Wearable activity trackers and health awareness: Nursing implications

Abstract

Purpose
Wearable devices are commonly used to measure physical activity. However, it remains unclear the effect of wearing these devices on health awareness. Our aim was to provide evidence related to wearing physical activity trackers and health awareness.

Methods
A quantitative comparison study design was used comparing participants who wore physical activity tracking devices (n = 108) and those who did not (n = 112). A paper-based Physical Health Knowledge survey designed for the purpose of this research was used for data collection in 2018.

Results
A difference between participants who wore physical activity tracking devices and those that did not was identified in relation to activity levels and physical health awareness. Wearable devices are suggested as an opportunity for nurses to engage people in physical activity with the potential to improve their health awareness.

Conclusions
Nurses are well placed in the healthcare landscape to work with patients who own an activity tracker device concerning increasing activity self-monitoring. This information the patient has from the device can also form the basis of health discussions between nurses and the people in their care.

Full text

Original Article
Wearable activity trackers and health awareness: Nursing implications
Karen-Leigh Edward
a
,
b
,
*
, Loretta Garvey
a
, Muhammad Aziz Rahman
c
a
Department of Health Professions, School of Health Sciences, Faculty of Health, Arts and Design, Swinburne University of Technology, Australia
b
Human and Health Sciences, University of Huddersfield, United Kingdom
c
School of Nursing and Healthcare Professions, Federation University, Australia
article info
Article history:
Received 15 December 2019
Received in revised form
1 March 2020
Accepted 19 March 2020
Available online xxx
Keywords:
Exercise
Fitness trackers
Health behaviour
Health literacy
Wearable electronic devices
abstract
Purpose: Wearable devices are commonly used to measure physical activity. However, it remains unclear
the effect of wearing these devices on health awareness. Our aim was to provide evidence related to
wearing physical activity trackers and health awareness.
Methods: A quantitative comparison study design was used comparing participants who wore physical
activity tracking devices (n¼108) and those who did not (n¼112). A paper-based Physical Health
Knowledge survey designed for the purpose of this research was used for data collection in 2018.
Results: A difference between participants who wore physical activity tracking devices and those that did
not was identified in relation to activity levels and physical health awareness. Wearable devices are
suggested as an opportunity for nurses to engage people in physical activity with the potential to
improve their health awareness.
Conclusions: Nurses are well placed in the healthcare landscape to work with patients who own an
activity tracker device concerning increasing activity self-monitoring. This information the patient has
from the device can also form the basis of health discussions between nurses and the people in their care.
©2020 Chinese Nursing Association. Production and hosting by Elsevier B.V. This is an open access article
under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
What is known？？
With the technology explosion, more people have access to
wearable technology such as FitBit and Apple Watch to
monitor their health.
Wearable technologies such as physical activity trackers are
underutilised in nursing.
What is new？？
People who wear a physical tracker are more health aware and
active.
We identified a positive effect that wearing a physical activity
tracker had in relation to activity levels and the awareness.
Nursing implications for using wearable devices in healthcare
as a change agent is worth further investigation.
1. Introduction
Chronic conditions have a long lasting impact on health and in-
cludes cardiovascular disease, respiratory disorders, mental illness
and obesity, with cardiovascular diseases remaining the top burden
of disease globally [1]. Improved activity such as exercise is central to
improving health and can improve cardiovascular function and other
conditions. Nursing practice involves several key actions such as
communicating, interpersonal relating, teamwork, decision making,
and undertaking person centred care that addresses the physical and
mental health of patients in their care [2]. Nursing practice also in-
cludes the implementation of interventions that meet the patient’s
needs in a timely manner while working with patients in a thera-
peutic alliance. With the recent explosion in health technologies
including personal devices used by patients (such as Apple watch
and Fit Bit), there is an opportunity for nursing practice to embrace
working with patients towards using personal trackers to promote
self-monitoring. Using personal technologies that patients already
own offers a cost effective and ready to use option to facilitate
nursing care that is personalised and accessible to patients. However,
the benefits and/or merits of people wearing physical trackers has
yet not been explored with regards to improvements in physically
activity and health literacy and the implications for nursing practice.
*Corresponding author. Department of Health Professions, School of Health
Sciences, Faculty of Health, Arts and Design, Swinburne University of Technology,
Mail H59, PO Box 218, Hawthorn, 3122, VIC, Australia.
E-mail address: kedward@swin.edu.au (K.-L. Edward).
Peer review under responsibility of Chinese Nursing Association.
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Contents lists available at ScienceDirect
International Journal of Nursing Sciences
journal homepage: http://www.elsevier.com/journals/international-journal-of-
nursing-sciences/2352-0132
https://doi.org/10.1016/j.ijnss.2020.03.006
2352-0132/©2020 Chinese Nursing Association. Production and hosting by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
International Journal of Nursing Sciences xxx (xxxx) xxx
Please cite this article as: Edward K-L et al., Wearable activity trackers and health awareness: Nursing implications, International Journal of
Nursing Sciences, https://doi.org/10.1016/j.ijnss.2020.03.006

