PhD Viva

Question 1

Overview: What is the title of your PhD thesis?

Answer 1

Improving physical activity for people with physical disabilities: A mixed methods approach

Question 2

Overview: What are the names of your PhD viva examiners?

Answer 2

Dr Emma Pullen (Internal) and Dr Jennifer Tomasone (External)

Question 3

Overview: Summarise your thesis in a sentence?

Answer 3

My thesis looks at ways of improving physical activity for people with physical disabilities through the use of a novel health intervention such as mobile health (mHealth) solutions

Question 4

Overview: How did you come up with the idea for this project?

Answer 4

I have always been interested in physical activity for people with disabilities. Based on my MSc dissertation, which explored the barriers and facilitators to physical activity for people with disabilities, I wanted to extend this type of work and find a solution to address this issue, which is how my PhD project came together.

Question 5

Overview: Describe your thesis in brief?

Answer 5

The overall focus of my PhD is to understand how to increase physical activity in adults with physical disabilities.

Question 6

Overview: Why did you choose this topic?

Answer 6

During my MSc my dissertation focused on the barriers and facilitators to physical activity for people with physical and sensory disabilities. As I was progressing onto a PhD, I wanted my PhD to address these barriers by developing an app. My PhD initially started with developing an intervention until Ali/Accessercise approached us where we ended up evaluating his intervention (or app).

Question 7

Overview: Why is this topic important, and to whom is it relevant?

Answer 7

Our topic is important because people with disabilities are a physically inactive population, are at risk of numerous health complications and are not meeting recommended guidelines. Therefore, this population requires support and need interventions to be designed to overcome this challenge.

Question 8

Overview: What are the key findings?

Answer 8

Chapters 2-5 have highlighted that mHealth is a potential and promising strategy to increase physical activity in marginalised populations, including adults with physical disabilities.

This mixed-methods thesis has provided a novel insight into ways of improving physical activity for adults with disabilities, an area which has been under researched.

Novel findings which have used the Accessercise have found to be positive. Overall, it is anticipated that the findings reported from this thesis will propose solid evidence base of the benefits of physical activity for adults with physical disabilities, and as a result influence the design, implementation and evaluation of future physical activity interventions that can lead to better QoL in this population.

Question 9

Overview: What are your contributions to knowledge?

Answer 9

We evaluated a novel mHealth application, namely Accessercise which has yet to be evaluated.

Question 10

Overview: What are some of the limitations of your thesis?

Answer 10

1. The overall effectiveness of the Accessercise app was yet to be established. We were unable to evaluate and understand the intervention’s long term effects.
2. The Accessercise app was under developed during the time that we evaluated it. Therefore, this may have impacted the findings that we obtained for the usability (Chapter 4) and our feasibility work (Chapter 5).
3. The majority of outcomes employed within our research used self-reported outcomes via questionnaires, which are at risk of social desirability and recall bias.
4. Recruiting difficulties - Most participants in our research were Male, White British, and were from the East Midlands areas.

Question 10

Overview: What is the future of your research?

Answer 10

Some recommendations include:

1. Further high quality RCTs, which include objective measures of physical activity, long-term follow-up and bigger sample sizes.
2. A larger definitive trial is needed to assess the effectiveness of the Accessercise app in terms of increasing physical activity.
3. To identify solutions to increase recruitment and retention of a diverse sample of adults with physical disabilities in mHealth interventions, that better reflects the population of the UK and internationally.
4. To identify better solutions to improve access to mHealth interventions for people with disabilities and identify ways to overcome social exclusion, marginalisation, and disability stigma.
5. To investigate whether delivering different physical activity interventions for manual wheelchair users with SCI via different modes of delivery (e.g., telephone, counselling, weekly video conferencing) can result in long term benefits.

Question 11

Overview: What is the benefit of your research to society?

Answer 11

My research can benefit theory, practice and health-care professionals.

1. My PhD can be encouraging for the community of people with physical disabilities, as the findings have indicated that Accessercise is feasible, adhered to, and was received positively among people with physical disabilities.
2. The app may support people with disabilities in the community to overcome physical activity barriers and help them in addressing the low physical activity rates in adults with physical disabilities across the UK.
3. Lastly, this research has shown the benefits of including people with disabilities in research and can help other researchers when designing and evaluating similar physical activity mHealth interventions for people with disabilities.

Question 12

Overview: How are you going to make sure your research has an impact and how are you going to share it?

Answer 12

Some of the ways that I will ensure my research has impact is through the following:

1. Academic publications (I will ensure that my work gets published, so that it’s readable to a wider audience e.g., researchers, app developers, lay audience).
2. Present my research at academic conferences (e.g., Pint of Science, Loughborough Annual Conference), so that other researchers can build upon my work.
3. Engaging with the public - Delivering presentation/talks about my work so that a lay audience can benefit.

Question 13

Overview: What are your next steps?

Answer 13

Some recommendations include:

1. Further high quality RCTs, which include objective measures of physical activity, long-term follow-up and bigger sample sizes.
2. A larger definitive trial is needed to assess the effectiveness of the Accessercise app in terms of increasing physical activity.
3. To identify solutions to increase recruitment and retention of a diverse sample of adults with physical disabilities in mHealth interventions, that better reflects the population of the UK and internationally.
4. To identify better solutions to improve access to mHealth interventions for people with disabilities and identify ways to overcome social exclusion, marginalisation, and disability stigma.
5. To investigate whether delivering different physical activity interventions for manual wheelchair users with SCI via different modes of delivery (e.g., telephone, counselling, weekly video conferencing) can result in long term benefits.

Question 14

Research Questions: What are your main research questions and how did you select them?

Answer 14

My main research questions was to assess ways of ‘improving physical activity for adults with physical disabilities’ By following the Medical Research Council (MRC) framework, we undertook four important questions:

(1) A systematic review to assess the effectiveness of physical activity interventions for manual wheelchair users with spinal cord injury

(2) Assess the theoretical underpinning of a smartphone application (Accessercise) that aims to increase physical activity for adults with disabilities

(3) Assess the Usability of the Smartphone App

(4) Assess the feasibility of the Smartphone App

Question 15

Chapter 1 (Introduction): What are models of Disability?

Answer 15

Models of Disability are frameworks that explain how disability is understood and addressed in society.

Question 16

Chapter 1 (Introduction): What is the Medical Model of Disability?

Answer 16

The medical model views disability as an ‘individualised problem’ rather than a social or political problem, as it focuses on what is ‘wrong’ with the individual rather than what the person
‘needs’ to function correctly.

Question 17

Chapter 1 (Introduction): What is the Social Model of Disability?

Answer 17

The model says that people are disabled by barriers in society, not by their impairment or difference.

Question 18

Chapter 1 (Introduction): What are some of the limitations of the medical model?

Answer 18

Disability is mainly portrayed as a medical problem, with an individual with disabilities could feel stigmatised and of less importance within society in general.

Question 19

Chapter 1 (Introduction): What are two of the most popular models of society?

Answer 19

The Medical and Social Models of Disabiltiy

Question 20

Chapter 1 (Introduction): Why have you chosen the Behaviour Change Wheel (BCW)?

Answer 20

The Behavior Change Wheel is the most comprehensive and practically useful methodology available for developing behavior change interventions.

Question 21

Chapter 1 (Introduction): Sum your PhD up in one sentence?

Answer 21

To understand how to increase physical activity for adults with physical disabilities.

Question 22

General: What are the weakness of your work?

Answer 22

1. When we evaluated the Accessercise app, it was mainly under development. Therefore, a good chunk of features of the app were not available, which may have impacted the findings of Studies 3 -4.
2. The majority of participants we recruited were White British, male, had a Spinal Cord Injury and lived within the East Midlands area. So, therefore, our findings are not generalisable to the wider population.
3. Effectiveness - Despite evaluating the Accessercise app, we were unable to test the overall effectiveness of the phyiscal acitvity app and whether the app can support people with disabilities in achieving long-term behaviour change.
4. The majority of outcomes that were measured (e.g., Systematic Review and Feasibility Trial) used self-reported such as questionnaires/surveys.

Question 23

General: What are you most proud of about your work?

Answer 23

I’m most proud about undertaking a systematic review with meta-analysis for the first time and understanding the different components that are involved in the process. In addition, working with people with various physical disabilities through testing their outcomes and seeing whether there were any improvements.

Question 24

General: What is the next logical step(s) for this research?

Answer 24

Some recommendations include:

1. Further high quality RCTs, which include objective measures of physical activity, long-term follow-up and bigger sample sizes.
2. A larger definitive trial is needed to assess the effectiveness of the Accessercise app in terms of increasing physical activity.
3. To identify solutions to increase recruitment and retention of a diverse sample of adults with physical disabilities in mHealth interventions, that better reflects the population of the UK and internationally.
4. To identify better solutions to improve access to mHealth interventions for people with disabilities and identify ways to overcome social exclusion, marginalisation, and disability stigma.
5. To investigate whether delivering different physical activity interventions for manual wheelchair users with SCI via different modes of delivery (e.g., telephone, counselling, weekly video conferencing) can result in long term benefits.

Question 25

General: What was the toughest part of your PhD work and how did you overcome it?

Answer 25

TBD

Question 26

General: How can physicians use your results to help patients?

Answer 26

Whilst healthcare professionals (e.g., Doctors, Nurses, Physios) have limited involvement in physical activity promotion due to a lack of knowledge, confidence and time), the findings reported in my thesis can be used as guidance within healthcare professionals practice. For instance, healthcare professionals working in physical activity for people with disabilities may use these findings to help people with disabilities make more sustained changes to their physical activity behaviour using mHealth interventions.

Question 27

General: Why did you choose to do a feasibility study?

Answer 27

Based on the MRC Framework for designing and evaluating interventions, we followed step 2 and undertook a feasibility study.

Question 28

General: Can you explain what you have done in your thesis and what is the most exciting part?

Answer 28

My main focus of my PhD was to understand how to increase physical activity in adults with physical disabilities. Specific aims of my PhD were the following:

1. Undertook a systematic review assessing the effectiveness of physical activity interventions for manual wheelchair users with SCI.
2. Assess the theoretical underpinning of a novel mHealth app, Accessercise that aims to increase physical activity in those with disabilities.
3. Examine the usability of the Accessercise application using concurrent Think-Aloud interviews.
4. Undertake a feasibility study of the Accessercise application before progressing onto a full-scale trial.

Question 29

General: Which authors influenced your thinking particularly at design stage?

Answer 29

Ma & Ginis (2018) - Meta-Analysis

Question 30

General: What is a PhD?

Answer 30

A PhD is the highest qualification

Question 31

General: Whose expertise would have been helpful in supporting you?

Answer 31

It would have been good to have had Prof. Vicky Tolfrey involved more in my project due to her knowledge on PA for people with SCI.

Also, it would be great to have some involvement from scholars out in Canada such as Kathleen Martin Ginis.

Question 32

General: Which parts of your thesis (other than the chapter that you have already published) do you think will be published and in which journals? How do you know?

Answer 32

Disability and Rehabilitation?

PLOS Digital Health?

Question 33

General: Why did you choose to structure your thesis by publication rather than by the general approach?

Answer 33

There are 3 reasons why I chose to structure my thesis by publication:

1. Loughborough University have been recently changing their formats and prefer students to undertake this approach.
2. I followed the MRC Framework for designing/evaluating interventions and because these follow different stages, it made more sense to structure each stage I did as a research article.
3. As I want an academic career, the opportunity to work on manuscripts, attempt to publish these during/after my PhD has developed my experience to be ready for this type of career.

Question 34

General: Explain how you identified (study participants) for your studies?

Answer 34

I used a variety of approaches such as word of mouth, used social media (e.g., X and Facebook), contacted National Governing Body Organisations (e.g., WheelPower) and by contacting participants that shared an interest in previous studies.

Question 35

General: What have you learnt doing a doctorate?

Answer 35

I have learnt many things during my PhD. Examples include:

1. Undertaking a systematic review, usability and feasibility studies, which were new experiences to me which I have never undertaken as an UG and PG.
2. Developed my planning and teaching skills
3. Invigilating
4. Marking
5. Supervising

Question 36

General: Can you tell us a bit more about what you learnt as a researcher?

Answer 36

I can provide a detailed answer for this.

Question 37

General: The examiner would refer to a page with a figure on it and ask me to explain the figure (e.g., Forest Plot).

Answer 37

TBD

Question 38

General: Take us through the process of analysis (e.g., UMARS, Content Analysis)?

Answer 38

TBD

Question 39

General: Any questions for us?

Answer 39

I have no questions

Question 40

General: Why did you choose this specific analysis? (e.g., Deductive Content Analysis)

Answer 40

TBD

Question 41

General: What are the advantages and disadvantages of the method of think-aloud interviews you used?

Answer 41

The advantages of think-aloud interviews are that participants’ thoughts and needs can be elicited during testing, and the ongoing verbalised information collected allows the researcher to better identify the source of possible problems

Question 42

General: Why did you choose that particular framework and not another? We feel that your chosen framework is weak!

Answer 42

TBD

Question 43

General: In one sentence, what is your thesis?

Answer 43

Understanding how to increase physical activity in adults with physical disability

Question 44

General: What methodology did you use and justify why?

Answer 44

I used a pragmatist methodology. This followed a mixed-methods approach.

The reason for this was because the Accessercise team approached the research team and wanted a series of studies to be completed. By following the MRC framework, which involves different qualitative/quantitative steps, a mixed-methods methodology was deemed most suitable.

Question 45

General: What are other methods available that can be utilised? Why don’t you employ then?

Answer 45

Understanding how to increase physical activity in adults with physical disability.

Question 46

General: Have you published your work and findings in any journals or conference proceedings?

Answer 46

I have managed to publish the following:

1. Study 2 (Assessing the theoretical underpinnings of the Accessercise application)
2. I have two papers under review (Studies 3-4 Usability and Feasibility)

Question 47

General: Have you presented your work in seminar or conferences?

Answer 47

I have presented my research nationally and internationally. For example,

1. I have presented my research at different events across the UK (e.g., Loughborough annual conference, pint of science, summer showcase, Peter Harrison Event)
2. I have also presented my research internationally (e.g., in Canada 2022-2023 and across several Canadian Universities such as Queens, McGill, Laval).

Question 48

General: If you were given an opportunity to do the same research, would you choose the same methodology?

Answer 48

Yes, based on following the MRC Framework for developing and evaluating a novel mHealth intervention, it made sense to follow the different phases, which involved a mixed methods approach using a pragmatist methodology.

Question 49

General: Can you mention several scholars who have done many research in the area related to your work?

Answer 49

Kathleen Martin Ginis, Jasmin Ma, Byron Lai, Sonja De Grott, Amy Latimer-Cheung, Shane Sweet.

Question 50

General: What are you most proud of in your PhD and why?

Answer 50

Studies 3 and 4 - I enjoyed working with people with disabilities to test them physiologically and to support them with using a novel intervention (i.e., Accessercise).

Question 51

General: Who has had the strongest influence in the development of your subject area in theory and practice?

Answer 51

Kathleen Martin-Ginis

Question 52

General: Who will be most interested in your work?

Answer 52

People specialising in the area of physical activity for people with disabilities, researchers, students, healthcare professionals etc.

Question 53

Introduction: Why was the Medical Model criticised and the Social Model recommended?

Answer 53

Disability must be considered as a role between the interaction between an individual’s impairment and an unbending society.

Question 54

Introduction: Why was the Social Model of Disability developed?

