Enhancing the Physical Activity Levels of Community-dwelling Older People With Frailty Through an Exercise Intervention With or Without a Wearable Activity Tracker (WAT)-Based Intervention: a Feasibility and Pilot Study
Phase: NA
Conditions: Frail Elderly
Sponsor: The Hong Kong Polytechnic University

 
 
 
 
 
 
Official Title: Enhancing physical activity levels of community-dwelling older people with 
frailty through an exercise intervention with or without a wearable activity tracker (WAT)-
based intervention: a feasibility and pilot study 
Date of the document: 22/03/2018 
Approved by the Human Subjects Ethics Sub-committee of The Hong Kong Polytechnic 
University on 13/04/2018 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
A. Background  
The current prevalence of frailty among community-dwelling older people is as high as 27%; this figure is 
expected to rise dramatically in the next decades due to the rapid growth in the aged population globally (Dent 
et al., 2017). The common adverse outcomes due to frailty include fatigue, increased risk of falls, unintentional 
weight loss, reduced levels of physical activity, and sarcopenia (Clegg, Barber, Young, Forster, & Iliffe, 2012). 
Frailty is also associated with depressed moods (Mezuk, Edwards, Lohman, Choi, & Lapane, 2012), restricted 
social participation (Liu, 2017), and a poorer quality of life (Strawbridge, Deleger, Roberts, & Kaplan, 2002). 
Frailty is an age-related state characterized by reduced strength and physiological malfunctioning that 
increases an individual’s susceptibility to dependency, vulnerability, and death (Clegg, Young, Iliffe, Rikkert, 
& Rockwood, 2013; Morley et al., 2013). Frailty also raises the risk of institutionalization, hospitalization, 
and mortality (Woo, Chan, Leung, & Wong, 2010). These adverse outcomes lead to considerable healthcare 
expenditures, and it is known that reducing such adverse outcomes could lead to reductions in medical costs 
(Cutler, 2001).  Fortunately, the evidence shows that frailty is a modifiable dynamic process characterized by 
frequent transitions between states (i.e., robust, pre-frail, and frail) over time. This suggests that specific 
intervention and health strategies should be developed and evaluated to provide evidence-based practices to 
prevent, postpone, or even reverse the phenomenon of frailty (Gill, Gahbauer, Allore, & Han, 2006). Thus, it 
is indeed a worthy cause to test interventions that can mitigate the effects of frailty or reverse its progress, to 
prevent or reduce the socioeconomic burden associated with this condition. 
 
Limitations of the current exercise programme for frail older adults 
Several recent systematic reviews and meta-analyses have found preliminary evidence of the exercise 
programme’s effectiveness in maintaining and improving the physical strength, function, and mobility of older 
adults with frailty (Chou, Hwang, & Wu, 2012; de Labra, Guimaraes-Pinheiro, Maseda, Lorenzo, & Millan-
Calenti, 2015; Theou et al., 2011). For example, a systematic review of nine RCTs concluded that exercise 
interventions led to improvements in different physical outcomes, including falls, mobility, balance, functional 
ability, muscle strength, and mass. Among all of these studies, however, only one demonstrated that frailty 
status could be reversed after a 3-month exercise programme (Kim et al., 2015).  
 
To achieve long-term beneficial effects, it is recommended that older adults accumulate at least 30 minutes of 
moderate-to-vigorous intensity physical activity (MVPA) on most, preferably all, days of the week (Nelson et 
al., 2007). Promotions of physical activity in older adults should emphasize moderate-intensity aerobic activity, 
muscle strengthening exercises, balance exercises, and reducing sedentary behaviour (Nelson et al., 2007). It 
has been suggested that an exercise programme with multiple components is an effective intervention to 
improve the overall health status and functional capacity of frail older people (Cadore et al., 2014; Villareal, 
Smith, Sinacore, Shah, & Mittendorfer, 2011). However, improvements in physical strength evidenced 
through laboratory assessments do not necessarily transfer to increased daily physical activity levels. The 
limitations of the exercise programmes in those clinical trials include the relatively short nature of the 
programme, no monitoring of daily physical activity levels, and a lack of strategies to encourage the 
participants to adopt a physically active lifestyle after the completion of the programme.    
 
