Testing Adaptive Interventions to Improve Physical Activity for Sedentary Women
Phase: NA
Conditions: Physical Activity
Sponsor: Rush University Medical Center

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Testing Adaptive Interventions to Improve Physical Activity for Sedentary Women
Study Protocol
I.
Purpose & Overview
The purpose of this study is to determine the most effective adaptive intervention combining 
four efficacious treatments (enhanced physical activity monitor, motivational text messaging, 
motivational personal calls, group meetings) to increase physical activity (step counts per day, 
minutes moderate/vigorous physical activity/week) and improve cardiovascular health (aerobic 
fitness, body composition) among sedentary women. This study with 312 women aged 18 to 70 
will also assess treatment effects on intervention targets (benefits, barriers, self-efficacy, and 
social support). The four adaptive interventions compared in this study consist of an initial 
treatment component (physical activity monitor or physical activity monitor+text messaging) 
followed by an augmented treatment component (personal calls or group meetings) for those 
who do not respond to the initial treatment component. For ease of management, the research 
team will limit the augmented treatments to only two of the four factorial combinations of 
personal calls and group meetings. The research team will focus on personal calls only (least 
expensive) and group meetings (current standard) and accept inherent limitations. It is well-
established that without intervention physical activity remains unchanged. 
The combination of the two initial treatment components and the two augmented treatment 
components delivered to non-responders yields four adaptive interventions that will be evaluated 
in this study:
1. Start with enhanced physical activity monitor, augment with motivational personal calls 
for non-responders, and continue enhanced physical activity monitor for responders;
2. Start with enhanced physical activity monitor, augment with motivational group meetings 
for non-responders, and continue enhanced physical activity monitor for responders;
3. Start with enhanced physical activity monitor+text messaging, augment with 
motivational personal calls for non-responders and continue enhanced physical activity 
monitor+text messaging for responders; and 
4. Start with enhanced physical activity monitor+text messaging augment with motivational 
group meetings for non-responders and continue enhanced physical activity monitor+text 
messaging for responders.
A methodologically rigorous SMART design will be used to test these adaptive 
interventions. Participants will be randomly assigned to one of the two initial treatment 
components: a) enhanced physical activity monitor only (physical activity monitor with goal 
setting and a physical activity prescription) treatment, or b) enhanced physical activity monitor+ 
motivational text messaging treatment for 8 weeks (early adoption phase). Week 8 has been set 
as the decision point for women who have not met their physical activity step goal (i.e., non-
responders). Non-responders will be those who a) fail to have valid wear time (i.e., wear a 
minimum of 3 days with 10 hours of wear time OR exceeding baseline step average), and b) 
average steps exceed the short-term goal of 600 steps above baseline average for two of the three 
weeks in weeks 6 to 8.. Non-responders to initial treatments will be randomly assigned to one of 
two augmented treatments: a) personal calls, or b) group meetings for Weeks 9-34 (later 
adoption phase). Responders will continue with their original treatment for Weeks 9-34 (later 
adoption). During Weeks 35-50 (maintenance), all women will receive enhanced physical 
activity monitors only. Data collection will occur at baseline and at Weeks 9-10 (end of early 
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adoption), 35-36 (end of later adoption), and 51-52 (end of maintenance). Data collection from 
the physical activity monitor (Fitbit Charge 2 or 3, hereafter referred to as Fitbit) will be ongoing 
and take place throughout the study. 
II. Inclusion & Exclusion Criteria
Participants will be recruited from Rush University Medical Center in Chicago, Illinois. 
Inclusion criteria are: 
1) Female employee at study site
2) Aged 18 to 70
3) Able to speak/read English
4) Owns a smartphone with text messaging capability
5) Willing to receive text messages at the proposed pace
6) We will include all participants who desire to be more physically active. However, we 
will also obtain present level of physical activity to assess if they meet or do not meet per 
self-report recommended moderate- or vigorous-intensity physical activity guidelines 
(moderate-intensity physical activity, >150 minutes/week; vigorous-intensity physical 
activity, >75 minutes/week).
7) We will include participants who have Type 1 diabetes, or Type 2 diabetes with an A1C 
≥ 9.0%, or have an A1C of ≥ 6.5% without a prior diabetes diagnosis, only if they have 
been given clearance by their health care provider
8) Without a disability that inhibits walking as determined by the PAR-Q & You (Physical 
Activity Readiness Questionnaire)
The sample is limited to women due to the substantive findings, including our own, 
suggesting that women have a more favorable response when interventions are specifically 
designed for women. The second round of randomization includes the group meeting, which 
requires > 6 participants, and we cannot guarantee adequate numbers of same-language 
participants unless we limit the sample to English. Due to wide use of smartphones and text 
messages, participants' own smartphones will be used. 
Exclusion criteria are:
1) Major signs/symptoms of pulmonary or cardiovascular disease
2) Systolic BP > 160 and/or diastolic BP > 100
3) Sufficiently active, as determined by a physical activity monitor worn for one week, 
indicating averaging >7,500 steps per day (“somewhat active”) 
III. Recruitment & Setting
Researchers will use reactive strategies to recruit participants (i.e., women will be informed 