Answer 54

1. It was developed to critique several limitations of the Medical Model
2. Attempt to better represent the views of people with disabilities and the urge to tackle such biological and reductionist views.

Question 55

Introduction: What is the Social Model of Disability?

Answer 55

The social model considers disability as a socially constructed concept which results from a society that fails to listen to the voice of functionally diverse people.

Even though the medical model might view a wheelchair user as disabled due to their diagnostic label, the social model would suggest a wheelchair user is disabled because of inaccessible environments or discriminatory guidelines.

The society must change not the individual.

Question 56

Introduction: Difference between the Medical and Social Model of Disability?

Answer 56

Medical model believes that an individual is disabled because of their condition and that their condition makes them disabled. On the other hand, the social model believes an individual is disabled because of society making them disabled such as an inaccessible building, inaccessible public transport.

Question 57

Introduction: What are some examples of barriers within the Social Model of Disability?

Answer 57

Lack of inclusion, poverty, badly designed buildings, inaccessible information, inaccessible public transport.

Question 58

Introduction: What are the 3 key barriers identified within the Social Model of Disability?

Answer 58

1. Attitudinal barriers
2. Physical barriers
3. Informational/communication

Question 59

Introduction: What are Attitudinal Barriers? (Social Model of Disability)

Answer 59

Attitudinal barriers are making assumptions about an individual’s capabilities which may not be true. For example, these are assumptions about individuals with disabilities that restrict them from participating fully in society. Such as if a person who uses a mobility scooter will also have a cognitive impairment even though this may not be the case.

Attitudinal barriers are ways that individuals with disabilities are labelled, classified, grouped, or disregarded by individuals that do not have a disability.

These attitudinal barriers normally arise from individuals such as friends, family, educators, carers, critics and the people with disabilities themselves.

Question 60

Introduction: What are Physical Barriers? (Social Model of Disability)

Answer 60

Physical barriers are tangible components of the physical environment within for example sports centres, gyms, hospital and offices.

These barriers restrict people with disabilities from participating in many activities in life.

Physical barriers are normally related to the architectural and design features of an environment.

Examples of physical barriers include Narrow doors, stairs, curbs, inaccessible buildings, lack of handrails and lack of ramps.

However, physical barriers involve more then just architectural barriers the also involve natural physical barriers.

Examples of natural physical barriers include Hill terrain, weather conditions (e.g., snow, rain) and rocky paths that for example, make it challenging.

Question 61

Introduction: What model of disability was produced because of limitations of the Medical Model?

Answer 61

The Social Model of Disability

Question 62

Introduction: How can we overcome Physical Barriers?

Answer 62

Policies (e.g., sidewalk maintenance)

Assistive technology (e.g., powered wheelchairs)

Strong support networks (e.g., friends to push, encourage you)

Question 63

Introduction: What are Information and Communication barriers (Social Model of Disability)

Answer 63

Information and communication barriers restrict people with disabilities from communicating and obtaining relevant information.

Information Barriers: Refer to difficulties in accessing information when it is unavailable or irrelevant.

Communication Barriers: Commonly occur due to limited knowledge regarding different styles and alternative modes of communication (e.g., verbal, written, picture, or sign).

Question 64

Introduction: What are some limitations of the Social Model?

Answer 64

1. Accused of failing to address impairment, known as fundamental to the experience of disability.
2. This model does not fully account for the lived experience of the disabled individual it seeks to help and assumes that all disabilities can be helped through changing societies.
3. The social model struggles to acknowledge many individual differences (e.g., physical and psychological conditions).
4. It labels disabilities as one homogenous group instead of people who vary in gender, age, ethnicity, race, sexuality and limitations.
5. Social Model has been criticised as being too simplistic and universalising to thoroughly understand the problems of disability.

Question 65

Introduction: What model was developed based on the limitations of the Social Model of Disability?

Answer 65

The International Classification of Functioning Disability and Health (ICF) Model

Question 66

Introduction: Why was the ICF model developed?

Answer 66

Developed to provide a standard language and universal classification for describing functioning and disability across all individuals and health conditions.

Question 67

Introduction: What is another name for the ICF model?

Answer 67

Bio-psycho-social model

Question 68

Introduction: Why is the ICF model also called the Bio-Psycho-Social Model?

Answer 68

It integrates parts of the Medical and Social Model to produce a coherent viewpoint of disability

Question 69

Introduction: What is the ICF model?

Answer 69

The ICF model acknowledges that disability is neither merely a ‘medical issue’ nor a ‘social issue’ but rather a complex phenomenon

Question 70

Introduction: What are some limitations of the ICF model?

Answer 70

With more then 1,400 categories in the ICF framework, the classification system is too extensive and detailed to be used in daily practice.

1,400 categories involved a significant investment of time, and categories may be discovered that do not offer information or are not relevant in some cases.

Therefore, it requires specific training allocation of further resources for it’s use.

Question 71

Introduction: How many people globally have a disability?

Answer 71

Over 1 billion people (15%) of the world’s population

This equates to 1 in 7 people or 1 in 4 households

Question 72

Introduction: How many adults in the world have a disability?

Answer 72

Adults accounts for between 110 and 190 million (3.8%)

Question 73

Introduction: Why are the rates of disabilities rising worldwide?

Answer 73

1. Ageing population
2. Increased life expectancy
3. Continuing growth in people with chronic diseases

Question 74

Introduction: Do people with disabilities experience many financial difficulties?

Answer 74

Yes

Question 75

Introduction: What was the global loss to disability worldwide in 2004?

Answer 75

Between 1.71$ trillion and $2.23 trillion per year

Question 76

Introduction: What are the 2 key expenses associate with disability?

Answer 76

1. Direct Costs
2. Indirect Costs

Question 77

Introduction: What are Direct Costs for Disability?

Answer 77

Direct costs relate to the visible costs associated with the resources used for the diagnosis and treatment of illnesses within the health systems (e.g., medical costs) and the costs of non-healthcare resources (i.e., non-medical costs)

Question 78

Introduction: What are some examples of direct medical costs?

Answer 78

Diagnostic testing, in-patient care, medications, and other medical supplies.

Question 79

Introduction: What are some examples of direct non-medical costs?

Answer 79

These costs represent transportation and costs of a special diet

Question 80

Introduction: What are indirect costs?

Answer 80

These refer to loss of productivity because of reduced force participation, presenteeism and reduced job performance while at work.

Question 81

Introduction: What are causes of indirect costs?

Answer 81

1. Disability
2. Premature death
3. Disease or injury

Question 82

Introduction: Name a few examples of different disabilities?

Answer 82

1. Physical
2. Sensory
3. Intellectual
4. Neurological

Question 83

Introduction: What is the most common category of disability in the world?

Answer 83

Physical disabilities

Question 84

Introduction: What is the definition of physical disability?

Answer 84

Physical disability refers to the lack of physical functioning, mobility, dexterity, or stamina that inhibits daily tasks.

Question 85

Introduction: What are some examples of physical disabilities?

Answer 85

1. Multiple Sclerosis
2. Spinal Cord Injury
3. Amputation

Question 86

Introduction: What is the most common physical disability?

Answer 86

Spinal Cord Injury

Question 87

Introduction: What causes a Spinal Cord Injury?

Answer 87

1. Traumatic Spinal Cord Injury
2. Non-Traumatic Spinal Cord Injury

Question 88

Introduction: What are examples of a Traumatic Spinal Cord Injury?

Answer 88

1. Car accident
2. Fall
3. Sports-related injury

Question 89

Introduction: What is an example of a primary Traumatic Spinal Cord Injury?

Answer 89

Occurs instantly after the injury occurs

Question 90

Introduction: What is an example of a secondary Traumatic Spinal Cord Injury?

Answer 90

Happens a few minutes after the injury has occurred

Question 91

Introduction: What is a non-traumatic spinal cord injury?

Answer 91

A non-traumatic SCI is when a disease directly impacts the spinal cord, such as a tumour, infection, or degenerative disk disease.

Question 92

Introduction: What is the classification of a SCI?

Answer 92

SCI can be classified into complete or incomplete or tetraplegia or paraplegia

Question 93

Introduction: What is a complete SCI?

Answer 93

Complete SCI injury refers to the complete loss of motor and sensory function below the level of injury

Question 94

Introduction: What is an incomplete SCI?

Answer 94

An incomplete spinal cord injury occurs whenever an injury survivor retains some feeling below the site of the injury.

Question 95

Introduction: What is the most common incomplete SCI?

Answer 95

Central Cord Syndrome (CCS)

Question 96

Introduction: What is a tetraplegia SCI?

Answer 96

An impairment in the cervical segments of the spinal cord (i.e., bottom of the neck to the bottom of the feet).

Question 97

Introduction: What is a paraplegia SCI?

Answer 97

An impairment in the thoracic, lumbar or sacral segments of the spinal cord (i.e, lower half of the body from waist to bottom of the feet).

Question 98

Introduction: How would a doctor determine whether you have traumatic/non-traumatic, complete/incomplete, paraplegia/tetraplegia?

Answer 98

They would normally use the AISA Impairment Scale normally within 72 hours by a trained personal such as a doctor.

Question 99

Introduction: How many people worldwide have a SCI?

Answer 99

250-500k new people worldwide each year, adding to the 2.5 million people around the world living with the condition.

Question 100

Introduction: What population are most likely to experience a SCI?

Answer 100

Young males between the ages of 18-35.

Question 101

Introduction: What are common causes of an SCI in young people?

Answer 101

1. Car crashes
2. Sports Injuries

Question 102

Introduction: What are common causes of an SCI in older people?

Answer 102

1. Tripping
2. Falling

Question 103

Introduction: What intervention has been considered as valuable to improve the overall quality of life in people with SCI?

Answer 103

Physical activity (PA)

Question 104

Introduction: What are the benefits of PA for people with SCI?

Answer 104

It’s meant to alleviate or prevent numerous health and well-being complications resulting from SCI.

PA can help people with SCI from developing diabetes, heart disease, cancer, stroke.

PA has been recommended in people with SCI as it provides numerous benefits such as improved fitness, developing cardiometabolic health and enhancing the quality of life.

Question 105

Introduction: How can someone with SCI achieve such benefits?

Answer 105

Following the recommended guidelines of 40 minutes of moderate to vigorous intensity aerobic physical activity each week for cardiorespiratory advantages and at least 90-minutes per week for cardiometabolic benefits.

Question 106

Introduction: Do people with SCI undertake enough PA?

Answer 106

No, they struggle to meet the recommended guidelines of 40 minutes of moderate to vigorous intensity aerobic physical activity each week

Question 107

Introduction: Why do people with SCI struggle to meet these recommended guidelines?

Answer 107

Due to intrapersonal (e.g., employment, psychological factors), interpersonal (e.g., social support), and policy-related factors (e.g., funding, transportation).

Question 108

Introduction: What is the focus of my PhD?

Answer 108

Identify ways to successfully promote physical activity in adults with SCI to minimise participation inequality.

Question 109

Introduction: Is changing Health Behaviour difficult?

Answer 109

Yes, changing behaviours are difficult as they are highly variable.

Question 110

Introduction: Why specifically are health behaviours difficult to change?

Answer 110

Health behaviours are difficult to change because they are habitual, normative and preventive.

Question 111

Introduction: What are habitual behaviours?

Answer 111

These behaviours are undertaken automatically without much consideration

Question 112

Introduction: What are normative behaviours?

Answer 112

These behaviours bear the weight of tradition and approval

Question 113

Introduction: What are preventive behaviours?

Answer 113

These behaviours commonly lack a salient immediate outcome

Question 114

Introduction: Does using health behaviour change theory improve physical activity interventions?

Answer 114

Yes, using behaviour change theory has been identified as a valuable strategy to increase the effectiveness of interventions.

Question 115

Introduction: What is behaviour change theory?

Answer 115

Set of ideas with specifications of how phemnomena are associated with one another

Question 116

Introduction: Why are behaviour change theories important?

Answer 116

Behaviour Change Theories are important to help us understand behaviour change and provide an organised framework for effective interventions.

Question 117

Introduction: Why is difficult to choose a specific behaviour change theory?

Answer 117

Some theories overlap with one another making it difficult to decide on one.

Also, only some theories consider interpersonal, intrapersonal and environmental factors.

Therefore, to overcome limitations of existing models and to improve intervention development, the Behaviour Change Wheel (BCW) was developed that incorporates multiple theories of behaviour change.

Question 118

Introduction: What is the Behaviour Change Wheel (BCW)?

Answer 118

The BCW can inform all phases of behaviour change from assessing barriers and facilitators to designing and evaluating interventions.
BCW integrates 19 different behaviour change frameworks

The BCW implies that researchers must understand the target behaviour, identify intervention options and then identify content in the form of behaviour change techniques when designing an intervention.

The BCW consists of 3 layers: (1) COM-B model, (2) intervention functions, and (3) and policy categories.

Question 119

Introduction: What is the COM-B Model?

Answer 119

The COM-B model proposes that for any behaviour to occur, an individual must have the capability, opportunity and motivation.

Each component can be broken down further..

Question 120

Introduction: What is Capability in the COM-B model?

Answer 120

Capability refers to an individual’s ‘physical’ or ‘psychological’ abilities to enact the behaviour.

This means an individual should hold the right psychological and physical capability to engage in the required specific behaviour.

Physical capability: Physical capability refers to the degree to which a person can participate in the necessary behaviour, for instance, if restricted by a medical illness.

Psychological capability: Psychological capability refers to whether an individual can participate in the right cognitive processes, comprehension, and reasoning to undertake the target behaviour. For example, this includes the knowledge of the behaviour and the ability to comprehend information and to reason.

Question 121

Introduction: What is Opportunity in the COM-B model?

Answer 121

Opportunity refers to having the ‘physical’ and ‘social’ context that makes it affordable, appropriate, and easy to perform the behaviour.

Physical opportunity: Physical opportunity refers to opportunities supported by the environment (e.g., time, resources, places)

Social opportunity: Social opportunity relates to the social factors that influence how we think about things (e.g., social clues).

Question 122

Introduction: What is Motivation in the COM-B model?

Answer 122

Motivation relates to an individual’s psychological processes that can trigger and direct behaviour including ‘reflective’ and ‘automatic’ motivation.

Reflective motivation: Refers to an individual’s evaluations and plans to engage in the desire behaviour, which includes analytical decision making.

Automatic motivation: Refers to the brain processes that strengthen and direct behaviour such as habitual processes.

Question 123

Introduction: What is the second layer of the BCW?

Answer 123

Nine intervention functions

Question 124

Introduction: What are intervention functions?

Answer 124

Intervention functions help to explain how an intervention seeks to change behaviour

Question 125

Introduction: What are some examples of intervention functions?

Answer 125

Modelling, environmental restricting and restrictions

Question 126

Introduction: What are Behaviour Change Techniques (BCTs)?

Answer 126

A BCT is a strategy that helps an individual change their behaviour to promote better health (e.g., setting goals, packing your gym kit the evening before).
BCTs are the “active components” of behaviour change interventions.

Question 127

Introduction: What is the Behaviour Change Taxonomy (BCTTv1)?

Answer 127

The BCTTv1 is an extensive and agreed list of BCTs which offer standardised definitions, labels, and examples of each BCTs that can support in designing interventions.

Question 128

Introduction: How was the BCTTv1 developed?

Answer 128

Over 50 behaviour change experts from different countries.

It comprises 93 BCTs that are hierarchically organised into 16 clusters.