Therefore, whether old people with frailty can adopt a physically active lifestyle after clinical trials with an 
exercise alone programme is still a major concern. The major obstacles to adopting a physically active lifestyle 
include a lack of self-belief, low self-efficacy, and poor coping strategies (Dent et al., 2017).  
 
In view of the limitations of an exercise alone programme, a pilot study was conducted to evaluate the 
preliminary effects of using an exercise programme plus the implementation of face-to-face behavioural 
change techniques (BCT). Eighty-five frail older people were randomly assigned to either the exercise 

combined with BCT intervention (COMB), exercise only (EXER), or usual care (control) groups (Liu et al., 
2017). Feasibility was achievable with high recruitment (87.2%) and low overall attrition (7.1%) rates. With 
the exception of the attendance rate and the self-perceived exercise compliance scores, we found no 
statistically significant differences in the other outcome assessments due to the small sample size in the pilot 
study. However, participants in the COMB group reported that ‘goal setting’ and ‘obtaining encouragement 
and suggestions from the BCT facilitator’ were the most effective ways of increasing their confidence in 
adhering to the exercise regimen. This pilot study showed that the combined exercise training and face-to-face 
BCT programme has the potential to strengthen the participants’ engagement in daily exercises, as reflected 
by their significantly higher self-reported exercise compliance and higher attendance rate in all of the training 
sessions during the 12-week programme [F(2,76) = 5.64, p < 0.01)] when compared with the other two groups. 
Not surprisingly then, a trend of greater improvement in physical endurance was observed in the COMB group 
than in the other two groups, although the figures did not reach statistical significance because of the small 
sample size. However, one drawback is that the effects of implementing face-to-face BCT are likely to 
gradually fade after the programme.    
 
Rationale for combining exercise training with a wearable activity tracker (WAT)-based intervention 
to increase physical activity levels in frail older people 
Wearable fitness trackers (WAT) are activity monitors that track daily activity levels and synchronize the data 
(such as step counts, time spent on MVPA, heart rate, calories burned) to smartphone applications. WAT 
technologies are increasingly accessible and offer the potential to support lifestyle interventions targeted at 
enhancing physical activity. It is believed that the mechanism that makes WATs effective at increasing the 
physical activity of older people relates to increasing their self-efficacy. Previous systematic reviews have 
identified a significant correlation between physical activity self-efficacy and different BCTs (French et al., 
2014). Some of these effective BCTs have already been incorporated into the design of the WATs, such as 
“prompting a review of behavioural goals”, “providing rewards contingent upon successful behaviour”, 
“alerting self-monitoring of behaviour”, “encouraging a focus on past successes”, and “giving cues to action” 
(Mercer et al., 2016). For instance, “cues to action” are important if sedentary behaviour is to be replaced with 
physical activity, as they provide real-time prompts to alert the participants of the need to avoid sedentary 
behaviour. In addition, the capacity for the user’s behaviour to be shared via the connectivity capabilities of 
smartphone applications can promote social support, feedback, and competition via social networking 
platforms (Nakhasi, 2014). Another systematic review has shown that activity monitors can positively 
influence multiple health behaviours, including physical activity (Fanning, 2012). These are important 
elements in changing and maintaining the change in behaviour (French et al., 2014).     
 
Before the availability of this technology, to implement these BCTs required well-trained instructors to 
continually conduct face-to-face or telephone sessions with the participants. It was highly likely that these 
elements would gradually fade out after the completion of the face-to-face or telephone programme. With 
advancements in technology, these important BCT elements are already embedded in the WATs. It is believed 
that even after the completion of the programme, users of WATs have a greater chance of adopting the BCTs 
and of maintaining a physically active lifestyle over the long term.  
 
Several previous studies have demonstrated that activity tracker-based interventions can effectively increase 
physical activity among adolescents and young adults with or without chronic illnesses (Choi, Lee, Vittinghoff, 
& Fukuoka, 2016; Lyons, Swartz, Lewis, Martinez, & Jennings, 2017; Mendoza et al., 2017; Partridge, 
McGeechan, Bauman, Phongsavan, & Allman-Farinelli, 2017).  For example, an RCT involving 51 inactive 
postmenopausal women showed that a 16-week wearable activity tracker-based intervention contributed to 
significantly increased MVPA and step counts when compared to the standard behavioural intervention 

(Cadmus-Bertram, Marcus, Patterson, Parker, & Morey, 2015).  However, evidence of the feasibility and 
acceptability of using WAT among older people remains scant.  
A recent survey of 127 older people evaluated WAT positively in terms of comfort, ease of installation, and 
usefulness (Kekade et al., 2018). Another trial invited 32 older people (mean age: 64) to evaluate the 
usefulness of six types of trackers after wearing each for 3 days. WATs, in general, were perceived as useful 
and acceptable, and 70% of the participants planned to purchase a WAT in the future to focus on improving 
their physical activity levels (Mercer et al., 2016). Although promising, these initial studies assessed the 
experiences of older people who were relatively young, and over short durations, which may not represent 
long-term experiences or the experiences of frail older people.   
 
