A Social Media Intervention for Exercise Motivation and Cardiac Rehabilitation Adherence

Research is still needed to determine the effectiveness of social networking interventions
used to promote health. Few randomized controlled trials have examined the use of social
networking as a tool for exercise adherence or health promotion. Further, there is no
research that addresses the use of social media and particularly Facebook, as a tool to
affect autonomous motivation in cardiac rehabilitation.

The purpose of the current randomized pilot trial is to determine the feasibility of using a
Facebook intervention, providing education, peer support and provider support, to affect
change in motivation and self-determination for exercise, and adherence to cardiac
rehabilitation in patients with CHD during a 12-week Phase II cardiac rehabilitation program.
It is hypothesized that:

1. Scores for motivation for exercise overall will increase for patients exposed to a
Facebook intervention and across individual motivational subtypes (regulations) relative
to a comparison group who receive educational handouts and emails.

2. Percentage of cardiac rehabilitation sessions attended will be higher relative to a
comparison group who receive educational handouts and emails.

3. Engagement in the private Facebook group (number of "hits" and "likes") will predict
number of cardiac rehabilitation sessions attended and the change in motivation. The
feasibility of a larger trial will be based on sample size and participants' engagement
in the Facebook group.

Methodology Design This is a prospective, randomized controlled pilot trial to evaluate the
feasibility of using a social media intervention to affect change in motivation for exercise
and adherence to cardiac rehabilitation sessions.

Setting and Sample:

The setting for this study will be in the outpatient cardiac rehabilitation at the main
campus of a large tertiary care center in Northeast Ohio, several satellite facilities in the
region, and in patients' homes or other locations where home computers might be accessed.
This cardiac rehabilitation program provides ECG-monitored, supervised exercise, dietary
guidance, smoking cessation, behavioral counseling and stress reduction. All patients receive
an individualized exercise prescription based on functional capacity at intake. Most
patients, depending on insurance coverage, will be able to attend up to 3 sessions per week
for a total of 36 sessions. In addition, patients are given guidance for unsupervised
exercise at home.

All patients who are current and regular Facebook users, have qualified for cardiac
rehabilitation (diagnosed with CHD), and are entering cardiac rehabilitation at the main
campus or one of the regional satellite hospitals of this tertiary care center, will qualify
to participate in the study prior to beginning Phase II cardiac rehabilitation. Current
Facebook users were chosen as it is important that participants are skilled at using the
internet and familiar with social media. Regular use will be defined as logging onto Facebook
at least 2 times in the last month. Inclusion criteria will include both men and women 18
years of age or older who speak English and live within 100 miles of the main campus of this
tertiary care center. Participants must be able to read and understand English in order to
complete the questionnaires: the Psychological Need Satisfaction in Exercise Scale (PNSE)
[37] and the Behavioral Regulation in Exercise Questionnaire-3 (BREQ-3). There will be no
exclusion based on secondary diagnosis; however, participants must be able to exercise well
enough to qualify to take part in cardiac rehabilitation.

Measures:

The primary hypothesis, change in motivation for exercise, will be measured at baseline and
post-intervention using the BREQ-3. The BREQ-3 is a 24 question validated instrument that
measures forms of intrinsic and extrinsic regulation of exercise behavior [34] and is based
on self-determination theory. Psychometrics were first completed for the BREQ-2 by Markland
and Tobin [38]. Cronbach's alpha reliabilities were as follows: amotivation = 0.83, external
regulation = 0.79, introjected regulation = 0.80, identified regulation = 0.73, and intrinsic
regulation = 0.86. The BREQ-3 includes 5 additional questions in addition to those on the
BREQ-2 and has a new subscale for integrated regulation [33]. The subscales (regulations) of
the BREQ-3 are used to calculate a relative autonomy index (RAI) [39]. Each question is
answered on a 5 point Likert scale (0-4) and represents one of the regulations. The
regulations are weighted then summed to give a single score. The resulting score or index
gives an indication of the individual respondent's self-determination for exercise.

