghana (RR = 1.09, 95% CI: 1.06–1.13) and India (RR = 1.09, 95% CI: 1.07–1.12) only. In India, greater years of education was associated with higher leisure physical activity, fruit and vegetable intake, rates following a special diet or taking insulin, but also higher mean BMI, waist and hip circumference. Relationships between education and self-management behaviours were rarely seen in the other countries. Conclusions Associations between education and diabetes, and behavioural self-management (India only) was more evident in the two least developed (Ghana and India) of the WHO SAGE countries, indicating increasing diabetes diagnosis with greater numbers of years of education. The lack of gradients elsewhere may reflect shifting risk from higher to lower educated populations. While there was some suggestion that self-management behaviours were greater with increased education in India, this was not observed in the other countries.

Background Physical activity is important for the control of high blood pressure (hypertension). We aimed to investigate the associations of current physical activity levels, sedentary time, knowledge of and attitude towards physical activity with blood pressure in people with hypertension in a rural area in Bangladesh. Methods A total of 307 adults aged 30 to 75 years with hypertension were recruited from the Banshgram Union of Narial district as part of a cluster-randomized control trial. Current blood pressure was measured as the outcome variable. Associated variables included physical activity at work, travel to and from places, recreational activity, metabolic equivalent task (MET)-min, sedentary time, and awareness of and attitudes towards physical activity. Rasch analysis was used to compute a combined score from the five awareness of and attitudes towards physical activity items and categorized into 0–40 (towards negative attitude), 41–60 score (mixed attitude) and 61–100 (positive attitude). We used a generalised linear model to analyze the data. Results Participants (n = 68, 22.1%) who engaged in vigorous-intensity physical activity that causes large increases in breathing or heart rate like carrying or lifting heavy loads, digging or construction work for at least 10 minutes continuously had lower systolic blood pressure (SBP) (mean (95% confidence interval (CI)), 143.6 (140.1, 147.2)) compared to those who did not take part in a vigorous-intensity physical activity (mean (95% CI), 150 (147.6, 152.3)). MET-min less than 600 min/week was significantly associated with higher SBP 153.8 (148.1, 159.6) than MET-min 600–2999 min/week 148.0 (143.0, 152.9) and MET-min>3000 min/week 146.9 (144.5, 149.3), p = 0.001 for trend. Sitting time more than four hours a day was associated with higher DBP 91.4 (89.7, 93.0) compared to those who had sitting time less than fours a day 88.6 (87.1, 90.1). People with positive attitudes were associated with a reduced SBP of 10.6 (0.36, 20.8) mmHg and DBP 5.88 (0.47, 11.3) compared to the people who had a negative attitude towards taking part in physical activity. Conclusions Participating in high physical activity and positive attitudes towards physical activity were associated with lower blood pressure levels. Physical activity awareness programs should be implemented to increase awareness of health benefits and increase participation in high physical activity.

Objectives This paper focuses on formative research as part of a broader study to develop and evaluate an innovative digital health platform for the self-management of cardiovascular disease (CVD). The primary objective is to better understand the perceptions of key stakeholders towards the proposed platform (Salvio) and to identify the development considerations they may prioritise based on their own experiences of CVD management.Design A qualitative research study using thematic analysis to explore patterns and themes within the various participant contributions.Setting Triangulation of data collection methods were used to generate data, including focus group discussions, semistructured interviews and guided conversations.Participants Participants (n=26) were people with a diagnosis of CVD (n=18) and relevant healthcare professionals (n=8).Results Findings indicate that the proposed platform would be a beneficial solution for certain groups whose health behaviour change is not currently supported by discrete solutions. Both participant groups perceive the digital health platform more trustworthy than accessing multiple interventions through unsupported digital repositories. Healthcare professionals agreed that they would endorse an evidence-based platform that had been rigorously developed and evaluated. CVD participants prioritised a decision support tool to guide them through the platform, as they perceive an unstructured approach as overly complex. Both participant groups perceived data sharing with certain self-selected individuals (eg, spouse) to be a useful method for gaining support with their health behaviour change.Conclusions A digital health platform offering a variety of existing, evidence-based interventions would provide users with suitable self-management solution(s) based on their own individual needs and preferences. Salvio could be enhanced by providing adequate support to platform users, guiding the diverse CVD population through a host of digital solutions, ensuring that Salvio is endorsed by trusted healthcare professionals and maintaining connections with usual care. Such a platform would augment existing self-management and secondary prevention services.

