[논문]Development of a mobile-based self-management health alarm program for obese children in South Korea and a test of its feasibility for metabolic outcomes: A study based on the information-motivation-behavioral skills model

Choi, Jihea; Park, Yon Chul; Choi, Sarah

doi:10.4094/chnr.2021.27.1.13

Development of a mobile-based self-management health alarm program for obese children in South Korea and a test of its feasibility for metabolic outcomes: A study based on the information-motivation-behavioral skills model 원문보기

CHNR : Child health nursing research, v.27 no.1, 2021년, pp.13 - 23

Choi, Jihea (Department of Nursing, Yonsei University Wonju College of Medicine) , Park, Yon Chul (Department of Family Medicine, Wonju Severance Christian Hospital) , Choi, Sarah (School of Nursing, University of California in Los Angeles)

Abstract ▼ AI-Helper

Purpose: This study aimed to develop a mobile-based self-management health alarm (MSHA) program for modifying obese children's lifestyle based on the information-motivation-behavioral skills (IMB) model and to test its feasibility. Methods: A methodological study for the development of the MSHA program and pilot study with a one-group pretest-posttest design for feasibility testing was conducted. The MSHA program was designed to provide obesity-related information (I), monitor daily diet and exercise, provide motivational text messages (M), and enhance healthy diet and exercise skills (B) via a mobile-based web platform. In the feasibility test, six obese children participated in the 4-week program, and the number of days per week that they achieved their goals and differences in metabolic components were assessed. Data were analyzed using descriptive statistics and the Wilcoxon signed-rank test. Results: Participants successfully achieved their diet and exercise goals≥5 days per week. Body mass index (z=-1.99, p=.046), waist circumference (z=-2.20, p=.028), and triglyceride levels (z=-2.21, p=.027) significantly decreased. Conclusion: The MSHA program showed positive effects on health behaviors and metabolic syndrome risk. The program may be effective in improving metabolic syndrome in obese children by promoting self-health management behaviors.

주제어

표/그림 (5)

그림 Figure 1. Conceptual framework of the mobile-based self-management health alarm (MSHA) program based on the information-motivation-behavioral skills (IMB) model.
표 Table 1. Summary of the Mobile-based Self-management Health Alarm Program Based on the Information-Motivation-Behavioral Skills Model
표 Table 2. Samples of Motivational Mobile Text Messages before Sleep as Health Alarms
표 Table 3. General Characteristics of Study Participants (N=6)
표 Table 4. Effects of the Mobile-based Self-management Health Alarm Program on Metabolic Outcomes (N=6)

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문제 정의

Furthermore, the theoretical significance of this study lies in its application of the IMB model to the development of a nursing intervention program aimed at maintaining the health behavior of obese children.
The purpose of this study was to develop and pilot-test the feasibility and effectiveness of the MSHA program based on the IMB model. The MSHA program was developed as a web platform aimed at giving children the ability to perform daily self-monitoring and management of their diet and exercise behavior to provide health behavior information, motivation, and skills.
Therefore, the authors intended to develop and test the feasibility of a mobile-based self-management health alarm (MSHA) program based on the IMB model in a simple and easy manner that would be suitable for late school-age children to monitor and manage their health behaviors using mobile devices. The MSHA program focused on enhancing obesity self-management knowledge, motivational attitudes, and health behavioral skills in children by having them self-mon- itor and manage their diet and exercise using mobile-based educational materials and supportive mobile text messages.
This study was conducted to develop an MSHA program based on the IMB model and to test its feasibility. The authors carried out a pilot study using a one-group pretest-posttest design to evaluate feasibility and effectiveness before applying the developed intervention program to a large population of obese children; thus, there are currently limitations in generalizing the results of this study to the general population.

가설 설정

The MSHA program focused on enhancing obesity self-management knowledge, motivational attitudes, and health behavioral skills in children by having them self-mon- itor and manage their diet and exercise using mobile-based educational materials and supportive mobile text messages. We hypothesized that the MSHA program would serve as an effective self-management tool for children to monitor and manage childhood obesity.

