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Presenter DisclosurePresenter: Melanie Bisnauth
Relationships with commercial interests• Grants/Research support:
•Pilot Study funded by a Connaught New Researcher Award (University of Toronto); Full CBE Implementation Study funded by the CIHR Community‐Based Research Initiative• Kelly O’Brien is supported by a CIHR New Investigator Award
• Speakers Honoraria: Waved• Other: Employee of Kelly O’Brien, University of Toronto, Physical Therapy Department, Canada‐UK HIV Rehabilitation Research Collaborative Research Coordinator
We have no conflicts of interest.
Implementing a Community‐Based Exercise Intervention to Improve the Health of Adults Living with HIV:
A Pilot Study
Melanie BisnauthDepartment of Physical Therapy, University of Toronto
OHTN Conference: HIV Endgame ITuesday October 25th, 2016
YMCA‐CBE Pilot Study TeamRESEARCH TEAM
Kelly O’BrienUniversity of TorontoPatty SolomonMcMaster UniversityAhmed BayoumiSt. Michael’s HospitalAileen DavisUniversity Health NetworkAda TangMcMaster UniversitySean RourkeSt. Michael’s Hospital/ OHTN
RESEARCH COORDINATORMelanie BisnauthUniversity of Toronto
KNOWLEDGE USERS &COLLABORATORS
Mehdi ZobeiryPrincipal Knowledge User, Toronto YMCAKen KingKnowledge User, Community MemberChris GodiKnowledge User, Toronto PWA FoundationJames MurrayCollaborator, Ontario Ministry of Health and Long‐Term Care, AIDS BureauKate MurzinCollaborator, realize Soo Chan CarusoneCollaborator, Casey House
YMCA Staff Community Advisory CommitteeKatie Lowe, Ivan Ilic
Background• People with HIV are living longer; more individuals may encounter physical, social and psychological health‐related challenges of HIV, the consequences of treatment, and multi‐morbidity associated with aging.
• Disability: Any symptoms and impairments, difficulties with day‐to‐day activities, challenges to social inclusion and uncertainty or worrying about the future experienced by an individual.
• Rehabilitation can assist in managing the health challenges (or disability) associated with HIV, and complex comorbidities.
• Community‐based exercise programs exist for people chronic illness and are an ideal approach for enhancing health for people with HIV using a self‐management framework.
• However, no known HIV‐specific CBE programs exist in Canada; and the impact of CBE when translated in the ‘real‐world’ community setting is unknown.
Purpose
To pilot test a community‐based exercise (CBE) intervention with adults living with HIV to reduce disability experienced by adults living with HIV and to determine optimal
implementation.
Methods
Study Design: Prospective 4 month pilot intervention study May‐September 2015 (involving 2 waves of participants).
Inclusion Criteria: Adults (18 years or older), living with HIV in Toronto who considered themselves medically stable and safe to engage in exercise, willing to participate in CBE program.
Recruitment: Recruited through 4 organizations and health centres in Toronto (YMCA, Casey House, Toronto PWA, realize) via posters, brochures, recruitment cards, and word of mouth.
CBE Intervention – 4 monthsPre CBE Intervention
• YMCA Fitness Instructors (n=7 instructors)• Realize (CWGHR) Interprofessional Learning Modules
CBE Intervention• 4 months (16 weeks)• Combination of aerobic, resistance, neuro‐motor and flexibility exercise• 3X per week for ~1.5 hours per session• Supervised (and progressed as tolerated) weekly by YMCA Fitness Coach• Individual and/or group‐based exercise (classes)• Monthly self‐management educational sessions (4 sessions)• Participants asked to keep an exercise log throughout.
CBE Assessments
Results
Recruitment and Retention
Characteristics of Participants at BaselineCharacteristics Baseline (n=28) N (%)
Median Age (years, IQR)Age Range>50 years
49 (44, 59)36 to 64 years13 (46%)
GenderMen
WomenOther (two‐spirited; gender spectrum)
20 (74%)5 (18%)2 (4%)
Median Year of Diagnosis (IQR)Range
2000 (1989, 2006)1984‐2014
Currently Taking Antiretrovirals (ARVs) 27 (96%)
Viral Load Undetectable 21 (75%)
Employment Status‐Currently Working for Pay (FT/PT) 11 (39%)
Receiving Care from HIV Doc or HIV Clinic 26 (93%)
Overall General Perceived HealthVery Good
GoodFair
12 (43%)11 (39%)5 (18%)
Common Comorbidities (>30%) included: mental health condition (e.g. anxiety, depression) (57%)high cholesterol (43%) muscle pain (36%)bone and Joint disorder (osteopenia, osteoporosis, osteoarthritis’ or osteonecrosis) (36%), joint pain (30%)
• Median # of comorbidities (IQR) 4 (2,7)• 82% (23 participants) were living with 2 or more
comorbidities
Goals of Participants at Baseline
Participant Activity Level
Approximately over half of sample had experience with current exercise
Activity Level At Baseline (n=28) N (%)
At Completion (n=19)
Exercise ActivityCurrently exercise, but not regularlyCurrently exercise regularly and have done so >6 monthsCurrently do not exercise, but thinking about starting Exercised regularly in the past, but not currentlyCurrently exercise regularly, but only within last 6 months
10 (36%)7 (25%)5 (18%)4 (14%)2 (7%)
7 (37%)4 (21%)0 (0%)0 (0%)8 (42%)
CBE Implementation Process
CBE Prescription Large variation in the CBE prescribed among participants. Majority included a combination of aerobic and resistance exercise.
Activity Monitoring 9/28 (32%) participants completed the exercise log.