Question 129

Introduction: What is the 3rd and final layer of the BCW?

Answer 129

The final layer comprises of seven policy options that can be used to help deliver the intervention functions.

These include service provision, communication/marketing, fiscal measures, regulation, guidelines, legislation and environmental/social planning.

Question 130

Introduction: Overall, what does the BCW help to do?

Answer 130

BCW allows intervention designers to consider (1) what behaviours need to be addressed? (COM-B model) (2) How will I successfully change the behaviour and what component does the intervention require, and (3) what needs to be put in placed for the intervention to be provided?

Question 131

Introduction: What is one physical intervention that in recent years that has been deemed useful?

Answer 131

Mobile Health (mHealth)

Question 132

Introduction: What is mHealth?

Answer 132

mHealth refers to the use of mobile technologies to support the success of health objectives such as physical activity.

Question 133

Introduction: Why is the mHealth market growing so quickly?

Answer 133

Widespread availability of wireless network infrastructure and smartphone technologies

Question 134

Introduction: What are some common mHealth apps to monitor physical activity?

Answer 134

1. Fitbit
2. Nike+
3. MyFitnessPal
4. Strava

Question 135

Introduction: Why are mHealth apps so good and have such a good track record?

Answer 135

1. mHealth apps provide real-time feedback
2. Apps can track activities (e.g., how many steps you have done)
3. Remind users to undertake physical activity
4. Easy way to socialise with other users (if that function is available)
5. It can help tailor interventions to the needs of users or specific groups
6. Can undertaken physical activity in nearly all environments (e.g., inside, outside)

Question 136

Introduction: Why would mHealth interventions be useful for people with disabilities?

Answer 136

1. Could support people with disabilities to overcome numerous physical activity related barriers
2. In-person barriers could be difficult for people with disabilities to undertake, so mHealth related interventions could be an effective solution.
3. Delivering an intervention through mHealth can reduce transportation and built environment barriers to access physical activity that are significant for people with physical disabilities.
4. mHealth apps may be more affordable rather than having to use a gym and pay for gym membership.
5. mHealth interventions can provide tailored content for people with disabilities
   Overall, the above shows the possible benefits of using mHealth forms (e.g., smartphone apps) to provide physical activity interventions to those with physical disabilities.

Question 137

Introduction: Why may there not be many physical activity mHealth apps for people with disabilities?

Answer 137

Although people with disabilities have access to mobile technology at the same rates as the general population, people with disabilities are 20% less likely than the general to own a smartphone.

Question 138

Introduction: What makes Accessercise novel to other physical activity apps?

Answer 138

1. Focuses on multiple disabilities (e.g., SCI, Amputee) unlike some other apps
2. Content is shaped around the disability that you select on the app, which no other app has.
3. Is a new app in the UK and has yet to be evaluated

Question 139

Introduction: What is the Medical Research Council (MRC) framework?

Answer 139

A framework that helps to design and evaluate effective health behaviour change interventions.

To maximise the effectiveness of new interventions for people with disabilities, these should be comprehensively designed and evaluated. To this end, the UK Medical Research Council (MRC) has provided updated guidance outlining how this can be best achieved.

Question 140

Introduction: So, why is the Medical Research Council (MRC) framework important?

Answer 140

The MRC framework outlines a five-stage conceptual framework to support the development and evaluation of complex interventions within healthcare settings that incorporate the following stages:

1. Development (or identification of the intervention) (Stage 1)
2. Feasibility/piloting (Stage 2)
3. Evaluation (RCT – Stage 3)
4. Implementation (Stage 4)

Each phase includes sub-stages which require applications to follow closely to develop, evaluate and implement an intervention appropriately.

Stage 1 (Development): Identifying the evidence base – Commonly through a systematic review), identifying appropriate theory, and modelling process and outcomes.

Stage 2 (Feasibility/Piloting): Testing procedures, testing sample size, testing equipment, estimating recruitment/retention.

Step 3 (Evaluation): Assessing effectiveness, acknowledging change processes and evaluating cost-effectiveness

Step 4 (Implementation): Dissemination, surveillance and monitoring, and long-term follow-up.

Question 141

Introduction: So, what stages do I follow in my PhD?

Answer 141

In this thesis, we focus on the development (stage 1) and feasibility/piloting (stage 2) phases of the MRC framework, using a triangulation of quantitative and qualitative methods.

Question 142

Introduction: Why did I use mixed methods in my PhD?

Answer 142

As we were contacted by the Accessercise team to conduct a formal evaluation of their newly developed app, which necessitated a combination of empirical studies, we felt that a mixed-methods approach was most suitable.

Question 143

Introduction: What research paradigm did we follow?

Answer 143

Pragmatism

Question 144

Introduction: Why did I go from SCI to Physical Disabilities?

Answer 144

Due to the world-leading expertise on SCI at the Peter Harrison Centre at Loughborough University, as well as people with SCI being at the lowest end of the spectrum, promoting physical activity in this population is imperative.

However, while Chapters 2-3 focus on addressing physical activity issues for adults with SCI, SCI patients have individual needs, problems, limits, minority issues and demographic distribution concerns. That said, recruiting participants with SCI was challenging. These individuals normally face difficulties participating in the community due to accessibility, affordability, and acceptability issues.

Question 145

Introduction: So, what is your PhD about?

Answer 145

The overall aim of this PhD thesis is to understand how to increase physical activity in adults with physical disabilities. Specific aims were to:

1. Assess the effectiveness of existing physical activity interventions in manual wheelchair users with SCI.
2. Examine the theoretical underpinning of a novel mHealth physical activity intervention, Accessercise, using the BCW.
3. Qualitative evaluate the usability of the Accessercise intervention using concurrent Think-Aloud interventions in adults with different physical disabilities.
4. Undertake a feasibility RCT assessing Accessercise in adults with physical disabilities prior to undertaking a full-scale trial.

Question 146

Introduction: So, tell me, why is your research significant?

Answer 146

This research contributes to the field of physical activity, behaviour change and physical disabilities by understanding how to increase physical activity in adults with disabilities.

Through this research, we evaluate a novel mHealth intervention. By doing this, we can understand the theoretical underpinning to facilitate physical activity in this population.

Most of all, this research can help intervention designers develop their knowledge of the effectiveness of existing intervention and appropriate ways of designing and evaluating physical activity behaviour change interventions.

Ultimately, this research can help with the overall goal of improving physical activity, quality of life and reducing sedentary behaviour in adults with physical disabilities.

Question 147

Systematic Review: What was the aim of the systematic review study?

Answer 147

The aim of this study was to assess the effectiveness of interventions to increase physical activity in adult manual wheelchair users with spinal cord injury.

Question 148

Systematic Review: How many databases were searched for the systematic review study?

Answer 148

9

Question 149

Systematic Review: What were your primary outcomes in your systematic review study?

Answer 149

Self reported physical activity, behavioural physical activity and functional fitness.

Question 150

Systematic Review: What were your secondary outcomes in your systematic review study?

Answer 150

Adverse effects, physiological health, psychological wellbeing, general health-related QoL, Feasibility (acceptability, usability and adherence).

Question 151

Systematic Review: How did you measure methodological quality?

Answer 151

Downs and Black (1999) checklist

Question 152

Systematic Review: How did you measure risk of bias? Also why did you measure Risk of Bias?

Answer 152

Risk of Bias 2

Assessment of risk of bias is regarded as an essential component of a systematic review on the effects of an intervention.

Question 153

Systematic Review: How did you measure certainty of evidence?

Answer 153

GRADE

Question 154

Systematic Review: How many studies did you end up including in your systematic review?

Answer 154

11

Question 155

Systematic Review: How many studies were included in your meta-analysis?

Answer 155

6 studies were included in the meta-analysis demonstrating that self-reported physical activity significantly improved in the intervention vs the control group.

Question 156

Systematic Review: What did you find for your other secondary outcomes?

Answer 156

Meta-analyses were not possible due to heterogeneity of outcome measures, but similar patterns of improvement were found for functional fitness, behavioural physical activity, physiological measures, psychosocial wellbeing, adverse effects and quality of life.

Question 157

Systematic Review: So, what are the conclusions of your systematic review study?

Answer 157

Interventions that aim to improve physical activity in manual wheelchair users with SCI appear to be effective, at least in the short term.

Future research should investigate whether delivering different interventions via different modes can result in longer-term benefits.

Question 158

General: What are some key strengths of your PhD thesis?

Answer 158

1. We used a mixed-methods approach using qualitative and quantitative techniques. It enabled more research gaps to be addressed within one body of work. For example, the feasibility study, the qualitative data offered further insight into the quantitative findings, as well as participants’ acceptability of the intervention by understanding what they liked or disliked about the trial.
2. We followed the MRC framework for designing and evaluating interventions as it’s more likely to lead to success.
3. We followed numerous reporting frameworks (e.g., TiDieR, CONSORT, PRISMA).
4. We used the Behaviour Change Wheel!

Question 159

Introduction: Why have you just looked at mHealth and not other formats of interventions?

Answer 159

Since the COVID-19 pandemic, the use of smartphones development of mHealth apps on the market has expanded, with the use of apps increasing among the disabled population. Additionally, since people with disabilities struggle to participate in physical activity interventions in-person, the use of a smartphone app like Accessercise overcomes barriers and offers people with disabilities with an easier format to undertake PA, socialise and to monitor physical activity performance.

Question 160

Systematic Review: Why is it important to develop, evaluate and implement intervention to encourage people with SCI to successfully engage in regular physical activity?

Answer 160

People with SCI are physically inactive and are at the lowest spectrum of the physical activity continuum.

People with SCI are at increased risk of developing numerous health complications because they are inactive.

People with SCI are not meeting the recommended physical activity guidelines to achieve such health benefits (e.g., reduced risk of depression, better QoL).

Question 161

Systematic Review: Why are people with SCI likely to be physically inactive?

Answer 161

This reduced levels of physical activity in individuals is likely to be explained by the numerous barriers to physical activity that this population experience.

Question 162

Systematic Review: What sort of PA barriers to people with SCI experience?

Answer 162

Lack of transportation, lack of time, negative attitudes towards physical activity and exercise, lack of funding for programmes, expensive equipment, limited coach/person with a SCI knowledge of what opportunities exist, increased cost to participate.

Question 163

Systematic Review: What sort of behavioural interventions have been shown to be efficacious in addressing some of the barriers to PA for people with SCI?

Answer 163

Home-and strength-based training (delivered in-person), (over the phone) or (online through video conferencing software).

Question 164

Systematic Review: What makes an intervention effective? (something related to psychology)?

Answer 164

Suitable behaviour change theories.

Question 165

Systematic Review: What suitable behaviour change theory exists?

Answer 165

Theory of Planned Behaviour, Social Cognitive Theory, Health Belief Model

Question 166

Systematic Review: What does the MRC Framework saying about Behaviour Change Theory

Answer 166

The MRC Framework recommend that the development and evaluation of complex health interventions should incorporate suitable theory to improve the likelihood that they will lead to behaviour change.

Question 167

Systematic Review: Have many interventions that aim to improve physical activity in people with a physical disability used health behaviour change theory?

Answer 167

No, it has been inconsistent.

Question 168

Systematic Review: Have many systematic reviews been undertaken that evaluate the effectiveness of physical activity interventions in people with physical disabilities?

Answer 168

Yes, a couple of interventions exist (e.g., Ma & Ginis, Watson, 2023).

Question 169

Systematic Review: What did the systematic reviews by Ma and Ginis 2018 and Watson 2023 find?

Answer 169

These studies found that interventions significantly increased physical activity in this population.

Watson also found that interventions were more effective when they incorporated specific behaviour change techniques (BCTs).

Question 170

Systematic Review: What makes my systematic review different from that of Ma and Ginis (2018) and Watson et al (2023)?

Answer 170

Ma and Ginis (2018) and Watson et al (2023) included studies that recruited heterogenous SCI populations, including ambulatory, as well as manual wheelchair users and powered wheelchair users. However, most (80%) individuals with SCI use a manual wheelchair for mobility.

Manual Wheelchair Users with SCI are among the least physically active population groups with only 13-16% of SCI Manual Wheel Users with SCI undertaking any form of physical activity.

Therefore, this systematic review addresses this gap and aims to investigate the effectiveness of physical activity interventions exclusively in this population (e.g., effectiveness of physical activity interventions for manual wheelchair users with SCI).

Question 171

Systematic Review: What is PROSPERO in your systematic review?

Answer 171

PROSPERO is an international database of prospectively registered systematic reviews in health and social care

Question 172

Systematic Review: What is PRISMA in your systematic review?

Answer 172

PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) is the standard format for reporting systematic reviews. This approach helps with structuring the methods and for ensuring the systematic review is done correctly.

Question 173

Systematic Review: What is PICOS in the systematic review?

Answer 173

To define a researchable question, the most commonly used structure is PICO, which specifies the type of Patient or Population, type of Interventions (and Comparisons if there is any), and the type of Outcomes that are of interest.

Question 174

Systematic Review: Why did you not include children in your systematic review?

Answer 174

Children and Adults experience different physiological adaptations.

Question 175

Systematic Review: What are Behaviour Change Interventions?

Answer 175

Behaviour change interventions are ‘Coordinated sets of activities designed to change specified behaviour patterns’.

Question 176

Systematic Review: What sort of research designs did you include in your systematic review?

Answer 176

Mainly peer reviewed articles: Randomised Controlled Trials (RCTs), Non-RCTs, pre-post, before and after studies were included.

Question 177

Systematic Review: What sort of research designs were not include in the systematic review?

Answer 177

Non-peer reviewed articles: Case reports, case studies, conference abstracts, posters and book chapters were excluded.

Question 178

Systematic Review: Can you name a couple of the databases that you searched for papers?

Answer 178

APA PsychINFO, MEDLINE, PubMED, ISRCTN, ClinicalTrials, SportDiscuss, Scopus, Web of Science and Cochrane Library.

Question 179

Systematic Review: When and how long did it take you to complete the database searches?

Answer 179

April 2021 and I completed them all in 1 day!

Question 180

Systematic Review: Did you use any software to record the amount of papers you obtained, removed, screened etc?

Answer 180

Covidence

Question 181

Systematic Review: What is covidence?

Answer 181

The world’s leading software for managing and streamlining your systematic review

Question 182

Systematic Review: What tool did you use to measure Risk of Bias?

Answer 182

Risk of Bias 2

Question 183

Systematic Review: What is Risk of Bias 2? Help us to understand what you do for it.

Answer 183

Each study was assessed using RoB2 which rates such as ‘low’ or ‘high risk’ or having ‘some concern’ of bias across five domains: randomisation process, deviatations from the intended interventions (including blinding), missing outcome data, the measurement of outcomes, and the selection of the results.

Question 184

Systematic Review: Why did you not look at the risk of bias of non-controlled RCTs?

Answer 184

These were not included in the meta-analysis and are at risk of bias due to the lack of a control group.

Question 185

Systematic Review: What is the funnel plot you included?

Answer 185

A funnel plot is a simple scatter plot of the treatment effects estimated from individual studies against a measure of the study size.

It helps check for publciation bias between the studies.

Question 186

Systematic Review: How did you recommend the overall quality of evidence?

Answer 186

We used GRADE

GRADE rates studies as high, moderate, low and very low quality (e.g., an RCT would be ‘high’ whereas a before and after study may be ‘low’).

Question 187

Systematic Review: Could you explain how you used the Downs and Black (1998) checklist?

