Among the 25 included articles, 12 (48%) (reporting on 12 unique studies) used a cross-sectional study design† with the purpose of describing the relationship between physical activity, or physical activity and sleep, and another variable of interest using WPAMs (Table 1). Seven articles (28%) (6 unique studies and 1 study protocol) were randomized controlled trials (RCTs) with the purpose of assessing the effect of an intervention that was not a WPAM to improve physical activity,41,43,44,55,61 lifestyle factors,44 nutrition,64 or neurocognitive function55,58 among adults living with HIV (Table 1). The remaining articles included 2 case reports (8%),47,57 2 systematic reviews (8%),46,62 1 case-control study (4%),59 and 1 observational study (4%) (nested within an aforementioned RCT44) 49 (Table 1).
The total sample size of participants at baseline in the 20 studies involving primary data collection was 1421 adults ranging in age from 33 to 67 years (Table 2). Of the 1421 participants, 1212 (85%) were adults living with HIV, 49 (3%) were HIV negative, and HIV status was not reported in the remaining 160 participants (11%). Of the 20 studies, 19 (95%) reported on the sex and/or gender of participants (n = 1193), of which 665 (56%) were female or women, 452 (38%) were male or men, and 76 (6%) were unreported. Of the 20 studies, 13 (65%) reported on ethnicity of participants (n = 808), of which 466 (58%) were identified as African American, 161 (20%) as Hispanic, 118 (15%) as Caucasian, 21 (3%) reported another ethnicity that was not specified, and 42 participants (5%) did not respond to ethnocultural background questions.
Among the 25 articles that described 20 unique studies, a total of 23 different WPAMs were worn by adults living with HIV: 10 (43%) WPAMs were actigraphs used to describe physical activity,* 8 (35%) were accelerometers used to describe physical activity,41,45,47,51–53,56,59 and 5 (22%) were pedometers used to measure steps taken and distance walked44,49,55,63,64 (Table 3). Of the 23 WPAMs, 6 (26%) were worn on the hip,32,44,45,50,56,58 6 (26%) on the waist,48,55,61,63 4 (17%) on the nondominant wrist or wrist,47,54,57,60 1 (4%) on the upper arm,42,43 1 (4%) on the chest,51 and the location of 5 (22%) were not explicitly stated.41,52,53,59,64 Accelerometers and actigraphs were generally worn on the wrist, whereas pedometers were generally worn on the waist or the hip (Table 3). The duration of WPAM use ranged from 48 hours64 of consecutive monitoring to 12 months.44
Of the 23 WPAMs used in the 20 included studies, 20 WPAMs were used to describe outcomes of interest in the given study including physical activity41–45,47–61,64,65 or physical activity in combination with sleep (Table 3). WPAMs used to assess physical activity specifically measured time spent in moderate or vigorous physical activity, heart rate, energy expenditure, sedentary time, steps taken, and distance walked.† Three articles used WPAMs to assess sleep (in combination with physical activity), whereby WPAMs measured sleep duration, sleep-onset latency (length of time to fall asleep measured in minutes), sleep cycle mesor (stages of sleep), total wake time, sleep efficiency (ratio of total sleep time to time spent in bed), and sleep fragmentation index (measure of restlessness, and wake after sleep onset).42,47,57 Of the 20 included studies, 2 (8%) compared the use of a WPAM (n = 3 WPAMs) to a self-reported description of physical activity32,63 (Table 3).
Of the 20 included studies, 2 reported on the comparison of a WPAM with a self-reported measure of physical activity.32,63 The first study compared a self-reported physical activity questionnaire, the International Physical Activity Questionnaire (IPAQ) Short Form, with 2 WPAMs. The Spearman correlation coefficients between the IPAQ minutes per week and pedometer steps per day revealed a correlation of 0.76.63 Participants had lower levels of physical activity as recorded by the accelerometer, and authors of this study concluded that a pedometer may help improve measuring physical activity among adults living with HIV who are capable of engaging in ambulatory acitivities.63
No included studies assessed the effectiveness of the WPAM as an intervention to change physical activity behavior. However, 2 articles reporting on the same study found that when using a WPAM, the WPAM could be used as an intervention to promote physical activity among adults living with HIV with risk factors for ischemic heart disease.44,49 Roos et al44 used the WPAM primarily as an outcome measure of physical activity by recording the number of steps taken among adults living with HIV. However, participants in this study reported that they also used the pedometer as a motivational tool to promote and increase their level of physical activity.44
Of the 25 articles included, authors of 11 articles (44%) mentioned that the WPAM used had been validated among either a healthy population or other chronic illness population such as people living with chronic pain, hypertension, and cancer.* None of the authors reported measurement properties of WPAMs specifically with adults living with HIV.