BackgroundThe management of heart failure is complex. Innovative solutions are required to support health care providers and people with heart failure with decision-making and self-care behaviors. In recent years, more sophisticated technologies have enabled new health care models, such as smart health ecosystems. Smart health ecosystems use data collection, intelligent data processing, and communication to support the diagnosis, management, and primary and secondary prevention of chronic conditions. Currently, there is little information on the characteristics of smart health ecosystems for people with heart failure. ObjectiveWe aimed to identify and describe the characteristics of smart health ecosystems that support heart failure self-care. MethodsWe conducted a scoping review using the Joanna Briggs Institute methodology. The MEDLINE, Embase, CINAHL, PsycINFO, IEEE Xplore, and ACM Digital Library databases were searched from January 2008 to September 2021. The search strategy focused on identifying articles describing smart health ecosystems that support heart failure self-care. A total of 2 reviewers screened the articles and extracted relevant data from the included full texts. ResultsAfter removing duplicates, 1543 articles were screened, and 34 articles representing 13 interventions were included in this review. To support self-care, the interventions used sensors and questionnaires to collect data and used tailoring methods to provide personalized support. The interventions used a total of 34 behavior change techniques, which were facilitated by a combination of 8 features for people with heart failure: automated feedback, monitoring (integrated and manual input), presentation of data, education, reminders, communication with a health care provider, and psychological support. Furthermore, features to support health care providers included data presentation, alarms, alerts, communication tools, remote care plan modification, and health record integration. ConclusionsThis scoping review identified that there are few reports of smart health ecosystems that support heart failure self-care, and those that have been reported do not provide comprehensive support across all domains of self-care. This review describes the technical and behavioral components of the identified interventions, providing information that can be used as a starting point for designing and testing future smart health ecosystems.

Abstract Background High blood pressure is an independent risk factor of cardiovascular disease (CVD) and is a major cause of disability and death. Managing a healthy lifestyle has been shown to reduce blood pressure and improve health outcomes. We aim to investigate the effectiveness of a lifestyle modification intervention program for lowering blood pressure in a rural area of Bangladesh. Methods A single-center cluster randomized controlled trial (RCT). The study will be conducted for 6 months, a total of 300 participants of age 30 to 75 years with 150 adults in each of the intervention and the control arms. The intervention arm will involve the delivery of a blended learning education program on lifestyle changes for the management of high blood pressure. The education program comprises evidence-based information with pictures, fact sheets, and published literature about the effects of high blood pressure on CVD development, increased physical activity, and the role of a healthy diet in blood pressure management. The control group involves providing information booklets and general advice at the baseline data collection point. The primary outcome will be the absolute difference in clinic SBP and DBP. Secondary outcomes include the difference in the percentage of people adopting regular exercise habits, cessation of smoking and reducing sodium chloride intake, health literacy of all participants, and the perceived barriers and enablers to adopt behavior changes by collecting qualitative data. Analyses will include analysis of covariance to report the mean difference in blood pressure between the control and the intervention group and the difference in change in blood pressure due to the intervention. Discussion The study will assess the effects of physical activity and lifestyle modification in controlling high blood pressure. This study will develop new evidence as to whether a simple lifestyle program implemented in a rural region of a low- and middle-income country will improve blood pressure parameters for people with different chronic diseases by engaging community people. Trial registration ClinicalTrials.gov NCT04505150 . Registered on 7 August 2020