Another study aimed to examine the short and long-term experiences of 95 older people using a WAT 
throughout the 8-month study. Their experiences were assessed after two main phases of the RCT: an 
intervention phase and a follow-up phase. During the 10-week intervention phase, the participants had regular 
contact with intervention staff and structured technical support for using their WAT. During the 6-month 
follow-up phase, the participants were left to use their own WAT independently. All ratings of the participants’ 
experience of using WAT, which included “ease-of-use”, “usefulness”, and “acceptance”, showed a 
downward trend between the intervention and follow-up phases.  These findings indicate that older people 
may need more support to continue to use the WAT to the point of achieving increased MVPA (McMahon et 
al., 2016).  
 
In addition, there may still be several challenges when using WATs with frail older people. First, there is no 
guarantee that the users will encounter the BCTs, even if they are present in the WATs (Mercer et al., 2016). 
This is particularly true for frail older people, as some studies have shown that older people may be fearful of 
new technology and reluctant to use it (Jen & Hung, 2010; Deng, Mo & Liu, 2013). Second, the WAT still 
lacks several important BCTs, which are essential to increasing the self-efficiency and motivation of older 
people to engage in exercise and to take up new physical activities (French, Olander, Chisholm, & Mc Sharry, 
2014; van Stralen, De Vries, Mudde, Bolman, & Lechner, 2009). Those BCTs that are lacking include action 
planning, problem solving, and the modelling of the desired health-related behaviour (Mercer et al., 2016).  
 
To further strengthen the use of WATs among frail older people, it is suggested that some additional measures 
should be implemented. First, they should be provided with structured technical training, support, and 
reassurance on using the WATs and their related mobile applications, especially during the early stages of the 
programme. Second, more support, focusing on action planning, problem solving (i.e., both exercise-related 
and IT-related problems), and the modeling of health-related behaviour should be delivered in person 
alongside the WAT intervention and exercise training (Cramp & Byron-Daniel, 2012; Edmonds, McGuire, & 
Price, 2004; Neill, Belan, & Ried, 2006; Pinto, Frierson, Rabin, Trunzo, & Marcus, 2005). Third, these forms 
of support should be gradually withdrawn to see if the older people can use the WATs on their own.   
 
Although the ultimate goal of using WATs should be increased MVPA, such data was not reported in previous 
studies on older people. Moreover, the suggested additional measures for facilitating the adoption of WATs 
by older people have not previously been tested. It is worth testing the efficacy of a combined intervention of 
exercise training plus WAT intervention in which BCTs have been incorporated. Little is presently known 
about the efficacy of using a WAT intervention among older people with frailty.  The main hypothesis is that 
the WAT intervention plus exercise training programme will increase physical activity levels compared to an 
exercise programme alone. If we are successful in proving the hypothesis, we will propose studying the long-
term effects (i.e., increased daily MVPA and the adoption of a physically active lifestyle) of this intervention 
in the main study with a larger sample size with a longer follow-up period. 

 
B. Research plan and methodology (Appendix 1: Consort Research Flowchart) 
Aim: A single-blinded, repeated-measures, two-arm pilot cluster RCT is proposed to examine the feasibility 
and preliminary effects of an exercise programme with or without a WAT intervention for promoting physical 
activity levels among community-dwelling older people with frailty. To explore the acceptability of the WAT 
intervention, a focus group with all participants in the experimental group (4-6 people per group) will be 
interviewed by JS (the Co-I). 
 
Subjects and Settings: A district community health centre will be viewed as one unit/cluster.  Eligibility 
criteria for district community health centres are those that are funded by the Hong Kong (HK) government 
and under the supervision of the Social and Welfare Department of HK, and thus that meet a specific set of 
standard regulations and criteria on environment and practices. Six community centres, which provide similar 
types of community care and social support services for community-dwelling older people, will be invited by 
a convenience method to work as collaborators in this study. The target population of this study are 
community-dwelling older people with frailty who will be recruited through the community centres. 
 
