i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 8 3 ( 2 0 1 4 ) 354–360
journal homepage: www.ijmijournal.com
One-year outcome of an interactive internet-based physical activity intervention among university students Kanzo Okazaki a,∗ , Shinji Okano b , Shinichiro Haga b , Akiho Seki c , Hisao Suzuki d , Kayo Takahashi b a
Tohoku Gakuin University, Faculty of Liberal Arts, Department of Human Science, 2-1-1 Tenjinzawa, Izumi-ku, Sendai, Miyagi 981-3193, Japan b Graduate School of Education, Okayama University, 1-1-3 Tsushima-Naka, Okayama, Okayama 700-8530, Japan c Department of Health Care Medicine, Kawasaki Medical School, 577 Matsushima, Kurashiki, Okayama 701-0192, Japan d Interactive Sport Education Center, Okayama University, 1-1-3 Tsushima-Naka, Okayama, Okayama 700-8530, Japan
a r t i c l e
i n f o
a b s t r a c t
Article history:
Objective: The purpose of the present study was to evaluate whether improvement in physical
Received 26 March 2013
activity of students following a 4-month intervention of a university course was maintained
Received in revised form
8 months later.
21 January 2014
Methods: Data on 77 students who responded to our scheduled inquiries completely through
Accepted 23 January 2014
1 year were analyzed. Participants of the intervention group (n = 49) using the internet-based physical activity program exhibited significant increases in energy expenditures measured
Keywords:
by IPAQ compared with the no-treatment control group (n = 28) through 1 year.
Physical activity
Results: Participants who did not engage in regular university sports activities (baseline:
Internet-based intervention
450 ± 351 kcal day−1 ; post: 587 ± 320 kcal day−1 ; 8-month follow-up: 580 ± 394 kcal day−1 ) only
Interactive learning system
exhibited significant increases in energy expenditures compared with those of the con-
University course
trol group (baseline: 498 ± 341 kcal day−1 ; post: 414 ± 242 kcal day−1 ; 8-month follow-up:
Follow-up
347 ± 275 kcal day−1 ). Conclusion: These results suggested that an internet-based interactive intervention could become a helpful tool in promoting and maintaining physical activity in the long term. © 2014 Elsevier Ireland Ltd. All rights reserved.
1.
Introduction
Regular physical activity is important to one’s health status and well-being [1]. The Ministry of Health, Labour and Welfare Japan in 2006 advocates physical activity as one of the most important practices in addition to eating well, stress management, and resting. For optimal health benefits, adults aged 18–65 years need moderate intensity physical
∗
activity for a minimum of 30 min at least 5 days per week [2]. Recently, the recommendation from the American College of Sports Medicine (ACSM) and the American Heart Association (AHA) were updated, and the recommendation suggested that all healthy adults aged 18–65 years need moderate intensity physical activity for a minimum of 30 min at least 5 days per week or vigorous intensity physical activity for a minimum of 20 min on the other 2 days of the week [3].
Corresponding author. Tel.: +81 22 773 3391. E-mail address: [email protected] (K. Okazaki). 1386-5056/$ – see front matter © 2014 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijmedinf.2014.01.012
i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 8 3 ( 2 0 1 4 ) 354–360
We assessed physical activity levels based on these 2 recommendations by a cross-sectional self-reported questionnaire among Japanese university students [4] and found that most students (46.7% of males and 61.3% of females) did not meet both recommended criteria. Insufficient physical activity in students is envisaged to become more prevalent after graduating from the university [5]. It is important for university students to consider their own health behaviors, such as physical activity during the university life because most students experience great changes in lifestyle, such as starting to live alone and holding a part-time job, as compared with high school [6]. Furthermore, advancement rates to the university have increased such that approximately 60% of high school graduates attend college in Japan. This high rate represents an optimal time for more and more students to learn how to modify the behavior of physical activity. Thus, an
355
effective physical activity program is warranted among university students. To promote physical activity, the internet-based physical activity program (i-PAP) among university students was developed, which demonstrated its effectiveness [7]. i-PAP is an interactive learning system conducted through the internet. Participants used i-PAP through a computer or mobile phone during their first semester in a 4-month intervention. This significantly enhanced physical activity compared with the no-treatment control group. i-PAP is mainly based on social cognitive theory [8] and the health belief model [9] and has several functions including goal-setting, scheduling, selfmonitoring, strength and stretch training, a Web-based quiz, and energy expenditure calculations for physical activity. The purpose of the present study was to evaluate whether the improvement in physical activity following the
Fig. 1 – Flow diagram of participants’ progress through the intervention and follow-up.
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completion of the 4-month intervention were maintained 8 months later. Little is known about the efficacy of internetbased interventions for physical activity. Some previous reviews [10–13] on the efficacy of internet-based physical activity intervention reported contradictory results of efficacy. There have been few studies to evaluate efficacy compared with a no-treatment control group and during a follow-up period. We hypothesized that physical activity would promote or remain the same in the participants of the 4-month intervention group compared with the control group during the follow-up period.
Portable Document Format (PDF) file textbook in i-PAP. The contents of PDF were concerned with health behavior skills, obesity, body images, strength and strength training, and first aid for sports injury. i-PAP was operated using MySQL, PHP, JavaScript, HTML, Adobe Flash, or Adobe Acrobat Reader. Their operating system requirements were also confirmed (i.e., Mac, Microsoft Windows). In addition, mobile phone functionalities were confirmed with a Japanese mobile company.
2.
Methods
2.1.
Participants and design
A follow-up was completed at 8 months after the 4-month intervention. Participants of the intervention group were able to use i-PAP continuously through the follow-up period, although neither the e-mails nor the Web-quiz were sent during the follow-up period.
