Acceptance by patients
Patient satisfaction and general approval
The participants were satisfied with the tablet-based intervention, as illustrated by the following quotes:
“It was motivating […] You sort of felt that you had to make a greater effort when you had that [tablet] there, you know. I thought it was great” P5.
“It was just the right thing for me. It was a good, gentle kick in the pants” P6.
“It’s fantastic motivation for walking, for getting out of the living room, yes, now you need to get over the doorstep and get out.” “I think it was a great programme” P10.
All of the participants would participate again, as expressed by the following participants:
“Then I would have said yes in the blink of an eye” P3.
“If I had been offered a chance to continue, I would have said yes straight away” “now there’s an empty space […] where it was standing. I would really have liked to put it back again.” P9.
Further, all participants would recommend others to participate:
“Yes, Absolutely” P2.
“Absolutely, absolutely” “unfortunately there are many people who have a tendency, when they find out that they have COPD, then they say, oh that’s why I’m so short of breath, yes, that’s why I don’t manage to do anything, then I have to sit here - and then it’s good to get a kind of kick in the pants” P8.
Virtual peer group and action planning
All participants except the one who was working updated their own activity status, kept track of the others’ status updates, and perceived the virtual peer group as useful to help them get going, as illustrated by expressions such as:
“It was quite fun […] to see that some [of the] others had also started, that it wasn’t only me walking” P3.
“It is motivating that there are others” “I was curious about [whether] they had got started” P5.
“At 10 o’clock, when I switch it on, I see, that one has started now, and then maybe some more […] heavens, here you just have to get going.” (P7).
“When you are part of a group, you do feel a bit of an obligation” P8.
“I thought, is it motivating in any way to walk together with others in the county that you just log in together with?” “And the motivation, that kick in the pants, it was much stronger than I had expected” (P9).
The participants found that having a time schedule for the exercises helped them to avoid postponing the exercise training to another time or day:
“I think that matters a lot. And I think that’s related to getting things in place, otherwise it’s easy to get into that, as most people when they are going to start exercising, yes, no, I had something else I must do today, I’ll do it tomorrow.” P8.
“When you don’t have it you can say that no, no, I’ll go tomorrow, you know.” P10.
The follow-along exercise video
The exercise video was well received by the participants, illustrated by expressions such as:
“Lots of people have seen it, you know […] and thought that it was so well made […] there are actually several people who have asked if they could buy it” P4.
“I fell in love with the video, […] that’s what was closest to me’” P5.
Two participants used the exercise video for the virtual group exercise only, while the others exercised to it several times a week. One participant used another set of exercises that s/he was already using. Almost all the participants placed the tablet in the living room in a place suitable for exercising.
Exercise diary
All participants recorded individual exercises in the diary. With one exception, the participants mainly used the predefined text options for describing the type of exercise and entered their own textual description only now and then.
There were technical challenges in integrating the activity sensor with the tablet app, and it was not ready for use by the first group of participants. While a few of the participants in the second group started out using the sensor with the tablet, they stopped after a short period due to technical problems.
Rewards
Most of the participants kept track of the number of rewards they achieved during a week, as illustrated by the following expressions:
“Tried the maximum. Managed it for three weeks, quite fun” P2.
Responses to the wallpaper were mainly positive, while a few of the participants had no strong opinion about it:
“It was cute! […] When I walk around [a small lake] […] there are ducks out there […] now I have them at home too” P3.
The participants had divided opinions about whether they would have preferred seeing the number of rewards the others achieved, as illustrated by the following expressions:
“No, I’m not kind of a competition person. Not about doing the most, no” P7.
“I would have liked to see how active the others had been” P8.
“What the others [got], I don’t think that mattered so much” P10.
Problem solving
As recommended, with bad weather or if the participant’s health allowed for indoor but not outdoor activities, the participants performed alternative indoor activities such as stationary biking, walking in a corridor, using a step, or using the exercise video:
“When the weather was miserable […] I used the exercise bike” P2.
“There were actually a couple of times […] when it was so awful outside that I took the walking trip inside back and forth in a long passage” P6.
“I had to improvise and do something at home [for health reasons]. I had what they call a mini stepper, I stand and step on that.” P7.
The weather forecast widget was used by some of the participants, but its usefulness for planning outdoor activities was limited. Many participants continued getting the weather forecast from TV, Teletext, the web, or simply by looking out through the window. In addition, the weather widget stopped working after a few weeks on several of the tablets.
Well-being
The participants experienced that participating in the exercise programme influenced their well-being and mood positively. The importance of doing outdoor walking was also emphasized by several of the participants:
“Speaking for myself, I know that as long as I am out in the fresh air I have a lot of benefit” P3.
“You get fitter when you do things outside and you are so satisfied when you come home too, at least I am” P10.
Individual adaptation
The participants took advantage of the opportunity for individual adaptation: one participant went walking with his/her spouse, one went alone or together with his/her spouse, and one participant walked with a neighbour. Another participant exercised to the video with his/her spouse. Some participants used the video frequently for the individual exercising, while others preferred walking or other physical activities.
Family and friends
Family and friends gave the participants positive feedback:
“Everyone was very curious about what I had started on now” “it was fine when they heard that it was all about exercising” P3.
“There’s been some […] discussion about it, yes” “they have […] been interested” P4.
“The kids, they just thought it was fun” P6.
Other aspects
One participant missed the social aspect of exercising physically together with others, while another participant thought that the exercise programme was as good as or better than centre-based rehabilitation programmes. A third mentioned feeling concern that something had happened if someone did not participate in a group session. This concern was due to the severity of COPD.
One participant living in a rural area mentioned the lack of exercise offerings and facilities outside the city centre and the lack of public transportation to the city. A seasonal challenge for outdoor walking, pointed out by another participant living in a rural area, was the darkness and lack of streetlights along the roads, and the lack of footpaths due to deep snow. However, April and May (the light season) was a good period for participation for these reasons.
No differences were found in the participants’ acceptance or physical activity behaviour that could be attributed to the fact that one of the groups also exercised together in person once a week.
Changes in physical activity level and programme adherence
Physical activity increased for the participants from on average 2.9 (range 0–10, median 2) sessions per week at baseline to 5.9 (range 3.3–10.33, median 4.8) sessions per week during the programme period. Of these, 2.3 (range 1.33–3, median 2.5) were virtual group exercises, and 3.6 (range 1.5–7.3, median 2.3) were individual exercises. This was on average a 77% attendance rate for the virtual group exercise sessions, and all participants performed individual exercises. The difference in physical activity at baseline and during the programme period was on average 3.06 with 95% CI [0.71, 5.40].
The results indicated that there might have been some underreporting of physical activity in the exercise diary:
“I saw that, that I haven’t recorded as much as I have done, I just haven’t” P4.
The results also indicated that the walking trips/physical activities tended to exceed the minimum time of 15 min.