Sample size: Teare et al., 2014 recommended that a pilot study is required a total number of participants 
between 60 and 100 when estimating the effect size for a continuous outcome.  Thus, sixty participants will 
be recruited from six community centres. We estimate that about 25-50% of the members of these centres will 
be eligible to participate (Schultz-Larsen et al., 2007; Liu, 2017). We will target moderate to large centres 
with the total number of centre members around 800.  Given that we can screen 200 older people (50 in each 
centre) per 4 to 6 weeks, and based on our previous study in similar centres (Liu et al., 2017), we believe that 
we will need about 3 to 4 months to recruit 60 participants (with 30 subjects recruited per 4 to 6 weeks in two-
three centres) for this study.  Given the difficulty of obtaining details of the backgrounds of all potential 
participants in these community settings, a properly random sample cannot be implemented.  Thus, 
convenience sampling will be used to recruit participants among the collaborative community centres.  Using 
computer-generated random numbers, a biostatistician not affiliated with this study will randomize the centres 
in a 1:1 ratio into either: the control or the experimental groups. Participants from each centre will be placed in their 
centre’s corresponding group to avoid ‘contamination’ effects across participants. To avoid selection biases, the 
allocation to the study groups will be concealed from the researchers until sample recruitment and baseline 
measurements have been completed. Appendices 1 and 2 show the CONSORT research flow chart and the 
timeline of this study. 
 
The Inclusion Criteria are: 1) community-dwelling older people aged > 65 years; 2) able to communicate in 
Cantonese to ensure that they understand our instructions; 3) able to walk with or without an assistive device 
and able to complete the Time Up and Go (TUG) test with no specific cutoff point to ensure that their mobility 
and balance is good enough to join the exercise training; 4) able to use a smartphone; and 5) in a pre-frail or 
frail state as determined using the Fried Frailty Index[1]; including: i) having experienced an unintentional loss 
of 10% of body weight in the past year; ii) exhaustion: by answering ‘Yes’ to either ‘I felt that everything I 
did was an effort’, or ‘I could not get going in the last week’; iii) a slow walk time: with an average walking 
speed in the lowest quintile stratified by median body height; iv) reduced grip strength: with maximal grip 
strength in the lowest quintile stratified by the body mass index quartile; and v) a Physical Activity Scale for 
Elderly-Chinese (PASE-C) score in the lowest quartile (i.e., < 30 for men and < 27.7 for women). The presence 
of 1-2 indicates pre-frailty, > 3 items indicates frailty.   
 
The Exclusion Criteria are older people who: 1) have any physical conditions that hamper their performance 
of the exercise programme or use of the WAT, such as visual or hearing problems.  2) regularly engage in 
moderately intense exercise (such as hiking, Tai Chi) for > 3 hours per week.   

 
Interventions: A 3-month exercise programme plus WAT intervention will be arranged for the participants 
in the experimental group. They will receive a weekly centre-based exercise programme for 3 months. 
Meanwhile, two face-to-face sessions followed by weekly to monthly telephone sessions offering support on 
dealing with technical issues and BCTs will be arranged for the experimental group (see Figure 1: Intervention 
components for the experimental group). The additional technical support given alongside the WAT 
intervention will be gradually withdrawn from the participants. Eventually, all additional measures to support 
the use of WATs among participants will be stopped. Participants will be left to use the WAT on their own 
for 3 months during the follow-up period. Another 3-month exercise programme with face-to-face, and 
telephone-delivered BCTs follow-up sessions will be arranged for the control group, with the number and 
timing of all sessions similar to that in the experimental group. All face-to-face sessions and exercise training 
sessions will have < 10 participants to maintain good interactions between the participants and the physical 
trainer / facilitator.  
 
Wearable activity tracker (WAT)-based intervention for the experimental group: The aim is to strengthen 
the participants’ motivation to develop the intention to gradually increase their physical activity levels to 
eventually meet the level recommended for older people by the American Heart Association (AHA)[2].The 
intervention consists of two face-to-face group-based sessions followed by a weekly to monthly telephone 
sessions offering support on technical issues and behavioural change techniques.  
 