Answer 187

The Downs and Black (1998) checklist consists of 28 questions. The total score you can achieve 28.

Based on your answers, you compare this action a quality schedule (e.g., excellent 24-28 points, good 19-23 points, fair 14-18 points or poor <14).

The checklist asks a list of questions such as whether the interventionist randomised participants, whether there is a hypothesis included, whether the author is clear about the outcomes they measure.

Question 188

Systematic Review: What did you assess within the moderator analyses?

Answer 188

Study characteritics, intervention characteristics, mode of delivery, BCTs and Behaviour Change Theory!

Question 189

Systematic Review: What approach did you use to code for BCTs?

Answer 189

We used the BCT taxonomy version 1(BCTTv1)

Question 190

Systematic Review: How many studies did you include in your review?

Answer 190

11

Question 191

Systematic Review: What is the TiDieR checklist?

Answer 191

Is a tool/guide that helps to provide transparency when reporting of interventions in clinical trials.

Question 192

Systematic Review: How did most of the studies in your systematic review record self-reported physical activity?

Answer 192

Mixture of questionnaires

• LTPAQ-SCI (leisure Time Physical Activity Questional for People with SCI)
• PARA-SCI (Physical Activity Recall Assessment for People with SCI)
• PASIPD (Physical Activity Scale for Individuals with Physical Disabilities)

Question 193

Systematic Review: How did you decide which studies were included in the meta-analysis or not?

Answer 193

1. Had to be an RCT
2. Outcomes were similar
3. We used the measure immediately post-intervention as this likely reflects the largest intervention effect.

Question 194

Systematic Review: So, what did you find for self-reported physical activity between the intervention and goal group?

Answer 194

I found that self-reported physical activity significantly improved in the intervention group compared to the control group.

Question 195

Systematic Review: What is a forest plot and why did you include it?

Answer 195

A forest plot is a figure of the findings of multiple studies that investigated the same research question and measured the same outcome.

Question 196

Systematic Review: Why did you include a meta-analysis?

Answer 196

A meta-analysis combines the results of multiple studies to give us a more reliable result as to whether physical activity interventions are effective in manual wheelchair users with SCI.

Question 197

Systematic Review: How was behavioural physical activity measured across studies?

Answer 197

Accelerometric monitors (wrist/body worn) or attached to the participants wheelchair and wrist.

Question 198

Systematic Review: Why did you not do a meta-analysis on behavioural physical activity?

Answer 198

Due to the heterogeneity (i.e., difference) in outcome measures assessed or research designs.

For example, some studies did not look at behavioural physical activity or were not RCT, so it was impossible to include pre-post data in the forest plot.

Question 199

Systematic Review: How did studies measure functional fitness in the studies for the systematic review?

Answer 199

1. Isometric Strength
2. Aerobic Endurance

Question 200

Systematic Review: Why did you not do a meta-analysis for functional fitness?

Answer 200

I did not do a meta-analysis for functional fitness because of the heterogeneity in outcome measures/study design.

Question 201

Systematic Review: What was the key finding for the ‘behavioural physical activity’ outcome?

Answer 201

Physical activity significantly improved in the intervention relative to the control groups.

Question 202

Systematic Review: What did you find for the ‘functional fitness’ outcome?

Answer 202

For isometric strength and aerobic endurance, improvements were found post-intervention.

Question 203

Systematic Review: What outcomes did you look at specifically for adverse effects?

Answer 203

1. Shoulder Pain
2. Fatigue
3. Upper extremity

Question 204

Systematic Review: What was the key finding for shoulder pain?

Answer 204

Significant reduction post-intervention.

Question 205

Systematic Review: What was the key finding for Fatigue?

Answer 205

No significant changes were found.

Question 206

Systematic Review: What was the key finding for Upper Extremity Function?

Answer 206

Significant main effect was found post-intervention.

Question 207

Systematic Review: What physiological outcomes were assessed?

Answer 207

1. Aerobic Fitness (Vo2 peak)
2. Cardiometabolic Health (blood lipids, blood glucose and blood pressure)
3. Body composition

Question 208

Systematic Review: What was the key finding for Aerobic Fitness?

Answer 208

3 studies found statistically significant improvements in aerobic fitness post-intervention.

Question 209

Systematic Review: What were the key findings for cardiometabolic health?

Answer 209

Blood lipids and blood pressure found improvements.

Question 210

Systematic Review: What were the key findings for BMI?

Answer 210

3 studies found no improvements post-intervention.

Question 211

Systematic Review: What were the key outcomes assessed for psychosocial wellbeing?

Answer 211

1. Depression
2. Anxiety
3. Self-Efficacy

Question 212

Systematic Review: What was the key finding for Psychosocial wellbeing?

Answer 212

All studies showed improvements in psychosocial wellbeing across all the domains (self-efficacy, depression and anxiety) post-intervention.

Question 213

Systematic Review: What were the key findings for General Health-Related QoL?

Answer 213

All studies except for 2 found improvements in Health-Related QoL post-intervention.

Question 214

Systematic Review: How was feasibility measured in your systematic review?

Answer 214

1. Adherence
2. Retention
3. Satisfaction
4. Engagement

Question 215

Systematic Review: What was the key finding for feasibility?

Answer 215

All outcomes were rated highly post-intervention.

Question 216

Systematic Review: For your moderator analyses - What was the key finding for ‘Study and Intervention Characteristics’?

Answer 216

No significant findings were found for any study or intervention characteristic moderators on self-reported physical actvity. [I NEED TO COME BACK TO THIS]

Question 217

Systematic Review: What was the key finding from the moderator analyses on ‘Use of Theory’?

Answer 217

The Q value did not differ significantly between studies that used theory compared to those that did.

Smaller effects were reported for those that used theory.

Question 217

Systematic Review: Did you find that self-reported physical activity was favoured more in the intervention or control groups more?

Answer 217

Intervention group

Question 218

Systematic Review: What was a key finding reported from your systematic review?

Answer 218

The review highlights that PA interventions have the potential to result in a broad range of beneficial outcomes in manual wheelchair users with SCI.

Question 219

Systematic Review: Because you only did a meta-analysis for self-reported physical activity and not other outcomes how do you know the other outcomes improved or not?

Answer 219

Due to heterogeneity of outcomes and research designs, meta-analyses were not possible for all outcomes.

However, a narrative synthesis suggested that behavioural physical activity, functional fitness, physical health, psychosocial wellbeing and QoL generally favoured the intervention relative to the control group.

All together, because of risk of bias and study quality varied across studies, we cannot conclude with certainty that PA interventions can improve such outcomes in manual wheelchair users with SCI. As a result, further high quality research is needed in this area.

Question 220

Systematic Review: What was the risk of bias like for some of the studies in your systematic review?

Answer 220

Several studies were fine as they were RCTs

However, some studies were reported as high risk of bias because they did not mention about randomisation, what the procedure was etc.

Question 221

Systematic Review: Were many studies within your systematic review incorporated with theory?

Answer 221

Several of the included studies were underpinned by theory (e.g., health belief model, SCT).

Health behaviour change theories help to design effective behavioural interventions.

Theory can improve the presentation of information by enhancing one’s physical activity intentions, motivation and behaviour.

Question 222

Systematic Review: Did Watson et al and Ma and Ginis find improvements in physical activity when interventions were developed by theory?

Answer 222

Yes.

Question 223

Systematic Review: Did many studies in the systematic review include many BCTs?

Answer 223

While several studies used theory when designing their PA interventions the number of studies that consistently included BCTs was limited WITH several BCTs not included in any reviews.

Consequently, these BCTs could be included in future interventions to determine their effectiveness at increasing PA in manual wheelchair users with SCI.

Question 224

Systematic Review: A key finding from your review is that the effect size was not statistically greater when theory was used compared to when theory was not used. Do you have a reason as to why you may have found this finding?

Answer 224

Rather then suggesting that the use of theory is ineffective, this finding could be down to the relatively small number of studies included.

Therefore, further high-quality research in this area is NEEDED so that the impact of these factors can be assessed.

Question 225

Systematic Review: What were some of the strengths of the systematic review?

Answer 225

1. We included a range of different study designs in our study (e.g., RCTs, non-RCTs, before/after) whereas a previous systematic review only included RCTs.

Unfortunately, despite RCTs being the “gold standard” for evaluating intervention effectiveness, they have limited external validity because participants may not be representative of the general clinical population.

Therefore, to fully accommodate the evaluation of research topics, such as assessing the effectiveness of interventions then MORE than one study should be included.

Question 226

Systematic Review: Can you name a couple of limitations/future recommendations from your systematic review?

Answer 226

1. Most primary and secondary outcomes were assessed using different scales (e.g., PASIPD, LTPAQ-SCI). Providing results from different scales may provide inaccurate estimates of the overall effect reducing certainty in the findings.

Future Recommendation: Future researchers should ensure greater consistency in how outcome measures are assessed allowing them to be more reliability synthesised for direct comparison.

2. The review search was limited to only papers written in English due to a lack of resources (e.g., professional translators). This could also explain why most studies were undertaken in North America (e.g., Canada, USA).

Unfortunately, studies that exclusively focus on studies published in English may miss necessary information on health interventions.

Future recommendation: Researchers should consider collaborating with researchers who are fluent in other languages to help expand the inclusion of studies in a review.

3. Most of the studies included in the review did not report effects beyond 12 months, with the average intervention period being 5.5.

Future research: Future researchers should consider employing longer follow-up duration’s greater than 12 months to provide better estimates of potential long-term benefit.

Question 227

Systematic Review: So, what are the overarching conclusions found from your systematic review?

Answer 227

We found that manual wheelchair users can become more physically active, health and fitter through the help of physical activity interventions. Also, as our review has shown that PA interventions can lead to improvements in functional fitness, psychosocial wellbeing, health-related QoL, adverse effects then our findings should be implemented within the rehabilitation community.

However, all the findings we have reported today should be interpreted with caution due to the high risk of bias and heterogeneity in outcomes and study designs.

Future research: High quality RCTs to address potential confounds of the existing evidence-based, as well as ensure greater consistency in the measured outcomes (i.e., using the same questionnaires to measure self-reported PA).

Altogether, the current review provides a foundation that may be useful to guide policies and programs to improve physical activity levels and tackle the high risk of a secondary lifestyle especially in manual wheelchair users with SCI.

Question 228

Study 2: How many target behaviours did you identify to improve PA in adults with SCI?

Answer 228

13

Question 229

Study 2: What was the name of the title of Study 2?

Answer 229

Applying the Behaviour Change Wheel to assess the theoretical underpinning of a novel smartphone application to increase physical activity in adults with spinal cord injuries.

Question 230

Study 2: How many stages was the Accessercise app evaluated across?

Answer 230

3

1. Understanding the behaviour
2. Identifying intervention options
3. Identifying content and implementation options.

Question 231

Study 2: Can you name a couple of the target behaviours you identified?

Answer 231

1. Problem Solving
2. Goal setting and monitoring
3. Increasing self-confidence
4. Improving access to facilities
5. Reducing stigma and negative attitudes associated with PA

Question 232

Study 2: So, what is your key finding for Study 2?

Answer 232

We identified that Accessercise incorporates the necessary components for adults with SCI to be physically and psychologically capable of undertaking PA, offers social and physical opportunities to reduce sedentary behaviours and supports automatic and reflective motivation.

Question 233

Study 2: So, what are the conclusions

Answer 233

By assessing the theoretical underpinnings of Acessercise using the BCW, we have revealed the potential mechanisms of action for improving physical activity in adults with SCI.

This helps to further inform intervention development, as well as high-quality effectiveness namely, RCTs, assessing whether fitness apps can improve physical and psychological health outcomes in individuals with SCI.

Question 234

Study 2: Apart from mHealth interventions, what have been the format of existing interventions?

Answer 234

Mainly in-person or via the telephone.

Question 235

Study 2: What are some advantages of using an mHealth intervention for people with SCI?

Answer 235

1. Can support individuals with SCI to undertake PA in their own home.
2. mHealth interventions can help overcome transportation and built environmental barriers.
3. Smartphones make it easier to monitor, track and transmit data on health-related outcomes.

Question 236

Study 2: What is so novel about Accessercise, why didn’t you evaluate another app?

Answer 236

Limited studies have concentrated on mHealth interventions to encourage PA in adults with SCI.

Despite Accessercise appearing helpful, the true effectiveness of the app in changing behaviours to increase physical activity has yet to be investigated.

Question 237

Study 2: Why is behaviour change theory so important for interventions?

Answer 237

1. Can assist in ensuring that an intervention meets the needs of the end-user and is likely to lead to long-term behaviour change
2. Behaviour change theory is vital because changing behaviour is notoriously difficult to achieve and requires a lot of work.
3. One key reason is that behaviours are habitual, normative and preventive.

Question 238

Study 2: What are habitual, normative and preventive behaviours?

Answer 238

1. Habitual Behaviours - Behaviours that occur in stable situations/contexs without much thinking.
2. Normative behaviours - Powerful forces of traditional and social approval.
3. Preventive - These normally miss a salient immediate outcome.

Question 239

Study 2: Can you name a couple of Behaviour Change Theories? Name at least 4?

Answer 239

1. Theory of Planned Behaviour (TPB)
2. Social Cognitive Theory (SCT)
3. Health Belief Model
4. Transtheoretical Model of Change (TTM)
5. Self-Determination Theory (SDT)

Question 240

Study 2: IMPORTANT QUESTION - What are limitations of existing models (e.g., SDT, Health Belief Model, TTM)?

Answer 240

1. These theories mainly focus on behavioural analysis of health issues and do not sufficiently explain variations in complex behaviours.
2. These theories can only assist in predicting behaviour and do not help explain how behaviour change occurs.
3. These models concentrate on a relatively small number of constructs and neglect more contextual and conscious processes

Question 241

Study 2: How is the BCW different from other psychological theories?

Answer 241

1. The BCW is different from traditional theories because it considers the role of context, an aspect of behaviour which has been under-investigated in the past.
2. The BCW has successfully informed interventions in numerous health contexts and has been viewed as helpful in charging target health behaviours.

Question 242

Study 2: Could you briefly explain what the BCW is?

Answer 242

The BCW synthesises 19 frameworks of behaviour change identified in the literature.

1. In the middle of the wheel is the Capability, Opportunity, and Motivation Model. This model beliefs that in order to change a behaviour reliant upon addressing three components: physical and psychological capability, social and physical opportunity and automatic and reflective motivation.
2. In the middle of the wheel is 9 Intervention functions
3. On the outside ring, comprises 7 policy options which can help support the intervention functions.

The BCW links influences from the COM-B model to potential intervention functions and policy categories.

Question 243

Study 2: Can you tell us a bit about Accessercise? Who developed the app?

Answer 243

The app was founded by Paralympic powerlifter, Ali Jawad and world-champion sailor Sam Breary and Financial Times European Lawyer Yulia Kyrpa.

Question 244

Study 2: What makes the app different from other apps?

Answer 244

Most apps provide content for just a singular disability.

Accessercise focuses on multiple physical disabilities and content is shaped around the users disability type.

Accessercise is a novel smartphone app developed for people with physical disabilities, which aims to get users physically active by offering users several functions.

Question 245

Study 2: Can you name a couple of the key functions of the Accessercise app?