Healthy students from the regional Japanese national university took either the internet-based physical activity education course or a course unrelated to health education at the university. The students were classified by the university’s online system (see Fig. 1). Fifty-seven students were allowed to register for the internet-based physical activity education course. Two students were excluded because they did not agree with this study. On the other hand, 181 students were allowed to register for a course that was unrelated to the health course. Finally, 29 of the 181 students completed all assignments of the present study. Eighty-four students, who were allowed to register for the internet-based physical activity education course (intervention group, n = 55) and the course unrelated to health (control group, n = 29), responded to a baseline survey. Data from 77 students (intervention group, n = 49; control group, n = 28) who responded to all our scheduled inquiries during the intervention and 8-month follow-up were analyzed. All participants were assessed at 3 time points: the baseline at entry; after 4 months of intervention; and 8 months later at a follow-up. The intervention and the follow-up were conducted between April 2008 and April 2009. The present study was approved by the Ethics Committee of the university.
2.2.
Intervention
Participants in the intervention group used i-PAP interactively during a first semester (Table 1). Face-to-face contact was limited to the introductory sessions and after survey; all other contacts with the participants were only through the internet. First, participants in the treatment group set their goals and weekly schedule in i-PAP at the time of the initial class session, and if necessary, they could modify their goals and schedule using i-PAP. Conformance to the schedule was confirmed once a week by an e-mail with an attachment stating the goals. The participants received some advice according to the achievement of the schedule. The Web-based quiz was uploaded weekly starting the third week of the intervention (Table 1), and the participants had to take the quiz repeatedly until full marks were obtained within the week from the day of upload. The weekly Web-based quiz consisted of approximately 10 questions. The participants learned to answer the weekly questions using
2.3.
2.4.
Follow-up
Measurements
The International Physical Activity Questionnaire (IPAQ) and the Stages of Change Scale for physical activity (SOC) were completed at all 3 assessment time points. The baseline and post-intervention surveys were conducted by paper in both the first and final class sessions of the semester, whereas the 8-month follow-up survey was conducted online. IPAQ [14] is a self-reported questionnaire that records duration of different levels of physical activity for a habitual or past week. The questionnaire is structured to capture physical activity in 4 generic dimensions of physical activity, namely vigorous, moderate, walking, and sitting. IPAQ has reasonable measurement properties for monitoring population levels of the physical activity among 18- to 65-year-old adults in diverse settings. SOC can assess the readiness to become and stay physically active in adults [15,16]. The participants were classified as being at one of the following 5 stages: precontemplation, contemplation, preparation, action, and maintenance.
2.5.
Control conditions
Participants in the control group did not use i-PAP and took other non-health-related course during 1 year of the present study.
2.6.
Statistical analyses
Baseline descriptive characteristics were analyzed by an independent samples t-test and chi-square test. SOC data were presented as median. Changes in SOC were analyzed by Friedman test, and multiple comparisons were analyzed by the Bonferroni-adjusted Wilcoxon’s signed rank test (P < 0.0025). The energy expenditures as measured by IPAQ at the 3 assessment time points were analyzed within and between groups by two-way (time × group) repeated-measures analysis of variance (ANOVA). When indicated by a significant F value, post hoc test (Bonferroni) was performed. All statistical significance was set at P < 0.05, excluding the Bonferroni adjustment.
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Table 1 – Intervention course. Week(date)
Place
1 (April, 11)
Lecture room
2 (April, 18)
Lecture room
3 (April, 25)
Lecture room
4
Title of internet-based quiz Introduction to the class; Baseline survey Explanation of the i-PAP; Setting the goals and weekly schedule Explanation of the i-PAP; Re-setting the goals and weekly schedule
(May, 9)
5 (May, 16)
Lecture room
Explanation of the i-PAP; Free communication
Lecture room
Post-survey
6 (May, 23) 7 (May, 30) 8 (June, 6) 8 (June, 13) 10 11 12 13 14 15
(June, 20) (June, 27) (July, 4) (July, 11) (July, 18) (July, 25)
3.
Results
3.1.
Descriptive characteristics
3.2.
Changes in SOC
In the Friedman test (Fig. 2), all participants of the intervention group exhibited significant improvement in SOC [X2 (2) = 15.9, P < 0.05], whereas the control group did not exhibit any improvement. Moreover, to identify the influence of the differences in university sports activities, both groups were classified respectively into 2 subgroups [one subgroup was “engaged in regular university sports” (ES) and the other “did not engage in regular university sports” (DS)] and differences between these subgroups were analyzed. ES [X2 (2) = 9.3, P < 0.05] and DS [X2 (2) = 7.9, P < 0.05] in the intervention group respectively exhibited significant improvement in SOC, whereas the both ES and DS in the control group did not. In the Wilcoxon’s sign rank sum test, SOC of all participants [Z score = −3.1, P < 0.025] and ES [Z score = −2.7, P < 0.025] in the intervention group exhibited significant improvement at the 4-month assessment point relative to baseline. In addition, at the 8-month follow-up assessment, SOC of all participants [Z score = −3.4, P < 0.025] and the ES [Z score = −2.4, P < 0.025] and
Quantity and Quality of Physical Activity and Exercise Promotion and Maintenance of Physical Activity and Exercise Weight Control Receipts and Disbursements Balance of Energy; Nutrition Calculation of Consumption Energy Four Type of Training Contractions: Isotonic, Eccentric, Isometric, Isokinetic Strength Training Methods Strength Training Meals Plan Stretch Training Methods Sports Injury Summary
the DS [Z score = −2.7, P < 0.025] subgroups in the intervention group were significantly improved relative to baseline.