Supervision of face-to-face sessions and telephone follow up: JL (the PI), has successfully conducted many 
psychosocial intervention trials to enhance behavioural changes in older people with different health problems, 
and RK, who has experience in using WAT with older people. They will be responsible for implementing the 
face-to-face sessions and training an RA as a facilitator to deliver telephone BCTs support. A protocol for the 
face-to-face sessions and a script for telephone behavioral support will be developed and validated by the 
experts in BCTs and WAT. The initial calls by the RA will be observed by JL and feedback will be provided 
to maintain quality. Throughout the study, the telephone support will be supervised by JL and RK.  
 
Physical training in the experimental and control groups A weekly 45-60 minute structured exercise 
programme, designed according to the AHA’s recommendations on exercise for older people[2] will be 
conducted for 12 weeks in the community centres. The exercise sessions will begin with a brief warm-up, 
followed by 30 minutes of moderate-intensity walking, 30 minutes of light upper and lower body resistance 
training, balance, and flexibility exercises. All of the participants will receive circuit training with set exercises, 
but the dosage of different components will be tailor-made for each participant based on his/her physical 
condition. Exercise intensity will be individually monitored using a subjective 0-10 scale for physical exertion 
(Borg CR10 scale). The participants will be initially instructed to walk at a moderate intensity, equivalent to 
5-6 on the CR 10 scale. They will then be encouraged to gradually incorporate periods of vigorous walking 
(7-8 CR10) towards the end of the programme. They will be asked to take around 5000 steps per day at the 
beginning of the programme, gradually increasing to > 7000 steps towards the end of the programme, 
depending on their physical condition.[3] 
 
Demonstrations and return demonstrations will be performed during the training to ensure that the participants 
are able to do the exercises properly. A YouTube video/pamphlet demonstrating the exercises used in this 
programme will be disseminated to all of the participants to encourage them to continually practice their 
exercises at home for at least 30 minutes at least 3 times per week. The participants will also be encouraged 
to perform 30–60 minutes of walking exercise at least 3 times per week. The intensity of the walking exercise 
should gradually increase from moderate to vigorous according to the CR10 scale.  Information on exercising 
safely (Appendix 2) will be discussed with all of the participants prior to the beginning of the physical training. 

 
Supervision of the physical training: Physical training will be conducted by a well-trained research assistant 
who will work as a physical trainer under the supervision of JL and RK. JL has successfully conducted many 
intervention studies using exercise to address different health problems among older people. JL and RK will 
also work closely with the physical trainer, to monitor the progress of each participant.  
 
The Control Condition: The same physical training and BCTs support will be arranged for the control group. 
 
Instruments and Measures: 
Participants will be assessed on a variety of outcomes (described below) at 1 week and at 1 and 3 months (T1 
– T3) after the programme, which will be compared with the baseline assessment (T0). The participants will 
be asked to wear an ActiGraph Wgt3x accelerometer on their non-dominant wrist for 7 days before the 
commencement of any intervention, as well as during each outcome assessment time point.   
 
Socio-demographic data: The following data will be collected: 1) data on age, gender, marital status, exercise 
habits, living conditions, and level of education, 2) the participants’ health-related information, including their 
morbidities, cognitive status, medications, and number of hospital and out-patient clinic visits in the past 12 
months.  
 
Feasibility:   
To understand the feasibility of this intervention, the frequency with which the participants in the experimental 
group use the tracker over the time of the study (i.e., 112 days), the recruitment rate, the attrition rate, the 
participants’ adherence to the exercise regimen, and reports of adverse effects will be monitored.  
 
Primary outcome measurement: Activity levels  
The participants’ physical activities and sedentary time will be objectively measured using a ActiGraph 
wGT3X accelerometer. 
 
Secondary outcome measurements  
Fitbit Data (only participants in the experimental group): The total steps per week, total walking distance 
per week, and time spent in different heart rate zones (50-69%, 70-84%, and >85% of the maximum heart rate) 
of an individual will be collected. 
 
Physical Endurance: This will be evaluated using different physical tests:  
1. 
The participants’ lower-limb muscle and upper-limb strength will be assessed using a 30-second chair 
stand test and a handheld Jamar Hydraulic Hand Dynamometer, respectively.  
 