The RAI will place individual motivational subtypes or behavioral regulations on the
self-determination continuum from amotivated (lacking intention to exercise) to intrinsically
motivated (self-determined or autonomously motivated).

The PNSE will be used to assess need satisfaction with exercise. This scale was designed to
assess the perception of psychological need satisfaction associated with self-determined
motivation for exercise and consists of 18 items on a 6 point Likert scale, with 3 subscales
measuring perceived competence, autonomy, and relatedness. The scale showed high internal
consistency (Cronbach >0.90) [37].

The secondary hypothesis, the percentage of cardiac rehabilitation sessions attended, will be
measured at the time of cardiac rehabilitation completion or dropout. It will calculated by
dividing the number of sessions attended in a 3 month period of time by the total number of
sessions allowed by insurance, and multiplying by 100.

The tertiary hypothesis, Facebook engagement, will be assessed by measuring the number of
"likes" by individuals on the private Facebook group. "Likes" (the number of times a
participant clicks "like" on any of the Facebook posts) will be counted and, along with
"hits" will be used to examine the association between engagement in the social media
intervention (Facebook), and cardiac rehabilitation adherence and change in motivation. A
post-intervention questionnaire will be given to determine number of "hits". The participants
will be asked to circle the number of times they accessed the private Facebook group per
week: 0, 1-5, 6-10, 11-15 or > 15 times. The questionnaire will also be used to collect
qualitative data on participants' perceptions of the intervention, including whether they
felt supported in their care, more in touch with providers, whether or not they chatted with
other Facebook members and if the Facebook group affected their exercise behaviors. The
questionnaire will use a Likert scale (1, "not at all"-5, "quite a bit") for all questions in
addition to a section for comments. Participants may also grant permission for the evaluation
of comments made on the private Facebook group, allowing the researchers to explore themes
for qualitative analysis. Examination of comments will allow for a better understanding of
the effectiveness of individual posts and the satisfaction of needs that may lead to
self-determined motivation.

Patient characteristics will be collected and will include key demographic variables (age,
gender, race, employment, distance to cardiac rehabilitation, socioeconomic status),
engagement (number of "hits" and "likes"), and key clinical variables (functional capacity as
measured in METS,cardiac rehabilitation indication, hypertension, diabetes, hyperlipidemia
and waist circumference), which will be obtained from the electronic medical record.

Data Collection Procedures:

Volunteers will be recruited from the main campus or regional satellite hospitals of this
tertiary care center during their inpatient stay, at the intake visit for cardiac
rehabilitation at the main campus and satellite facilities in the region, or via phone call
after discharge and up to the first cardiac rehabilitation session. Volunteers will be
screened for Facebook use and interest in the study, then an email link will be sent which
will include an information sheet. The information sheet states that continuing with the
questionnaire that follows will imply consent. The information sheet will address the fact
that Facebook is a public forum and names and comments are seen by other participants and the
research team. The Facebook group will be private in the sense that those not in the group
will not be able to see the content. Participants will be given a baseline BREQ-3
questionnaire and PNSE scale at the time of consent. Participants will then be randomized to
Facebook versus comparison groups using blocked randomization.

Intervention. The Facebook intervention will include peer support, education, provider
support and text message prompts when new posts are added. These interventions are designed
to minimize pressure, offer choices, and allow for peer interaction, positive feedback,
guidance and direction, in order to provide support for competence, autonomy and relatedness.
Competence will primarily be supported with use of educational posts in the Facebook group.
Autonomy support will come from the provider posts. Finally, relatedness will be supported by
peer interaction and engagement in the Facebook group.

1. Educational posts will cover 12 topics that will encourage participants to practice
preventive heart care while offering a variety of suggestions and encouragement for
making personal healthcare choices. The educational portion of the intervention is
designed to offer clear information and structure, thus supporting competence which may
help to enhance intrinsic motivation. These 12 educational topics will be standardized
such that they will be posted on the Facebook group, one each week and then the same
ones will be re-posted again every 12 weeks. The posts may be in the form of text, video
and/or pictures and will include materials from the hospital's health library and other
fact sheets and videos produced by the hospital, the American Heart Association and the
Center for Disease Control.

