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Wireless Physical Activity Monitor Use Among Adults Living With HIV

A Scoping Review

Dagenais, Matthieu, BSc1; Cheng, Darren, BSc2; Salbach, Nancy M., PhD, MSc, BScPT3; Brooks, Dina, PhD, MSc, BScPT4; O'Brien, Kelly K., PhD, BScPT, BSc5

doi: 10.1097/01.REO.0000000000000153
META ANALYSIS & SYSTEMATIC REVIEW
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SDC

Introduction: Physical activity (PA) can help promote healthy aging while addressing health-related challenges experienced with HIV infection. To determine the benefits of PA or consequences of inactivity, it is critical to ensure that we have accurate ways of measuring PA in the context of HIV infection. Wireless physical activity monitors (WPAMs) are increasingly used for measuring PA; however, evidence of their use in the context of HIV infection is unclear. Our aim was to characterize the literature (nature and extent and gaps in evidence) pertaining to WPAM use among adults living with HIV.

Methods: We conducted a scoping review using the Arskey and O'Malley framework. We answered the following question: “What is the nature and extent of evidence pertaining to WPAMs and their use among adults living with HIV?” We searched databases including MEDLINE, EMBASE, CINAHL, PubMed, Cochrane, and PsycINFO from 1980 to September 2016. Two authors independently reviewed titles and abstracts, followed by full texts for inclusion. Two authors independently piloted and then extracted data from included articles. We described characteristics of included studies using frequencies and medians and collated results from text data using content analytical techniques.

Results: Our search strategy yielded 1315 citations, of which 25 articles were included. The majority of articles (76%) were published between 2011 and 2016. Among a total sample of 1212 adults living with HIV in the included studies, 56% were women. Across the 20 studies, 23 WPAMs were used including actigraphs (n = 10 WPAMs), accelerometers (n = 8), and pedometers (n = 5) to measure PA. WPAMs were used primarily as an outcome measure of PA. No included studies assessed measurement properties of WPAMs among adults living with HIV.

Conclusion: WPAM use in the context of HIV infection primarily involved measuring PA. Areas to address in future research include examining the effectiveness of WPAMs for enhancing PA and assessing measurement properties of WPAMs to ensure they accurately assess PA among adults living with HIV.

1MSc candidate, Rehabilitation Sciences Institute (RSI), University of Toronto, Toronto, Ontario, Canada

2MSc candidate, Rehabilitation Sciences Institute (RSI), University of Toronto, Toronto, Ontario, Canada

3Associate Professor, Rehabilitation Sciences Institute (RSI), University of Toronto, Toronto, Ontario, Canada; Associate Professor, Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada

4Professor, Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada; Full Member and Graduate Coordinator, Graduate Department of Rehabilitation Sciences, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada

5Assistant Professor, Rehabilitation Sciences Institute (RSI), University of Toronto, Toronto, Ontario, Canada; Assistant Professor, Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada; Assistant Professor, Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, Ontario, Canada

Correspondence: Matthieu Dagenais, BSc, Rehabilitation Sciences Institute (RSI), University of Toronto, 500 University Ave, Toronto, ON M5G 1V7, Canada (matthieu.dagenais@mail.utoronto.ca).

Grant Support: Matthieu Dagenais was funded by a University of Toronto Fellowship and Early Researcher Award with the Ontario Ministry of Research and Innovation (O'Brien). Darren Cheng was funded by a University of Toronto Fellowship and a Supervisor Stipend (Salbach). Kelly K. O'Brien and Nancy M. Salbach were supported by a Canadian Institutes of Health Research (CIHR) New Investigator Award. Kelly O'Brien is supported by a Canada Research Chair (CRC) in Episodic Disability and Rehabilitation.

The authors declare no conflicts of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.rehabonc.com)

HIV/AIDS is a chronic illness where individuals with access to antiretroviral therapy are living longer with the health-related consequences of HIV infection and concurrent conditions.1–3 Multimorbidity, defined as the simultaneous occurrence of 2 or more medical conditions, is increasingly common among adults living with HIV.4–8 Concurrent health conditions such as diabetes mellitus, cardiovascular disease, bone and joint disorders, and renal failure are more prevalent in adults living with HIV than in the general population.4–11 This may be due to negative consequences of HIV, long-term use of highly active antiretroviral therapy, and aging.1 , 3 HIV infection and multimorbidity can present with health-related consequences, such as physical, cognitive, mental and emotional symptoms and impairments, difficulties with day-to-day activities, challenges to social inclusion, and uncertainty or worrying about future health.12–14 These health-related consequences, known as disability, can be multidimensional and episodic in nature.14 Hence, it is important to consider strategies that individuals living with HIV can adopt to mitigate risk factors and potential disability associated with HIV infection and multimorbidity.