2. 
Mobility will be assessed through the Timed-up-and-Go (TUG) test and by their gait speed (2-m walk). 
These two tests assess the overall performance of the lower limbs and walking speed, which can reflect 
the effect of exercise in enhancing the participants’ overall physical endurance.  
 
Exercise Self-efficacy: The participants’ self-confidence in their ability to exercise in a variety of 
circumstances (e.g., even when they were feeling tired) will be assessed using the Chinese Self-Efficacy for 
Exercise scale (CSEE).  
 
Frailty status: This will be assessed based on Fried’s frailty five phenotypes as mentioned in the sample 
inclusion criteria. Physical activity level is one criterion of frailty that will be assessed using the 10-item 
PASE-C to measure self-reported occupational, household, and leisure activities for the last week.  

 
Self-reported sedentary behavioral and physical activity: This will be assessed using the Global Physical 
Activity Questionnaire-Chinese version (C-GPAQ), which comprises 16 questions designed to estimate an 
individual’s self-perceived level of physical activity in three domains (occupational, transport-related and 
discretionary or leisure time).  
 
Motivation to engage in physical activity: This will be assessed by the 19-item Chinese version of the 
Behavioral Regulation in Exercise Questionnaire-2 (C-BREQ-2). The C-BREQ-2 is a 19-item questionnaire 
assessing five dimensions: amotivation, external regulation, introjected regulation, identified regulation, and 
intrinsic regulation. Each item is rated on a 5-point scale ranging from 0 = “not true for me” to 4 = “very true 
for me”, with higher scores indicative of higher motivation. 
 
Procedures: Ethical and access approval will be obtained from the Ethics Review Committee of The 
University and study venues, respectively. Potential participants will be referred to the research team by the 
community centres. An RA will screen all potential participants for their eligibility to participate in this study. 
Written informed consent will then be obtained from all of the participants, to whom all aspects of the study 
will be explained and questions answered. They will then be interviewed to obtain their demographic data, 
and baseline assessment. After that, the participating community centres will be randomized to either the 
control or experimental group. Participants from each centre will be placed into their centre’s corresponding 
group to avoid ‘contamination’ effects across participants. At 1 week, 1 month, and 3 months post-intervention, 
an independent assessor who is blinded to the group allocations will assess the participants’ outcomes, which 
will be compared with the baseline assessment. Another RA will collect all “Fitbit activity-related data” from 
the participants in the experimental group every week. All of the participants in the experimental group will 
be invited to attend the focus group interviews, which will be conducted by JS after the first post-test T1 and 
T3.      
 
Intervention fidelity and RA training: User guidelines for each instrument will be obtained by the 
developers of the instrument or through a literature review. The PI (JL) will train an RA on how to use all of 
the outcome instruments, so that the RA can serve as an independent outcome assessor. He/she will practise 
using all of the instruments with various clinical vignettes and on-site practice. The PI will evaluate the 
assessor on his/her use of all of the instruments to ensure that quality assessments are performed as intended 
prior to the start of the study, and on a monthly basis throughout the data collection period. In addition, intra-
class correlations (ICC) will be used to test the intra-rater reliabilities. Acceptable levels of reliability (ICC 
>0.9) will be established by comparing the scores rated by the assessor and the PI prior to the start of the study, 
and checking them on a monthly basis throughout the data collection period.  
 
Exercise, WAT intervention protocols, and a scripted telephone support guideline will be developed and used 
to guide the implementation of all interventions involving participants in the experimental and control groups 
to ensure standardization of the intervention/study procedure. All physical training and face-to-face sessions 
must follow the protocol and will be run by the same facilitator/physical trainer to ensure consistency. To 
reduce the expectation bias from the physical trainer as well as the BCT facilitator, he/she will be instructed 
to use the same approach of encouraging all participants to adherence to their recommended exercise regimen. 
After receiving training on behavioural change techniques, an RA will conduct the telephone support based 
on the guideline under the supervision of JL and RK to the experimental and control groups.  
 
Intervention fidelity checking will be conducted in the training period and then monthly to bi-monthly during 
the intervention period, based on the face-to-face facilitation / physical training checklists / telephone scripted 
guideline. Achieving a fidelity rate of >90% will be considered acceptable, based on the recommendations of 

the NIH Behaviour Change Consortium (Bellg et al., 2004). This is to ensure that all of the interventions are 
executed by the physical trainer and the psychoeducation facilitator as intended. Monthly to bi-monthly 
quality-control meetings will be arranged with all research personnel in this study to evaluate their 
instruction/facilitation skills. 
 