3.3. At baseline, there were no significant differences in descriptive characteristics between the groups (Table 2). We have indicated a percentage of the students’ activities in the follow-up data in Table 2 because their university sports activities clearly influence the outcomes of physical activity. The outcomes of the both groups were analyzed based on the difference in their sports activities.
Physical Activity and Exercise
Change in energy expenditure
Fig. 3 indicated the changes in the energy expenditure measured by IPAQ. In the SOC analysis, we classified and analyzed energy expenditure according to their activities involvement. In a two-way repeated-measures ANOVA, only the DS subgroup in the intervention group (baseline: 450 ± 351 kcal day−1 ; post: 587 ± 320 kcal day−1 ; 8-month follow-up: 580 ± 394 kcal day−1 ) exhibited significant increases in energy expenditures compared with the control group (baseline: 498 ± 341 kcal day−1 ; post: 414 ± 242 kcal day−1 ; 8month follow-up: 347 ± 275 kcal day−1 ) [F(2, 72) = 3.5, P < 0.05]. In post hoc testing, energy expenditure of the DS subgroup in the intervention group was significantly higher than that in the control group at the 8-month follow-up [F(1, 36) = 4.3, P < 0.05].
4.
Discussion
We previously reported the efficacy of i-PAP through a 4-month intervention period [7]. The purpose of the present study was to evaluate whether the efficacy of i-PAP was maintained through an 8-month follow-up period after the intervention. The results indicated the efficacy of i-PAP through the 8-month follow-up. Particularly, the university students who did not engage in regular university sports activities increased their physical activity. Although little is known about the long-term efficacy of the internet-based interventions [10–13] such as i-PAP, only one previous study [17,18] reported the long-term efficacy of the internet-based program named ALED-I (Active
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Table 2 – Baseline characteristics of 77 samples responded to our scheduled inquiries completely during this study. Intervention (n = 49)
Control (n = 28)
Gender, n (%) 35 (71) Male 14 (29) Female 19.1 ± 1.3 Age (years), mean ± SD 21.7 ± 3.1 BMI (kg m−2 ), mean ± SD IPAQ (kcal day−1 ), mean ± SD 714 ± 648 Engaged in regular university sports activities (Yes/No), n (%) 17 (35)/32 (65) Baseline 28 (57)/21 (43) 8-Month follow-up Stage distribution, n (%) 3 (6) Precontemplation Contemplation 15 (31) 14 (29) Preparation 17 (34) Action and maintenance
P-value
15 (54) 13 (46) 19.4 ± 1.2 20.4 ± 2.3 602 ± 423
0.11 0.35 0.08 0.42
9 (32)/19 (68) 11 (39)/17 (61)
0.82 0.13
5 (18) 7 (25) 10 (36) 6 (22)
0.27
IPAQ, International Physical Activity Questionnaire.
Living Every Day). Their report indicated that 19 participants increased their steps per day after the 4-month intervention, but relapsed (−1340 steps day−1 ) through the 8-month followup after that. Furthermore, the efficacy of the follow-up was not compared with those of a no-treatment control group. Therefore, it is valuable that our results indicated the longterm efficacy of the internet-based program compared with those of the no-treatment control group. It was presumed that one of the reasons why physical activity was promoted in the present study was because of an extremely low attrition rate. The attrition rate of the present study was 2% during the intervention and 8% during the follow-up, whereas Carr et al. [18] reported an attrition rate of 51% during the intervention and 40% during their followup period. The low attrition rate indicates that capacities and advantages of the computer- and mobile phone-mediated communication approaches may have driven university
students to more interest in physical activity [19]. Kypri and McAnally [20] found a significant increase in physical activity and a low attrition rate of 14% through their internet-based, 6-week, short-term intervention among university students. Perhaps, the low attrition rate during the intervention was affected by the course credit after completing the intervention, whereas the control was not affected by their course credit. However, most of the students responded to the follow-up survey in which no reward was given. These successful results in the present study may indicate that an internet-based program is more effective than traditional face-to-face programs through 1 year among university students. For example, the Project Graduate Ready for Activity Daily (GRAD) [5,21], which was a face-to-face physical activity promotion program among university students through the first semester and a follow-up, reported unsuccessful results at the 1-year assessment point, but demonstrated increased
A
B
5
3 2
Intervention Control
0
3 2
Intervention Control
1
1
0 Baseline
4 month
12 month
*
*
4
SOC score
SOC score
*
*
4
5
Baseline
4 month
12 month
C Intervention Control
5
SOC score
4
*
3 2 1 0
Baseline
4 month
12 month
Fig. 2 – Change of the SOC score. (A) All participants were analyzed; (B) the participants who engaged in regular university sports activities at the follow-up were analyzed; (C) the participants who did not engage in regular university sports activities at the follow-up were analyzed. SOC, the Stages of Change Scale for physical activity. *Significant difference with baseline.
