Health New Media Res > Volume 5(2); 2021 > Article
Chan, Cheung, Yue, Li, Mengoni, and Tam: Feasibility of a mHealth intervention to increase physical activity and health literacy among Chinese new retirees

Abstract

Released from the hectic work environment, many new retirees now have time to attend to their own health. This study tested an exploratory mHealth intervention with a design based on Social Cognitive Theory to promote active aging among the newly retired. A convenience sample of 14 community living healthy elderly aged 50 to 62 that retired from full-time jobs in the previous three years was recruited. Participants were given a Mi Smart Band 4 (similar to a Fitbit band) for self-monitoring of physical activities. They attended five health workshops delivered face to face by professionals in health technology, sport, and Chinese medicine. Data on physical activity was gathered from the smartphones that synchronized with Mi Smart Band 4. Focus group interviews were administered before and after the intervention. Results indicated that all participants achieved their steps goal during the program period. The sample on the whole overachieved their steps goal by 22 percent. Participants reported a significant increase in knowledge, skill, and behaviors related to physical exercise as well as Chinese medicine acupuncture points. Participants gained confidence in doing exercise. The health intervention was found feasible and effective in promoting physical exercise and enhancing self-efficacy among newly retired participants. Health organizations should grasp this time window to promote physical activity with the “young-old” cohort.

Introduction

As residents of a busy city, employees in Hong Kong work on average 42 hours a week. This average is significantly higher than that of most advanced countries such as the UK and the US, with the exception of Singapore (Legislative Council Secretariat, 2019). The transition to retirement provides an opportunity window to promote physical activity in later life (Barnett et al., 2012). According to official statistics, the proportion of the population aged 65 and above will reach 31 percent in 2036 (Census and Statistics Department, 2017). With the aging demographic trend in Hong Kong, the health of older adults has become an important public health issue. Aging actively can benefit individuals as well as provide savings for the government in treating various health issues later in life. Active aging is defined as “the process of optimizing opportunities for health, participation, and security in order to enhance the quality of life as people age” (World Health Organization, 2002). The active aging approach is endorsed by the United Nations and its principles of “independence, participation, dignity, care, and self-fulfillment” (World Health Organization, 2002).
Studies found that physical activity enhances empowerment through mastery of experience and perceptions of functional ability and self-efficacy (McAuley & Elavsky, 2006). A meta-analysis found that physical activity has a positive influence on self-efficacy, self-perception, and the overall well-being of older people (Netz et al., 2005). The World Health Organization recommends that adults between 18 and 65 should have at least 150 minutes of moderate intensity of physical activity each week to maintain good physical health. However, many older adults are sedentary and do not engage in physical activities. Only 2 percent and 14 percent of respondents aged 65 and above in Hong Kong performed vigorous physical activities and moderate physical activities respectively (Department of Health and Department of Community Medicine, 2005). Walking and practicing qigong or tai chi are two popular physical activities among Hong Kong adults aged 65 and above (Department of Health and Department of Community Medicine, 2005). Retirement involves changes in daily routines, social networks, and access to resources and has been associated with changes in physical activity (Jones et al., 2017). However, existing research on physical activity during the retirement transition has been mainly conducted in Western countries. Few papers reported physical activity among retirees in the Chinese context (Hui, 2004).
The Hong Kong government is keen to promote the use of technology to provide solutions to increase vitality and quality of life among its aging population (Hong Kong SAR Government, 2019). The concept of eHealth proposes that information and communication technologies can enhance health by providing support of healthcare, health surveillance, health education, and health research (Oh et al., 2005). The concept of mHealth is a sub-segment of eHealth that focuses on the adoption of mobile communication devices and wearable devices in health promotion (World Health Organization, 2011). Interventions using e- and mHealth have the potential to change health behaviors, including the promotion of physical activity and healthy eating (Krebs et al., 2010). Advances in sensing and mobile technology provide an efficient way to provide individual feedback on health conditions and tailor-made health interventions at the right time (Nahum-Shani et al., 2018). Wearables that monitor physical activity are now synchronized with machine learning algorithms to open up new approaches in personalizing physical activity interventions (Dijkhuis et al., 2018). Hong Kong is an ideal place to promote mHealth as ownership of smartphones is very high. In 2020, 98.2 percent of persons aged 45-64 had smartphones. The popularity of smartphones provides an opportunity to incorporate them into the design of mHealth intervention.
In this study, we report on a health intervention that aims at increasing physical activity and health management incorporating sports science, Chinese medicine practices, and the use of health technology. The program adopts the tenets of Bandura’s (1986) Social Cognitive Theory as its guiding principles. Key variables, including setting health goals, building knowledge on the benefits of physical activities and self-care from the Chinese medicine perspective, and developing self-efficacy, were incorporated into the health intervention to promote active aging. The program attempts to fulfill the vision of the World Health Organization as outlined in its global action plan for physical activity 2018-2030: “More active people for a healthier world” (World Health Organization, 2018). This article outlines the design and the features of a pilot health intervention and evaluates its effectiveness. It facilitates future intervention design to promote physical health among retirees on a larger scale. The study has a unique contribution to the literature because the health intervention incorporates the prevalent culture of Chinese medicine as well as the application of mobile technology in personal health management.