Wearable activity devices or activity trackers are becoming
increasingly popular. The revenue from fitness and activity trackers
worldwide has increased from under $5 Billion (USD) in 2014, to
over $20 Billion (USD) in 2017 [3]. This trend demonstrates a sig-
nificant uptake of wearable devices by people in the community.
Such devices can be used to monitor sleep, dietary intake, the
number of steps taken, speed of walking, pace and distance trav-
elled, heart rate, and calorie usage [4]. This information can even be
shared with friends when authorised by the wearer.
Evidence supports that physical trackers are used for health
purposes by individuals [5] as well as for research [6], and by
sporting groups [7]. Healthy behaviours such as monitoring phys-
ical activity and other aspects of health, such as sleep and heart
rate, may indicate a degree of health or physical awareness by
wearers [8,9].Patel, Asch [10] proposed that by monitoring physical
activity using wearable devices, healthy behaviours may improve.
However, they caution that improvements in health are not likely to
be achieved by wearing the devices alone and that positive health
behaviour engagement strategies are also essential. A recent review
examining low cost wearable devices to assist people in monitoring
their physical activity found few studies that examined the
acceptability, usefulness and effectiveness of wearing these devices
to promote health awareness and thus healthy behaviours [11].A
definition of health awareness has been derived from the World
Health Organization where the concept of health is being a state of
physical, mental and social wellbeing and informed by opinion and
active co-operation [12]. The research question that guided this
study was: Does wearing a physical activity tracker improve health
awareness and healthy behaviours in healthy adults?
2. Materials and methods
2.1. Design
The study design used was a quantitative comparison study
between two groups, those who wore a physical health activity
tracking device and those who did not. This aim of this study was to
investigate if wearing activity trackers improved health awareness
in healthy adults. The potential benefits of gaining knowledge from
this research is the idea that evidence for improved health aware-
ness from using a wearable device could be an used as an oppor-
tunity to inform practice of nurses in promoting self-monitoring in
patients who own a personal activity trackers. The Health Belief
Model informed the development of the survey for the study. The
Health Belief Model (HBM) is commonly used by healthcare pro-
viders to understand and explain health behaviours of people, and
suggests that people’s beliefs about their health informs their
subsequent actions [13]. The fundamental premise of the HBM is
that people will engage in health behaviours if they think they are
at risk for a disease, that their condition has serious consequences,
that their behaviour could be of benefit in reducing illness sus-
ceptibility or harm and that there are benefits to taking action (i.e.
being physically active). Recent evidence examining the HBM in
relation to technology further proposes that people who engage
with technology for health purposes are already undertaking a
proactive health behaviour [14]. The questions for the survey used
were generated by two experienced registered nurses and centred
on the key outcomes of interest (health awareness, health behav-
iours and the influence of wearing a physical activity tracker on the
person’s health awareness and behaviour). The reliability of the
items in the scale were analysed as part of the study after the
survey was completed by participants and presented in this paper
in the results section.
2.2. Method
Participants in this study were adults (>18 years) in the general
community of Melbourne recruited by students enrolled in an
undergraduate nursing degree. The population of Melbourne has
approximately 4.8 million residents [15], accounting for almost 20%
of the population of Australia. With a confidence interval of 6.6 and
a confidence level of 95% a sample size of 220 would provide
adequate power. The sample consisted of 220 participants, with
n¼108 self-identified as wearing an activity tracking device and
n¼112 who did not wear a device. Data collection was undertaken
using a paper-based survey designed specifically for the purpose of
this research.
Participants who consented to join the study completed the
survey which included two sections, the first was information
related to demographics and the second physical health awareness.
The demographic section contained4 questions about age, gender,
qualification, and use of a wearable activity tracker. The remaining
11 questions were related to participant’s awareness of their
physical health and health behaviours. Participants were required
to respond to statements on a 5-point Likert scale ranging from
“strongly agree”to “strongly disagree”. An example question in the
survey was “I change my activity levels in response to my beliefs
about my physical health”. The content and face validity for the
survey was considered high as it was developed by two experi-
enced registered nurses and checked for face validity by a third
nurse practitioner with expertise in primary health care.
2.2.1. Data analysis
Data were collected between March and June 2018 and written
informed consent was obtained prior to data collection. Analysis
included descriptive statistics of demographic data, reliability
analysis for the tool, and chi square testing. Data were analysed
using SPSS version 24. Characteristics of the study participants
were analysed using descriptive statistics at first. Independent
sample t tests were used to determine existence of association for
the individual responses of the item and statistical significance was
determined by the Pvalue <0.05. The individual responses were
then categorised for further analyses. Responses on ‘Strongly agree’
and ‘Agree’were grouped to ‘Agree’,‘Strongly disagree’and
‘Disagree’were grouped to ‘Disagree’, and ‘Neutral’were moved to
missing values. Chi-squared tests were then used to determine
association between users and non-users of trackers. Bivariate
analyses were conducted to determine strength of association by
calculating odds ratios (ORs) and 95% confidence intervals (CIs).
2.2.2. Ethical considerations
Ethical approval was given by the Human Research Ethics
committee of the university (No. 2017/291). Informed consent was
sought prior to participation in the survey and data is presented
here in aggregate format to protect the anonymity of participants.
3. Results
A total of 220 participants was included in this study. About half
of them (n¼100, 46%) belonged to the age group of 18e34 years
and two-thirds (n¼132, 60%) were males. More than one-third of
the study participants (n¼88, 40%) had Technical and Further
Education (TAFE) certificate of Diploma as their highest qualifica-
tions (Table 1). About half of the study participants (n¼108, 49%)
used a physical health activity tracking device. Most of the tracker
users belonged to the age group of 18e34 years (n¼52, 48%) and
were males (n¼68, 63%). However, there was no statistically sig-
nificant difference between the users and non-users of tracker in
terms of gender and age groups. There was a significant association
K.-L. Edward et al. / International Journal of Nursing Sciences xxx (xxxx) xxx2
Please cite this article as: Edward K-L et al., Wearable activity trackers and health awareness: Nursing implications, International Journal of
Nursing Sciences, https://doi.org/10.1016/j.ijnss.2020.03.006

