Engagement with mHealth COVID-19 digital biomarker measurements in a longitudinal cohort study: a mixed methods evaluation.

BACKGROUND: The COVID-19 pandemic accelerated the interest in implementing mHealth in population-based health studies, but evidence is lacking on engagement and adherence in studies. We conducted a fully remote study for over 6-months tracking COVID-19 digital biomarkers and symptoms using a smartphone app nested within an existing cohort of UK adults. OBJECTIVE: To investigate participant characteristics associated with initial and sustained engagement in digital biomarker collection from a bespoke smartphone app and if engagement changed over time or as a result of COVID-19 factors. To explore participants' reasons for consenting to the smartphone sub-study and experiences related to initial and continued engagement. METHODS: Participants in the Fenland COVID-19 study were invited to the app sub-study from August-October 2020 until study closure (30 April 2021). Participants were asked to complete digital biomarker modules (oxygen saturation, body temperature, resting heart rate (RHR)) and possible COVID-19 symptoms in the app three times/week. Participants manually entered measurements, except RHR measured using the smartphone camera. Engagement was categorised from median weekly frequency of completing the three digital biomarker modules (categories; 0, 1-2 and 3 or more/times per week). Socio-demographic and health characteristics of those who did or did not consent to the sub-study, and by engagement category were explored. Semi-structured interviews were conducted with 35 participants and data analysed thematically; 22 who consented to the app sub-study and 13 who did not consent, purposively sampled by sex, age, educational attainment and by engagement category. RESULTS: A total of 2,524 (63%) of Fenland COVID-19 study participants consented to the app sub-study. Of those, 90.2% completed the app onboarding process. Median time in the app sub-study was 34.5 weeks (IQR 34, 37) with no change in engagement from 0-3 months or 3-6 months. Completion rates (1/week) across the study between digital biomarkers were similar (RHR 72.8%, temperature 73.1%, oxygen saturation 73.5%). Older age groups, lower managerial and intermediate occupations were associated with higher engagement whilst working, being a current smoker, overweight or obese and high perceived stress were associated with lower engagement. Reasons for consenting included altruism, previous positive participation experiences and interest in health research, and non-consent was due to confusion regarding study invitation and perceived phone incompatibility. Continued engagement was facilitated by routine and personal motivation, poor engagement was caused by user error and app/equipment malfunctions preventing data input. From these results we developed key recommendations to improve engagement in population-based mHealth studies. CONCLUSIONS: This mixed-method study demonstrated both high initial and sustained engagement in a large mHealth COVID-19 study over at least 6-month period in UK adults. Being nested in a known cohort study enabled the identification of participant characteristics and factors associated with engagement, to inform future applications in population-based health research.

Supporting Weight Management during COVID-19 (SWiM-C): twelve-month follow-up of a randomised controlled trial of a web-based, ACT-based, guided self-help intervention.