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1200 1000
A
1400 Intervention Control
†
800 600 400
Mean of Energy Expenditure (kcal / day)
Mean of Energy Expenditure (kcal / day)
1400
1200 1000 800 600
Intervention Control
400 200
200 0
B
Baseline
0
4 month
12 month
Mean of Energy Expenditure (kcal / day)
1400 1200 1000
Baseline
4 month
12 month
C Intervention Control
†
800
*
600 400 200 0
Baseline
4 month
12 month
Fig. 3 – Change in energy expenditure measured by IPAQ through 1 year. (A) All participants were analyzed; (B) the participants who engaged in regular university sports activities at the follow-up were analyzed; (C) the participants who did not engage in regular university sports activities at the follow-up were analyzed. † Interaction (time × group) effect was found. *Significant difference between groups. energy expenditure (kcal kg−1 wk−1 ) after the assessment [5]. The GRAD students received some advice on physical activity promotion through phone calls and mail during the followup period, and the calls and mails decreased in frequency toward the end of the follow-up. Although our study design was not compared with other traditional health-related faceto-face programs, physical activity was promoted through 1 year. Further study is needed to examine the long-term efficacy, comparing the internet-based program with face-to-face traditional intervention. The internet has infiltrated many aspects of our daily life. The International Telecommunication Union in Geneva reported that approximately 1.4 billion people in the world use the internet. In 2008 alone, 91 million used the internet and 90% of people between the age of 15 and 35 years used the internet in Japan [22,23]. It is presumed that most university students are accustomed to using the internet. Therefore, it could be useful for supporting an intervention after completing a course and graduating. In addition, the content can be changed according to attractive new knowledge when it becomes available [19]. i-PAP could be a lifelong physical activity promotion and maintenance tool. There are some limitations to the present study. The participants of both groups respectively were randomly and automatically classified by the university online system before the semester started. Thus, the participants in the intervention may prefer to be more active than the control group. However, there were no differences between the groups in several demographic characteristics and the stage distribution. And, it has been reported that Japanese students are in general interested in health concerns [7]. A second limitation of this study was the reliance on self-report of outcomes. However, previous reports indicated the significant confidence and validity of IPAQ and SOC, relative to a
pedometer and an accelerometer [14,24]. Finally, discrepancy in number between intervention and control participants may affect the results. However, there were no differences between the groups in several demographic characteristics and stage distribution.
5.
Conclusion
In conclusion, i-PAP promoted physical activity through the 1-year study period. In particular, students who did not previously engage in regular university sports increased their physical activity. These results suggest that an internet-based interactive intervention such as i-PAP has a long-term efficacy for promoting and maintaining physical activity after the students completed the course.
Author contributions K. Okazaki proposed the initial idea and design of the project, participated in system development, analyzed the results and wrote the manuscript. S. Okano proposed the idea of the project and system development, and actively participated in conducting the project and data analysis. S. Haga proposed system development and participated in conducting the project and data analysis. A. Seki participated in critical system development. H. Suzuki participated in the initial idea of the project and conducting the project and critical review of the manuscript. K. Takahashi participated in the guidance, supervision, and review of the manuscript.
Conflicts of interest Authors declare that they have no competing interest.
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Summary points What was already known before this study: • Some previous reviews on short-term efficacy of internet-based physical activity intervention. • There have been few studies to evaluate efficacy compared with a no-treatment control group. What this study has added to our knowledge: • Our intervention promoted physical activity among university students through the 1-year study period including an 8-month follow-up. • In particular, students who did not previously engage in regular university sports increased their physical activity. • These results suggest that an internet-based interactive intervention has a long-term efficacy for promoting and maintaining physical activity.
Acknowledgements The present study was supported by JSPS KAKENHI Grant-inAid for Young Scientists B (No. 12814972) and Support Program for contemporary educational needs found by the Ministry of Education, Culture, Sports, Science and Technology (MEXT).
references
[1] Y.K. Kesaniemi, E. Danforth Jr., M.D. Jensen, et al., Dose–response issues concerning physical activity and health: an evidence-based symposium, Med. Sci. Sports Exerc. 33 (6) (2001) 351–358. [2] R.R. Pate, M. Pratt, S. Blair, et al., Physical activity and public health: a recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine, JAMA 273 (5) (1995) 402–407. [3] W.L. Haskell, I.M. Lee, R.R. Pate, et al., Physical activity and public health: updated recommendation for adults from the American College of Sports Medicine and the American Heart Association, Med. Sci. Sports Exerc. 39 (8) (2007) 1423–1434. [4] K. Okazaki, H. Suzuki, M. Kaga, et al., Physical activity and exercise levels, and their relationship with selected health factors in university students, Jpn. J. Phys. Educ. Health Sport Sci. 54 (2) (2009) 425–436 (in Japanese). [5] K.J. Calfas, J.F. Sallis, J.F. Nichols, et al., Project GRAD: two-year outcomes of a randomized controlled physical activity intervention among young adults. Graduate Ready for Activity Daily, Am. J. Prev. Med. 18 (1) (2000) 28–37. [6] Japanese National University Council of Health Administration Facilities Web Site [Internet], White Paper on the Students’ Health, Nagoya, 2005 http://www.htc.nagoya-u.ac.jp/∼kondo/homepage/2005.pdf (cited 08.01.10).