Ethical Considerations: Ethical approval will be obtained from the Ethics Review Committee of The Hong 
Kong Polytechnic University. The participants will be informed of the study before it begins; anonymity will 
be guaranteed. All eligible participants will be asked for their informed written consent. A letter clearly 
explaining the nature of the study will be provided to all. The nature, conduct, and potential risks and benefits 
of the study will be fully explained to the participants. The participants will be made aware that their 
participation is entirely voluntary and that refusing to take part will not have a negative impact on the usual 
care provided by the service. They will be given assurances throughout the study that their data will be kept 
confidential in accordance with the Privacy Ordinance. The research personnel involved will work closely 
with the clinical team to monitor the occurrence of any untoward effects on the participants. Standard 
guidelines for the management of, for example, symptoms of intolerance, will be used. The involvement of a 
multi-disciplinary team and the aforementioned monitoring and safety procedures have been specifically 
designed to minimise any potential risks to the physical health of the participants.  
 
 
 
 
 
 
 

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Post- Assessments at 1 week (T1), 1 month (T2) and 3 months (T3) after the programme 
1. Physical activity levels - will be objectively measured by ActiGraph wGT3X accelerometer 
2. Fitbit data (experimental group only) – will be measured by Fitbit Charge 2 activity tracker  
3. Physical endurance – assessed by a 30-second chair stand test and a hand grip strength test 
4. Mobility – and overall physical endurance – assesses by timed up and go test and 2-m walk test 
5. Exercise self-efficacy – assessed by the 9-item Chinese Self-Efficacy for Exercise scale  
6. Frailty status – assessed by the Fried Frailty Index.  
7. Self-reported sedentary behaviour & physical activity – assessed by the Chinese Global Physical Activity Questionnaire 
8. Motivation to engage in physical activity – assessed by the Chinese Behavioural Regulation in Exercise Questionnaire 
Pre-
Study 
Recruitment and screening  
Inclusion Criteria are: 1) community-dwelling older people aged > 65 years; 2) able to communicate in Cantonese; 3) 
able to walk with or without an assistive device and able to complete the Time Up and Go (TUG) test with no specific 
cutoff point; 4) the smartphone user and 5) in a pre-frail or frail state as determined using the Fried Frailty Index (Fried 
et al., 2001),  
Exclusion Criteria are older people who: 1) have any physical conditions that hamper their performance of exercise 
programme or using the WAT, such as visual or hearing problem.  2) have regularly engaged moderately intense 
exercise (such as hiking, Tai Chi) for > 3 hours per week.   
Appendix 1: Consort Research Flowchart  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Study 
      Experimental Group - 3 community health centres    
         (i.e., Wearable activity tracker (WAT)-based Intervention)   
 
1)    2 face-to-face WAT programme sessions (45-min each) with    
        behavioral change techniques at week 1 and week 2 of the   
        programme. 
2)    4 weekly, 2 bi-weekly, and 1 monthly telephone support 
with   technical and behavioural change techniques  
3)    12 weekly centre-based exercise programme sessions (45-
60 min each) with resistance, balance exercise and aerobic 
training. 
Control Group – 3 community health centres   
1)   2 face-to-face behavioral change techniques sessions 
(45-min each) at week 1 and week 2 of the  programme. 
2) 4 weekly, 2 bi-weekly, and 1 monthly telephone 
behavioral change techniques follow-up sessions.  
3) 12 weekly centre-based exercise programme  
sessions (45-60-min each) with resistance, balance 
exercise and aerobic training.  
 
Focus Group within 1 week and 3 months after the PP-WATE Intervention 
A semi-structured interview with all the participants in the experimental group to understand their perceptions 
of the WAT intervention 
Feasibility Assessments from Recruitment Stage throughout the 12-week Study 
Frequency of participants using the activity tracker over time of the intervention period (Experimental group only), 
recruitment rate, attrition rate, weekly record on adherence to exercise regimen, and report of adverse effects  
Baseline Assessment (T0) 
Cluster Randomisation (n = 6 community health centres) 
Invite community centres to join the study 
 (n = 6 community health centres) 

 
Appendix 2: Example of lecture notes about tips of exercise safety 
Example of lecture notes about tips of exercise safety