Making a Game of Digital Tools Ups Exercise in High-Risk Postpartum Women

For women who develop unusually high blood pressure during pregnancy, turning fitness into a game can provide added support and motivation. The addition of this element, on top of text reminders and tracking fitness with a wearable device, increased daily step counts over a 12-week period.

Results from the randomized study, known as Social Ties to Encourage Physical activity among Postpartum Mothers (STEPUPMom), were recently published in JAMA Cardiology.

“Preeclampsia and other hypertensive disorders of pregnancy are important risk factors for developing chronic hypertension and heart disease later in life for women,” lead author Jennifer Lewey, MD, MPH (University of Pennsylvania Perelman School of Medicine, Philadelphia), told TCTMD.

Awareness about this connection is growing, she noted. Both the American Heart Association and the American College of Obstetricians and Gynecologists, for instance, advise clinicians to “counsel these postpartum women to adopt healthy lifestyle changes to reduce their cardiovascular risk,” said Lewey.

Yet it’s unclear what form this counseling should take, “especially when they have newborns at home,” she observed. “There really is an evidence gap in terms of understanding how to engage this population to become healthier.”

Prior research has shown that gamification (ie, creating a game out of tasks or services) can encourage people with conditions like diabetes or obesity, as well as economically disadvantaged, high-risk individuals, to increase their physical activity. What’s unique about STEPUPMom is its focus on postpartum women.

Lewey stressed that the most important thing for clinicians to convey to their patients in this situation is that increasing physical activity, even if only by a little, makes a difference. “We know that small changes have big impact when added up over time,” she said.

Step by Step

For STEPUPMom, Lewey and colleagues recruited participants who’d been diagnosed with a hypertensive disorder in a recent pregnancy, contacting them via text message between October 2019 and June 2020. Nearly 40% of the 1,885 postpartum women they texted responded with interest. Ultimately 127 women met inclusion criteria and were randomized, at a mean of 8 weeks after giving birth. Their mean average age was 32.3 years, 55.1% were Black, 41.9% had Medicaid insurance, and 19.7% had preeclampsia with severe features.

Both of the study arms received Inspire HR (Fitbit) activity trackers. Step counts were gathered using Way to Health, a University of Pennsylvania’s online research platform that communicates with wearables and delivers behavioral interventions by text messaging and email. All participants were compensated with $30 at enrollment, $30 upon study completion, and the wearable device.

The women in the intervention group participated in a team-based game throughout the 12-week study period, while the controls got daily feedback about attaining goals.

We know that small changes have big impact when added up over time. Jennifer Lewey

At baseline, the mean daily step count was 6,175 in the game group and 6,042 in controls. Both groups showed pronounced increases in steps at first, and though this dissipated, the intervention group consistently was more active than the controls.

By 12 weeks, with adjustment for baseline steps and the calendar month, the women who participated in the game took 647 more steps per day, on average, than those given the fitness tracker/feedback alone (P = 0.009). The game group also tended to achieve their step goals more regularly than did the controls (on 47% vs 38% of days; P = 0.003).

Yet around one-third of the women (37.5% of controls and 31.7% of game participants) went for more than 6 days without synching their trackers by the end of the study. Those in the control arm were more likely to do so earlier. The women who stopped synching were more likely to be younger, Black, have a lower household income (below $50,000), and unmarried.

Eight in 10 women completed the full 12 weeks. Among them, 94.2% said they’d recommended it to others. Within the game group, 29.4% of those who finished the study asked to connect with teammates for additional encouragement and motivation.

Elements of Success

Several aspects of the game likely contributed to its success, said Lewey. One strategy it employed was “loss aversion,” she noted. “As part of the game people started with a set number of 70 points and if they didn’t meet their goal, they lost points. We know that people respond to losses more strongly than they respond to gains.” Additionally, teams as a whole could lose points if some of their members didn’t reach their goals, Lewey noted. “They didn’t want to let their teammates down.”

Notably, almost one in four study participants reported postpartum depression at baseline. Taking part in a game may ease feelings of isolation, she said. “For future studies if we can figure out how to facilitate that social engagement, it has the potential to not only improve physical activity but other important health measures like mental health and feeling connected to other people.”

By virtue of being remote, the intervention could be applied in different healthcare settings, said Lewey. The main cost barrier is the expense of providing wearable devices. But it may be possible to track steps using women’s own smartphones, making the intervention even more affordable.

Lewey said the positive changes they found in their study give her hope. She looks forward to testing how best to attain this momentum beyond a 12-week intervention.

“We need to understand what behavioral strategies are needed to maintain engagement, because as you can imagine in the first postpartum year there’s a lot going on at home and at work, and so demands change,” Lewey pointed out. “How can we keep this novel and interesting to people moving forward?”