[7] K. Okazaki, S. Okano, S. Haga, et al., Development and its evaluation of the distance and interactive proper system for university students that promotes physical activity through the internet, Educ. Technol. Res. 33 (4) (2010) 363–372 (in Japanese). [8] A. Bandura, Social Foundations of Thought and Action: A Social Cognitive Theory, Prentice-Hall, Englewood Cliffs, NJ, 1986. [9] M.H. Becker, L.A. Maiman, Sociobehavioral determinants of compliance with health and medical care recommendations, Med. Care 13 (1) (1975) 10–24. [10] B.H. Marcus, J.T. Ciccolo, C.N. Sciamanna, Using electronic/computer interventions to promote physical activity, Br. J. Sports Med. 43 (2) (2009) 102–105. [11] J.T. Ciccolo, B. Lewis, B.H. Marcus, Internet-based physical activity interventions, Curr. Cardiovasc. Risk Rep. 2 (4) (2008) 299–304. [12] G.J. Norman, M.F. Zabinski, M.A. Adams, et al., A review of eHealth interventions for physical activity and dietary behavior change, Am. J. Prev. Med. 33 (4) (2007) 336–345. [13] C. Vandelanotte, K.M. Spathonis, E.G. Eakin, et al., Website-delivered physical activity interventions a review of the literature, Am. J. Prev. Med. 33 (1) (2007) 54–64. [14] C.L. Craig, A.L. Marshall, M. Sjöström, et al., International physical activity questionnaire: 12-country reliability and validity, Med. Sci. Sports Exerc. 35 (8) (2003) 1381–1395. [15] J.O. Prochaska, C.C. DiClemente, J.C. Norcross, In search of how people change – applications to addictive behaviors, Am. Psychol. 47 (1992) 1102–1114. [16] B.H. Marcus, L.R. Simkin, The transtheoretical model: applications to exercise behavior, Med. Sci. Sports Exerc. 26 (1994) 1400–1404. [17] L.J. Carr, R.T. Bartee, C.M. Dorozynski, et al., Internet-delivered behavior change program increases physical activity and improves cardiometabolic disease risk factors in sedentary adults: results of a randomized controlled trial, Prev. Med. 46 (5) (2008) 431–438. [18] L.J. Carr, R.T. Bartee, C.M. Dorozynski, et al., Eight-month follow-up of physical activity and central adiposity: results from an internet-delivered randomized control trial intervention, J. Phys. Activ. Health 6 (4) (2009) 444–455. [19] M.J. Fotheringham, D. Owies, E. Leslie, et al., Interactive health communication in preventive medicine: internet-based strategies in teaching and research, Am. J. Prev. Med. 19 (2) (2000) 113–120. [20] K. Kypri, H.M. McAnally, Randomized controlled trial of a web-based primary care intervention for multiple health risk behaviors, Prev. Med. 41 (3–4) (2005) 761–766. [21] J.F. Sallis, K.J. Calfas, J.F. Nichols, et al., Evaluation of a university course to promote physical activity: project GRAD, Res. Q. Exerc. Sport 70 (1) (1999) 1–10. [22] International Telecommunication Union Web Site [Internet]. World Telecommunication/ICT Indicators Database, Geneva, http://www.itu.int/ITU-D/icteye/Indicators/Indicators.aspx (cited 12.05.10). [23] Ministry of Public Management, Home Affairs, Posts and Telecommunications, Communications Usage Trend Survey in 2008 Compiled, 2009 http://www.soumu.go.jp/johotsusintokei/ tsusin riyou/data/eng tsusin riyou2008.pdf (in Japanese). [24] A.H. Robinson, G.J. Norman, J.F. Sallis, et al., Validating stage of change measures for physical activity and dietary behaviors for overweight women, Int. J. Obes. 32 (7) (2008) 1137–1144.
journal homepage: www.ijmijournal.com
One-year outcome of an interactive internet-based physical activity intervention among university students Kanzo Okazaki a,∗ , Shinji Okano b , Shinichiro Haga b , Akiho Seki c , Hisao Suzuki d , Kayo Takahashi b a
Tohoku Gakuin University, Faculty of Liberal Arts, Department of Human Science, 2-1-1 Tenjinzawa, Izumi-ku, Sendai, Miyagi 981-3193, Japan b Graduate School of Education, Okayama University, 1-1-3 Tsushima-Naka, Okayama, Okayama 700-8530, Japan c Department of Health Care Medicine, Kawasaki Medical School, 577 Matsushima, Kurashiki, Okayama 701-0192, Japan d Interactive Sport Education Center, Okayama University, 1-1-3 Tsushima-Naka, Okayama, Okayama 700-8530, Japan
a r t i c l e
i n f o
a b s t r a c t
Article history:
Objective: The purpose of the present study was to evaluate whether improvement in physical
Received 26 March 2013
activity of students following a 4-month intervention of a university course was maintained
Received in revised form
8 months later.
21 January 2014
Methods: Data on 77 students who responded to our scheduled inquiries completely through
Accepted 23 January 2014
1 year were analyzed. Participants of the intervention group (n = 49) using the internet-based physical activity program exhibited significant increases in energy expenditures measured
Keywords:
by IPAQ compared with the no-treatment control group (n = 28) through 1 year.
Physical activity
Results: Participants who did not engage in regular university sports activities (baseline:
Internet-based intervention
450 ± 351 kcal day−1 ; post: 587 ± 320 kcal day−1 ; 8-month follow-up: 580 ± 394 kcal day−1 ) only
Interactive learning system
exhibited significant increases in energy expenditures compared with those of the con-
University course
trol group (baseline: 498 ± 341 kcal day−1 ; post: 414 ± 242 kcal day−1 ; 8-month follow-up:
Follow-up
347 ± 275 kcal day−1 ). Conclusion: These results suggested that an internet-based interactive intervention could become a helpful tool in promoting and maintaining physical activity in the long term. © 2014 Elsevier Ireland Ltd. All rights reserved.
1.
Introduction
Regular physical activity is important to one’s health status and well-being [1]. The Ministry of Health, Labour and Welfare Japan in 2006 advocates physical activity as one of the most important practices in addition to eating well, stress management, and resting. For optimal health benefits, adults aged 18–65 years need moderate intensity physical
∗
activity for a minimum of 30 min at least 5 days per week [2]. Recently, the recommendation from the American College of Sports Medicine (ACSM) and the American Heart Association (AHA) were updated, and the recommendation suggested that all healthy adults aged 18–65 years need moderate intensity physical activity for a minimum of 30 min at least 5 days per week or vigorous intensity physical activity for a minimum of 20 min on the other 2 days of the week [3].