Weekly Coaching Session Adherence
15/28 (54%) participants attended >40% of weekly supervised sessions.
Exercisedindependently outside YMCA
17 /28 (61%) participants exercised on their own outside the YMCA during the study (e.g. walking, swimming, fitness classes at work, office gym, home exercise)
Health Status 12/28 (43%) participants experienced changes in health status during the study.
Progression of Program
21/28 (75%) participants changed their fitness program during the study (majority increased frequency and intensity of exercise; whereas some decreased with episode of illness).
Fitness and Questionnaire Assessments
Median time to complete fitness assessments = 75 min; questionnaire assessments = 85 min.
Self‐management education sessionsSelf‐Management Education Session Topic
Speaker Participants AttendedN/# still enrolled at the time of the session(%)
1) Welcome / Introduction to the Study & HIV and Exercise
Physical TherapistYMCA Volunteer
19/30 (63%)
2) Steps to a Healthy Weight Dietician 16/26 (62%)
3) Role of Occupational Therapy in HIV
Occupational Therapist 12/25 (48%)
4) Complementary and Alternative Therapy and HIV
Naturopathic Doctor 8/24 (33%)
Feedback • Positively received‐ provided them with an opportunity to learn, ask questions as
well as socialize with other participants.• Opportunity to provide feedback to the study team.
Reasons for not attending
• Challenges with Scheduling• Hard to juggle (or conflicts) with social schedule / work schedule / medical appointments / family matters
• Away / out of town / work travel / Busy• Fluctuations in Health
• Feeling unwell, not physically able to attend• Fatigue, Pain, surgery, migraines, back spasms, stomach issues, injuries
• 20‐30% experienced episodes of illness• Lack of motivation
Pilot Study ResultsFeedback Study Completion
N (%)
Felt the CBE Intervention was Beneficial• I am not afraid of the gym anymore• Opportunity to work with a trainer one on one; opportunity to use machines I was not
aware of; someone to push me and show me another way of exercising• Better sleep habits, strength, less stress, less stiffness
19 (100%)
Felt Initial Meeting with Fitness Instructor was Helpful• Spoke about medical issues and were able to plan exercises accordingly• Set the framework for my exercise plan; Helped me set goals
19 (100%)
Level of Fitness Instruction ‐ Very good or excellent 14 (74%)
Felt they Achieved their Goals set at the Beginning of the Study• Achieved some (energy level increase, body fat reduced, but weight no change)• Some achieved, others are ‘work in progress’• Improved stamina, flexibility, enjoy going to gym
13 (72%)
Experienced a Negative Event While Participating in the CBE InterventionLogistics – Difficulty scheduling with the instructor; administrative/logistics around membershipHealth – Overdoing it; Health issues interfered sometimes
7 (39%)
Strengths of the Study (quotes): Practical and important intervention, Central Toronto YMCA is a great setting in the community, felt better overall, access to Fitness Coaches.
DiscussionOver 60% of participants completed the 4 month intervention. Factors contributing to the success of the CBE pilot included: Extensive interest from the community in the study – recruited sample
within 8 weeks. Partnership with the YMCA & Meetings with Research Team and YMCA Staff
were critical to debrief on process throughout. Coaches were knowledgeable, dedicated, and supportive.
Considerations for Full CBE Implementation Study include: Strategies to mitigate last minute cancellations or ‘no shows’ to the fitness
assessments and coaching sessions (episodic nature of HIV); streamline communication between participants, coordinator and coaches.
Few (32%) completed the exercise log – tedious, did not fit diversity of exercise programs.
Respondent burden ‐ questionnaire and assessments.
Conclusions
• CBE intervention was positively received by participants who completed the pilot study
• Need to identify strategies to maximize adherence to exercise, enhance measurement of physical activity, and reduce the burden of assessments for future phases of CBE implementation
Next (Current) Steps ‐ Full CBE Implementation StudyPurpose: To evaluate the translation of a community‐based exercise (CBE) intervention for adults living with HIV within the community.
Study Design: Interrupted Time Series Study
Inclusion Criteria: • Adults (18 years of age and older)• Living in Toronto• Able to safely engage in exercise• Commit to 22 month study
Funded by: Canadian Institutes of Health Research (CIHR), Community‐Based Research Initiative
Study Timeline (22 months)
As of October 2016 – 80/120 participants enrolled to date
For more information:
Melanie BisnauthResearch Coordinator & CUHRRC [email protected]
Acknowledgements:Connaught New Researcher Award (UofT)Canadian Institutes of Health Research (CIHR)
Thank You
Extra slides
Multi-morbidityAt Baseline (n=28) N (%)
Median # of Concurrent Health Conditions (IQR) 4 (2, 7)
Living with >1 concurrent health condition (living with at least 1) 26 (93%)
Living with >2 concurrent health condition (multi‐morbidity) 23 (82%)
Common Concurrent Conditions (>10%)Mental Health Condition (e.g. depression, anxiety)High CholesterolMuscle pain‘Bone and Joint’, ‘Osteopenia or Osteoporosis’, ‘Osteoarthritis’ or ‘Osteonecrosis’Joint Pain (arthritis)
16 (57%)12 (43%)10 (36%)10 (36%)8 (30%)
High Blood PressureAddictionElevated Lipid LevelNeurocognitive Decline (e.g. memory loss, confusion, trouble thinking clearly..)
7 (25%)5 (18%)5 (18%)4 (15%)
Peripheral NeuropathyObesityDiabetesFibromyalgiaAsthma
4 (14%)4 (14%)4 (14%)3 (11%)3 (11%)
DementiaHepatitis C
3 (11%)3 (11%)