Literature Review

The Social Cognitive Theory

The Social Cognitive Theory (SCT) developed by Albert Bandura (1986) proposes that human agency and action plans are intentional. Their behaviors are affected by key variables including self-efficacy, outcome expectations, and goals. Self-efficacy is concerned with a person’s beliefs in his or her ability to perform an action to attain a desired outcome. They reflect on their ability to take certain actions through functional self-awareness. People will do things that give them desirable physical, social, or self-evaluative outcomes. To adopt a desired behavior, people first form a goal and then attempt to achieve the goal. There is a difference between short-term goals vs long-term goals. A long-term goal gives general direction while a short-term goal focuses on specific activities in the near future. In addition to cognitions of self-efficacy, outcome expectations, and goals, SCT also includes the socio-structural factors of facilitators and impediments.
Bandura (2004) specified how the SCT could be applied in the context of health promotion. He proposed that an individual’s decision to learn and adopt a particular health behavior depends on his or her knowledge of health risks, the benefits of different health practices, outcome expectations related to the health behavior, personal health goals and plans for achieving such goals, perceived facilitators, and perceived barriers to the change required (Bandura, 2004). Self-efficacy plays an important role in health promotion design as participants need to perceive that they have the power to stop performing a negative behavior (for example, staying sedentary), and instead perform a positive behavior (for example, engaging in physical exercise). Self-efficacy was found to be one of the most important determinants of personal decisions of physical activities (McAuley et al., 2005). Self-efficacy refers to the belief that a person is able to complete a particular task (Bandura, 1982). Bandura (1977) proposed that people developed judgments on efficacy through four sources, including enactive mastery experience, vicarious experience, verbal persuasion, and physiological arousal. Enactive mastery experience refers to the competence of a behavior or the perception of competency. Vicarious experience refers to the observation of a peer performing a task and developing a belief whether a person can perform the same task by comparing his or her competence with the peer’s competence. Verbal persuasion refers to the belief conveyed to the person that he or she is capable of completing the task. Physiological arousal refers to the experience of sensations from the body that leads to the emotional arousal about the belief of efficacy (Bandura, 1977). Among these four information sources, enactive mastery experience was found to correlate most highly with self-efficacy (Ashford et al., 2010).
Setting personal goals and monitoring the achievement of the goals can set the course for behavior change. Bandura (2004) encouraged the setting of less challenging goals within a shorter time frame as the goals would be viewed as attainable. Short-term success would also lead to the setting and achieving of longer-term goals.