Corresponding author. Tel.: +81 22 773 3391. E-mail address: [email protected] (K. Okazaki). 1386-5056/$ – see front matter © 2014 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijmedinf.2014.01.012
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We assessed physical activity levels based on these 2 recommendations by a cross-sectional self-reported questionnaire among Japanese university students [4] and found that most students (46.7% of males and 61.3% of females) did not meet both recommended criteria. Insufficient physical activity in students is envisaged to become more prevalent after graduating from the university [5]. It is important for university students to consider their own health behaviors, such as physical activity during the university life because most students experience great changes in lifestyle, such as starting to live alone and holding a part-time job, as compared with high school [6]. Furthermore, advancement rates to the university have increased such that approximately 60% of high school graduates attend college in Japan. This high rate represents an optimal time for more and more students to learn how to modify the behavior of physical activity. Thus, an
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effective physical activity program is warranted among university students. To promote physical activity, the internet-based physical activity program (i-PAP) among university students was developed, which demonstrated its effectiveness [7]. i-PAP is an interactive learning system conducted through the internet. Participants used i-PAP through a computer or mobile phone during their first semester in a 4-month intervention. This significantly enhanced physical activity compared with the no-treatment control group. i-PAP is mainly based on social cognitive theory [8] and the health belief model [9] and has several functions including goal-setting, scheduling, selfmonitoring, strength and stretch training, a Web-based quiz, and energy expenditure calculations for physical activity. The purpose of the present study was to evaluate whether the improvement in physical activity following the
Fig. 1 – Flow diagram of participants’ progress through the intervention and follow-up.
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completion of the 4-month intervention were maintained 8 months later. Little is known about the efficacy of internetbased interventions for physical activity. Some previous reviews [10–13] on the efficacy of internet-based physical activity intervention reported contradictory results of efficacy. There have been few studies to evaluate efficacy compared with a no-treatment control group and during a follow-up period. We hypothesized that physical activity would promote or remain the same in the participants of the 4-month intervention group compared with the control group during the follow-up period.
Portable Document Format (PDF) file textbook in i-PAP. The contents of PDF were concerned with health behavior skills, obesity, body images, strength and strength training, and first aid for sports injury. i-PAP was operated using MySQL, PHP, JavaScript, HTML, Adobe Flash, or Adobe Acrobat Reader. Their operating system requirements were also confirmed (i.e., Mac, Microsoft Windows). In addition, mobile phone functionalities were confirmed with a Japanese mobile company.
2.
Methods
2.1.
Participants and design
A follow-up was completed at 8 months after the 4-month intervention. Participants of the intervention group were able to use i-PAP continuously through the follow-up period, although neither the e-mails nor the Web-quiz were sent during the follow-up period.
Healthy students from the regional Japanese national university took either the internet-based physical activity education course or a course unrelated to health education at the university. The students were classified by the university’s online system (see Fig. 1). Fifty-seven students were allowed to register for the internet-based physical activity education course. Two students were excluded because they did not agree with this study. On the other hand, 181 students were allowed to register for a course that was unrelated to the health course. Finally, 29 of the 181 students completed all assignments of the present study. Eighty-four students, who were allowed to register for the internet-based physical activity education course (intervention group, n = 55) and the course unrelated to health (control group, n = 29), responded to a baseline survey. Data from 77 students (intervention group, n = 49; control group, n = 28) who responded to all our scheduled inquiries during the intervention and 8-month follow-up were analyzed. All participants were assessed at 3 time points: the baseline at entry; after 4 months of intervention; and 8 months later at a follow-up. The intervention and the follow-up were conducted between April 2008 and April 2009. The present study was approved by the Ethics Committee of the university.
2.2.
Intervention
Participants in the intervention group used i-PAP interactively during a first semester (Table 1). Face-to-face contact was limited to the introductory sessions and after survey; all other contacts with the participants were only through the internet. First, participants in the treatment group set their goals and weekly schedule in i-PAP at the time of the initial class session, and if necessary, they could modify their goals and schedule using i-PAP. Conformance to the schedule was confirmed once a week by an e-mail with an attachment stating the goals. The participants received some advice according to the achievement of the schedule. The Web-based quiz was uploaded weekly starting the third week of the intervention (Table 1), and the participants had to take the quiz repeatedly until full marks were obtained within the week from the day of upload. The weekly Web-based quiz consisted of approximately 10 questions. The participants learned to answer the weekly questions using
2.3.
2.4.
Follow-up
Measurements
The International Physical Activity Questionnaire (IPAQ) and the Stages of Change Scale for physical activity (SOC) were completed at all 3 assessment time points. The baseline and post-intervention surveys were conducted by paper in both the first and final class sessions of the semester, whereas the 8-month follow-up survey was conducted online. IPAQ [14] is a self-reported questionnaire that records duration of different levels of physical activity for a habitual or past week. The questionnaire is structured to capture physical activity in 4 generic dimensions of physical activity, namely vigorous, moderate, walking, and sitting. IPAQ has reasonable measurement properties for monitoring population levels of the physical activity among 18- to 65-year-old adults in diverse settings. SOC can assess the readiness to become and stay physically active in adults [15,16]. The participants were classified as being at one of the following 5 stages: precontemplation, contemplation, preparation, action, and maintenance.
2.5.
Control conditions
Participants in the control group did not use i-PAP and took other non-health-related course during 1 year of the present study.
2.6.
Statistical analyses
Baseline descriptive characteristics were analyzed by an independent samples t-test and chi-square test. SOC data were presented as median. Changes in SOC were analyzed by Friedman test, and multiple comparisons were analyzed by the Bonferroni-adjusted Wilcoxon’s signed rank test (P < 0.0025). The energy expenditures as measured by IPAQ at the 3 assessment time points were analyzed within and between groups by two-way (time × group) repeated-measures analysis of variance (ANOVA). When indicated by a significant F value, post hoc test (Bonferroni) was performed. All statistical significance was set at P < 0.05, excluding the Bonferroni adjustment.