BackgroundSmart home systems could enhance clinical and self-management of chronic heart failure by supporting health monitoring and remote support, but evidence to guide the design of smart home system functionalities is lacking.ObjectiveTo identify consensus-based recommendations for functions of a smart home system that could augment clinical and self-management for people living with chronic heart failure in the community.MethodsHealthcare professionals caring for people living with chronic heart failure participated in a two-round modified Delphi survey and a consensus workshop. Thirty survey items spanning eight chronic health failure categories were derived from international guidelines for the management of heart failure. In survey Round 1, participants rated the importance of all items using a 9-point Liket scale and suggested new functions to support people with chronic heart failure in their homes using a smart home system. The Likert scale scores ranged from 0 (not important) to 9 (very important) and scores were categorized into three groups: 1–3 = not important, 4–6 = important, and 7–9 = very important. Consensus agreement was defined a priori as ≥70% of respondents rating a score of ≥7 and ≤ 15% rating a score ≤ 3. In survey Round 2, panel members re-rated items where consensus was not reached, and rated the new items proposed in earlier round. Panel members were invited to an online consensus workshop to discuss items that had not reached consensus after Round 2 and agree on a set of recommendations for a smart home system.ResultsIn Round 1, 15 experts agreed 24/30 items were “very important”, and suggested six new items. In Round 2, experts agreed 2/6 original items and 6/6 new items were “very important”. During the consensus workshop, experts endorsed 2/4 remaining items. Finally, the expert panel recommended 34 items as “very important” for a smart home system including, healthy eating, body weight and fluid intake, physical activity and sedentary behavior, heart failure symptoms, tobacco cessation and alcohol reduction, medication adherence, physiological monitoring, interaction with healthcare professionals, and mental health among others.ConclusionA panel of healthcare professional experts recommended 34-item core functions in smart home systems designed to support people with chronic heart failure for self-management and clinical support. Results of this study will help researchers to co-design and protyping solutions with consumers and healthcare providers to achieve these core functions to improve self-management and clinical outcomes in people with chronic heart failure.

BackgroundMobile games can be effective and motivating tools for promoting children’s health. ObjectiveWe aimed to determine the comparative use of 2 prototype serious games for health and assess their effects on healthy lifestyle knowledge in youth aged 9-16 years at risk for type 2 diabetes (T2D). MethodsA 3-arm parallel pilot randomized controlled trial was undertaken to determine the feasibility and preliminary effectiveness of 2 serious games. Feasibility aspects included recruitment, participant attitudes toward the games, the amount of time the participants played each game at home, and the effects of the games on healthy lifestyle and T2D knowledge. Participants were allocated to play Diabetic Jumper (n=7), Ari and Friends (n=8), or a control game (n=8). All participants completed healthy lifestyle and T2D knowledge questionnaires at baseline, immediately after game play, and 4 weeks after game play. Game attitudes and preferences were also assessed. The primary outcome was the use of the game (specifically, the number of minutes played over 4 weeks). ResultsIn terms of feasibility, we were unable to recruit our target of 60 participants. In total, 23 participants were recruited. Participants generally viewed the games positively. There were no statistical differences in healthy lifestyle knowledge or diabetes knowledge over time or across games. Only 1 participant accessed the game for an extended period, playing the game for a total of 33 min over 4 weeks. ConclusionsIt was not feasible to recruit the target sample for this trial. The 2 prototype serious games were unsuccessful at sustaining long-term game play outside a clinic environment. Based on positive participant attitudes toward the games, it is possible to use these games or similar games as short-term stimuli to engage young people with healthy lifestyle and diabetes knowledge in a clinic setting; however, future research is required to explore this area. Trial RegistrationAustralia New Zealand Clinical Trials Registry ACTRN12619000380190; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=377123

Objective Higher level impairments and activity limitation among those scheduled for total knee arthroplasty (TKA) is known. Sex differences in participation restriction which is the final domain of disablement pathway is not known. No data from developing countries exist on sex differences in disability levels at the time of TKA. Methods In a cross‐sectional analysis of 240 patients (188 women; 72 men) scheduled for TKA, impairment (pain, symptoms, quadricep muscle strength, and knee range of motion [ROM]), activity limitation (self‐reported and objective performance‐based measurements), and participation restriction were compared. Multivariable regression analyses were used to adjust for key sociodemographic and clinical characteristics. Associations between impairments and participation restriction were analyzed. Results Compared with men, women were more likely to have higher levels of impairment (knee injury and osteoarthritis outcome pain score adjusted mean difference [aMD]: −6.9 [95% confidence interval {CI} −13.7 to −0.18]; flexion ROM of less than 100° adjusted odds ratio: 5.7 [95% CI 1.6‐20.3]; and 36% lower muscle strength [95% CI 24%‐49%]) and lower objectively measured functional ability (walking speed aMD: −0.12 m/s [95% CI −0.23 to −0.02]; stair climbing time aMD: 9.5 s [95% CI 1.5‐17.5]). Participation restriction was higher in women compared with men. Of the impairment measures (pain, ROM, and muscle strength), pain contributed to participation restriction in both sexes. Conclusion This study demonstrated higher levels of disability in women than in men at the time of TKA. Effect of pain on participation restriction was higher compared with muscle strength and ROM. Evidence of delay in decision‐making to undergo TKA and reasons for delay need to be studied specifically in the context of lower middle–income countries.