Applying SCT in the promotion of physical activity among older people

Many studies apply SCT to promote physical activity among older persons. Studies found gender differences in perceived barriers to physical activities. In a focus group study among retired men, participants reported that not wanting to show bodily weakness, overdoing exercise because of the intention to compete, and worries about injuries hindered them from engaging in physical activities. They preferred to engage in meaningful tasks in their daily routine such as repairs and painting than working out in the gym. Environmental factors such as poor road surfaces, bad weather, or lack of resting places were perceived as barriers to physical activity. Over-caring family members also prevented them from physical activity (Bredland et al., 2018).
There is evidence that community-based interventions can be effective in promoting physical activity. A health promotion program implemented in disadvantaged communities in South Africa among primary school children, adults, and older adults found that factors contributing to the program's success included: scientifically sound program content, appropriate activities, program leadership, encouraging staff, and building up a social network. Fellowship among the exercising community was especially important for the senior group, with members showing concern and care for one another in physical activities as well as life-related challenges (Draper et al., 2009). A one-year intervention program with aerobic training and strength training conducted among institutionalized elders found improvements in body strength, aerobic endurance, body flexibility, and balance. The study concluded that regular exercise programs were able to contribute to preventing functional decline among elders (Lobo et al., 2011). The European Commission-funded Active Ageing Project designed a one-year exercise intervention among healthy people aged over 70 in England, France, and Italy. There was evidence that participants demonstrated a significant improvement in neuromuscular control and endurance. Participants reported that they experienced improvements in strength and functional ability and that the program prevented them from falling into an inactive and unfit state (Davis & Fox, 2007).
A systematic review was conducted to identify motivators for and barriers to physical activity among persons aged 50-64 and persons aged 65-70 to facilitate an age-specific health promotion strategy. Altogether 55 articles were reviewed. Results showed that environmental factors and lack of resources were the most frequently reported barriers for both age groups. Among persons aged 65-70, social influences, reinforcement, and assistance in managing change were the most identified motivators. Among persons aged 50-64, goal-setting, perceiving an activity as beneficial, and social influences were the most identified motivators (Spiteri et al., 2019).

Use of mHealth to promote physical activity

Mobile health (mHealth) is defined by the adoption of mobile devices such as mobile phones and tablets to improve health conditions (Agarwal et al., 2016). Technological development in sensing wearables paired with machine learning enabled mobile devices can provide tailor-made health interventions based on individual assessment (Dijkhuis et al., 2018). A meta-ethnography of 15 qualitative studies coverage populations with or without chronic health issues on mobile health and physical activity identified five themes. They were: (a) personal motivational factors and experience of using mobile health devices, (b) changes in thinking that facilitate physical activity, (c) user experience of mobile apps such as goal setting, gamification, and timely prompts, (d) personalization and tailored-made health solutions, and (e) technical issues in mobile health and their effect on user experience (Carter et al., 2018). A systematic review found that studies on the use of mHealth to increase physical activity in older people demonstrate short-term benefits for the maintenance and improvement of physical activity (Aslam et al., 2020).

Research objectives

In view of the lack of studies about the promotion of physical activities among recent retirees in Hong Kong, we proposed the current study. The research objectives are
• To measure new retirees’ perceptions of physical activities and physical health in general
• To examine new retirees’ perceived barriers and motivators of physical exercise
• To explore new retirees’ responses to a health intervention program that incorporates mHealth technology

Methods

This was an exploratory study to examine the perceptions of health management and responses to a health intervention program. A qualitative methodology was selected. A new active aging health intervention was designed and implemented. The study received approval from the Research Ethics Committee at a university in Hong Kong. Participants signed consent forms before data collection. Qualitative methods of pre- and post-program focus group discussions were used for program evaluation. Quantitative data on physical activities measured by daily step counts and heartbeat rates were collected through a health wearable as one of the indicators to evaluate the effectiveness of the health intervention.

Participants

Altogether 14 (9 females, 5 males) new retirees aged 50 to 62 who had retired in the past three years were recruited from a senior community center and our social network to participate in the study. All of them were community living and were working full-time in white-collar jobs before retirement. Four participants were known to the first author. As the study was conducted during the pandemic, it was difficult to recruit participants to attend face-to-face workshops. As a result, we recruited some participants from our social network. There was no control group in this study. Each participant was given a Mi Smart Band 4 (similar to a Fitbit) of value HK$200 (US$25) and briefed on how to monitor their physical activities by synchronizing the wearable with their smartphone app. They agreed to attend at least four out of five health workshops conducted face-to-face at a university.

The health intervention

The design of the group-based health intervention was informed by the Social Cognitive Theory. The health intervention consists of five health workshops and the adoption of wearables to monitor participants’ daily physical activities. These workshops were designed as a form of health communication as well as a venue for practicing physical exercises and health management. We implemented an interdisciplinary approach that combined knowledge and skills from sports science and Chinese medicine. The selection of topics attempted to address common health issues experienced by older adults. The intervention was considered as a total package. In measuring the effectiveness of the intervention, we did not isolate the effectiveness of individual components of the intervention. To enhance enactive mastery experience, the intervention provides opportunities for participants to practice specific skills with the help of the workshop conveners. The workshops were conducted face-to-face so that participants could observe how other people were practicing the skills. The enactive mastery experience and vicarious experience in the SCT were included in this way to enhance self-efficacy. We asked participants to set up a short-term goal of physical activity for the coming five weeks in terms of daily step count. The intervention incorporates a wearable that has been synchronized with the participant’s mobile phone to give feedback on daily step count, together with other data such as heart rate and calorie consumed in the physical activities.