about the program, and those interested in participation will be able to initiate contact with the 
researchers). The strategies will include e-mail communication from the employer human 
resource department, flyers, and using recruitment posters on electronic and paper employee 
bulletin boards located near work areas. All strategies will include a brief description of the 
program, provide a phone number to call for further information, program website URL, and 
program email address. 
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Because of changes related to COVID-19, the researchers had to take the study online and 
virtual. Now the researchers are reopening the study for in-person contact when needed. They 
have minimized the amount of in-person contact needed going forward, through the remainder of 
the study by doing the following. During this time, no in-person recruitment will be done on-line 
only through Rush advertising and using Rush flyers. A Webinar format may be used as part of 
the recruitment efforts. When it is safe to do so, the research team may return to limited in-
person recruiting.
The recruitment setting for this study is the Rush University Medical Center, a large urban 
academic medical center located in the Midwest, which delivers state-of-the-science health care 
to its patients. The institution employs approximately 7,577 females from diverse ethnic 
backgrounds: African American (24%), Asian (10%), Hispanic (14%), White (47%), and other 
ethnicities (5%). The mean age of employees is 39.97 years (standard deviation = 19.22). 
Assuming that employed women fail to meet aerobic physical activity guidelines at a rate that is 
half the rate of the general population of women, we estimate that we will have a pool of 
approximately 1,900 women for targeted recruitment. However, we expect the actual rate of 
physically inactive women to be much higher. 
Because the majority of women spend one-third or more of their waking time at work, the 
worksite presents an ideal setting from which to recruit for participation in physical activity 
interventions. Low levels of physical activity are exacerbated by the large amount of sedentary 
behavior imposed in many worksites (defined as the physical environment in which people 
perform the majority of their vocational duties). The increase in sedentary occupational activity 
in the U.S. over the past 50 years has contributed significantly to the increase in body weight for 
adults. Women now comprise almost half of the U.S. work force. In addition to their work 
activities, 47% of employed women have children younger than 18 years, and 20% have other 
caregiving responsibilities, both of which serve as barriers to leisure-time physical activity.
For the proposed study, all research-related visits will be offered at the Rush University 
Medical Center worksite on both daytime and evening shifts. Data collection appointment 
assessments will be split over several days. Participants will be given Appointment Reminder 
forms with the date, time and location of their appointment.  Participants will also receive 
reminder phone calls and/or text messages regarding appointments, and to wear and sync their 
Fitbit, as well as to wear their Actigraph. Participants will also have the option for research-
related visits to be at a convenient location of their choosing (e.g., their home). Participants 
assigned to group meetings may use their phones for audio conferencing or Webex 
videoconferencing if they are unable to attend the group meeting in-person. Participants will be 
provided healthy snacks at the group meetings. Participants will be given $40 gift card after 
completing each of the four data collections (total received will be $160 in gift cards). 
Researchers will identify multiple means of remaining in contact with participants including: 
work, home, and cell phone numbers (including text messages); home and email addresses; and 
contact information of three people. 
Participants who are randomly assigned to receive the augmented group meeting component, 
will receive two reminder telephone calls, text messages, or e-mails one week before and one 
day before data collection and group meetings. If the participant misses the first session, they 
will be asked to meet individually with the interventionist, prior to the second group meeting 
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session. Group meeting participants who miss a session after the first one, will be contacted by 
the interventionist and given a link to the Webex of the missed group meeting. The woman will 
be asked to view the Webex video within a week.. The number of regular and make-up sessions 
attended will be included in the analyses. 
University of Illinois at Chicago (UIC) will participate in this study as a performance site 
under the guidance of Dr. Spyros Kitsiou (site- PI) and will be responsible for the following:
1) Remote collection of physical activity data generated from the wearable activity monitors 
(Fitbit) that will be provided to enrolled study participants; and 
2) Delivery of the text-messaging intervention that has been developed by Dr. Buchholz at 
Rush. 
UIC has developed a secure research application (iCardia) that allows researchers to remotely 
collect different physical activity properties (e.g. steps, intensity of activity, and sedentary 
minutes) from registered Fitbit wearable devices, and send personalized, short-messages service 
(SMS) text-messages participants’ cell phones through the Twilio communications platform. 
iCardia is password-protected and hosted in a HIPAA compliant environment at UIC. It will only 
be accessible by authorized personnel associated with this study. Exportation of Fitbit data from 
iCardia is done using de-identified codes only. Text-messages send from iCardia will utilize the 
Twilio communications platform, which is also HIPAA compliant. Text-messages will be 
scheduled/programmed in iCardia by key research personnel based on the incoming Fitbit data. 
UIC will NOT serve as a recruitment site or be involved in the recruitment process. 
IV. Procedures
Recruitment Strategies

