Admission to hospital for treatment of many health conditions is associated with impaired mobility and a period of bed rest that can lead to reduced physical activity. These low levels of physical activity observed during hospital admission predispose patients to the secondary consequences of inactivity, particularly deconditioning and increased risk of adverse events and mortality. Behaviour change interventions (eg, goal setting, self-monitoring, providing feedback on performance, goal review) are used to increase physical activity. Previous reviews have evaluated the impact of behaviour change interventions on physical activity levels in community or outpatient settings and in people with chronic conditions. This systematic review aimed to estimate the effects of behaviour change interventions compared to usual care on physical activity levels in the inpatient setting. A secondary objective was to explore the association between specific behaviour change techniques and increased physical activity in hospitalised patients.
Guided by a prospectively registered protocol, sensitive searches in 6 databases (including Medline and PEDro) and citation tracking were performed to identify randomised controlled trials evaluating behaviour change interventions applied in inpatient settings. The patients were people of any age who were hospitalised for any physical or mental health condition, including acute hospital care, inpatient rehabilitation, and inpatient mental health care. Behaviour change interventions included those described in the 40-item taxonomy of behaviour change techniques. The comparator was usual care (ie, hospitalised patients who did not receive the behaviour change interventions). The primary outcome was any objective measure of physical activity assessed during the admission (eg, daily steps, activity counts). Two reviewers independently selected trials for inclusion, extracted data, classified the behaviour change techniques used in the intervention, and evaluated trial quality (Cochrane risk of bias 2 tool). Any disagreements were resolved by discussion or arbitration by a third reviewer. Certainty of evidence was evaluated using the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach. Meta-analysis was used to pool the trials, with the between-group differences reported as standardised mean differences or weighted mean differences and their 95% confidence intervals (CI). One subgroup analysis was planned for setting: acute hospital care vs. inpatient rehabilitation. Meta-regression was used to explore associations between the behaviour change techniques used in more than three trials and the treatment effects.
20 trials (2,568 participants) were included in the review. The average age of participants was 67 years and 56% were women. The most common diagnosis was stroke (4 trials). 14 trials were conducted in acute hospital care (10 surgical, 3 medical, 1 mixed surgical/medical) and 6 in inpatient rehabilitation. 23 behaviour change techniques were used across the included trials, with most trials using more than one technique. The techniques used by more than three trials were goal setting (10 trials), feedback on performance (8 trials), reviewing behavioural goals (4 trials) and instructing on how to perform a behaviour (4 trials). The interventions were commonly applied by physiotherapists in at least daily, face-to-face sessions with individual patients.
Different outcome measures were used to quantify physical activity, so the standardised mean difference was calculated. On average, participants receiving behaviour change interventions had higher physical activity than those receiving usual care (standardised mean difference 0.34; 95% CI 0.14 to 0.55; 18 trials; 1,730 participants; moderate certainty). This translates to a mean of 429 more steps/day (95% CI 177 to 695), the outcome measure used in the review when physical activity was measured with more than one method, for behaviour change intervention compared to usual care. [Note: the weighted average baseline standard deviation across all groups from the three included trials reporting physical activity in steps/day (https://dx.doi.org/10.1177/0269215518755841, https://dx.doi.org/10.1016/j.jphys.2019.08.006, https://dx.doi.org/10.1177/0269215519901153) and guidance from the Cochrane Handbook v6.1 were used to calculate this estimate].
The subgroup analysis suggests that larger effects were observed in acute hospital care (standardised mean difference 0.46; 95% CI 0.16 to 0.75; 12 trials; 1,039 participants) than in inpatient rehabilitation (standardised mean difference 0.16; 95% CI -0.08 to 0.40; 6 trials; 691 participants). Meta-regression found that the behaviour change technique of goal setting (standardised mean difference 0.29; 95% CI 0.05 to 0.53; 10 trials) was independently associated with increasing physical activity compared to usual care, but feedback (standardised mean difference 0.25; 95% CI -0.02 to 0.53; 8 trials), reviewing of behavioural goals (standardised mean difference 0.24; 95% CI -0.12 to 0.61; 4 trials), and providing instruction on how to perform a behaviour (standardised mean difference 0.24; 95% CI -0.12 to 0.59; 4 trials) were not.
Targeted behaviour change interventions were associated with increases in physical activity in hospitalised patients compared to usual care, with the behaviour change technique of goal setting being particularly important.
Taylor NF, et al. Behaviour change interventions to increase physical activity in hospitalised patients: a systematic review, meta-analysis and meta-regression. Age Ageing 2021 Jul 24:Epub ahead of print