Health workshops

Five health workshops were delivered by commercial marketers and health professionals. Each workshop lasted about 60 to 80 minutes and made use of audiovisual materials. The first health workshop introduced two commercial mobile applications. The first one, OK Care (https://caregiver.okcare.com.hk/en), is an e-commerce platform that allows patients and their family members to search for professional on-site healthcare services at residential homes, elderly care homes, or hospitals. The second mobile application, Jockey Club All Brilliant Carers Project (https://womencentre.org.hk/En/Services/carer/jcabc/), supports healthcare givers and builds social capital at the community level. It provides information about community resources in healthcare, training, and career planning for healthcare givers.
The second and the third workshops were about stretching and muscle strengthening exercises. Two scholars in sport science conducted the workshops. They introduced various types of exercises, including endurance exercises, strength exercises, balance exercises, and flexibility exercises. A resistance band was distributed and the participants followed the instructors in exercising. Instructors also walked around to check participants’ postures and answer their questions. The instructors’ exercise demonstration was video recorded using an iPhone and distributed to the participants through the WhatsApp group.
The fourth and the fifth workshops concerned Chinese medicine practices in maintaining an active brain and pain management. A registered Chinese medicine practitioner conducted the workshops. She introduced certain Chinese medicine concepts and herbal dietary practices in preventing dementia and managing pain and demonstrated how to stimulate body acupuncture points. She walked around pressing acupuncture points for participants, checking their acupuncture-point technique, and answering questions. Lecture notes were handed out after the workshops. Attendance was very high. Only one participant missed one workshop. The other participants attended all five workshops. Participants could communicate with one another during the workshop. However, most of the communication was between the participants and the workshop conveners according to our observation.
The workshop lasted for five consecutive weeks from April 19 to May 17, 2021. A debriefing session was held on July 5, 2021, seven weeks after the final health workshop. The activities of the health intervention are summarized in Table 1. A WhatsApp group was set up by the project’s student helper as the point of contact. The first author sent out a voice message a few days after each workshop to encourage participants to apply what they learned in the workshops. Participants could ask for help from the student research assistant about problems in using the wearable or synchronizing the wearable with their mobile phones.

Pre-and post-intervention focus group interviews

Participants attended a pre-program and post-program focus group session of about one hour. The first author served as the moderator of the sessions. The questions for the pre- and post-program focus group interviews are listed in the online Appendix 1. These questions are based on constructs in SCT and a previous study (Melillo et al., 2001). The fourteen participants were divided into two groups of seven randomly. The interviews were audio-taped and transcribed.

Debriefing

Participants were invited to attend a debriefing session seven weeks after the completion of the intervention. Only seven participants came. Participants were asked to fill in a short questionnaire to see if they had continued with the physical activities and acupuncture-point stimulation. Those who did not attend the debriefing were asked to fill in the questionnaire through Google Forms.

Data analysis of the focus group interviews

Two authors analyzed the transcripts of the focus group interviews. The first author applied Marshall and Rossman’s (1999) comparison analysis method to analyze the data by constantly comparing and contrasting statements. The first author read through the full transcript once and then read through it again. We paid attention to strong emotions, actors and actions, and motives (Belk et al., 2013). Codes were created from specific segments of the data. These codes merged to become themes. The data were then compared to the themes. Once a statement was coded under a certain theme, it was removed. The process of reading, coding, and refining the themes continued until the list of themes saturated. The data together with the identified themes were read through by another author to see if she agreed with the coding. Disagreements were discussed and resolved. Because of the small sample size, we did not analyze the results further by age or by sex.

Results

The effectiveness of the interdisciplinary health intervention was evaluated based on the information collected throughout the program period. Two measures were used: the physical activity data recorded in the wearables during the program, as well as the participants’ knowledge, attitudes, skills, and behaviors before and after the program collected through analysis of the focus group interviews.

