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(7–10). Activity monitors can generate various para-
meters that provide information on PA, e.g. number
of steps, walking distance, or energy expenditure. It is
possible that providing this objective insight motivates
patients to increase their levels of PA (11). In addi-
tion, objective insight is not only useful for increasing
levels of PA, but it can help patients to regulate their
behaviour, e.g. by improving the distribution of activity
during the day with regard to the individual’s capacity.
Van Achterberg et al. (12) support this by stating that
self-monitoring contributes to successful behaviour
change. Thus, wearable activity monitors facilitate
self-management of health behaviour of patients and
therefore have the potential to improve patients’ fun-
ctional independence (10).
Literature reviews have shown that interventions
that include objective monitoring of PA are moderately
effective in healthy subjects and relatively inactive po-
pulations (13–16). However, the methodology of these
studies differs considerably. First, the types of popu-
lations included varies between reviews and between
studies included in reviews. The reviews concentrated,
for example, on children, adults (with and without a
diagnosis of a specific disease), or, in contrast, on a
specific population, such as obese adults with diabetes
(13–16). Therefore, these results cannot be transfer-
red directly to healthcare and rehabilitation. Hence, a
review that includes patient populations only is needed
to support statements of the possible effectiveness of
such self-management tools for the promotion of PA in
healthcare interventions (16). Another characteristic of
studies included in the reviews is that PA monitoring
was applied in relatively broadly defined health inter-
ventions, which targeted more aspects than PA, e.g.
nutrition. Unlike previous reviews, the current review
focusses on interventions in which the main goal was
promoting PA using wearable monitors. Finally, another
methodological issue highlighted by previous reviews
is the diversity in intervention strategies applied, which
makes comparison complex. In healthcare, in particular,
interventions promoting PA using wearable technology
are often combined with components of behavioural
change techniques (BCT) targeting PA levels, e.g. beha-
vioural counselling with goal-setting, education on the
advantages of being active, or identification of barriers
to PA (13, 17). These BCT components are often already
present in usual care programmes, which makes it even
more complex to evaluate objective feedback on PA
interventions in healthcare (13). Another example of va-
rying strategies is the method of feedback; interventions
differ in showing real-life feedback on a display, text
messages or in real-life consultations with therapists.
In addition, feedback is provided by multiple types of
wearable devices. Both feedback strategy and the pre-
www.medicaljournals.se/jrm
sence and type of BCT components may influence the
amount of behaviour change. A more detailed insight
into the presence of intervention strategies applied in
healthcare, together with objective activity monitoring,
such as feedback type and BCT components, is needed.
A literature review on the effectiveness of objective
feedback on PA in a PA promotion intervention that
focuses solely on patient populations would provide
valuable knowledge to enable its effective application
in healthcare. In addition, the presence of different
intervention strategies should be considered.
The aim of this study was to determine the effective-
ness of interventions promoting PA in healthcare that
use objective feedback about PA via wearable activity
monitors. Interventions that use objective feedback
about PA are compared either with control groups recei-
ving usual care or with an intervention without objec-
tive feedback. Although providing objective feedback
can be beneficial for either increasing or regulating PA,
this study focuses on the effect of increasing PA levels
and includes only those interventions in which the main
goal is to promote PA. Furthermore, the influence of
intervention strategies is explored by describing the
type of feedback and the presence of BCT.
METHODS
Data sources and searches
PubMed, Embase, MEDLINE and the Cochrane Library were
searched to identify randomized controlled trials (RCTs) up to
August 2017. The key words included in the literature search
were: physical activity, feedback and objective device and
their synonyms (see Appendix 1 for complete PubMed search
strategy). The study design RCT was added to the literature
search. Reference lists from the included articles were screened
to check and extend the search.
Study selection
Inclusion criteria for RCTs were studies published after 2007 in
which: (i) the mean age of subjects was >21 years; (ii) subjects
were (former) patients treated within the healthcare system; (iii)
PA was used as an outcome measure for the intervention; (iv) PA
was measured objectively with a wearable monitor; (v) feedback
on objectively measured PA was part of the intervention; (vi) the
main goal of the intervention was promoting PA; (vii) concurrent
strategies, such as behavioural change techniques, were related
primarily to PA; (viii) intervention groups received feedback on
objectively measured PA as part of the intervention, whereas
the control group received an intervention with no feedback on
objectively measured PA or usual care.
Exclusion criteria were: (i) the full text was not available
in English; (ii) the document was a conference or oral session
abstract, research letter or commentarial note; (iii) interventions
that combined disciplines, such as nutrition and psychology,
which were not primarily related to PA.
Two reviewers (HB and MB) applied the inclusion criteria
to the titles and abstracts independently to select potentially
relevant studies from the search results. When disagreements