Physical activity can help promote healthy aging while addressing some of the health-related challenges experienced by adults living with HIV. Physical activity can be defined as any type of bodily movement that results in the expenditure of energy that may include (but is not limited to) occupational, sports, structured exercises, household chores, or other activities that entail movement.15 The Canadian Society for Exercise Physiology (CSEP) and the United States Physical Activity Guidelines recommend that adults 18 years and older engage in at least 150 minutes of moderate to vigorous physical activity each week (7 days).16–18 These activities may include brisk walking, bike riding, and any household chores that involve physical movement such as mowing the lawn, raking leaves, and navigating up and down stairs.18 These guidelines are believed to augment improvements in fatigue, neurocognitive functioning, quality of life, and overall health for adults 18 years and older.17 , 18 It is important to determine how much physical activity adults living with HIV are engaging in and its potential effect on health and risk of multimorbidity.19

Engaging in moderate to vigorous physical activity can improve health-related quality-of-life outcomes among the general healthy population.20 Specifically, for adults living with HIV, engaging in physical activity can lead to improvements in fatigue, neurocognitive functioning, and quality of life.19 , 21 , 22 For instance, community-dwelling adults living with HIV who self-reported higher physical activity levels possessed less neurocognitive impairment.22 Furthermore, adults living with HIV in the United States who met physical activity guidelines of 150 minutes per week engaging in moderate physical activity displayed an approximate 20% reduction in fatigue compared with adults living with HIV who did not meet these guidelines.21 Finally, adults living with HIV who engaged in more frequent (vs less frequent) physical activity reported higher levels of general health status.23 Hence, physical activity plays an important role in the lives of adults living with HIV. However, the proportion of adults living with HIV who are physically active documented in the literature ranged from 19% to 73%, demonstrating a diversity of physical activity estimates among this population.24 Hence, despite the documented benefits, it remains unclear the extent to which adults living with HIV engage in physical activity.

Measuring physical activity involves quantifying the frequency and type of movement undertaken by an individual,25 which can be done using subjective (self-reported) or objective (motion sensor) measures.26 One objective measure becoming increasingly popular is wireless physical activity monitors (WPAMs). WPAMs can offer an economical, feasible, and noninvasive way to measure physical activity and energy expenditure (energy expended by a person expressed as a rate in kilocalories [kcal]). WPAMs are used among healthy populations, along with people with chronic conditions such as stroke, those with chronic heart failure, and people with sleep disorders.27–30 WPAMs measure physical activity by counting the number of steps taken during walking and running activities and calculating the time spent engaged in sedentary behavior and moderate to vigorous exercises.27–30 Self-reported measures have also been used to measure physical activity among healthy populations and adults living with HIV.31 , 32 However, some self-reported measures can overestimate physical activity among adults living with HIV.32 Hence, WPAMs may be useful to objectively measure physical activity in the context of HIV infection. However, evidence of WPAM use among adults living with HIV is unclear.

Our aim was to characterize the literature pertaining to WPAM use among adults living with HIV. Specific objectives were to explore the nature and extent, as well as gaps, in the evidence pertaining to WPAM use among adults living with HIV.

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METHODS

We conducted a scoping review to explore what is known and not known about WPAMs among adults living with HIV. We used the Arksey and O'Malley framework, supplemented by recommendations and clarifications on advancing the methodology for scoping reviews, to inform the following methodological steps.33–35 We describe our methods and results in accordance with the guidelines and checklist of the PRISMA Extension for Scoping Reviews (PRISMA-ScR).36

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Stage 1: Identifying the Research Question

We set out to answer the following primary research question: What is the nature and extent of evidence pertaining to WPAMs and their use among adults living with HIV? Secondary research questions included the following: (a) How have WPAMs been used with adults living with HIV? (b) What types of WPAMs are used among adults living with HIV? and (c) What are the current gaps in the literature pertaining to the use of WPAMs among adults living with HIV? We defined the “nature of evidence” as the type of literature on WPAMs and their use with adults living with HIV (eg, study location, study design, type of WPAMs, and effect of WPAM use on health outcomes). We defined “extent of evidence” as the amount of literature on WPAMs and their use among adults living with HIV (eg, number of publications). Finally, we defined gaps in evidence as areas in the literature that have not been explored related to WPAM use with adults living with HIV and future research directions.