Answer 245

1. Accessercise offers users the opportunity to exercise in multiple locations (e.g., gym, home, park), which can help users to overcome PA barriers such as transportation and built environment difficulties.
2. Accessercise offers users an exercise library tailored to individual needs and impairments, which are demonstrated by a role model with the same impairment.
3. Accessercise has an accessibility function where you can put your postcode in ad find local accessible gyms.
4. The app also offers a social function, where users can follow other users and react to their workouts by commenting or reacting with an emoji.
5. Users are able to record their workouts and review them at the end of their sessions.

The overarching point of the app is to offer educational knowledge, tracking ability and behavioural prompts to hopefully increase physical activity among it’s users (mainly people with physical disabilities).

Question 246

Study 2: Can you explain the different stages of the BCW that you used to evaluate the Accessercise app?

Answer 246

The BCW is split up into 8 steps across 3 stages.

Stage 1 - Involves 4 steps which helps to understand the behaviour to influence and incorporates the COM-B model in step 4.

Stage 2 - Included step 5-6 which identifies the suitable intervention options

Stage 3 - step 7-8 identifies the content and implementation options.

Question 247

Study 2: So, take us through Stage 1 (Step 1), what did you do?

Answer 247

Stage 1 - Step 1 looks at understanding the behaviour.

Here, we undertook a systematic review to assess the effectiveness of physical activity interventions for manual wheelchair users with SCI

Afterwards, we delved into the literature looking at the barriers and facilitators to PA in this population.

Based on all this information, this helped us to define the problem as: How to improve physical activity in adults with SCI to meet recommended guidelines: 20 minutes of moderate to vigorous aerobic activity alongside strength training 2x per week).

It was acknowledged that individuals with SCI experience physical activity in numerous locations such as home, gym or outside. Thus, the location (or context) of the problem was defined.

Question 248

Study 2: Can you go through what you did for stage 1 step 2?

Answer 248

Selected the target behaviour:

Here, we generated a list of 13 behaviours relevant to the problem identified in step 1 (improving PA to meet recommended guidelines to reduce sedentary behaviour)

These candidate behaviours were based on the barriers and facilitators to physical activity experience by adults with SCI.

The target behaviours were then prioritised by considering the following factors

• Potential impact of changint the behaviour
• Likelihood of shifting behaviours
• Impact of change on other behaviours
• Ease of measuring or monitoring the behaviour

Several candidate behaviours were identified as promising or very promising across all four factors

Question 249

Study 2: Stage 1 - Step 2. Can you name a few of the 13 candidate behaviours that you identified?

Answer 249

1. Goal setting and monitoring
2. Action Planning
3. Reduce stigma and negative attitudes
4. Improve access to facilities
5. Improve knowledge in those delivering PA
6. Problem Solving
7. Increase confidence and motivation

Question 250

Study 2 - What was Stage 1 Step 3 all about?

Answer 250

Specify the target behaviour:

Who: Improving PA for adults with SCI

What: React adaptively to SCI by applying the strategies suggested by the intervention.

When: On a regular basis, preferably at a time that suits them to achieve the SCI-recommended guidelines of 20 minutes of moderate to vigorous intensity aerobic PA 2x per week)

Where: Any given situation (e.g., outside, inside)

How often: As often as they can by ensuring that they meet the recommended guidelines of 20 minutes 2x per week of moderate to vigorous intensity PA)

With whom: Individuals or as a group (e.g., with friends, family, care givers).

Question 251

Study 2: Stage 1 - What was Step 4?

Answer 251

The COM-B model was used to help us to change in the individual or environment in order for the desired changes in behaviour to occur.

Altogether, we identified that changes need to be made across all the components of the COM-B model (Capability, Opportunity, Motivation)

Question 252

Study 2: Step 4 - Could you provide examples of Capability (e.g., Physical and Psychologyical)

Answer 252

Physical capability (e.g., physical skills, strenght or stamina) was increasing physical abilities to undertake PA.

Psychological capability (e.g., knowledge, mental stamina) would include improving problem solving as well as making suitable decisions related to PA.

Question 253

Study 2: Step 4 - Could you provide examples of Opportunity (e.g., Physical and Social).

Answer 253

Physical opportunity (e.g., time, resources) which may involve appropriate access to facilities, equipment and resources to undertake PA.

Social opportunity (e.g., social cues) such as social support from family, friends, care givers to undertake PA.

Question 254

Study 2: Step 4 - Could you provide examples of Motivation (e.g., Automatic and Reflective)

Answer 254

Automatic (e.g., emotion reactions) could involve the completion of weekly diaries to monitor performance and set goals.

Reflective (e.g., self-conscious intentions plans) such as holding beliefs that undertaking PA is achievable and will lead to positive outcomes.

Question 255

Study 2: What is the name of Stage 2?

Answer 255

Identify intervention options

Question 256

Study 2: Stage 2 - What is involved in Step 5?

Answer 256

Intervention Function

Based on the findings from the COM-B model (Step 4), Step 5 involved using the BCW to identify the most suitable intervention functions.

In order to assess the most appropriate intervention functions, we used the APEASE criteria.

Overall, we identified 7/9 functions were selected as suitable intervention functions to facilitate PA in adults with SCI.

These intervention functions were education, persuasion, training, modelling etc)

Question 257

Study 2: What does the APEASE criteria stand for?

Answer 257

Affordability, Practicability, Effectiveness, Acceptability, Side-Effects and Equity.

Question 258

Study 2: Name a couple of the intervention functions that you identified?

Answer 258

1. Education
2. Training
3. Coercion
4. Persuasion
5. Enablement
6. Modelling
7. Incentivisation

Question 259

Study 2: Stage 2 - Step 6. What is involved in this stage?

Answer 259

Policy Categories

7 policy strategies were selected to help support and enact the intervention functions (e.g., communication/marketing, guidelines, legislation, social planning).

Overall, after using the APEASE criteria to determine the most effective policy categories. We identified that 2/7 were deemed most appropriate such as Communication/Marketing (e.g., verbal, written, posters of the benefits of PA for this population) and service provision (e.g., establishing PA in numerous contexts and communities).

Question 260

Study 2: What is the name of Stage 3 for the BCW?

Answer 260

Identify Content and Implementation Options

Question 261

Study 2: Stage 3 - What is involved in Step 7?

Answer 261

Behaviour Change Techniques (BCTs)

This stage involved identifying the most appripriate BCTs that can deliver the intervention functions (step 5) and policy categories (step 6)

1. The most frequently used BCTs were derived from the BCT taxonomy which involve 93 BCTs organised across 16 categories.
2. The most relevant BCTs were assessed in relation to the APEASE criteria.
3. As a team, we made a final decision on the included BCTs were undertaken.
4. Based on the intervention functions selected in Step 5 (e.g., education, training, modelling, persuasion, incentivsation) the appropriate BCTs identified were for example: Goal setting, action planning, reviewing behavioural goals, social support.
5. The Accessercise app included BCTs associated with education by offering feedback on behaviour through instructional videos and modelling by demonstrating the behaviour.

Question 262

Study 2: Based on Step 7 (Stage 3) you identified several BCTs. What BCTs could the app developers include in the future?

Answer 262

1. Graded tasks (offering users more challenging exercises).
2. As some users may be inexperienced with PA, offering live chats/forums will help users that have numerous questions about exercising.

Question 263

Study 2: Stage 3 (Step 8): What is the name of this step?

Answer 263

Mode of delivery

Question 264

Study 2: Stage 3 (Step 8): What did you do in this step?

Answer 264

The most suitable mode(s) of delivery for the chosen BCTs are identified using the APEASE criteria.

Most modes of delivery not suitable for our study due to the high costs for development and service provision (e.g., affordability).

The mode of delivery that was identified as the most suitable was digital media (e.g., internet or smartphone s) since this mode would be low cost, allow for the BCTs to be easily delivered and would be both acceptable to and reach the end-users.

Question 265

Study 2: How did you assess the Behaviour Change Potential of the Accessercise app?

Answer 265

We used the ABACUS scale

Question 266

Study 2: What does ABACUS (Behaviour Change Potential) stand for?

Answer 266

App Behaviour Change Scale

The scale was used to review the behaviour change potential of the app

Question 267

Study 2: What was involved when we assessed Behaviour Change Potential of Accessing using the ABACUS scale?

Answer 267

The ABACUS consists of 21 items that examine potential behaviour change of an app:

It focuses on key areas such as:

(1) knowledge and information

(2) goals and planning

(3) feedback and monitoring

(4) actions

Question 268

Study 2: How do you get the overall result of the ABACUS score for the Accessercise app?

Answer 268

Every question has 1 point. You add up all the answers from the 21 questions and you have a final answer.

Higher score indicates more confidence of behaviour change potential

Question 269

Study 2: Overall, what did you find for Behaviour Change Potential using the ABACUS?

Answer 269

Accessercise included 16/21 items indicating a high number of BCTs included in the app suggesting “strong confidence” in behaviour change potential.

Question 270

Study 2: What could Accessercise do to possibly improve it’s overall Behaviour Change Potential?

Answer 270

1. Offers users reminders and prompts
2. Encourage positive habit formation
3. Offer users opportunities to export data out of the app and onto social media channels.
4. Incorporate graded tasks.
5. Notifying users with a text message on a selected day/time that they are likely to exercise.

Question 271

Study 2: What were the key findings that you found?

Answer 271

1. The Accessercise may be a practical approach for adults with SCI offering users the capability, opportunity and motivation to undertake PA and reduce sedentary behaviour.
2. Accessercise targets all components of the COM-B model (e.g., goal setting - capability, self-monitoring (opportunity) and reviewing goals (motivation)
3. Our findings are promising given that Accessercise was not initially developed using theory. Overall, the method of retrofitting Accessercise to the BCW framework was appropriate as it can help identify the BCTs that have been included in the app to support physical activity. Therefore, the current study could be used by other research seeking to employ similar methods in the design/evalaution of similar interventions for people with SCI.
4. Accessercise includes relevant BCTs to help people with SCI to overcome barriers to PA.
5. As Accessercise is a novel application, many users may miss the opportunity to be signed posted or to know what Accessercise can offer. Future research may consider ways to increase access to mHealth technologies. One way is by reducing social exclusion, marginalisation, and disability stigma through mainstreaming disability.

Question 272

Study 2: What are some of the key limitations of Study 2?

Answer 272

1. The development, evaluation and implementation of mHealth apps can be time consuming. Therefore, technology and target groups interest can quickly change and become outdated.
2. The functionality and features of Accessercise continue to expand, making it challenging to know the exact time to fully evaluate the apps behaviour change potential as this may change over time.
3. Even though the BCW can assist with designing interventions, it lacks a formal guide in translating BCTs. Consequently, translating BCTs into app features relies heavily on the expertise and and creativity of the research team and/or app developers.
4. Coding the BCTs from the app and completing the specified worksheets was time-consuming and labour-intensive. Therefore, this labour and time-consuming process could make it unfeasible for specific problems, organisations, and/or circumstances.

Question 273

Study 2: What are the key conclusions from Study 2?

Answer 273

This study reveals the value of using the BCW to systematically identify the potential mechanisms of action for improving physical activity in adults with SCI, as well as the potential of a novel mHealth smartphone fitness app, Accessercise to change behaviour.

Question 274

Study 2: So, what future recommendations would you provide?

Answer 274

1. The effectiveness of Accessercise to facilitate the desired behaviour change should be assessed, such as via a Randomised Control Trial (RCT). Such high quality evidence would provide the foundation that could guide decisions concerning how to increase PA as well as health more generally, in adults with SCI.

Question 275

Study 3: What is the title of your 3rd study?

Answer 275

Assessing the usability of Accessercise to increase physical activity in adults with physical disabilities: a qualitative think-aloud study

Question 276

Study 3: How many participants did you undertake a think-aloud interview on?

Answer 276

12 (10 male and 2 female)

Question 277

Study 3: How did you analyse the data?

Answer 277

Deductive Content Analysis

Question 278

Study 3: What was the name of the framework you used to analyse the data using Content Analysis?

Answer 278

uMARS (User Version of the Mobile Application Rating Scale)

Question 279

Study 3: How many domains did you match onto the uMARS scale?

Answer 279

12 out of 15

Question 280

Study 3: What were some of the key findings from this study?

Answer 280

The majority expressed positive views concerning most elements and features of the Accessercise app namely entertainment, customisation, tailoring to the target group, ease of use and navigation, as well as visual information.

However, while some features were viewed positively, some required modification to increase their usability, credibility and relevance including the app’s layout (Placing content in alphabetical order), visual appeal (in-built-colour setting), interactivity (providing real-time feedback), quality of information (number or bullet pointing content) and quantity of information (removing content such as equipment not related to a specific goal).

Question 281

Study 3: So, what are the implications of my findings?

Answer 281

Our study is one of the first to show that a think-aloud protocol is acceptable and can be informative within the context of assessing mHealth apps to increase PA in people with disabilities.

As such, this study offers an evidence-based example that app developers and researchers could use to inform their usability evaluations in this area.

Question 282

Study 3: What are some of the benefits of using mHealth interventions for people with disabilities?

Answer 282

1. mHealth interventions can support people with disabilities overcome numerous barriers to PA (e.g., transportation, high costs)
2. mHealth apps by people with disabilities can alleviate social and health disparities
3. mHealth interventions are cost-effective, can be undertaken practically anywhere and users can personalise the app based on their own needs and requirements.
4. Users are also not required to contact a personal trainer which could be costly because they can access personalised content via apps.
5. mHealth interventions appear to be promising (small-to-moderate effects) at increasing physical activity in the general population. Therefore, such results may be similar for people with disabilities.

Question 283

Study 3: What are some limitations of apps that exist at the moment (e.g., FisioFriend, WHEELS, ParaSportAPP, SCI Step Together)?

Answer 283

1. Most of these interventions target a specific disability (e.g., amputee, spinal cord injury). For example WHEELS is aimed at wheelchair users with SCI or lower-limb amputation, while the 9zest Parkinson’s Therapy app was created to promote PA in people with Parkinson’s disease.
2. Very few focus on multiple disabilities, which restricts access to physical activity mHealth apps for people with disabilities, potentially increasing their risk of sedentary behaviour and lack of engagement in PA programs.

Accessercise is unique because it focuses on multiple physical disabilities on one platform. Also, to our knowledge, no PA app has been developed and evaluated that provides tailored content for multiple physical disabilities via an mHealth-based platform.

Question 284

Study 3: What are some key features of the Accessercise app?

Answer 284

1. You can select your own disability and the content of the app is shaped based around that impairment.
2. Exercise video library with numerous exercises which are delivered by a role model with that specific disability you have selected.
3. Accessibility/Explore Function - You can place your postcode in the search and find local facilities that are accessible.
4. Social Hub Feature - You can follow other users, follow their workouts and react and comment on their workouts to boost motivation.
5. Opportunities to build your own custom workout
6. Chance to exercise outside, in the gym or at home with many workout goals to choose from.

Question 285

Study 3: What is Usability?

Answer 285

Usability is the evaluation to which a product/device is effective, efficient and viewed as satisfactory by the end-user.

Question 286

Study 3: What are some of the key reasons for doing Usability Testing?

Answer 286

Usability testing helps to identify possible issues with the app, to improve it’s functionality and acceptance among it’s users and hopefully lead to long term use.

Question 287

Study 3: What are some examples of poor usability?

Answer 287

Hardware issues like small screens and limited input opportunities, which can lead to low adherence or app rejection.

Question 288

Study 3: Has the usability of mHealth apps in the context of behaviour change behaviour received little attention for people with disabilities?

Answer 288

Yes

Question 289

Study 3: What are some examples of methods to assess usability for mHealth apps?