between use of tracker and highest qualification of the study par-
ticipants. Those with TAFE certificate or Diploma (ORs 2.47, 95% CIs
1.24e4.91) and bachelor’s degree (ORs 3.24, 95% CIs 1.52e6.85)
were more likely to use tracker (Table 2). However, there was no
difference of variables of those with a Master’s degree when
comparing users and non-users of trackers. The total score
(Mean ±SD) of the 220 participants was 36.52 ±4.37, followed a
normal distribution.
The questionnaire with 11-items had low internal consistency
(Cronbach’s
a
0.403), therefore the questionnaire did not seem
reliable. It was determined that removing Q2, 3, 9, 11 would
improve the reliability of the survey based on itemetotal correla-
tions. Most items appeared to be worthy of removal except for Q5
and Q10, as the itemetotal correlations were between >0.3
and <0.8 (Table 3) which is considered satisfactory according to
Lindahl, Elmqvist [16]. While assessing the variability by examining
floor and ceiling effects, it was found that >15% of scores were
assigned to the highest score across five items (Q1, Q2, Q5, Q10 and
Q11) and to the lowest score across three items (Q3, Q4 and Q9).
This indicated no substantial ceiling or floor effects (Table 3).
Given that only questions 5 and 10 total correlations were
acceptable these were combined and retained for further analysis.
The questions were as follows: “I change my activity levels in
response to my beliefs about my physical health”and “I regularly
exercise as I know this will improve my physical health”respec-
tively. The responses were compared between the users and non-
users of trackers. Analyses of individual responses indicated that
there was a significant difference in the mean values for change of
activity levels between the users (Mean 3.95) and non-users of
tracker (Mean 3.70) (P<0.05). There was also a significant differ-
ence in the mean values for doing regular exercise between the
users (Mean 4.04) and non-users of tracker (Mean 3.65) (P<0.01)
(Table 4). Analyses of the categorical responses indicated that the
study participants who changed their levels of activity were more
likely to use tracker (94% vs. 83%, P<0.05, ORs 2.97, 95% CIs
1.11e7.96) and those who did regular exercise were more likely to
use tracker (92% vs. 74%, P<0.01, ORs 3.92, 95% CIs 1.59e9.71).
4. Discussion
The findings showed only two items/questions (question 5 &10)
had item-total correlations that were acceptable for further anal-
ysis in relation to our research question. The subsequent analysis
between participants who used wearable activity trackers
compared to those who did not use a wearable tracker revealed a
significant difference regarding activity levels and physical health
awareness.
Much of the burden of disease is caused by unhealthy behav-
iours and the use of media campaigns to trigger healthy choices
people make are generally passive, albeit commonplace in public
health campaigns [17]. While these public health campaigns
contribute to the better life choices that people make, the use of
wearable devices offers an opportunity for nurses engage patients
who wear wearable activity trackers in activities that improve their
healthy behaviours and health awareness. In the past 5 years
wearable devices have been tested with a number of groups for
example, pregnant women for the purpose of increasing physical
activity in pregnancy [18], for weight loss [19e21] and for physical