제안 방법

This section was intended to stimulate an attitude within the participants to maintain healthy behaviors through self-monitoring and self-reporting their diet and exercise. "Motivation: Support" was provided twice per day (8 PM and 10 PM) by study facilitators (research assistants), who sent simple motivational text messages to participants via SNS as health alarms. The messages were based on each child's daily goal achievement status.
Review and appraisal of existing obesity management interventions A search for literature on existing obesity management interventions for children was conducted using the terms "child", "children", "obesity management", "mobile in- tervention", and "mobile health";. The previous and existing intervention programs that were found included the weight management elements of diet and exercise, nutritional education and counseling, behavioral treatments, psychological in- terventions, information sharing via social network services (SNS), and individual weight management counseling as major components [6, 14, 19].
Metabolic outcome data were collected twice: immediately before and immediately after the 4-week MSHA program. After all of the anthropometric variables (BMI, WC, SBP, DBP) were measured twice by two trained research assistants, the mean value of the dou- ble-measured data was used. BMI was calculated as weight divided by height squared (kg/m²).
Construction of the mobile-based self-management health alarm program based on the information-motivation-behavioral skills model Based on the results of step 1, the authors developed the MSHA program based on the IMB model. The entire content of the developed intervention was provided only to study participants via the developed mobile accessible web-based platform and SNS text message.
Evaluation of content validity and implementation of the mobile-based self-management health alarm program The content of the developed program was evaluated using the content validity index (CVI) (Likert scale; 1=very inappro- priate, 4=very appropriate) by experts (three nursing professors and one medical professor). The mean value of the CVI ranged from 3.
This study had those advantages. It was also convenient for the researchers to evaluate the status of participants' daily goal achievements according to the uploaded data on the MSHA platform and to immediately provide constructed motivational text messages of what steps the child should take next for their self-manage- ment behaviors on that day or the following day. This ability to manage the health of many subjects with a small number of healthcare providers could also be considered a benefit of the program in terms of cost-effectiveness.
Phase I was a methodological study focused on the development of the MSHA program based on the IMB model using a wearable pedometer and a mobile-phone diet application (app) for obese children. Phase II was a pilot study using a one-group pretest-posttest design to evaluate the feasibility and effectiveness of the MSHA program.
WC was measured at the midpoint between the lowest margin of the rib and uppermost lateral border of the iliac crest during expiration, using a flexible tape measure during minimal respiration. SBP and DBP were measured on the right arm after the subject had rested for 5 minutes in a seated po- sition, using a mercury sphygmomanometer. Biochemical variables (TG, HDL-C, and FPG levels) were analyzed from a blood specimen that was collected by trained medical personnel after overnight fasting at the laboratory at the study director's affiliated university hospital.
The MSHA program was developed as a web platform aimed at giving children the ability to perform daily self-monitoring and management of their diet and exercise behavior to provide health behavior information, motivation, and skills. The authors also evaluated the program's final effectiveness in changing and maintaining children's health behavior and improving their metabolic components as result of persistent health behavior.
The general characteristics of the study participants (age, gender, sitting hours per day, numbers of days that participants exercised for over 60 minutes per week, and perceived health status) were surveyed before study participation. Parental medical history of diabetes, hypertension, and hyperlipidemia was surveyed through a simple parental medical history questionnaire that was provided to parents with the study consent form.
, Armonk, NY, USA). The general characteristics of the subjects were analyzed using descriptive statistics. The maintenance of participants' health behavior was analyzed using the mean and standard deviation of the number of days per week that the goals were achieved.
The general characteristics of the subjects were analyzed using descriptive statistics. The maintenance of participants' health behavior was analyzed using the mean and standard deviation of the number of days per week that the goals were achieved. Improvement of metabolic components was analyzed using the Wilcoxon signed-rank test to compare the differences in metabolic components (BMI, WC, SBP, DBP, TG, HDL-C, and FPG) between the pretest and posttest results.
To change and enhance obese children's diet and exercise self-management health behavior, the MSHA program was developed based on the IMB model and evaluated for its effectiveness and feasibility. The IMB model was well suited as a conceptual framework to develop a self-management interventional program for obese children.
To develop the MSHA program, the authors (1) reviewed and appraised the existing interventional programs for the management of obesity in children, (2) constructed the specific strategies of the program based on the IMB model, (3) evaluated the content validity of the developed program using a group of experts (three nursing professors and one medical professor), and (4) revised the program based on the experts' recommendations and implemented it as a mobile-based program.