Answer 289

1. Think-Aloud Interviews
2. Questionnaires
3. Focus-Groups
4. Eye-Tracking
5. Interviews

Question 290

Study 3: What has been the most widely applied tool for assessing Usability in mHealth apps?

Answer 290

Think-Aloud Interviews

Think-Aloud interviews is commonly used for evaluating health behaviour change interventions.

Question 291

Study 3: What are some advantages of Think-Aloud Interviews?

Answer 291

1. Researchers can gain data on participants thoughts and needs during testing and ongoing verbalised information collected allows the researcher to identify the source of possible problems.
2. Think aloud interviews can help identify usability issues and identify improvements providing direct information on a user’s thinking as they happen (real-time).
3. Think-aloud interviews help to overcome memory/recall bias of other methods (e.g., interviews, questionnaires) because Think-Aloud interviews collect real-time data as they happen while preventing the loss of data that may occur as a result of memory constraints.

Question 292

Study 3: What are the benefits of using Think-Aloud interviews over other methods (e.g., Questionnaires, Scales, Interviews)

Answer 292

These methods are at risk of recall/memory bias. Think-Aloud interviews allow us to get data on thought processes while they happen.

Question 293

Study 3: What are the implications of our Think-Aloud Study?

Answer 293

Our findings will help to inform future app development and hopefully improve adherence, physical activity, and health as well as providing this population a voice in and through research.

Question 294

Study 3: What was your overall aim of the usability study?

Answer 294

The current study employed think-aloud interviews to examine the usability of the Accessercise app, specifically designed for people with different physical disabilities.

Question 295

Study 3: What is SRQR?

Answer 295

Standards for Reporting Qualitative Research

Question 296

Study 3: You said in your methods you used a qualitative relativist epistemology. What is that?

Answer 296

This approach believes that multiple realities are socially constructed and meaning is created through the interaction between the researcher and the participants.

Question 297

Study 3: How did you ensure Reflexivity in your work?

Answer 297

Hand-written field notes were undertaken in a reflexive diary, which included comments during and after each interview.

My supervisors also acted as “Critical Friends” who debated and contested the conclusions identified in the data analysis and the final report.

Question 298

Study 3: Why did you choose face-to-face interviews rather then focusgroups?

Answer 298

Face-to-face interviews are better for marginalised groups (i.e., people with disabilities) to help build report.

Question 299

Study 3: What is purposive sampling strategy?

Answer 299

Purposive sampling is when you select participants because they have characteristics that you need in your sample.

Question 300

Study 3: Again, what are think-aloud interviews?

Answer 300

Think-aloud interviews allow an individual to verbalise aloud everything they think about whilst completing a task.

Question 301

Study 3: What is the most common method to analyse qualitative research?

Answer 301

Content Analysis

Question 302

Study 3: What is involved in Content Analysis?

Answer 302

Content Analysis involves assigning the text to one or more domains.

Question 303

Study 3: Why was Content Analysis selected over other methods?

Answer 303

It’s systematic and objective approach for identifying what content and information was contained in the discourse.

Question 304

Study 3: Why did you choose the uMARS as your framework for your content analysis?

Answer 304

uMARS provides simplified reliability and a reduced number of items, which makes it easier for mHealth evaluations by individuals with different educational backgrounds, making it more of an inclusive analysis..

Question 305

Study 3: What is involved in the uMARS scale?

Answer 305

The uMARS is a simple, validated scale which assesses the overall quality of mHealth apps across four domains: Engagement, Functionality, Aesthetics and Information Quality.

Question 306

Study 3: Can you take us through the steps that you undertook for the Usability Study?

Answer 306

Step 1: Created a formative categorisation matrix with four pre-set categories based on the uMARS.

Step 2: Fimilarised myself with the data by re-reading all the interview transcripts and going through my reflexive diaries.

Step 3: Specific relevant passages of text were highlighted and then colour coded using highlighter pens.

Step 4: Colour-coded passages were clustered and a descriptive code was produced.

Step 5: Any codes were then categorised based on their meanings, similarities and differences and then aligned to the pre-arranged categorisations within different themes and secon-dorder themes (higher-order themes and then second-order themes).

Step 6: A content analysis map was then produced to share a view of the themes, codes and quotations.

Question 307

Study 3: How did you ensure trustworthiness in your research?

Answer 307

Trustworthiness is one of the essential components of ‘rigour’ in Qualitative Research.

Even though, four criteria is widely used, these have been criticised for violating the philosophical underpinnings of qualitative research.

‘Reflexivity’ was used. Therefore, specifically, a ‘critical friends’ approach was used.

We also pilot tested the interview schedule

All authors met three times to critically review and discuss the codes, sub themes and overall view of the content analysis.

Each transcript and field note was emailed to participants to enhance trustworthiness.

Question 308

Study 3: What are your final thoughts about the usability study?

Answer 308

Overall, our study adds to the number of limited studies that look at usability of mHealth apps.

1. This study has demonstrated that despite several troubleshooting difficulties, Accessercise can be effectively operated by various users with physical disabilities.
2. Our research has shown that Accessercise can be an effective app at supporting people with disabilities in overcoming numerous barriers to physical activity.
3. Such findings could help app developers/researchers consider ways that apps are currently designed based on user’s preferences, which may in turn lead to an increase in uptake.

Question 309

Study 3: What are the 4 limitations

Answer 309

1. Several features on the app were under development during the testing phase, which could have affected the users’ thoughts/feelings about the app. Therefore, future researchers should consider incorporating these functions to gain rich data on this and whether they will support usability from it’s end-users.
2. Most participants were young male, Caucasians, English speaking and under the age of 58 and had sufficient mobile phone skills, which limits the generalisaiblity of our findings to other people with disabilities. Therefore, future researchers want to consider involving a more heterogeneous sample.
3. Interviewing participants in a controlled laboratory setting and audio-voice recording their responses may have lead to overly positive feedback/bias responses and may have induced or increase anxiety and impacted the participants’ ability to use the app efficiently.
4. Participants completed a think-aloud interview in an unfamiliar setting, which is not how they would engage with the app in a real-world setting (e.g., at home or at the gym). Therefore, valuable data on the app’s performance in a more ecologically valid environment could have been overlooked. Future researchers may want to supplement think-aloud interviews with field testing to address such issues.

Question 310

General: What is the impact of the work that you have done?

Answer 310

The impact of my work is that we now know that Accessercise is a useful intervention that can increase physical activity in adults with physical disabilities

Question 311

Study 4: What is the title of Study 4?

Answer 311

Assessing the effectiveness of Accessercise to improve physical activity in adults with physical disabilities: A randomised controlled feasibility trial

Question 312

Study 4: What were the key primary outcomes you were assessing?

Answer 312

1. Feasibility
2. Attrition
3. Implementation of study delivery
4. Intervention fidelity

Question 313

Study 4: How many participants took part in the trial?

Answer 313

20 but only 14 completed the trial

Question 314

Study 4: Why did you understand qualitative interviews in this study?

Answer 314

We undertook qualitative interviews to assess participants experience of the RCT design

Question 315

Study 4: So, what were the key findings that you found?

Answer 315

Feasibility was ‘amber’ for both adherence and attrition.

Participants generally expressed happiness with the trial methods and intervention.

Question 316

Study 4: So, what is the conclusion from this study?

Answer 316

The mHealth intervention (Accessericse) appears feasible and acceptable and can proceed to a full trial but just requires a few changes.

Due to moderate adherence and attrition rates, better recruitment techniques would be needed such as recruiting through the NHS and reducing the number of visits needed to the lab by completing assessments remotely, as well as reimbursing transportation costs.

Question 317

Study 4: How have most PA interventions for people with disabilities been delivered?

Answer 317

Face-to-face and/or viva the telephone

Question 318

Study 4: What is mHealth?

Answer 318

mHealth refers to mobile health which is the practice of public health that is supported by mobile phones, such as smartphone apps.

Question 319

Study 4: What are some of the advantages/benefits of using mHealth apps

Answer 319

1. They are normally free or inexpensive
2. Apps provide real-time feedback and content that can be personalised to an individual’s needs
3. Can be accessed virtually anywhere (home, gym, park)
4. Apps are safe, usable and cost-effective
5. Apps can alleviate transportation and architectural barriers, which are enormous for people with physical disabilities.

Question 320

Study 4: What are some of the limitations of existing apps?

Answer 320

Some of the existing apps are limited by focusing solely on several individual physical disabilities.

No physical activity app has been developed and evaluated that provides tailored content for multiple physical disabilities via an mHealth-based platform.

Question 321

Study 4: What is Accessercise can you tell us a bit more about this?

Answer 321

Accessercise is a novel fitness and health application which was developed in 2021 by Ali Jawad and Sam Breary.

The app was designed to increase physical activity for those with disabilities including those with spinal cord injuries, amputees and dwarfism.

The app provides many interesting functions such as a social function, explore map function and an exercise video library.

Question 322

Study 4: What is the Medical Research Council (MRC) framework?

Answer 322

The MRC framework provides 4 key phases when developing and evaluating new complex interventions

Question 323

Study 4: What are the 4 steps involved in the MRC framework?

Answer 323

1. Development
2. Feasibility/piloting
3. Evaluation
4. Implementation

Question 324

Study 4: What phase of the MRC framework are you following in Study 4 (Feasibility Trial)

Answer 324

Since the Accessercise app has already been developed, it’s acceptability and feasibility should now be assessed in the next stage (Step 2)

Question 325

Study 4: What are some benefits of doing a feasibility trial?

Answer 325

1. Assess the feasibility and acceptability of the intervention
2. Assess whether the outcomes, number of participants and equipment used is acceptable.
3. Assess whether parts of the intervention are good for a big trial
4. Determine whether undertaking a full-scale trial is worth it in terms of cost, time and resources.

Question 326

Study 4: What were the 3 key aims for the Feasibility Trial?

Answer 326

1. Measure the following outcomes before and after using Accessercise: Self-reported PA, psychological health, physiological health, adverse effects, health-related QoL and usability.
2. Qualitative assess implementation of study design and intervention fidelity
3. Determine the willingness of adults with physical disabilities to take part in the trial, as well as their retention through to follow up

Question 327

Study 4: What are the CONSORT guidelines?

Answer 327

The CONSORT statement is made up of a 25-item checklist that provides the author with a solid backbone around which to construct and present an RCT.

Question 328

Study 4: What were some of the key inclusion criteria for this study?

Answer 328

1. Adult aged 18+ to 65 years old?
2. Live with a physical disability (e.g., SCI, amputee, dwarfism).
3. Have access to a compatible smartphone device to use Accessercise
4. Live within the United Kingdom (UK)

Question 329

Study 4: How did you recruit participants for this study?

Answer 329

1. Social Media Channels (e.g., X, Facebook)
2. Word of mouth
3. National Governing Bodies (e.g., WheelPower)
4. Rehabilitation Centres
5. Contacting participants from previous studies who had provided consent to be contacted for future studies.

Question 330

Study 4: What is Qualtrics that you used in this study?

Answer 330

Qualtrics is an online system, which I used to place all the demographics, questionnaire questions onto to allow participants to answer them.

Question 331

Study 4: When did participants complete your outcome measures (e.g., self-reported PA, QoL, physiological, psychological health, etc)?

Answer 331

Baseline (i.e., Week 1) and post-intervention (i.e., Week 12).

Question 332

Study 4: How did you measure adherence and implementation?

Answer 332

This was down to Willingness to take part., which was down to the traffic light system to assess progression to a full-scale trial.

Question 333

Study 4: What is the traffic light system (e.g., for adherence/attrition across green, amber and red)?

Answer 333

The traffic light system assess adherence (how often participants took part) and attrition (how many participants dropped out) against a green, amber and red traffic light system.

Green: Proceed to a full trial

Amber: Proceed to a full trial but requires amendments

Red: A full trial should not be undertaken.

You work out the number of participants that took part and how many dropped out and this will help determine whether it’s green, amber or red.

Question 334

Study 4: What were your secondary outcomes that you measured?

Answer 334

1. Self-reported Physical Activity
2. Psychological Health
3. Physiological Health
4. General-Health Related QoL
5. Adverse Effects
6. Usability

Question 335

Study 4: What questionnaire did you use to measured Self-Reported PA?

Answer 335

PASIPD (Physical Activity Scale for Individuals with Physical Disabilities)

Question 336

Study 4: What questionnaire did you use to measure Self-Reported Psychological Wellbeing?

Answer 336

WEMWBS (Warwick Edinburgh Mental Wellbeing Scale)

Question 337

Study 4: What did you use to measure Body Composition, Waist Circumference, Resting Heart Rate and Blood Pressure?

Answer 337

1. Body Composition (Weight)
2. Waist Circumference (Tape measure)
3. Heart Rate (Heart Rate Sensor)
4. BP (Blood Pressure Monitor)

Question 338

Study 4: What questionnaires did you use to measure Pain and Fatigue?

Answer 338

1. Pain was measured using BPI-SF (Brief Pain Inventory - Short Form)
2. Fatigue was measured using FSS (Fatigue Severity Scale)

Question 339

Study 4: How did you measure General-Health Related QoL?

Answer 339

We used the SF-36 (Short Form - 36 Questionnaire)

Question 340

Study 4: How did you measure usability?

Answer 340

We used the uMARS (User Version of the Mobile Application Rating Scale)

Question 341

Study 4: How did you analyse the secondary outcomes (e.g., self-reported PA, Physiological outcomes)?

Answer 341

Due to this feasibility study was not powered to test for statistically significant differences as the sample size was too small, Mann Whitney U tested were to analyse differences between groups for all secondary outcome measures.

Question 342

Study 4: How/why did you undertake qualitative interviews for this study?

Answer 342

To understand participants experiences of the RCT design as well as the intervention implementation and fidelity, we undertook interviews at the end of the 12-week trial.

Question 343

Study 4: What sort of questions did you ask during the interview at the end of the trial?

Answer 343

1. Motives for participating
2. Possible barriers to attending
3. Research design (e.g., recruitment, randomisation, outcomes)
4. Intervention implementation and fideity

Question 344

Study 4: How did you analyse the qualitative interviews?

Answer 344

Reflexive thematic analysis

Question 345

Study 4: What were the key findings you found for secondary outcomes?

Answer 345

1. We found between the intervention and control groups did not differ statistically between any of the assessed measures.

Question 346

Study 4: What did you find for usability when you used the uMARS scale?

Answer 346

The scores were above 3 for all subscales, suggesting acceptable usability of Accessercise across all uMARS subscales

Question 347

Study 4: What were some of the key themes found from the thematic analysis?

Answer 347

1. Study adherence
2. Study testing
3. Study satisfaction
4. Researcher involvement

Question 348

Study 4: So, tell us, what were the main results from your feasibility trial?

Answer 348

1. The feasibility relating to the willingness of participants to engage and complete the trial were satisfied (feasible) but required amendments.
2. The implementation and interview fidelity were well-perceived among participants (e.g., regarding the ranomisation, researcher involvement and outcomes)
3. However, responses regarding app usage, whether the app would be recommended to others was perceived unfavorably among participants.

Question 349

Study 4: Are there any possible reasons as to why you had high dropouts?

Answer 349

Possibly the intervention (or app) did not meet the users’ needs, goals and expectations.

Participants reported that the app was not always relevant to users disability, lacked appropriate exercises and app functions were still under development.

People with disabilities experience numerous barriers in research (e.g., transport) so this could have made it more difficult for them.

Question 350

Study 4: Are there any other reasons as to why participants dropped out during the study?