Of the 25 included articles, 2 were systematic literature reviews. The purpose of one review was to establish expected steps per day in a given day among populations living with chronic illnesses or disabilities, including people living with HIV.62 Sixty studies were included in this review, of which one study specifically included adults living with HIV.62 Tudor-Locke et al62 reported the median number of steps walked per day for each population, which included people living with heart diseases, chronic obstructive pulmonary disease, diabetes, breast cancer, neuromuscular diseases, arthritis, joint replacement, intellectual disabilities, and other special populations including adults living with HIV. The expected number of steps taken per day for each special population were provided with the use of a waist-mounted WPAM such as an accelerometer or and ankle-mounted WPAM such as a pedometer. Authors of the one included study specific to adults with HIV63 reported a mean of 7594 and 7495 steps walked per day as recorded by a pedometer for males and females living with HIV, respectively, and 7151 and 7886 mean steps per day as recorded by an accelerometer for males and females living with HIV, respectively.62
Authors of the other systematic literature review examined interventions in the literature used to promote exercise and nutrition among adults living with HIV and chronic disease.46 Botros et al46 included 22 publications pertaining to nutrition and lifestyle interventions and 10 publications pertaining to exercise among those with chronic disease and adults living with HIV. Interventions to increase physical activity identified by the authors from included publications were educational sessions, specialized equipment, and multicomponent physical activity and nutrition education with structure exercise classes.46 A pedometer-based publication was included where the goal of the pedometer was to increase motivation and time spent engaged in physical activity.46,66 Botros et al46 concluded that the aforementioned interventions may be used among adults living with HIV to promote exercise and nutrition that, in turn, improve adverse health outcomes such as cardiovascular, metabolic, and psychological consequences of HIV and treatments.46
This study is the first scoping review to characterize the literature pertaining to the use of WPAMs to measure or enhance physical activity among adults living with HIV. The majority of articles were published during the years 2011-2016, indicating that evidence of WPAM use is becoming increasingly prevalent in the literature. In summary, WPAMs were used primarily as an outcome measure to describe physical activity among adults living with HIV and to a lesser extent as a motivational intervention tool to enhance physical activity. The types of WPAMs used were accelerometers, actigraphs, and pedometers to measure the number of steps taken, distance walked, and active minutes engaged in physical activity. Gaps in the literature included a paucity of evidence assessing the measurement properties of WPAMs and the effectiveness of WPAMs in promoting physical activity among adults living with HIV.
Our results suggest a paucity of evidence documenting the role and effectiveness of WPAMs as an intervention or motivational tool to enhance physical activity among adults living with HIV. Authors of 2 systematic reviews suggested WPAMs may be used as a motivational intervention to increase physical activity among people who are overweight, obese, or living with type 2 diabetes.71,72 In this review, authors noticed in the discussion of one included study that participants suggested WPAMs motivated them to increase their physical activity levels.44 Future research should evaluate the effectiveness of WPAMs for enhancing outcomes of physical activity in this population.
Measurement tools should be validated specifically for use with a given target population because instruments can produce differing outcomes between the observation and what the measurement tool is supposed to measure across different populations.74 Adults living with HIV are experiencing health challenges (or disability) as a consequence of HIV infection, side effects associated with long-standing antiretroviral use, and emerging concurrent health conditions aging with HIV infection.1,3,75 Some of the multimorbidity associated with HIV infection and long-term antiretroviral use may include peripheral neuropathy, HIV-associated myopathy (although relatively rare), and type 2 diabetes.3 Peripheral neuropathy specifically has a prevalence rate of approximately 30% to 70%76 and may present with numbness, paresthesia, and dysesthesia in the lower extremities, which, in turn, may lead to slower gait and gait impairments.3 Slower gait speed may lead to inaccurate measures of physical activity by WPAMs as measured by step counts, active minutes, and distance walked. For instance, some WPAMs were shown to be less accurate at slower walking speeds than faster walking speeds among people who have sustained a stroke.28 Hence, WPAMs may not provide accurate and reliable measurements of physical activity for adults living with HIV with gait impairments. Older adults living with HIV are more likely to have a greater number of concurrent health conditions including peripheral neuropathy and diabetes than younger adults living with HIV.77 In turn, older adults living with HIV may be more likely to experience the negative consequences associated with peripheral neuropathy, thus leading to gait impairments affecting WPAM use.3,77 Hence, it is important to consider the properties of WPAMs for their use in the context of HIV infection.
A paucity of evidence exists on the effectiveness of WPAMs as an intervention to increase physical activity among adults living with HIV. Authors of a systematic review suggested WPAMs can demonstrate ways to monitor health and evoke behavior changes to enhance physical activity among populations of all ages.78 Future research should focus on how WPAMs may play a role in promoting and adhering to physical activity among adults living with HIV. Second, none of the studies in our scoping review reported on the measurement properties of WPAMs specifically among adults living with HIV. Therefore, further research is needed to assess the validity and reliability of WPAMs in the context of HIV infection.
More than half of the participants (56%) in the included studies who reported on sex or gender self-identified as women or female living with HIV. On a global scale, approximately 35 million adults are currently living with HIV.79 Of those 35 million people, approximately 18.2 million are females (52%).79 Although it appears that the sex and gender breakdown reflects the global estimates of HIV, it is important to consider sex and gender difference among this population when using WPAMs. For instance, Kenyan women initiating antiretroviral therapy were approximately 10 times more likely to develop peripheral neuropathy than men within the first year of starting treatment.80 Sex and gender differences may exist when considering the ability, interest, and uptake of using WPAMs to measure physical activity. Hence, it is important to consider the measurement properties of WPAMs across a diverse sample of adults living with HIV to ensure external validity among the population.
Approximately half of the articles (52%) included in our scoping review were completed in high-income countries such as the United States.81 Adults living with HIV in developing countries may not have the resources to access WPAMs and thus may have resulted in fewer studies included in the review. Future research should explore the role of WPAMs in measuring and promoting physical activity among adults living with HIV living in high- as well as low- to middle-income contexts.
The authors thank Erica Lenton, Faculty Liaison and Instruction Librarian at the University of Toronto, for her help with the search strategy.
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