activity for people who are obese and have a serious mental illness
[22]. While a number of devices are readily available to the com-
munity, no studies have examined whether wearing the device
improves a person’s health awareness [11]. The results of our study
provide an initial understanding about the potential advantage
wearable devices can have regarding health awareness. Our find-
ings suggest that people who wear a physical tracker are more
health aware and active, as we identified a positive effect that
wearing a physical activity tracker has in relation to activity levels
and the awareness.
Our findings also show an association between the use of a
wearable physical tracker and the person’s highest qualification.
Evidence suggests education can have protective health effects [23]
and potentially improve health literacy. Health literacy is the de-
gree to which individuals have access to and understand basic
health information. Improvements in health literacy have shown
improved medication adherence in those with asthma [24], better
adherence to treatment for cardiovascular disease patients [25] and
better glycaemic control in people with type 1 diabetes [26].
However, no difference in variables for Master’s degree comparing
user and non-user of trackers, which may be attributed to the low
numbers of participants (n¼6) in that educational group. However,
the findings offer an opportunity for nurses to extend their practice
by incorporating self-monitoring activities using physical trackers
owned by the patient to improve health awareness and healthy
behaviours. There is the potential that this can impact a large group
of people particularly those living in developed countries and who
are more likely to wear such a device.
Limitations: This study provides new understanding of the
relationship between wearing of physical health trackers and
health awareness in healthy adults. Limitations were identified in
association with the reliability of the survey instrument. For future
use it is suggested the tool be modified and retested to improve the
reliability. The study did, however, include a large sample size and
therefore provides new information related to activity levels and
health awareness in adults who use a wearable activity device.
Table 1
Characteristics of study participants(N¼220).
Variables n(%)
Age (years)
18e34 100 (45.5)
35e55 99 (45.0)
56 21 (9.5)
Gender
Male 132 (60.0)
Female 88 (40.0)
Highest qualification
Year 9e12 60 (27.3)
TAFE certificate or Diploma 88 (40.0)
Bachelor’s degree 60 (27.3)
Master’s degree 12 (5.5)
Use of tracker 108 (49.1)
Table 2
Comparing the users and non-users of tracker (N¼220).
Variables Use of tracker, n(%) POR95% CI
Yes No
Total participants 108 112
Age (years)
18-34 52 (48.1) 48 (42.9) 1
35e55 49 (45.4) 50 (44.6) 0.724 0.90 0.52e1.58
56 7 (6.5) 14 (12.5) 0.125 0.46 0.17e1.24
Gender
Male 68 (63.0) 64 (57.1) 1
Female 40 (37.0) 48 (42.9) 0.383 1.28 0.74e2.19
Highest qualification
Year 9e12 19 (17.6) 41 (36.6) 1
TAFE certificate or Diploma 47 (43.5) 41 (36.6) 0.010 2.47 1.24e4.91
Bachelor’s degree 36 (33.3) 24 (21.4) 0.002 3.24 1.52e6.85
Master’s degree 6 (5.6) 6 (5.4) 0.230 2.16 0.61e7.57
K.-L. Edward et al. / International Journal of Nursing Sciences xxx (xxxx) xxx 3
Please cite this article as: Edward K-L et al., Wearable activity trackers and health awareness: Nursing implications, International Journal of
Nursing Sciences, https://doi.org/10.1016/j.ijnss.2020.03.006