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Table 1 – Intervention course. Week(date)
Place
1 (April, 11)
Lecture room
2 (April, 18)
Lecture room
3 (April, 25)
Lecture room
4
Title of internet-based quiz Introduction to the class; Baseline survey Explanation of the i-PAP; Setting the goals and weekly schedule Explanation of the i-PAP; Re-setting the goals and weekly schedule
(May, 9)
5 (May, 16)
Lecture room
Explanation of the i-PAP; Free communication
Lecture room
Post-survey
6 (May, 23) 7 (May, 30) 8 (June, 6) 8 (June, 13) 10 11 12 13 14 15
(June, 20) (June, 27) (July, 4) (July, 11) (July, 18) (July, 25)
3.
Results
3.1.
Descriptive characteristics
3.2.
Changes in SOC
In the Friedman test (Fig. 2), all participants of the intervention group exhibited significant improvement in SOC [X2 (2) = 15.9, P < 0.05], whereas the control group did not exhibit any improvement. Moreover, to identify the influence of the differences in university sports activities, both groups were classified respectively into 2 subgroups [one subgroup was “engaged in regular university sports” (ES) and the other “did not engage in regular university sports” (DS)] and differences between these subgroups were analyzed. ES [X2 (2) = 9.3, P < 0.05] and DS [X2 (2) = 7.9, P < 0.05] in the intervention group respectively exhibited significant improvement in SOC, whereas the both ES and DS in the control group did not. In the Wilcoxon’s sign rank sum test, SOC of all participants [Z score = −3.1, P < 0.025] and ES [Z score = −2.7, P < 0.025] in the intervention group exhibited significant improvement at the 4-month assessment point relative to baseline. In addition, at the 8-month follow-up assessment, SOC of all participants [Z score = −3.4, P < 0.025] and the ES [Z score = −2.4, P < 0.025] and
Quantity and Quality of Physical Activity and Exercise Promotion and Maintenance of Physical Activity and Exercise Weight Control Receipts and Disbursements Balance of Energy; Nutrition Calculation of Consumption Energy Four Type of Training Contractions: Isotonic, Eccentric, Isometric, Isokinetic Strength Training Methods Strength Training Meals Plan Stretch Training Methods Sports Injury Summary
the DS [Z score = −2.7, P < 0.025] subgroups in the intervention group were significantly improved relative to baseline.
3.3. At baseline, there were no significant differences in descriptive characteristics between the groups (Table 2). We have indicated a percentage of the students’ activities in the follow-up data in Table 2 because their university sports activities clearly influence the outcomes of physical activity. The outcomes of the both groups were analyzed based on the difference in their sports activities.
Physical Activity and Exercise
Change in energy expenditure
Fig. 3 indicated the changes in the energy expenditure measured by IPAQ. In the SOC analysis, we classified and analyzed energy expenditure according to their activities involvement. In a two-way repeated-measures ANOVA, only the DS subgroup in the intervention group (baseline: 450 ± 351 kcal day−1 ; post: 587 ± 320 kcal day−1 ; 8-month follow-up: 580 ± 394 kcal day−1 ) exhibited significant increases in energy expenditures compared with the control group (baseline: 498 ± 341 kcal day−1 ; post: 414 ± 242 kcal day−1 ; 8month follow-up: 347 ± 275 kcal day−1 ) [F(2, 72) = 3.5, P < 0.05]. In post hoc testing, energy expenditure of the DS subgroup in the intervention group was significantly higher than that in the control group at the 8-month follow-up [F(1, 36) = 4.3, P < 0.05].
4.
Discussion
We previously reported the efficacy of i-PAP through a 4-month intervention period [7]. The purpose of the present study was to evaluate whether the efficacy of i-PAP was maintained through an 8-month follow-up period after the intervention. The results indicated the efficacy of i-PAP through the 8-month follow-up. Particularly, the university students who did not engage in regular university sports activities increased their physical activity. Although little is known about the long-term efficacy of the internet-based interventions [10–13] such as i-PAP, only one previous study [17,18] reported the long-term efficacy of the internet-based program named ALED-I (Active
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Table 2 – Baseline characteristics of 77 samples responded to our scheduled inquiries completely during this study. Intervention (n = 49)
Control (n = 28)
Gender, n (%) 35 (71) Male 14 (29) Female 19.1 ± 1.3 Age (years), mean ± SD 21.7 ± 3.1 BMI (kg m−2 ), mean ± SD IPAQ (kcal day−1 ), mean ± SD 714 ± 648 Engaged in regular university sports activities (Yes/No), n (%) 17 (35)/32 (65) Baseline 28 (57)/21 (43) 8-Month follow-up Stage distribution, n (%) 3 (6) Precontemplation Contemplation 15 (31) 14 (29) Preparation 17 (34) Action and maintenance
P-value
15 (54) 13 (46) 19.4 ± 1.2 20.4 ± 2.3 602 ± 423
0.11 0.35 0.08 0.42
9 (32)/19 (68) 11 (39)/17 (61)
0.82 0.13
5 (18) 7 (25) 10 (36) 6 (22)
0.27
IPAQ, International Physical Activity Questionnaire.
