The current project is designed to expand the knowledge on HEPA in RA by a progressive approach regarding population, setting, intervention, time frames and outcome measures. It integrates physiological and behavioral aspects of HEPA behavior, aiming to assess the impact on self-perceived general health.
A majority of earlier studies have been performed within the health care system in clinical settings under supervision of physiotherapists. We aim to identify a subgroup within the RA population motivated to increase their physical activity to HEPA levels, likely to manage their HEPA in settings outside the health care organization. The setting for this study is public gyms with easy-to-use equipment, attracting a varied population with and without activity limitations. To our knowledge this is the first long-term HEPA program performed in a real life environment to demonstrate if increased and maintained physical activity in people with RA can be promoted in this new setting. With limited resources of health care, groups capable of self-management should be identified, thus freeing resources for patients in need of more support and care.
Our choice of recruitment via the SRQ for a matched cohort study with one intervention sample confer excellent opportunities to perform thorough analyses to characterize those consenting to participate compared to those declining, those adopting HEPA compared to non-adopters, and those reporting beneficial health outcomes compared to those who do not benefit, thus enabling conclusions about different subgroups in an RA population. The comparison sample constitutes the rest of our total target sample, can be monitored via the SRQ and is similar to the intervention sample as regards age, activity limitation and interest in a HEPA intervention. Although our focus is on the intervention sample, we expect the representative comparison sample to mirror the natural course of RA during the study period. Our belief is that this design fits our purposes better than a randomized controlled design that may jeopardize long-term compliance with the HEPA intervention as well as with the control conditions.
The intervention is based on physiological and behavioral knowledge of HEPA in RA. We emphasize the intensity and load of everyday activity and exercise, and use theory on behavioral change to guide the content of the intervention as well as the training of the physiocoaches. The theoretical framework used in this study, the Social Cognitive Theory, is in line with directions for future research on how to design, deliver and evaluate self-managementprogram in patients with RA [69
]. The design of the intervention corresponds well with a recent review of physical activity trials concluding that interventions are more likely to achieve maintenance if they are conducted over more than 24
weeks, include some face-to face contact, use more than six behavioral strategies and include follow-up prompts [70
]. The use of weekly SMS reports as a measure of HEPA and a cue for performing HEPA behavior has not been evaluated in an RA population previously. Our study uses a long-term approach by performing the intervention in two steps during two years; the group intervention is performed during the first year and the participants are responsible for the continuation of HEPA during the second year. The rationale is that individuals need time to initiate, adopt and maintain new behaviors in order to reduce the risk of relapsing into previous unwanted behaviors.
Our intervention is evaluated from different perspectives and thus a multitude of assessment methods are used. While most questionnaires in our study are valid for use either in the general population or for people with musculoskeletal conditions, the validity of the answers could still be questioned due to an extensive amount of questions. However, since the questionnaires are mailed, the participants may choose to fill them in over a couple of days and thus reduce the burden and the threat to the validity of their answers.
We expect that our HEPA program, integrating physiological and behavioral aspects of HEPA, will encourage and support the participants to reach the new guidelines on HEPA and thus improve general health perception, reduce pain and fatigue, increase muscle function and aerobic capacity, and have beneficial long-term effects on cardiovascular events. The results are expected to be externally valid for a subgroup within the RA population, motivated to manage their own HEPA behavior in settings outside the health care system. Results from this intervention study are expected to be published from 2013.