Abstract Background Household chaos, represented by the level of disorganisation or environmental confusion in the home, has been associated with a range of adverse child and family outcomes. This review aims to (1) identify how household chaos is measured, (2) chart study details of household chaos literature, and (3) map the existing literature with respect to the relationship between household chaos and child, parent, and family outcomes. We expect that this review will highlight the need to consider the importance of household chaos in child well-being research, particularly in those families where children may be more vulnerable to the adverse effects of household chaos. Methods We searched five electronic databases (last updated September 1st 2018) in addition to Google Scholar, and identified publications via a 3-stage screening process, which was conducted by two researchers. Published studies were included if they investigated the association between household chaos and child, parent, or family outcomes. Research that investigated household chaos as a mediator or moderator, or that investigated how the relationship between household chaos and the outcome of interest was mediated or moderated, were also included. Results One hundred twelve studies in 111 publications were included. The majority were conducted in the United States (n = 71), and used either cross-sectional (n = 60) or longitudinal (n = 49) study designs. Outcomes of interest were categorised into seven categories: (1) cognitive and academic (n = 16), (2) socio-emotional and behavioural (n = 60), (3) communication (n = 6), (4) parenting, family, and household functioning (n = 21), (5) parent outcomes (n = 6), (6) hormone (n = 8), and (7) physical health and health behaviours (n = 19). There was consistent evidence for significant correlations between household chaos and adverse outcomes across all seven categories in diverse populations with respect to age, disease status, and socio-economic status (SES). Conclusion There is consistent evidence for associations between household chaos and a number of adverse child, parent, and family-level outcomes. Household chaos may also help describe variations in outcomes between low SES and child development.

Abstract Background A healthy lifestyle program that appeals to, and supports, obese New Zealand (NZ) European, Māori (indigenous) and Pasifika men to achieve weight loss is urgently needed. In Scotland, Football Fans in Training (FFIT), a weight management and healthy lifestyle program for overweight and obese men aged 35–65 years , delivered by community coaching staff at professional football clubs, has been shown to be beneficial and cost-effective. A pilot program inspired by FFIT but delivered by professional rugby clubs in NZ (n = 96) was shown to be effective in weight loss, improved physiological outcomes, and adherence to healthy lifestyle behaviors in overweight and obese men. The objective of this trial is to determine the effectiveness and cost-effectiveness of the Rugby Fans in Training New Zealand (RUFIT-NZ) program. Methods A pragmatic, two-arm, multi-center, randomized controlled trial involving 308 overweight and obese men aged 30–65 years, randomized to either an intervention group (n = 154) or a wait-list control group (n = 154). The intervention-group participated in the 12-week RUFIT-NZ program, a gender-sensitized, healthy lifestyle intervention adapted to the environment and cultural diversity of NZ and delivered through professional rugby clubs. Participants in the intervention group undergo physical training sessions, in addition to workshop-based sessions to learn about nutrition, physical activity, sleep, sedentary behavior, and a range of behavior-change strategies for sustaining a healthier lifestyle. The control group receives the program after 52 weeks. The primary outcome is change in body weight from baseline to 52 weeks. Secondary outcomes include change in body weight at 12 weeks; waist circumference, blood pressure, fitness, and lifestyle behaviors at 12 and 52 weeks; and cost-effectiveness. A process evaluation informed by the RE-AIM framework will evaluate potential implementation of RUFIT-NZ as an ongoing program in NZ after the trial. Discussion This trial will investigate the effectiveness and cost-effectiveness of the RUFIT-NZ program in overweight and obese NZ men. Trial registration Australia New Zealand Clinical Trials Registry, ACTRN12619000069156. Registered on 18 January 2019, according to the World Health Organization Trial Registration Data Set. Universal Trial Number, U1111-1245-0645.