Living Every Day). Their report indicated that 19 participants increased their steps per day after the 4-month intervention, but relapsed (−1340 steps day−1 ) through the 8-month followup after that. Furthermore, the efficacy of the follow-up was not compared with those of a no-treatment control group. Therefore, it is valuable that our results indicated the longterm efficacy of the internet-based program compared with those of the no-treatment control group. It was presumed that one of the reasons why physical activity was promoted in the present study was because of an extremely low attrition rate. The attrition rate of the present study was 2% during the intervention and 8% during the follow-up, whereas Carr et al. [18] reported an attrition rate of 51% during the intervention and 40% during their followup period. The low attrition rate indicates that capacities and advantages of the computer- and mobile phone-mediated communication approaches may have driven university
students to more interest in physical activity [19]. Kypri and McAnally [20] found a significant increase in physical activity and a low attrition rate of 14% through their internet-based, 6-week, short-term intervention among university students. Perhaps, the low attrition rate during the intervention was affected by the course credit after completing the intervention, whereas the control was not affected by their course credit. However, most of the students responded to the follow-up survey in which no reward was given. These successful results in the present study may indicate that an internet-based program is more effective than traditional face-to-face programs through 1 year among university students. For example, the Project Graduate Ready for Activity Daily (GRAD) [5,21], which was a face-to-face physical activity promotion program among university students through the first semester and a follow-up, reported unsuccessful results at the 1-year assessment point, but demonstrated increased
A
B
5
3 2
Intervention Control
0
3 2
Intervention Control
1
1
0 Baseline
4 month
12 month
*
*
4
SOC score
SOC score
*
*
4
5
Baseline
4 month
12 month
C Intervention Control
5
SOC score
4
*
3 2 1 0
Baseline
4 month
12 month
Fig. 2 – Change of the SOC score. (A) All participants were analyzed; (B) the participants who engaged in regular university sports activities at the follow-up were analyzed; (C) the participants who did not engage in regular university sports activities at the follow-up were analyzed. SOC, the Stages of Change Scale for physical activity. *Significant difference with baseline.
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1200 1000
A
1400 Intervention Control
†
800 600 400
Mean of Energy Expenditure (kcal / day)
Mean of Energy Expenditure (kcal / day)
1400
1200 1000 800 600
Intervention Control
400 200
200 0
B
Baseline
0
4 month
12 month
Mean of Energy Expenditure (kcal / day)
1400 1200 1000
Baseline
4 month
12 month
C Intervention Control
†
800
*
600 400 200 0
Baseline
4 month
12 month
Fig. 3 – Change in energy expenditure measured by IPAQ through 1 year. (A) All participants were analyzed; (B) the participants who engaged in regular university sports activities at the follow-up were analyzed; (C) the participants who did not engage in regular university sports activities at the follow-up were analyzed. † Interaction (time × group) effect was found. *Significant difference between groups. energy expenditure (kcal kg−1 wk−1 ) after the assessment [5]. The GRAD students received some advice on physical activity promotion through phone calls and mail during the followup period, and the calls and mails decreased in frequency toward the end of the follow-up. Although our study design was not compared with other traditional health-related faceto-face programs, physical activity was promoted through 1 year. Further study is needed to examine the long-term efficacy, comparing the internet-based program with face-to-face traditional intervention. The internet has infiltrated many aspects of our daily life. The International Telecommunication Union in Geneva reported that approximately 1.4 billion people in the world use the internet. In 2008 alone, 91 million used the internet and 90% of people between the age of 15 and 35 years used the internet in Japan [22,23]. It is presumed that most university students are accustomed to using the internet. Therefore, it could be useful for supporting an intervention after completing a course and graduating. In addition, the content can be changed according to attractive new knowledge when it becomes available [19]. i-PAP could be a lifelong physical activity promotion and maintenance tool. There are some limitations to the present study. The participants of both groups respectively were randomly and automatically classified by the university online system before the semester started. Thus, the participants in the intervention may prefer to be more active than the control group. However, there were no differences between the groups in several demographic characteristics and the stage distribution. And, it has been reported that Japanese students are in general interested in health concerns [7]. A second limitation of this study was the reliance on self-report of outcomes. However, previous reports indicated the significant confidence and validity of IPAQ and SOC, relative to a
pedometer and an accelerometer [14,24]. Finally, discrepancy in number between intervention and control participants may affect the results. However, there were no differences between the groups in several demographic characteristics and stage distribution.
5.
Conclusion
In conclusion, i-PAP promoted physical activity through the 1-year study period. In particular, students who did not previously engage in regular university sports increased their physical activity. These results suggest that an internet-based interactive intervention such as i-PAP has a long-term efficacy for promoting and maintaining physical activity after the students completed the course.
Author contributions K. Okazaki proposed the initial idea and design of the project, participated in system development, analyzed the results and wrote the manuscript. S. Okano proposed the idea of the project and system development, and actively participated in conducting the project and data analysis. S. Haga proposed system development and participated in conducting the project and data analysis. A. Seki participated in critical system development. H. Suzuki participated in the initial idea of the project and conducting the project and critical review of the manuscript. K. Takahashi participated in the guidance, supervision, and review of the manuscript.
Conflicts of interest Authors declare that they have no competing interest.
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Summary points What was already known before this study: • Some previous reviews on short-term efficacy of internet-based physical activity intervention. • There have been few studies to evaluate efficacy compared with a no-treatment control group. What this study has added to our knowledge: • Our intervention promoted physical activity among university students through the 1-year study period including an 8-month follow-up. • In particular, students who did not previously engage in regular university sports increased their physical activity. • These results suggest that an internet-based interactive intervention has a long-term efficacy for promoting and maintaining physical activity.
Acknowledgements The present study was supported by JSPS KAKENHI Grant-inAid for Young Scientists B (No. 12814972) and Support Program for contemporary educational needs found by the Ministry of Education, Culture, Sports, Science and Technology (MEXT).
references
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