OBJECTIVES: We developed a guided self-help intervention (Supporting Weight Management during COVID-19, "SWiM-C") to support adults with overweight or obesity in their weight management during the COVID-19 pandemic. This parallel, two-group trial (ISRCTN12107048) evaluated the effect of SWiM-C on weight and determinants of weight management over twelve months. METHODS: Participants (≥18 years, body-mass-index ≥25 kg/m2) were randomised to the SWiM-C intervention or to a standard advice group (unblinded). Participants completed online questionnaires at baseline, four months, and twelve months. The primary outcome was change in self-reported weight from baseline to twelve months; secondary outcomes were eating behaviour (uncontrolled eating, emotional eating, cognitive restraint of food intake), experiential avoidance, depression, anxiety, stress, wellbeing and physical activity. INTERVENTIONS: SWiM-C is based on acceptance and commitment therapy (ACT). Participants had access to an online web platform with 12 weekly modules and email and telephone contact with a trained, non-specialist coach. Standard advice was a leaflet on managing weight and mood during the COVID-19 pandemic. RESULTS: 388 participants were randomised (SWiM-C: n = 192, standard advice: n = 196). The baseline-adjusted difference in weight change between SWiM-C (n = 119) and standard advice (n = 147) was -0.81 kg (95% CI: -2.24 to 0.61 kg). SWiM-C participants reported a reduction in experiential avoidance (-2.45 [scale:10-70], 95% CI: -4.75 to -0.15), uncontrolled eating (-3.36 [scale: 0-100], 95% CI: -5.66 to -1.06), and emotional eating (-4.14 [scale:0-100], 95% CI: -7.25 to -1.02) and an increase in physical activity (8.96 [MET-min/week], 95% CI: 0.29 to 17.62) compared to standard advice participants. We found no evidence of an effect on remaining outcomes. No adverse events/side effects were reported. CONCLUSIONS: Whilst we were unable to conclude that the intervention had an effect on weight, SWiM-C improved eating behaviours, experiential avoidance and physical activity. Further refinement of the intervention is necessary to ensure meaningful effects on weight prior to implementation in practice. TRIAL REGISTRATION NUMBER: ISRCTN 12107048.

Supporting Weight Management during COVID-19: A Randomized Controlled Trial of a Web-Based, ACT-Based, Guided Self-Help Intervention.

INTRODUCTION: Adults with overweight and obesity are vulnerable to weight gain and mental health deterioration during the COVID-19 pandemic. We developed a web-based, guided self-help intervention based on Acceptance and Commitment Therapy (ACT) that aims to support adults with overweight and obesity to prevent weight gain by helping them to manage their eating behaviours, be more physically active, and protect their emotional wellbeing ("SWiM-C"). SWiM-C is a guided self-help programme using non-specialist guides to enhance scalability and population reach while minimizing cost. This study evaluated the effect of SWiM-C on bodyweight, eating behaviour, physical activity, and mental wellbeing in adults with overweight and obesity over 4 months during the COVID-19 pandemic in the UK. METHODS: We randomized adults (BMI ≥25 kg/m2) to SWiM-C or to a wait-list standard advice group. Participants completed outcome assessments online at baseline and 4 months. The primary outcome was self-measured weight; secondary outcomes were eating behaviour, physical activity, experiential avoidance/psychological flexibility, depression, anxiety, stress, and wellbeing. We estimated differences between study groups in change in outcomes from baseline to 4 months using linear regression, adjusted for outcome at baseline and the randomization stratifiers (BMI, sex). The trial was pre-registered (ISRCTN12107048). RESULTS: 486 participants were assessed for eligibility; 388 participants were randomized (196 standard advice, 192 SWiM-C), and 324 were analysed. The adjusted difference in weight between SWiM-C and standard advice was -0.60 kg (-1.67 to 0.47, p = 0.27). SWiM-C led to improvements in uncontrolled eating (-3.61 [-5.94 to -1.28]), cognitive restraint (5.28 [2.81-7.75]), experiential avoidance (-3.39 [-5.55 to -1.23]), and wellbeing (0.13 [0.07-0.18]). CONCLUSIONS: SWiM-C improved several psychological determinants of successful weight management and had a protective effect on wellbeing during the pandemic. However, differences in weight and some other outcomes were compatible with no effect of the intervention, suggesting further refinement of the intervention is needed.

Population level physical activity before and during the first national COVID-19 lockdown: A nationally representative repeat cross-sectional study of 5 years of Active Lives data in England.