Abstract Food fussiness is associated with non‐responsive parent feeding practices, such as persuasive and instrumental feeding. Although most children described as ‘fussy eaters’ are likely exhibiting developmentally typical behaviours, up to half of the parents of children 2–5 years old express concerns. Concern for fussy eating may mediate the use of non‐responsive feeding practices and so must be addressed in parent feeding interventions. Therefore, it is critical to better understand parents' concerns and how they may relate to feeding practices. This study aimed to explore how parents' feeding practices and the social cognitive factors that may drive them clustered based on parents' concern for fussy eating. Data were collected from parent discussions of fussy eating on a Reddit forum (80,366 posts). Latent Dirichlet allocation was used to identify discussions of fussy eating. Relevant posts (1542) made by users who identified as a parent of a fussy eater (n = 630) underwent qualitative coding and thematic analysis. Five clusters of parents were identified, ranging in size from 53 to 189 users. These were primarily characterised by parents' degree of concern and feeding practices: (1) High concern, nonresponsive; (2) Concerned, nonresponsive; (3) Low concern, responsive; (4) Low concern, mixed strategies; (5) Low concern, indulgent. Parents who used responsive practices tended to be less concerned for fussy eating, have greater trust in their child's ability to self‐regulate hunger, have longer‐term feeding goals, and exhibit greater ability for personal self‐regulation. Future research should further examine how these constructs may be leveraged in parent feeding interventions.

BackgroundHypertension is the most common modifiable risk factor for cardiovascular diseases in South Asia. Machine learning (ML) models have been shown to outperform clinical risk predictions compared to statistical methods, but studies using ML to predict hypertension at the population level are lacking. This study used ML approaches in a dataset of three South Asian countries to predict hypertension and its associated factors and compared the model's performances.MethodsWe conducted a retrospective study using ML analyses to detect hypertension using population-based surveys. We created a single dataset by harmonizing individual-level data from the most recent nationally representative Demographic and Health Survey in Bangladesh, Nepal, and India. The variables included blood pressure (BP), sociodemographic and economic factors, height, weight, hemoglobin, and random blood glucose. Hypertension was defined based on JNC-7 criteria. We applied six common ML-based classifiers: decision tree (DT), random forest (RF), gradient boosting machine (GBM), extreme gradient boosting (XGBoost), logistic regression (LR), and linear discriminant analysis (LDA) to predict hypertension and its risk factors.ResultsOf the 8,18,603 participants, 82,748 (10.11%) had hypertension. ML models showed that significant factors for hypertension were age and BMI. Ever measured BP, education, taking medicine to lower BP, and doctor's perception of high BP was also significant but comparatively lower than age and BMI. XGBoost, GBM, LR, and LDA showed the highest accuracy score of 90%, RF and DT achieved 89 and 83%, respectively, to predict hypertension. DT achieved the precision value of 91%, and the rest performed with 90%. XGBoost, GBM, LR, and LDA achieved a recall value of 100%, RF scored 99%, and DT scored 90%. In F1-score, XGBoost, GBM, LR, and LDA scored 95%, while RF scored 94%, and DT scored 90%. All the algorithms performed with good and small log loss values

BackgroundThe growing prevalence of non-communicable diseases (NCDs) in South African workers has been shown to be associated with absenteeism and increased risk of morbidity. Low-income workers living in urban settings are particularly vulnerable. Consultation with workers is crucial for understanding risks and identifying opportunities for intervention to promote health in the workplace. The purpose of this study was to examine South African pharmaceutical manufacturing workers' perspectives of health risk factors and absenteeism, and to identify how they perceived a role for the organisation to initiate interventions to improve their health.Materials and methodsFive focus groups were conducted to capture 27 employees' perspectives. The semi-structured focus group discussions were recorded and analysed using a thematic content analysis approach.ResultsParticipants indicated that they were aware of behavioural health risks such as prolonged sitting. They showed insight into strategies to prevent injuries and stay healthy, but also expressed dissatisfaction about the lack of organisational support, leading to stress and consequently absenteeism. Participants emphasized the responsibility of the organisation to support a range of health promoting strategies.ConclusionsThe findings of this study are important for cultivating a tailored workplace intervention to reduce NCD risk factors in the pharmaceutical manufacturing workforce. It is vital that these be supported by leadership of the company through the provision of funding and the development of internal healthcare services.