Evidence from the wearables

Data from the wearables were downloaded from the connected smartphones for the program period. One wearable malfunctioned during the first week and some data were missing for the last few days because participants did not synchronize the data with their mobile phones. Among all data collected by the devices, only step count and heart rate were considered and analyzed. Missing data were replaced by an individual’s average weekly step count. Figure 1 shows the steps of goal distribution among the participants. Participants’ goals varied from 5,000 to 10,000 steps. A majority of the participants set up a goal of 8,000 steps. As participants had different step goals, we computed a new variable that represents the degree of achievement of his or her goal. For example, with a steps goal of 5,000 steps a day (or 35,000 steps a week) and an actual step count of 40,000 for the week, the achievement over the goal is 14.3 percent (5,000/35,000*100%). A negative achievement means that the person does not achieve the steps goal for that week.
Figure 2 shows the box plot by week for the sample. The box represents the values between the second and third quartile. The line inside the box represents the median value for the percentage of steps over the goal among all the participants for that week. The upper whisker represents the fourth quartile, and the lower whisker represents the first quartile. The dots on the sides of whiskers represent outliers that either had exceptional achievements in that week or did not reach their step goal by a wide margin. The median percentage of steps over the goal for all five weeks was above zero, indicating that all participants achieved their steps goals, with the exception of a few outliers. The average achievement over goals varied from 9 percent for week 5 to 30 percent for week 2, with a mean value of 22 percent. In other words, the sample overachieved the steps goal by 22 percent. A steep increase in the median percentage of achievement over the goal was observed for the first two weeks. This value increased from a median value of 20% in week 1 to a median value of 31% in week 2. After that point, the median value registered a slow decrease until the last week where we find a median value of 8%. The reasons for this decrease can have multiple explanations. Some of the participants forgot to save the data in the last week, and some showed lower motivation when reaching the end of the program. Regarding heart rates, we plotted the charts for each individual’s minimum, average, and maximum heart rate for the entire period. There was no significant change for all three heart rate readings over time using time-series analysis. We, therefore, concluded that there was no significant change in the heart rates for the overall sample.
Some participants reported that they were not that good at mobile health technology. However, they found the Mi-band easy to use and the synchronized data on their smartphone was comprehensive and informative. Most of the respondents showed trust in the data recorded by the wearables. One participant cast doubt about the heart rates recorded by the wearable as he found it higher than what he expected.