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Stage 2: Identifying Relevant Studies

We searched for relevant research articles (eg, peer-reviewed journal articles), gray literature (eg, technical reports, position papers, and hard-to-locate or unpublished literature), reference lists (eg, bibliographies), hand-searched important HIV-related journals, and networks and organizations related to WPAMs and HIV. We searched for gray literature, specifically by exploring HIV infection or chronic disease–related conference proceedings (eg, abstracts) and using Google Scholar. We searched electronic databases including MEDLINE, EMBASE, CINAHL, PubMed, Cochrane, and PyscINFO published from January 1980 to September 2016. Our search strategy aimed to capture any article that addressed WPAMs AND included adults 18 years and older living with HIV AND published from 1980 and onward. We modified our search strategy depending on the database searched with an information specialist to optimize our ability to search for relevant articles for our scoping review. This is in accordance with the recently published PRISMA-ScR guidelines.36 For an example of our search strategy, see Appendix A (Supplemental Digital Content 2, available at: http://links.lww.com/REHABONC/A11).

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Stage 3: Study Selection

We imported citations (titles and abstracts) yielded from the search strategy into EndNote referencing software program37 and then into Covidence to facilitate our process of screening for inclusion.38 Two authors (M.D. and D.C.) piloted an article selection criteria checklist by independently screening 10 articles for inclusion by answering “yes,” “no,” or “maybe” to the following questions: (1) Does this article include WPAMs? (2) Does this article include (or refer to) adults living with HIV? (3) Was this article published from 1980 and onward? If M.D. and D.C. responded “yes” to all 3 questions, then the article proceeded to the next stage of full article review. If at least one reviewer responded “no” to any of the 3 questions, then the article was excluded. Both M.D. and D.C. revised the checklist after the pilot phase, and 2 reviewers (M.D. and D.C.) independently screened all abstracts and citations using the updated article selection checklist. The 2 reviewers (M.D. and D.C.) independently reviewed full text of articles for inclusion when at least one reviewer rated “maybe” or “yes” on at least one of the 4 questions in the abstract screening phase. In situations of discrepancies, a third reviewer determined final inclusion. Upon our review of articles for study selection, we noticed some articles addressed WPAM use as a measure of sleep only (and not physical activity). Given our focus on physical activity, and in keeping with the iterative process of scoping reviews methodology, we refined our inclusion criteria to include only articles that addressed WPAMs and physical activity among adults living with HIV. We asked: does this article primarily focus on WPAMs measuring and describing physical activity only? If M.D. and D.C. both responded “yes,” then we included the article in the review. This was in accordance with the PRISMA-ScR guidelines that were recently published.36

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Stage 4: Charting the Data (Data Extraction)

We extracted characteristics and the following data from included articles and abstracts. Refer to Appendix B (see Supplemental Digital Content 3, available at: http://links.lww.com/REHABONC/A15) for the characteristics and data extracted: the author(s), year article published, study location, purpose, study design, population, outcome measures, intervention (if applicable), type of WPAM used or discussed in the article, results, and overall author(s) conclusion. We also included a category on the data extraction form to document our interpretations of the article in how it addressed our research question of what is the nature and extent of evidence pertaining to WPAM use among adults living with HIV. Two reviewers (M.D. and D.C.) piloted the data extraction form by independently extracting data from 5 articles that met the inclusion criteria. To facilitate data extraction, we developed a list of operational definitions of concepts we planned to extract from the included articles and continually revised it throughout the data extraction process (Appendix B, see Supplemental Digital Content 3, available at: http://links.lww.com/REHABONC/A15). Both M.D. and D.C. extracted data from the remainder of included articles independently onto the finalized data extraction form using Microsoft Excel (Appendix B, see Supplemental Digital Content 3, available at: http://links.lww.com/REHABONC/A15).