대상 데이터

SBP and DBP were measured on the right arm after the subject had rested for 5 minutes in a seated po- sition, using a mercury sphygmomanometer. Biochemical variables (TG, HDL-C, and FPG levels) were analyzed from a blood specimen that was collected by trained medical personnel after overnight fasting at the laboratory at the study director's affiliated university hospital. The specimens were analyzed within 1 hour after blood collection.
The authors then contacted the legal guardian of each study participant and explained the purpose and process of the study. Six students (two each aged 10, 11, and 12 years) were recruited and enrolled in the study with their legal guardian's permission for study participation. Children who met the following conditions were excluded from the study: current medical treatments related to obesity, diabetes, metabolic syndrome, and others; a medical history of congenital heart disease, diabetes, or hyperthyroidism; or a request by the participant or legal guardian to discontinue study participation during the study period.
In response to these rec- ommendations, the times for self-monitoring and uploading the data and providing the motivational text messages were modified to "before dinner" and "before sleeping" to allow flexibility. The confirmed intervention program was developed by a specialized information technology (IT) company as a mobile accessible web platform (http://mshealthyalarm.online/). The developed MSHA platform was constructed in a simple and convenient manner with (1) a page explaining how the program operated; (2) an educational page for providing the "Information" and "Motivation skills" sections of the program, dealing with topics such as obesity and its complications, checking one's daily diet and exercise rec- ommendations, and diet and exercise management skills; (3) a data monitor and upload page for diet and exercise amounts; and (4) an inquiry page.
Three school nurses who understood the purpose of the study and assisted with participants' recruitment responded that they would like to join. The selection criteria for participants in this study were children aged ≥10 years with a body mass index (BMI) ≥95th percentile as defined by the 2017 Korean National Growth Charts [18] who could use mobile devices, wearable pedometers, and diet phone apps by themselves. Using the results of a school health examination, the school nurses recruited suitable parti- cipants.
The study participants were four boys (66.7%) and two girls (33.3%). The mean age of the study participants was 11.

데이터처리

The maintenance of participants' health behavior was analyzed using the mean and standard deviation of the number of days per week that the goals were achieved. Improvement of metabolic components was analyzed using the Wilcoxon signed-rank test to compare the differences in metabolic components (BMI, WC, SBP, DBP, TG, HDL-C, and FPG) between the pretest and posttest results.

성능/효과

Among metabolic components, BMI (Z=-1.99, p=.046), WC (Z=-2.20, p=.028), and TG levels (Z=-2.21, p=.027) significantly decreased; thus, metabolic outcomes significantly improved from before the intervention to after the intervention. The other variables showed no significant differences (Table 4).
In particular, the knowledge and motivation components of the IMB model were shown to be the most powerful factors in the model for changing children's health behavior [11]. In this study, the MSHA program to strengthen children's knowl- edge, motivation, and behavioral skills for obesity self-man- agement may have resulted in successful goal achievement on more than 5 days per week and maintenance of their daily health behaviors. In particular, based on the IMB model's theoretical assumption that providing motivation is important for behavior change, the successful completion of the program by all participants without dropout indicates that intensively providing motivation in the form of health alarms was effective in changing these obese children's behavior.
of study participants [14]. Similar results were confirmed in this study; all study participants were fully engaged and successfully completed the 4-week program, and the mean number of goal achievement days per week was more than 5 days for both diet and exercise. In particular, before the intervention engagement, the mean number of days per week when the participants exercised for over 60 minutes was only 1.
5-fold higher adult cardiovascular mortality than adolescents with a BMI in the 5~24th percentiles. That study verified the importance of childhood BMI as an important index for predicting cardiovascular disease in adulthood, and confirmed the urgent need for interventions to reduce BMI in obese children. From this per- spective, the MSHA program, which led to a significant decrease in children's BMI, could be effective in reducing the prevalence of metabolic syndrome in adulthood by reducing BMI in childhood.
These results confirmed that the reduction in TG levels could contribute to reduction in the incidence of metabolic syndrome and cardiovascular disease in the future, especially when TG levels decrease following reduced intake of simple sugars and saturated or trans fats [29]. The decrease in TG levels in this study could have resulted from the MSHA program helping children monitor and maintain their daily calorie intake for 4 weeks with a low-sugar and low-fat diet. Therefore, the MSHA program was feasible and effective in engaging and maintaining obese children's self-management health behavior and improving metabolic outcomes.
Fourth, long-term effects could not be examined in this study. The effectiveness of the MSHA program was examined through the number of days per week when children achieved their goals for diet and exercise and improvements metabolic outcomes for only 4 weeks. The lasting effects of the MSHA program were not evaluated.

후속연구

The lasting effects of the MSHA program were not evaluated. Considering the findings of a previous study [13] that an online intervention for obesity prevention showed significant weight loss up to the first 6 months, but no significant difference was observed at fol- low-up after 2 years, further research is needed to evaluate possible long-term effects after the intervention. Lastly, the direct effect of each component of the IMB model on children's knowledge, motivation, and behavioral skills was not eval- uated, but only assumed in light of the final outcomes in this study.
Determining which component of IMB has the strongest influence on children's behavior could inform tailored interventions for this population with higher effectiveness. Therefore, a future study should consider evaluating the elements of the IMB model to improve the effectiveness of the developed interventional program.
From this per- spective, the MSHA program, which led to a significant decrease in children's BMI, could be effective in reducing the prevalence of metabolic syndrome in adulthood by reducing BMI in childhood. Therefore, a future study with a larger sample is needed to evaluate the long-term effectiveness of the MSHA program. Moreover, in this study, the mean WC significantly decreased from 94.

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