Evidence from the focus group interviews

The pre-program focus group interviews found that participants had a holistic view of health and well-being that cover the physical, mental, relational, and spiritual perspectives. The major barriers to physical activities included insufficient willpower, inability to identify the appropriate level of physical activities, knee/joint pain, and lack of motivation. Transcripts of the post-program focus group interviews generated six themes as follows:
Theme 1: setting goals of daily steps and monitoring with the wearable motivated me to develop an exercise routine
Setting goals for daily steps and monitoring step count with the wearable/mobile phone motivated participants to engage in physical exercise and develop an exercise routine. Most of these participants reported that they were not active physically before joining the program. Setting the step count goal and attempting to fulfill it was a challenge to them. Nevertheless, participants demonstrated a strong motivation to meet the targeted step counts. All participants could use the wearable and the mobile phone app for self-monitoring. They were keen to meet the target throughout the program period. If they found they had fallen short of the target at night, they would make an effort to fulfill their goal. Some participants said that they started walking around the neighborhood in order to meet their target. One participant said that at first it was difficult to meet the target. With persistence, it became much easier. Two participants paid attention to heart rates. When the heart rate was too high, they would slow down. Here is an illustrative quote:
“I set the goal of 10,000 steps a day. I can achieve it most of the time. Before joining the program, I did not pay attention to how many steps I walked a day. Perhaps it was around 3,000 to 5,000. With the goal in mind, I started to take a longer walk or even go on a hiking trail. I found my legs stronger and my steps easier. I also checked and found that my heart rate was rather steady during the walk. I felt that meeting the goal ensured my health.” (female)
Theme 2: Participants identified changes in knowledge, attitudes, skills, and behaviors after joining the intervention program
Nearly all participants reported changes in knowledge, attitudes, skills, and behaviors after joining the program. First, participants reported that they gained knowledge about exercising in general, and resistance training in particular. Most of the participants had never used a resistance band before. They commented that resistance training would help them to build muscle. Female participants appreciated the use of the resistance band as an alternative to weights for muscle building. They expressed their dislike of weight training. Two participants said that they came to know more about their bodies. They learned when they practiced a specific posture that some muscles were seldom trained. Some participants said they learned about the importance of various types of exercise. Some gained more knowledge of acupuncture points and nutritional aspects of Chinese medicine. However, they found there was insufficient time allocated to the stimulation of acupuncture points. Other knowledge gained in the program included not over-exercising and the importance of warming up and cooling down when exercising. Here are two illustrative quotes:
“I found the two stretching exercise workshop impressive. First, I have never used the resistance band before. Second, I now pay more attention to muscle training exercise. Third, the instructor told us that we need all three types of exercise including stretching, muscle building, and aerobic exercise. The instructor said we needed to maintain higher level of heart rates for at least 15 minutes for aerobic exercise.” (male)
“I think the experience of practicing the exercise and the pressing of the acupuncture points were insightful to me. The resistance band was easier to learn how to use. I gained the knowledge that certain puncture points were beneficial to pain management and brain activation. However, without individual supervision, it was hard to apply the right amount of pressure as recommended by the instructor on the puncture points to achieve the desirable effects.” (female)
Theme 3: Participants gained confidence through the intervention program
Participants reported that they worried that exercising the wrong way would result in hurting the body. One participant used the metaphor of a “worn down machine” to describe his body as he did not have time to attend to its needs in the past. Several participants specifically mentioned that the nature of office work had made their bodies inflexible. They were motivated to increase their physical activities with their change in life routine and the availability of time to do so. They reported that the program gave them confidence to exercise as they were able to learn skills, such as correct posture for stretching and exercises to relieve pain. They complimented the instructors in explaining clearly the correct way to exercise and the theory behind it. Participants gained confidence in physical exercise mainly because of the expertise of the instructors. Participants perceived workshop conveners as credible sources who provided evidence-based approaches to exercise and the practice of Chinese medicine. Participants found them authoritative as the workshop conveners could explain the theory behind certain physical movements and answer their questions about exercising and Chinese medicine satisfactorily. Here is an illustrative quote:
“I know that physical exercise is good for health. However, I am not sure if I am practicing it correctly. The instructors are all experts of their field. I can learn the correct postures in physical exercise here. This program helps to build up my knowledge in physical exercise. It enhances my confidence to practice.” (female)
Theme 4: Most of the participants reported improvement in the physical health through the intervention
A majority of participants reported significant improvement in aspects of their physical condition, including pain relief, a more relaxed shoulder, a more relaxed knee joint, a more stable heart rate, feeling more energetic, less shortage of breath, better sleep quality, and a more agile body. Two participants reported that the program stimulated their interest in exercising. Two participants commented that they enjoyed exercise with others and found they were less likely to give up. Here is an illustrative quote:
“During these five weeks, I walked every day in the morning and in the evening. I found that the exercise improved my blood circulation. From the Chinese medicine perspective, I have more blood circulated to the brain. I felt that my whole body was more awake during the day. I had a clearer mind when I completed a task.” (female)
Because of the knowledge and confidence gained as well as the improvement in physical health, participants, in general, considered the health program successful. One participant complimented the program well designed and informative. One participant said that the government would save a lot of public money if all new retirees acquired the knowledge and skills that they, the participants, had gained.
Theme 5: Group exercise was better than exercising on my own
Participants reported that they enjoyed the face-to-face workshops because of the instant feedback and clarifications from the instructors. Even though there were many free online videos showing people how to exercise, participants found less motivation to follow them. They found it boring to practice it alone at home. They considered the group environment engaging. They were more able to concentrate when they practiced with others. Here is an illustrative quote:
“I think coming here to learn from the instructor is clearer. Just like the other participant said, we can raise questions and get responses right away. I can imitate the instructor’s action. I feel more focused when I practice with others. If I work out at home, I feel tired, bored and I give up. When we exercise together, I become more focused.” (male)
Theme 6: Participants were eager to know more about health management informed by Chinese medicine
Participants perceived that the scope of Chinese medicine was broad and not well covered in two workshops. They requested more health workshops on Chinese medicine herbal dietary approaches to health maintenance. Three participants wanted to know more about Chinese medicine. They wanted to learn how Chinese medicine addresses specific health issues such as high blood pressure. One participant wanted to learn about “pseudoscience” in health management. He said there were many myths and much dubious advice about Chinese medicine on the internet, which he hoped the University professors could clarify with research evidence. For example, the recommendation that older persons should carry the “an gong niu huang wan” (安宮牛黃丸) pill and take it immediately when experiencing stroke. He commented that this medicine was very expensive at almost US$130 per pill and whether it could serve the purpose was unknown. Here is an illustrative quote:
“I want to learn more about Chinese medicine. I used to put more trust in western medicine and therefore I knew very little about Chinese medicine. In these two workshops, I knew more about how to improve my physical health. For example, I learned which puncture points to press if I did not sleep well. There were things about Chinese medicine that I did not understand in the workshops. Therefore, I hope the University can organize more workshops on Chinese medicine.” (female)
Besides these six themes, the study found that only a few participants mention the mobile health apps introduced in the first workshop in the post-program focus group session. None of them made a service transaction or joined the activities announced in the apps. However, they considered the health apps useful resources.
Participants offered many suggestions for improvements if the program were to be re-run. Several participants wanted to have individual health assessments and advice on daily step count goals. Some wanted to get more advice on Chinese medicine informed dietary and nutrition.
Other evaluations
Altogether 10 out of the 14 participants responded to a short questionnaire seven weeks after the program. All of them kept the same steps goals. They reported that they continued to use the wearables and achieved their goals most days. Five participants said that they had increased their physical activities, and four said that their exercise patterns had become more persistent. One participant manipulated acupuncture points habitually, six did so occasionally, and three not at all. Besides step count, eight participants paid attention to heart rate data, and four paid attention to sleep data. One commented that he or she was motivated to join other online exercise classes.