6. Conclusion
Our findings offer an opportunity for nurses to augment practice
by incorporating the patient’s personal activity tracker into in-
terventions to improve health awareness and thus healthy behav-
iours in people who use them. This point has implications for using
wearable devices in healthcare and use of such devices as a change
agent. Wearable devices are commonly worn as watches (i.e. Apple
watch) and are therefore readily accessed by patients. Nurses are
well placed in the healthcare landscape to work with patients who
own an activity tracker device concerning increasing activity self-
monitoring. This information the patient has from the device can
also form the basis of health discussions between nurses and the
people in their care. This is especially significant for patient pop-
ulations where activity and health choices can alter the trajectory of
their recovery.
Funding statement
No funding was received for this project.
CRediT authorship contribution statement
Karen-Leigh Edward: Conceptualization, Methodology, Writing
- original draft, Project administration, Supervision. Loretta
Garvey: Data curation, Writing - review &editing. Muhammad
Aziz Rahman: Formal analysis, Writing - review &editing, Writing
- review &editing.
Acknowledgements
We would like to acknowledge the contribution of the nursing
students who undertook data collection for this project during
2018.
Appendix A. Supplementary data
Supplementary data to this article can be found online at
https://doi.org/10.1016/j.ijnss.2020.03.006.
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Item performance and reliability estimates of the questionnaire(N¼220).
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Cronbach’s
a
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a
¼0.403.
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for Equality of
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Difference
Std. Error
Difference
95% Cl of the
Difference
Lower Upper
Change of activity levels due to own beliefs Equal variances assumed 16.217 <0.001 2.097 218 0.037 0.257 0.123 0.499 0.015
Equal variances not
assumed
2.110 200 0.036 0.257 0.122 0.498 0.017
Do regular exercise as being aware of the
benefits
Equal variances assumed 11.752 0.001 2.715 218 0.007 0.385 0.142 0.665 0.106
Equal variances not
assumed
2.726 212 0.007 0.385 0.141 0.664 0.107
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Nursing Sciences, https://doi.org/10.1016/j.ijnss.2020.03.006

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Nursing Sciences, https://doi.org/10.1016/j.ijnss.2020.03.006