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Stage 5: Collating, Summarizing, and Reporting the Results

We described characteristics of included articles using frequencies (percent) and medians (interquartile ranges) for categorical and continuous variables, respectively. We synthesized text-related data (eg, author's results and conclusions) using content analytical techniques.39 Where applicable, we specifically reported on (a) the measurement properties of the WPAM in the context of HIV infection, (b) their use as a measure of physical activity among adults living with HIV; (c) their use as an intervention to enhance physical activity among adults living with HIV; and (d) the current gaps in the literature as reported by authors of the included articles.

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RESULTS

Of the 1315 titles and abstracts yielded from the search strategy, 43 (3.2%) articles originally met our inclusion criteria. After refining our inclusion criteria to focus on WPAM use in the context of physical activity, we excluded 18 articles that used WPAMs to solely measure sleep among adults living with HIV. As a result, 25 peer-reviewed articles representing 20 full-text articles, 2 published abstracts, 2 systematic literature reviews, and 1 study protocol were included in our review (Figure 1).40 The majority (76%; 19/25) were published between 2011 and 2016,41–59 and the majority (52%; 13/25) were published in the United States including 10 articles that reported on 9 individual studies and 2 systematic literature reviews* (Table 1). Of the 25 articles, 3 (12%) reported on the same home-based exercise intervention study, with the aim to increase physical activity among adults living with HIV,41–43 and 2 (8%) reported on the same home-based pedometer walking program among adults living with HIV with risk factors for ischemic heart disease.44 , 49

Fig. 1

Fig. 1

TABLE 1

TABLE 1

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Research Methodology Used When Using WPAMs Among Adults Living With HIV

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).

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Description and Study Purpose of the Literature on WPAMs and Adults With HIV

Of the 25 articles, 11 (44%) assessed associations between physical activity and an outcome variable(s) of interest.* All 25 articles used WPAMs to describe physical activity among adults living with HIV, and 5 (20%) additionally assessed the effect of an intervention while measuring changes in physical activity using a WPAM among adults living with HIV.44 , 55 , 58 , 61 , 64 Two articles (8%) examined WPAMs and compared them with self-reported measures of physical activity among adults living with HIV.32 , 63 Two articles (8%) described physical activity and sleep among adults living with HIV using WPAMs.57 , 59 One article (4%) described the study protocol of an RCT designed to increase physical activity at home among adults living with HIV,41 1 article (4%) evaluated traditional and novel functional assessments,54 and finally 1 article (4%) assessed adherence to an exercise program among adults living with HIV.49 The final 2 articles (8%) were systematic literature reviews where one article reported on interventions designed to promote nutrition and exercise46 and the other reported on expected step count in special populations including adults living with HIV62 (Table 1).

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Characteristics of Participants in Included Studies

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.

TABLE 2

TABLE 2

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Characteristics of WPAMs in the Included Studies

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

TABLE 3

TABLE 3

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Purpose for Utilization of WPAMs and Outcomes Assessed by WPAMs

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).

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Comparison of WPAMs to Self-reported Measures of Physical Activity

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

Another study compared the IPAQ Long Form in adults living with HIV with an accelerometer where this WPAM was the objective criterion.32 Fillipas et al32 reported that the total number of metabolic equivalents per week as measured by the IPAQ showed a moderate correlation with the criterion measure of total weekly activity counts as measured by the accelerometer (r = 0.41). They reported a moderate correlation between the IPAQ score and vigorous physical activity recorded by the accelerometer (r = 0.38). They reported the Bland-Altman plots that systematically showed time spent in moderate and vigorous physical activity were overreported on the IPAQ compared with the accelerometer.32 The authors of this study concluded that the IPAQ may be useful in estimating physical activity among adults living with HIV, but more precise measurements may come from using a WPAM.32

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WPAM Use as a Potential Motivation to Promote Physical Activity

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

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WPAM Measurement Properties Among Adults Living With HIV

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.

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Systematic Literature Reviews on WPAMs

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

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DISCUSSION

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.