Discussion

This interdisciplinary group-based mHealth intervention demonstrates an acceptable and feasible way to promote physical activities and self-health management, at least in Hong Kong. The evidence that all participants adhered to and even exceeded the set steps goals is encouraging. The self-reported post-program compliance among some participants indicates that change can be sustainable. It demonstrates that goal setting and self-monitoring of progress are strong motivators in encouraging physical activities. Participants’ setting of the short-term goal and its corresponding positive health outcome expectation led to their action to fulfill the goal. This chain of action was consistent with the SCT. The findings confirm that goal setting is an influential motivator for physical activities among persons aged 50-64. Participants reported that they often used wearables and mobile phones to check their heart rate to avoid over-exercising. With the integration of the mobile phone into people’s daily lives, using it for health self-management is convenient and highly desirable. The result is consistent with a previous study on the adoption of a smartwatch that health information motivation is a positive predictor of the intention to use a smartwatch (Choe, 2018). Most of the participants showed trust in the wearable device and the data capture apps. Unlike a previous study on women who use period-tracking mobile applications (Rubinsky et al., 2018), the current study did not find tension between self-monitoring of health and the opportunity for autonomy. This opens up a new market for user-friendly devices that link with mobile applications for the new-old population segment.
Evidence from the focus group discussion shows that some participants experienced improvements in physical health. The insignificant change in heart rates may be because the period for the health intervention was rather short. An insightful finding is that participants’ self-efficacy was improved in two ways. First, participants’ self-efficacy in using health technology was enhanced. Second, participants’ self-efficacy in performing physical activities and Chinese medicine self-care practices were also enhanced. Participants reported that practicing the exercises and modeling after the instructors’ movements were helpful. Practicing with others in the same physical space made them more focused and willing to pay attention. Worrying about hurting the body by exercising the wrong way was the major barrier to engaging in physical activities among the sample. The perception that they were getting professional advice from academia and the opportunity for feedback from face-to-face interaction with the instructors enhanced their confidence in exercising, in practicing Chinese medicine, and in stimulating the acupuncture points. The findings are in line with the SCT in that self-efficacy is an influencer in the adoption of health behavior. It illustrates that enactive mastery experience and vicarious experience were key sources of efficacy information (Bandura, 1977).
While there are many free exercise videos available online, participants reported that they were not motivated to use these as they were lacking in the human touch. This supports the literature in that the establishment of a supportive social environment is needed to adopt a health initiative (Netz et al., 2005). The significant change in knowledge, attitudes, and behavior brought by the health intervention is encouraging. Participants suggested other topics such as mental health and Chinese medicine-informed dietary approaches for future health programs. Participants were aware of the dramatic changes in the transition to retirement and the need for more specific advice tailored to their needs. The program echoes the World Health Organization’s proposal of a population-based approach for culturally appropriate interventions.