Answer 350

1. Costs and travel challenges involved in attending in-person sessions.

Question 351

Study 4: What could you do in future research studies to increase adherence?

Answer 351

1. Make relevant changes to the research design to allow users to complete the assessments online rather then in-person reducing transportation, time and costs.
2. Researchers should undertake regular check-ins via phone/video calls and to perform assessments at participants’ home/closer locations to overcome accessibility barriers.
3. Another solution is to involve potential users during the entitle cycle of intervention development. User-centred design is helpful for mHealth app development as it enables better designs and improves interventions.

Question 352

Study 4: How can you overcome challenges with recruiting participants into disability related research?

Answer 352

1. Recruitment from GPs or the NHS could be more valuable than advertisement via mass media strategies such as leaflets or social media posts in a future large-scale trial to recruit people with physical disabilities at high risk of loneliness or social isolation.

Question 353

Study 4: What are some strengths of your feasibility study?

Answer 353

1. We undertook the study following key guidelines (e.g., SRQR, CONSORT, MRC) as well as employed the “traffic light system”. Following these guidelines improved the reporting of the evidence, promoted transparency, comprehensiveness, accuracy and well-written research, as well as improved the communication of the results to the scientific community. Therefore, the reliability and validity of the findings were maximised by following these guidelines.
2. The mixed methods approach (qualitative and quantitative) enabled the researches to gain a comprehensive understanding of the trial feasibility and intervention acceptability.
3. The intervention component of the trial required minimial resources, was cost-effective (free to participants) and required no additional thoughts from the researchers.
4. The Accessercise app was simple to use, can be used in any suitable location and can be personalised to the individual’s needs.
5. We followed the MRC framework, by undertaking the first feasibility RCT of a novel app (Accessercise) for people with physical disabilities, which was valuable to identify potential refinements to the intervention, address any issues with the study design and assess the preliminary effects of the intervention.

Question 354

Study 4: Can you name a couple limitations of your feasibility trial (Study 4)?

Answer 354

1. As this was a feasibility RCT, it was not sufficiently powered to detect changes in quantitative outcomes pre-to-post intervention. However, it provides some useful information to help inform the design of a full-scale RCT to establish the overall effectiveness of the Accessercise app in people with physical disabilities.
2. The majority of participants were Male, White British and had a spinal cord injury.
3. Due to technical difficulties, only those that had owned a compatible smartphone device could participate, which could explain why most participants were young to middle aged.
4. Due to privacy reasons, we were unable to access data on how often participants engaged with the app and it’s provided features. This is imperative because researchers should not only rely on self-reported measures because this data is often unreliable, perhaps due to poorer recall.
5. Blinding the participants and researchers was not possible due to the nature of the intervention and trial design, which could have led to bias.
6. This trial was completed in a single laboratory, which could limit the generalisability of results.
7. Interviews were only taken on those that completed the trial, which could be a sense of bias, as we don’t know why some participants dropped out.

Question 355

Study 4: What are the key conclusions from the feasibility trial (Study 4)?

Answer 355

1. We have found that Accessible is feasible and can proceed to a full-trial with some amendments.
2. The intervention implementation and fidelity are acceptable and deliverable among participants and the adherence and drop outs are moderate based on the traffic light system. However, with moderate adherece and drop-out rates, further refinements are needed to enhance users’ engagement before a full-trial.
3. Therefore, the next step is to undertake a full-scale RCT which could indicate whether Accessecise can effectively increase PA in adults with disabilities.
4. Future researchers may also want to use the findings I have found in my study to improve feasibility (e.g., recruiting through the NHS, undertaking assessments online and performing regular check-ins) to overcome accessibility barriers when designing similar RCTs in the future.

Question 356

Study 4: How did you ensure trustworthiness within your feasibility trial?

Answer 356

1. David acted as a “critical friend” by meeting with James regularly to discuss any field notes that he produced.
2. The interview schedule was pilot tested with the first participant to assess and refine question order and wording etc.
3. Interview transcripts were emailed to participants for comments/corrections to maximise transparency and trustworthiness of the datasets (I.e., member checking) with no amendments made to the final transcripts.

Question 357

Discussion: What was the principal aim of your PhD thesis?

Answer 357

The principal aim of this thesis were to understand how to increase physical activity in adults with disabilities. To answer this research question, 4 small research aims were undertaken:

1. To evaluate the effectiveness of physical activity interventions in manual wheelchair users with SCI.
2. To assess the theoretical underpinnings of a new mobile health application (or app), Accessercise, using the Behaviour Change Wheel (BCW)
3. To qualitatively examine the usability of the Accessercise application using concurrent Think-Aloud interviews.
4. To determine the feasibility of undertaking a full-scale evaluation of the Accessercise app

Question 358

Discussion: So, tell us about your systematic review, why did you undertake this study?

Answer 358

Before evaluating a behaviour change intervention, which we do in Chapter 3-5, a systematic review and meta-analysis were undertaken in accordance with the Medical Research Council (MRC) framework for developing and evaluating complex interventions.

Question 359

Discussion: Systematic Review - So, what was the aim of your systematic review study?

Answer 359

To examine the effectiveness of physical activity interventions in manual wheelchairs users with SCI.

Question 360

Discussion: What was the key finding you found for self-reported physical activity in the systematic review?

Answer 360

Eleven studies were included in the review with 6 being included in the meta-analysis. It was found that post-intervention that self-reported physical activity significantly improved in the intervention group relative to the control group.

Question 361

Discussion: What did you find post-intervention for the other outcomes (e.g., behavioural PA, functional fitness, quality of life)?

Answer 361

Unfortunately, due to heterogeneity in outcome measures and research designs we were unable to perform a meta-analysis for these outcomes. However, based on a narrative synthesis we found similar patterns of improvements in behavioural physical activity, functional fitness, adverse effects, physiological, psychosocial wellbeing and quality of life were found.

Question 362

Discussion: So, how does this study link onto your study 2 (assessing the theoretical underpinning)?

Answer 362

Given that behaviour change theories are imperative when evaluating interventions, based on the MRC guidance, the next step following this study, is to begin to develop a new intervention and/or identify interventions that already exist.

During the PhD, the research team were contacted by the Accessercise team who sought a formal evaluation of their newly developed app. Given the apps alignment to the current work (i.e., aims to improve physical activity for people with disabilities), we first assessed the theoretical underpinning using the BCW.

Question 363

Discussion: So, what were the key findings from your Study 2?

Answer 363

Using the BCW, we have identified that Accessercise offers users the physical and psychological capability (goal-setting) to improve physical activity, offers users the physical and social opportunity (feedback) to reduce sedentary behaviour and offer users automatic and reflective motivation (reviewing goals).

Also, Accessercise was found to have high behaviour change potential, which indicates that Accessercise should be able to support people with spinal cord injuries to increase their physical activity levels.

Question 364

Discussion: How does Study 2 link onto the Usability Study?

Answer 364

While Accessercise seems to be a strategic approach for increasing physical activity, little is known about its usability and how this might impact physical activity in people with physical disabilities. Therefore, the next study (Chapter 4) assessed the usability of the Accessercise app.

Question 365

Discussion: What was the research gap to allow you to undertake your usability study?

Answer 365

Currently, there is a limited number of usability studies of mHealth apps which focuses on changing behaviours in people with physical disabilities, such as physical activity.

Question 366

Discussion: What was the aim of your usability study?

Answer 366

We qualitatively examined the usability of the Accessercise app that aims to increase physical activity in people with disabilities by using concurrent Think-Aloud interviews.

Question 367

Study 3: How many participants were involved in your study?

Answer 367

12

Question 368

Discussion: How did you analyse your think-aloud interviews?

Answer 368

We used Deductive Content Analysis using the uMARS scale.

Question 369

Discussion: What were the key findings of the usability study?

Answer 369

The findings revealed high acceptance and potential for the Accessercise app to provide people with physical disabilities with an easy-to-use, accessible intervention to increase physical activity.

Question 370

Study 3: What are the implications of the findings that you found?

Answer 370

These findings provided insight into the usability of the app, which may help support developers to refine mHealth interventions specifically targeted at this population.

Question 371

Discussion: How does Study 3 (Usability) link onto Study 4 (Feasibility)?

Answer 371

Since smartphone have become an integral part of life/society with over 3.5 billion users worldwide, smartphone may be a suitable intervention to increase physical activity in adults in with physical disabilities.

However, few studies have evaluated mHealth physical activity interventions in this population. This final study extends the findings of Chapter 4 and builds onto the next phase of the MRC framework (i.e., feasibility/piloting) before undertaking a large-scale RCT.

Question 372

Discussion: How many participants took part in the trial?

Answer 372

20 participants with only 14 participants completing the trial.

Question 373

Discussion: What were the key findings for the RCT?

Answer 373

Overall an RCT design assessing the effectiveness of Accessercise was considered feasible in terms of fidelity, acceptability, and adherence, with the next stage being to progress to a full-scale RCT with some amendments.

Question 374

Discussion: How can we help people with physical disabilities become more physically active?

Answer 374

mHealth is a potential and promising strategy to increase physical activity in marginalised problems, including adults with physical disabilities.

However, despite the Accessercise having high behaviour change potential, including 22 BCTs, and being viewed as usable, feasible and acceptable, it is unlikely that just an app alone even if it’s specific for people with disabilities, will increase their PA levels.

Question 375

Discussion: So, even though Accessercise is unlikely to increase physical activity, what would you recommend?

Answer 375

Interventions should be multi-component. For example, designing interventions that incorporate nutritional alongside education into an intervention. Overall, the empirical study chapters have highlighted that the Accessercise intervention worked for some participants but not for others, leading to difficulties in engagement.

Question 376

Discussion: To ensure mHealth behaviour change interventions are acceptable and accessible to the needs of all people with disabilities?

Answer 376

Proactive involvements of stakeholders (e.g., people within the disability community, healthcare providers, family members, etc). One helpful approach is to evaluate stakeholders’ ideas and experiences during all phases of the development of the intervention, therefore to ensure that intervention is person-centred and more acceptable to the target population.

Question 377

Discussion: Can you let us know what you found for the mode of delivery in the discussion?

Answer 377

Most interventions that aim to increase physical activity for people with disabilities are delivered in-person or over the phone.

However, due to the presence of environmental barriers (e.g., lack of transportation) and architectural obstacles (e.g., inaccessible facilities) when accessing intervention settings (e.g., clinics, universities) alternative forms of remote intervention delivery (e.g., mHealth) may be more effective than face-to-face delivery for people with physical disabilities.

Unlike face-to-face interventions, which require more attention from participants and may be labour intensive, mHealth interventions including Accessercise can be delivered long-distances, and have high cost-effectiveness, efficiency, and accessibility, as well as allow for easy data collection.

Additionally, these interventions require minimal to no ongoing human involvement in their set-up and can be delivered automatically. These advantages may have made it more easier for participants to engage in more physical activity opportunities throughout this current research. Overall, this thesis has reported that mHealth technologies have a potential advantage in facilitating health behaviour change to support people with physical disabilities in increasing physical activity and reducing sedentary behaviour.

Question 378

Discussion: What did you include about ‘Reducing barriers to physical activity’ in the discussion?

Answer 378

It is well known that many barriers exist when it comes to undertaking physical activity for people with disabilities. The use of mHealth has emerged as a potential and promising strategy to tackle potential barriers for individuals with disabilities, particularly those with restricted mobility, such as wheelchair users.

Overall, our research has shown that mHealth may be an easy-to-use and feasible tool to overcome physical activity-related barriers for adults with physical disabilities.

The Accessercise app allows users to exercise in any suitable location (e.g., home, gym, park), offers a free-to-use service, and is adapted based on users’ needs. These features are effective as digital exercise platforms can overcome barriers, provide convenience and guided programs, do not require transportation, and have potential cost savings compared to traditional approaches like a gym membership or personal training.

Question 379

Discussion: Did you achieve your overall thesis aim?

Answer 379

The research provided in this thesis has answered the principal aim by showing that mHealth interventions can help people with disabilities overcome physical activity-related barriers, which may support people with disabilities in increasing their physical activity levels.

For example, mHealth interventions can be delivered remotely reducing the need to travel, it offers users opportunities to exercise at home, and can reduce the high costs of a gym membership. Specifically, this thesis has shown that the Accessercise app could be a useful solution to support PA in people with disabilities due to its high behaviour change potential and good usability.

In addition, it has been shown that a full-scale RCT assessing the effectiveness of Accessercise would be feasible. Nevertheless, before making definitive conclusions, the Accessercise app must still be tested in an RCT to determine the overall effectiveness in adults with physical disabilities.

Question 380

Discussion: What are the implications of your research for theory?

Answer 380

We know that undertaking PA for people with disabilities is difficult. Changing behaviours is hard work. Therefore, interventions that aim to increase PA for people with disabilities need to consider using techniques to enable engagement in the target behaviour.

Chapter 3 has revealed that using the BCW revealed that the BCW app incorporates opportunities for adults with SCI to be physically and psychologically capable of undertaking PA, offers opportunities to reduce sedentary behaviours and supports motivation. Interventions that are underpinned by theory are more effective then atheoretical interventions as they outline the mechanisms of behaviour change.

Question 381

Discussion: What are some of the implications of your research ‘For practice’

Answer 381

The implications of this thesis could be encouraging for the community of people with physical disabilities, as the findings have indicated that Accessercise is feasible, adhered to and was received positively among people with physical disabilities.

However, although this intervention may support some individuals, it may not be supportive for others.

If those who find it strategies and effective use it, this may be pivotal in overcome PA barriers and helping address the low PA rates in people with disabilities.

This thesis has shown the benefits of engaging with people with disabilities in research and in product development, which may support other researchers when designing and evaluating similar PA mHealth interventions for people with disabilities.

Question 382

Discussion: What are some of the implications of your research ‘For health care professionals’?

Answer 382

Whilst most health care professionals (e.g., nurses, doctors) have limited involvement in PA promotion) due to a lack of knowledge, confidence and time, the findings reported within this thesis may be used as guidance within healthcare professionals practice. For instance, healthcare professionals working in PA for people with disabilities may use these findings to help people with disabilities make more sustained changes to their PA behaviour using mHealth interventions.

Question 383

Discussion: Can you name a couple of strengths from your PhD thesis?

Answer 383

1. Mixed methods approach
2. Structure of studies (Systematic Review) first
3. Followed the MRC framework for developing and evaluating interviews
4. Retrofitted the BCW to the Accessercise app
5. Followed several frameworks (e.g., TIDIER, SRQR, PRISMA, CONSERT)

Question 384

Discussion: Can you name a couple of limitations from your PhD thesis?

Answer 384

1. Most participants were Male, British, under the age of 58 and were from the East Midlands area.
2. Most outcomes in this thesis relied on self-reported outcomes (e.g., PASIPD)
3. Accessercise was under developed during testing
4. We were unable to assess the effectiveness of Accessercise (yet to establish the effectiveness of the app)

Question 385

Discussion: What are recommendations for future research?

Answer 385

1. Further high quality RCTs that incorporate objective measures of physical activity, bigger sample sizes and over a longer period of time.
2. To investigate whether delivering different PA interventions for manual wheelchair users with SCI via different modes (e.g., telephone counselling, weekly video conferencing) can result in long-term benefits.
3. To identify strategies to improve access to mHealth technologies for people with disabilities and identify ways to overcome social exclusion, marginalisation, and disability stigma.
4. A large definitive trial is needed to assess the effectiveness of the Accessercise app in terms of increasing PA for people with disabilities.
5. To increase recruitment and retention of a diverse sample of adults with physical disabilities in mHealth interventions, that better reflects the population of the UK and internationally.