WPAMs were used as an outcome measure of physical activity similarly among adults living with HIV and other chronic illness populations. Physical activity similarly was assessed using WPAMs as measured by the number of steps taken in a day, tracking time spent in predefined physical activity levels, and reporting daily energy expenditure among adults living with chronic obstructive pulmonary disease and adults with stroke using an accelerometer.67 , 68 Pinto et al69 also used a pedometer to measure physical activity by counting the number of steps taken among women living with breast cancer (stages 0-2) during a home-based physical activity intervention. Tudor-Locke et al62 conducted a systematic review to identify the expected step counts among special populations using WPAMs. Adults living with HIV had expected step counts of approximately 7540 steps per days, whereas other chronic disease populations had differing expected step counts.62 Adults living with neuromuscular complications had expected steps counts of approximately 6000 steps per day, and adults with chronic obstructive pulmonary disorder had expected step counts of 2240 steps per day as recorded by WPAMs worn at the waist.62 Approximately 7000 to 13 000 steps per day is expected among young healthy adults (20-50 years of age), 6000 to 8500 steps per day for healthy older adults, and 3500 to 5500 for individuals living with chronic illness.70 Among the included studies in our review, most adults living with HIV appeared to achieve the expected step count range for healthy adults and exceeded step counts of individuals living with chronic illness. Nevertheless, it is important to consider the potential episodic nature of disability that may influence the ability of adults to achieve targeted step counts depending on whether they may be experiencing a “good day” or “bad day” living with HIV.13

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.

Two studies in our scoping review compared WPAMs with self-reported measures of physical activity, and authors concluded that self-reported measures overestimated physical activity among adults living with HIV.32 , 63 Similar findings were reported in other chronic diseases whereby authors found that responses on the self-reported IPAQ and a 7-Day Physical Activity Recall Questionnaire overestimated physical activity compared with the WPAM among women diagnosed with breast cancer.73 In our review, WPAMs were used as a comparison or criterion measure with other self-reported measurement tools among adults living with HIV32 , 63; however, to our knowledge, the measurement properties of the WPAMs in the context of HIV infection are unknown.

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.

Distinct features of disability experienced by adults aging with HIV infection may influence the nature and extent of WPAM use and highlight the importance of our study characterizing WPAM use specifically in the context of HIV infection. Adults living with HIV can experience concurrent health conditions at an earlier age compared with the general population and experience clusters of multimorbidty (peripheral neuropathy, diabetes, chronic obstructive pulmonary disease associated with increased prevalence of smoking among this population, bone and joint disorders, mental health conditions), which further add complexity to the nature and extent of disability living with HIV.1 , 3 , 75 Types of disability associated with these conditions such as symptoms and impairments (eg, weakness, diminished sensation, shortness of breath) and difficulties with day-to-day activities (decreased mobility, physical activity) may be similar to those experienced by other chronic disease populations; however, the way in which disability is experienced by adults living with HIV can be episodic and unpredictable in nature, subsequently influencing WPAM use in this population.13 Intrinsic and extrinsic contextual factors that influence disability with HIV such as living strategies (positive outlook, lifestyle, substance use) and personal factors (multimorbidity, age) can influence behavior surrounding the uptake and sustained use of WPAMs among people with HIV as an intervention tool to enhance physical activity.14 For instance, WPAM use can depend on the desire of an individual to wear the device, his or her access to and comfort using health technology, as well as readiness to engage in physical activity.12 Future research may explore the similarities and differences in WPAM uptake and use among different chronic disease populations so that health providers can apply strategies for enhancing physical activity more broadly across chronic illness populations.

Despite WPAM use among other chronic conditions, the effect of physical activity (or inactivity) among adults living with HIV is still emerging, justifying our approach for conducting a scoping review. As an increasing number of adults age with HIV, the potentially episodic nature of HIV/AIDS in combination with stigma, social support, isolation, and increasing multimorbidity may influence the nature and extent of uptake and use of WPAMs among people living with HIV compared with other chronic illness populations.13 Readiness to engage in physical activity could be influenced by the uncertainty of HIV infection, as well as the episodes of disability that may vary from day to day, preventing physical activity engagement and the willingness to engage in physical activity.12 Hence, scoping review methodology enabled us to map the WPAM evidence with this unique target population at a critical time when physical activity is increasingly important for adults with HIV and health care providers to consider in order to promote healthy aging with HIV.