Limitations

The current study has a few limitations. First, the sample was small and those who signed up for the health intervention were already motivated to do something to improve their own health. Second, as participants were aware that their data would be used for scientific research they may have tried harder than usual to meet the expectations of the researchers. As four participants were friends of the first author, this limitation could be more profound. Lastly, the intervention adopted a communication channel in the form of a WhatsApp group. It cultivated a strong group allegiance that enhanced adherence. Further studies with a larger group or with other older groups are needed to verify the results of this study. A quantitative survey can be conducted to triangulate the findings.

Conclusion

A community-based mHealth intervention with a Chinese medicine component to encourage active aging was designed and implemented. The participants showed improved knowledge and attitudes toward physical exercise. Nearly all of them achieved their target level of step counts and their performances sustained seven weeks after the program had ended. Participants’ self-efficacy in using health technology and engagement in physical activities were enhanced. The health intervention has the potential to inform the design of future interventions to promote physical exercise and self-management of health among older adults.

Acknowledgements

Ms. Wing Yan Kwok and Ms. Qiqi Li served as student research assistant and senior research assistant for the project respectively.

Notes

Disclosure

This is to acknowledge there is no financial interest or benefit that has arisen from the direct application of the research.

Funding details

This work was supported by a grant funded by Research Development Fund: Research Network on Healthy Ageing, Hong Kong Baptist University. Project title: A community action program in empowering newly retired persons to be health ambassadors [RNHA202104].

Figure 1.
Distribution of steps goal set by the participants
hnmr-2020-5-2-278f1.jpg
Figure 2.
Box plot of the achievements (in steps over goal) of the participants by week
hnmr-2020-5-2-278f2.jpg
Table 1.
Activities of the health intervention
Date Activities Speakers
April 12, 2021 Distribution of the wearable and setting up of the data sharing mechanism Student helper
Pre-intervention focus group interview Principal investigator
April 19, 2021 Health workshop 1: Introducing two health apps Two commercial mobile app developers
April 26, 2021 Health workshop 2: Stretching exercise 1 and the introduction of the resistance band Two PhD scholars in sports and physical education
May 3, 2021 Health workshop 3: Physical exercise to retain muscle strength Two PhD scholars in sports and physical education
May 10, 2021 Health workshop 4: Maintaining an active brain the Chinese medicine way A registered Chinese medicine practitioner
May 19, 2021 Health workshop 5: Pain management the Chinese medicine way A registered Chinese medicine practitioner;
Post-intervention focus group interviews Principal investigator of the project
Resetting the wearable to the manufacture state Student helper
July 5, 2021 Debriefing session: collecting post-intervention health practices Principal investigator

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Appendices

Appendix

Pre- and post-intervention focus group questions in English and Chinese

Pre-intervention focus group questions
1. How do you feel about your physical condition after retiring?
2. What is “physical health” to you?
3. People think that exercise is good for physical health. What kind(s) of exercise do you think is fit for new retirees? What kind(s) of exercise is not fit for new retirees?
4. What makes you think you should exercise?
5. What makes you think you should not exercise?
6. How do you feel during exercise or after doing exercise?
7. What indicators do you use to measure your physical health?
8. Did you use any health, exercise, or sports mobile app? If so, what kind(s) of app did you use?
9. If we are going to design a mobile app to encourage you to exercise, what kind(s) of function do you think is necessary?
Post-intervention focus group questions
1. Please share your experience of using the Mi Band.
2. Have you become more knowledgeable about your physical status after participating in the program?
3. The program consisted of workshops and using a wearable. Do you think they are beneficial for your health? If so, would you please tell us in what specific way that you benefit?
4. What are your expectations of the program? Did the program meet your expectations?
5. Which of the health workshops do you think was impressive?
6. The workshops introduced some healthy behaviors. What are the barriers to putting them into practice?
7. The workshops introduced some healthy behaviors. What are the facilitators that motivate you to practice?
8. What other topics can be added if we are hosting similar health-related workshops?
9. Have you changed your perception about health after you participated in the program?
10. Have you changed your physical activity after you participated in the program?
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