BACKGROUND: To limit the spread of COVID-19 in March 2020, the population of England was instructed to stay home, leaving only for essential shopping, health-care, work, or exercise. The impact on population activity behaviours is not clear. We describe changes in duration and types of activity undertaken by adults ≥16 years in England between March and May 2016-19 and 2020, by socio-demographic strata. METHODS: Using nationally representative data collected between November 2015 and May 2020 by the Sport England Active Lives Surveys (n=726,257) we assessed trends in amount and type of non-occupational moderate-to-vigorous physical activity. Using data from n=74,430 mid-April to mid-May respondents, we then estimated the odds ratios of reporting any activity in the four-week recall period in 2020 compared to 2016-19. Gamma regressions estimated the mean ratios (MR) of duration amongst those reporting any activity in 2020 compared to 2016-19. FINDINGS: Population activity declined substantially after the restrictions were introduced. Compared to 2016-19 levels, the odds of reporting any activity in 2020 were 30% lower (95% confidence interval (CI) 26-34%). The largest declines were amongst non-white ethnicities, the youngest and oldest age groups, and the unemployed; no socio-demographic subgroup had higher odds. Amongst those undertaking activity, weekly duration was similar in the two periods (MR 0.99, 95%CI (0.96-1.01%)). The odds of participating in walking for leisure and gardening were 11% (6-16%) and 15% (9-21%) higher, respectively, whereas the odds for team and racket sport and walking for travel participation were 76% (73-79%) and 66% (64-68%) lower, respectively. INTERPRETATION: Restrictions introduced in Spring 2020 likely reduced physical activity levels in England. The magnitude of the declines were not uniform by demographic groups or by activity type, which future policies should consider. FUNDING: TS, KW, SJS, and SB are supported by UK Medical Research Council [grant numbers MC_UU_00006/4 and MC_UU_12015/3] and SB is supported by the NIHR Biomedical Research Centre in Cambridge (IS-BRC-1215-20014).

Physical distancing interventions and incidence of coronavirus disease 2019: natural experiment in 149 countries.

OBJECTIVE: To evaluate the association between physical distancing interventions and incidence of coronavirus disease 2019 (covid-19) globally. DESIGN: Natural experiment using interrupted time series analysis, with results synthesised using meta-analysis. SETTING: 149 countries or regions, with data on daily reported cases of covid-19 from the European Centre for Disease Prevention and Control and data on the physical distancing policies from the Oxford covid-19 Government Response Tracker. PARTICIPANTS: Individual countries or regions that implemented one of the five physical distancing interventions (closures of schools, workplaces, and public transport, restrictions on mass gatherings and public events, and restrictions on movement (lockdowns)) between 1 January and 30 May 2020. MAIN OUTCOME MEASURE: Incidence rate ratios (IRRs) of covid-19 before and after implementation of physical distancing interventions, estimated using data to 30 May 2020 or 30 days post-intervention, whichever occurred first. IRRs were synthesised across countries using random effects meta-analysis. RESULTS: On average, implementation of any physical distancing intervention was associated with an overall reduction in covid-19 incidence of 13% (IRR 0.87, 95% confidence interval 0.85 to 0.89; n=149 countries). Closure of public transport was not associated with any additional reduction in covid-19 incidence when the other four physical distancing interventions were in place (pooled IRR with and without public transport closure was 0.85, 0.82 to 0.88; n=72, and 0.87, 0.84 to 0.91; n=32, respectively). Data from 11 countries also suggested similar overall effectiveness (pooled IRR 0.85, 0.81 to 0.89) when school closures, workplace closures, and restrictions on mass gatherings were in place. In terms of sequence of interventions, earlier implementation of lockdown was associated with a larger reduction in covid-19 incidence (pooled IRR 0.86, 0.84 to 0.89; n=105) compared with a delayed implementation of lockdown after other physical distancing interventions were in place (pooled IRR 0.90, 0.87 to 0.94; n=41). CONCLUSIONS: Physical distancing interventions were associated with reductions in the incidence of covid-19 globally. No evidence was found of an additional effect of public transport closure when the other four physical distancing measures were in place. Earlier implementation of lockdown was associated with a larger reduction in the incidence of covid-19. These findings might support policy decisions as countries prepare to impose or lift physical distancing measures in current or future epidemic waves.