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Gaps in the Literature on WPAMs 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.

Next, the majority of included studies measured physical activity using WPAMs ranging from 48 hours64 to 1 year44 (Table 1, see Supplemental Digital Content 1, available at: http://links.lww.com/REHABONC/A14). The one study that measured physical activity for 1 year involved a small sample of participants wearing a WPAM intermittently throughout the year. Of the 25 included articles, 12 (48%) used a cross-sectional study design where physical activity was measured with the WPAM at one point in time. It remains unclear how much physical activity adults living with HIV are engaging in over the long term. Future research should consider use of a WPAM for a duration of at least 7 days, as CSEP recommends a total of 150 minutes of moderate to vigorous physical activity over a 7-day period.18 Furthermore, adults living with HIV can experience episodes of disability that can impact the amount of physical activity engagement on a day-to-day basis.13 Future research should consider using longitudinal study designs to report physical activity among adults living with HIV over time.

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.

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Limitations of this Scoping Review

Despite our adherence to the PRISMA-ScR guidelines,36 our scoping review is not without limitations. First, we may not have captured all the literature pertaining to WPAM use among adults living with HIV. The various terminologies for WPAMs such as “activity tracker,” “activity monitor,” and “wireless activity monitor” may have limited our initial search of the 6 databases in this scoping review. However, we consulted with an information specialist to develop our search strategy, which we revised a few times in order to capture the relevant literature to our review. Second, while we initially searched for all articles that used WPAMs with adults living with HIV, we refined our selection criteria to include articles that used WPAMs to measure physical activity in the context of HIV infection. Given our focus on physical activity in this review, we excluded 18 articles that used WPAMs to solely measure sleep among adults living with HIV. However, sleep disturbance and quality are a significant problem among adults living with HIV82–84 and the use of WPAMs to measure sleep should be explored. Third, our search strategy completed in September 2016 may exclude more recently published literature characterizing WPAM use among adults living with HIV. While a fulsome update of the review goes beyond the scope of this article, we ran an updated search in our original 6 databases from October 2016 to August 2018. Of the 766 citations yielded from the search, a preliminary review by the primary author (M.D.) suggested that 8 articles, 3 of which were abstracts of conference proceedings, used WPAMs in the context of HIV infection.85–92 Of the 5 articles and 3 abstracts, 7 reported on studies that measured physical activity among adults living with HIV using a WPAM,86–92 similar to the literature included in our review where physical activity was measured using WPAMs. In the remaining abstract, Mari and colleagues85 aimed to assess the validity of an actigraph among community-dwelling older adults living with HIV, which suggests new evidence may be addressing gaps identified in our review by assessing measurement properties of WPAMs in this target population. As WPAM literature in the context of HIV infection continues to emerge, future updates of this scoping review are warranted. Furthermore, a systematic review involving a critical appraisal of the literature will be important for assessing the effectiveness of WPAM use on physical activity and health for adults living with HIV.

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CONCLUSION

Evidence on the use of WPAMs in the context of HIV infection is increasingly prevalent in recent literature. The majority of evidence involving WPAMs among adults living with HIV involved the use of WPAMs (actigraphs, accelerometers, and pedometers) as a measurement tool to describe physical activity and to a lesser extent as an intervention to promote physical activity. Gaps in this emerging field include evidence examining the effectiveness of WPAMs as an intervention to enhance physical activity and evidence assessing measurement properties of WPAMs among adults living with HIV.

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ACKNOWLEDGMENTS

The authors thank Erica Lenton, Faculty Liaison and Instruction Librarian at the University of Toronto, for her help with the search strategy.

* References 41–43 , 45–48 , 52 , 54 , 55 , 60–62.
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References 32 , 42 , 45 , 48 , 50–54 , 56 , 60 , 63.
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* References 42 , 43 , 45 , 47 , 48 , 50–52 , 56 , 60.
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* References 32 , 48 , 50 , 54 , 55 , 57 , 58 , 60 , 61 63.
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References 31 , 41 , 43–45 , 48 , 50–53 , 55 , 56 , 58 , 61 , 63 , 65.
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* References 32 , 41 , 42 , 44 , 47 , 51 , 56 , 59–61 , 63.
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Keywords:

activity monitors; HIV; physical activity; rehabilitation

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