Question 386

Discussion: What are your overall conclusion for the thesis?

Answer 386

This mixed-methods PhD thesis has provided a novel insights into ways of improving physical activity for people with disabilities, an area that has been under researched.

The systematic review provided an overview of the effectiveness of existing interventions to increase PA for people with disabilities, providing a rationale for the remaining chapters.

Novel findings regarding the use of a novel smartphone app (Accessercise) to increase PA have been found and positively evalauted, in line with the MRC framework, with clear directions.

Overall, it is anticipated that the findings reported from this thesis will propose solid evidence base of the benefits of physical activity for adults with physical disabilities and, as a result, influence the design, implementation and evaluation of future physical activity interventions that can ultimately enhance their psychological wellbeing and quality of life.

Question 387

General: Why did I include just 18-65 years old in my usability and feasibility study?

Answer 387

Loughborough has strict requirements when it comes to ethics. It’s strict in terms of allowing researchers to undertake physical activity interventions in people over the age of 65. Therefore, we capped the the age at 18-65 years old only.

Question 388

General: Why did you include just manual wheelchair users with SCI?

Answer 388

Manual Wheelchair users are among the most physically inactive population of SCI.

80% of manual wheelchair users with SCI

Question 389

General: Can you briefly introduce yourself before we start the PhD?

Answer 389

• Talk about my PhD project
• My career ambitions
• My experience at Loughborough (e.g., teaching, invigilating)

Question 390

General: Can you tell us what your project is about?

Answer 390

My PhD project is about understanding how to increase physical activity in adults with disabilities. To achieve this we undertook 4 research studies/aims:

1. To assess the effectiveness of physical activity interventions for manual wheelchair users with SCI.
2. To examine the theoretical underpinning of the Accessercise app aimed at increasing physical activity for people with disabilities using the BCW
3. To qualitatively evaluate the usability of a novel mHealth intervention (Accessercise) using concurrent Think-Aloud interviews
4. To determine the feasibility of the Accessercise app before undertaking a full-scale trial

Question 391

General: Can you tell us in an non-academic way - What is the benefit of your work for society?

Answer 391

Enter this here

Question 392

General: What are the implications of your work?

Answer 392

Enter this here

Question 393

General: If this work will go to publication, what part of your thesis will go to what journal and what part of your thesis?

Answer 393

Enter this here

Question 394

General: Why did you focus on spinal cord injury? Why not a different disability?

Answer 394

Due to the experience and research expertise of staff at Loughborough University and because people with SCI are at the lowest end of the physical activity spectrum for people with physical disabilities, SCI was a suitable intervention for my PhD.

Question 395

General: Why did you go from SCI to Physical Disabilities?

Answer 395

Enter here

Question 396

General: Why did you go with manual wheelchair users with SCI?

Answer 396

Ma and Ginis (2018) and Watson (2023) used a range of SCI populations. However, people with SCI are heterogeneous and have different requirements.

Among this population, manual wheelchair users with SCI are the most physically inactive..

Question 397

General: Introduction chapter - They will ask about aims/objectives - What were they?

Answer 397

My aim of my PhD thesis was to understand how to increase PA in adults with disabilities. This was answered by answering 4 small sub-aims.

Question 398

General: Could you explain the structure of your introduction, why did you structure it in this way? Why did you include this section in your introduction? Why this subheading?

Answer 398

I felt like the introduction had clear thread to help the reader understand disability, spinal cord injury and then into why interventions are important for people with disabilities.

Question 399

General: Why didn’t you put a section about the different modes of delivery and that in this section?

Answer 399

Due to the COVID-19 pandemic and the development of smartphone use of over 3.5 billion individuals, mHealth interventions have been viewed as a possible solution at helping people with disabilities in overcome physical activity barriers.

Question 400

General: Systematic Review - Any difficulties writing this paper.. Any limitations of writing this paper?

Answer 400

1. The majority of outcomes we assessed were self-reported (e.g., PASIPD, LTPAQ-SCI), which has increased risk of recall bias.
2. We only allowed studies that were written in English which reduces the number of eligible studies to be included.
3. All the interventions were no longer then 12 months. The mean length of interventions was 5.5 months, which limits the understanding on whether the interventions could lead to long-term behaviour change.

Question 401

General: (Methodology) - What was your research approach? What is your epistemological/ontological position in the research?

Answer 401

Enter here

Question 402

General: (Methodology) - Why not interpretavist, why not critical realist?

Answer 402

Enter here

Question 403

General: Why did I use mixed methods in my PhD?

Answer 403

As the Accessercise app approached us, they wanted a series of research studies to be undertaken, which are mixed in various ways.

Also, as we followed the MRC framework, this involved different steps and these different steps require a mixed approach.

Question 404

General: With so many options available, why did you use content analysis for study 3 (Usability)

Answer 404

1. Most popular approach to analysing qualitative data
2. Enter here

Question 405

General: What are some of the limitations of content analysis?

Answer 405

1. Time-Intensive: Analysing large amounts of content can be time-consuming, potentially limiting the scale of the study.
2. Limited Context: Content analysis may lack the context that could provide a deeper understanding of the material being studied.
3. Subjectivity: The interpretation of content can vary between analysts, leading to subjective results.

Question 406

General: How did I ensure that I was fair and reliable in recruiting participants?

Answer 406

I used a combination of recruitment strategies (e.g., word of mouth, rehabilitation centres, social media, websites) to ensure that I recruited a number of suitable and reliable participants.

Question 407

General: What software did you use to analyse the content analysis?

Answer 407

While useful software like NVIVO is helpful with analysing qualitative research, however due to limited time on the PhD and experience with this software, I reverted back to old school with using highlighters and pens to manually analyse my transcripts.

Question 408

General: What are some limitations of Rev Man? Why did I choose Rev man (Systematic Review)?

Answer 408

I’m not aware of any limitations of using RevMan but this software is valuable in helping undertake meta-analyses.

Question 409

General: What were the steps that I took in inputting the data onto SPSS (Study 4 - Feasibility)?

Answer 409

I had collected pre and post data on these outcomes.

Step 1: I had one column for the number of participants (e.g., P1, P2, P3) followed by the next column which showed what group the participants were in either the intervention or control group.

Step 2: I input the pre and post data next to the participants ID number and their group.

Step 3: Once I had the pre and post data inputted, I then pressed transform, compute variable, transform, placed post minus pre and got a difference score.

Step 4. Once I got my difference score, I then ran a Mann Whitney U which gave me the results I needed.

Question 410

General: What were the steps that I took in inputting the data into RevMan (Systematic Review)?

Answer 410

For each study, I checked the results for each study when it came to self-reported PA. For self-reported PA I collected pre and post-date for this outcome and placed it within the RevMan software.

Question 411

General: What is the general limitation of the methodology of your thesis (mixed methods)?

Answer 411

Some limitations of mixed methods are the following:

1. Mixed methods can be challenging and time consuming to undertake if you are predominantly either a qualtiative or quantitative researcher. Researcher has to learn multiple methods and be able to know how to mix each method effectively
2. Time consuming to collect, analyse and write up the paper if you have limited experience.

1.

Question 412

General: What is the general limitation of pragmatism?

Answer 412

Enter here

Question 413

General: What are your main findings for your PhD?

Answer 413

Come back to this one

Question 414

General: What are the implications of your research as a whole?

Answer 414

N/A

Question 415

General: What are your plans as a researcher moving forward? (Job, career)?

Answer 415

I have accepted a 3-year postdoctoral role at the University of Chichester, where I will be teaching and working on exciting NHS project. I inspire to eventually progress onto a Lectureship with my dream of eventually being a Professor.

Question 416

General: What are future recommendations in your area? (Name 4-5)?

Answer 416

Moving forward beyond this research, there are a number of recommendations I would offer. These are the following:

1. Undertook more high-quality RCTs which included objective measures of PA (e.g., actigraphs, accelerometers), bigger sample sizes and long-time period.
2. To investigate whether deliveirng different modes of mHealth interventions (e.g., telephone counselling, weekly video conferencing) can lead to long term benefits in manual wheelchair users with SCI.
3. To examine the effectiveness of Accessercise at increasing PA in adults with physical disabilities in a full-scale trial.
4. To identify solutions to better engage people with disabilities in mHealth interventions to overcome social exclusion, disability stigma and marginalisation.
5. To identify strategies to improvement recruitment and engagement of a diverse sample of people with physical disabilities, which better represents the popualtion of the UK and internationally.

Question 417

General: Where will you publish your work?

Answer 417

Usability Study (e.g., Disability and Rehabilitation, Clinical Rehabilitation, Rehabilitation Psychology)

Feasibility Study (e.g., Plos Digital Health, Plos One, Health Psychology)

Systematic Review (e.g., Archives of Physical Medicine and Rehabilitation)

Question 418

General: 25. To non-academic community - How will you write about this thesis to a lay audience?

Answer 418

(Simplified the language, worked as a care worker to make it easier) I’m going for further study (post-doc) and that I am starting to look forward for an academic career

Question 419

Study 4: Why did I do 12 weeks intervention study?

Answer 419

Enter here

Question 420

Study 4: Why did I do Mann Whitney U tests?

Answer 420

We did a feasibility study which is not powered to test for statistical differences. Therefore, as our sample size was small, had 2 groups etc, we decided to do a Mann Whitney U

Question 421

Study 3: What are some limitations of think-aloud interviews?

Answer 421

1. Social Desirability Bias
2. It can be difficult to concentrate on complex thoughts when you’re thinking out loud.

Question 422

Study 4: Why did you only include 12 participants for the usability study?

Answer 422

Between 12-15 participants is enough to determine usability.

Question 423

What did you enjoy about your PhD?

Answer 423

1. Evaluating a novel physical activity app
2. Working with people with disabilities
3. Developing my knowledge of psychological theory
4. Publishing articles.

Question 424

What are you doing next?

Answer 424

I am starting a post-graduate associate role in health psychology at the University of Chichester.

Question 425

What are your career goals?

Answer 425

My career goals are that I inspire to be a Professor of Psychology.

Question 426

What was the favourite method you used?

Answer 426

I really enjoyed using the Think Aloud method. It’s quite rare as an UG or PG to use this technique so this was a new experience for me.

Question 427

Why did you want to undertake a PhD?

Answer 427

I wanted to undertake a PhD to push the boundaries of knowledge when it came to physical activity interventions for people with disabilities.

Question 428

How is doing this PhD going to impact your career?

Answer 428

By getting this PhD, I can undertake more advanced academic positions which will help me get the job of Professor of Psychology in the future.

Question 429

Common Viva Question: Can you start by summarising your thesis?

Answer 429

Using a mixed method approach, we aimed to understand how to increase physical activity in adults with physical disabilities. In order to answer this question, we had 4 sub-aims. For example:

1. To assess the effectiveness of physical activity interventions in manual wheelchair users with SCI.
2. To evaluate the theoretical underpinning of the Accessercise application using the BCW.
3. To examine the usability of the Accessercise app in adults with disabilities using concurrent think-aloud interviews.
4. To determine the feasibility of the Accessercise app before undertaking a full-scale trial evaluation.

Question 430

Common Viva Question: What is the central idea of your thesis?

Answer 430

To identify ways of improving physical activity for people with disabilities in order to support them in achieving recommended guidelines, reducing risk of noncommunicable diseases and sedentary behaviour.

Question 431

Common Viva Question: What inspired you to carry out this research?

Answer 431

My MSc project looked at the barriers and facilitators to physical activity for young adults with sensory/physical barriers. From this study, I then wanted to develop an intervention to increase PA in these populations.

Therefore, I progressed onto a PhD which looked at understanding how to increase PA in adults with physical disabilities.

Question 432

Common Viva Question: What are the main issues and debates in this subject area?

Question 433

Common Viva Question: Which of these issues does your research address?

Question 434

Common Viva Question: Why is the problem you have tackled worth tackling?

Answer 434

People with disabilities are physically inactive, increasing their risk of noncommunicable diseases and placing pressure on the NHS. Therefore, we need to design, implement and evaluate physical activity interventions in this population.

Question 435

Common Viva Question: What published work is closest to yours? How is your work different?

Question 436

Common Viva Questions: How did your research questions emerge?

Answer 436

We were approached by the Accessercise team, which seeked an evaluation of their app. In order to achieve this, we followed the MRC Framework, with the first step being the systematic review and from this study it opened up the rationales/gaps for the remaining studies.

Question 437

Common Viva Questions: What were the most crucial research decisions you made?

Question 438

Common Viva Questions: Why did you use this particular research methodology?

Question 439

Common Viva Questions: How did you address the ethical implications of your work?

Question 440

Common Viva Questions: How do you know that your findings are accurate / representative?

Answer 440

We undertook many trustworthiness attempts to ensure are work is accurate. For example:

1. We pilot tested the interview schedule (Studies 3-4)
2. David Maidment acted as a “critical friend” where he would read some of my codes, themes and write up to ensure that he was happy with what I provided.
3. Member checking - I also sent my participants their transcripts to ensure that they were happy with what I included.

Question 441

Common Viva Questions: What are the strongest / weakest parts of your work?

Question 442

Common Viva Questions: To what extent do your contributions generalise?

Question 443

Common Viva Questions: Who will be most interested in your work?

Answer 443

Researchers, people with disabilities, disability activists, health care professionals, students.

Question 444

Common Viva Questions: What is the relevance of your work to other researchers?

Question 445

Common Viva Questions: If you could go back and change anything, what would that be?

Question 446

Common viva questions: What surprised you the most about your findings?

Question 447

Common viva questions: What are the main achievements and limitations of your research?

Question 448

Study 4: Why did you decide to do a Mann-Whitney U test for this study?

Answer 448

The small sample size meant the data was not normally distributed and therefore it was a non-parametric test and based on the data the Mann Whitney U test was the most suitable.

Question 449

Study 4: Why did you only include 18-65 years old?

Answer 449

Loughborough have strict ethical guidelines when it comes to doing physical activity interventions for individuals over the age of 65. Therefore, we decided to cap on our participants at 18-65 because anyone older would be unethical.

Question 450

General: How did you design your study and why did you take this approach?

Answer 450

We followed the MRC framework.. Each step requires us to design our study in a particular way (e.g., usability, feasibility, etc)..

Question 451

How did your findings relate to the existing research?

Answer 451

Discussion section of my research..

Question 452

Were there any findings that you found surprising?

Answer 452

Yes. In the systematic review, I was assuming that the physical activity interventions would improve as a result of using theory. However, I actually found the opposite, which may be due to a small sample size being used.

Question 453

What biases exist in your research?

Answer 453

1. Every study has problems/limitations/some sort of bias
2. Recall bias (self-reported outcomes)
3. Overrepresentation of participants (too many SCI and too many young people)
4. Social desirability
5. Feasibility Study - No external researcher was involved in blinding or randomising the participants

Question 454

What developments have there been in this field since you began your doctorate? How have these changed the research context in which you are working?

Answer 454

Enter here

Question 456

Study 3: How did you select the group of people to interview?”

Answer 456

I emailed potential participants if they were interested with 12 out of 20 participants wanting to take part in this research.

Question 457

Study 4: How did you select the group of people to interview?”

Answer 457

I emailed potential participants if they were interested with 12 out of 20 participants wanting to take part in this research.