2. Provider posts will include topics such as motivational quotes, encouragement, reminders
to exercise independently, and reminders to contact providers with questions. These
postings are designed to promote a sense of choice and help participants feel that
providers see them as having a unique frame of reference thus being autonomy-supportive.
Providers will be nurses on the research team, exercise physiologists and nurse
practitioners and physicians who may or may not choose to reveal personal identities.
All Facebook participants will see the same content. Provider support will also include
links to provider health chats, in which patients can chat online with providers at set
dates and times.

3. Peer interaction on Facebook will be as frequently as the participant freely chooses to
do so and will be monitored daily by the research team for appropriateness of content.
Engagement in Facebook is designed to offer an opportunity for social inclusion and a
sense of involvement, allowing for relatedness.

The comparison group will receive the same educational and provider support materials as the
Facebook group but will receive it in the form of a handout, or via email in the event the
patient cannot be contacted or misses cardiac rehabilitation on a particular week. Both
groups will have the opportunity for weekly education classes and typical peer interactions,
which will involve up to 3 hours of group cardiac rehabilitation per week.

Upon cardiac rehabilitation completion or dropout, post-data will be collected. It is
anticipated that this pilot will take up to one year and will be completed when 30
participants for each group have been obtained.

Data Analysis Statistical Methods. This is a feasibility study and the sample size obtained
will determine if the study is appropriately powered to detect the desired effect size.
Patient characteristics will be summarized by group using frequencies and percentages for
categorical factors, and means and standard deviations for continuous measures. In order to
examine the primary outcome, differences in change in motivation between groups, overall
motivation using the RAI from the BREQ-3 will be evaluated using analysis of covariance
(ANCOVA) models. Mean differences with 95% confidence intervals for group differences will be
presented. Multivariate analysis of variance models will be used to evaluate differences in
the change across individual motivation subtypes (regulations), using the BREQ-3, between
groups overall. If significant, separate ANCOVA models for each subtype will be fit. Similar
ANCOVA models will be used to compare changes in needs satisfaction scores, overall and
separately among the three subscales, between groups. Two-sample t-tests will be used to
compare number of sessions completed. As a secondary analysis, the relationships between
patient characteristics, "hits" and "likes", and the outcome variables RAI change, number of
sessions, and needs satisfaction change will be examined using t-tests and Pearson
correlations. The correlation between changes in RAI and needs satisfaction will also be
evaluated. Analyses will be performed using SAS software (version 9.4; Cary, NC). An overall
significance level of 0.05 will be assumed for all tests.

Sample Size. The investigators plan to enroll 30 patients in each group. In the first 9
months of 2016, cardiac rehabilitation at the main campus of this tertiary care center had
approximately 170 patient intakes. It is assumed that there will be a similar number of
patient intakes for a 9 month period in 2017. Based on Facebook participation rates for those
over age 50 [21] and the high participation rates in previous research projects in this
facility's cardiac rehabilitation, it is estimated that 40% may meet eligibility requirements
and agree to participate. Allowing for use of the first 8 participants to establish the
Facebook group, the estimated sample size would then be 60 total participants for
randomization to study group who can then be included in analysis. With this sample size,
there will be 86% power to detect large effect sizes (d=0.8) for our study outcomes [40]. The
primary aim of this sample size determination is to evaluate whether the proposed
intervention is feasible, and to estimate the differences that might exist so that a larger
trial that would have adequate power to detect smaller differences could be designed based on
what was learned in this pilot study. The sample size of 30 per group was chosen primarily to
facilitate a large intervention group, since the value of the intervention is predicated upon
interaction among the participants.

Inclusion Criteria:

- All male and female patients who are current and regular Facebook™ users, 18 years of
age or older, have qualified for cardiac rehabilitation (diagnosed with cardiovascular
disease), and are entering cardiac rehabilitation at the Main Campus of the Cleveland
Clinic, will qualify for the study.

Exclusion Criteria:

- Participants must be able to exercise to the extent that they can take part in cardiac
rehabilitation, must live within 100 miles and must be able to read and speak English.