As already noted, potential participants will be recruited using different strategies 

Potential participants who are identified during an in-person recruitment session will be 
invited to schedule an initial eligibility screening over the phone, or if preferred and 
available, in-person in a private office in the College of Nursing

It is expected that most potential participants will self-refer by either leaving a voice mail 
message or sending an email to the research team who will reach out by phone for a brief 
explanation of the study 

If interested, participants will be invited to take part in an initial eligibility screening 
conducted over the phone or, if preferred and available, in-person in a private office in the 
College of Nursing
Initial Eligibility Screening 

Interested participants will be asked to provide verbal consent to be screened for inclusion 
criteria (listed again below)
o
Rush University Medical Center  female employee 
o
Age 18 to 70 
o
Speak and read English language
o
Have a Smartphone with a text messaging plan and assess if potentially compatible 
with a Fitbit
o
Provide information about their current physical activity
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
Interested participants will be requested to provide the research team with information about 
how they heard about the study

Those who meet these criteria will be scheduled for their next visit where they will be 
consented and further screened

Those who need to supply additional information regarding their smartphone will be 
contacted within one week to determine the compatibility of their device with study 
procedures

Those who do not meet these criteria will be thanked for their time and considered ineligible 
for participation 
Consent and Health Screening Appointment 

Because of changes related to COVID-19, participants will be asked to review an emailed 
consent ahead of time, prior to signing the consent at the in-person visit. 

The consent process will be completed in a private room in the Rush University Medical 
Center, and will include the Study Consent and the consent for Photographing and 
Videotaping

Following the consent process, should a participant choose to continue their participation 
they will be entitled to continue directly into the screening visit, or schedule an additional 
appointment for those such procedures

Screening includes:
o
Completing the Physical Activity Readiness Questionnaire (PAR-Q & You) 
o
Completing the Health History questionnaire

Includes questions about health history, health problems, gynecological 
health, and psychosocial health
o
Undergoing height, weight and waist measurements
o
Undergoing three blood pressure (B/P) readings
o
Being asked for A1C results done within the past 30 days

If they do not remember or do not have  test results, they will be provided 
with A1C testing using self-monitoring kits to determine their A1C level for 
screening, at no cost to them (using a A1CNow +  monitor which is approved 
by the FDA for self-monitoring of A1C)

It is possible that a participant will have had an A1C done for a specific wave, 
but did not complete enrollment for that wave, and asks to be part of the next 
wave. In that case only participants who had an A1C > 6.5%  and/or have a 
diagnosis of diabetes will need to have a new A1C test.
o
A Physical Measures handout will be given to the participant that records the findings 
of the height, weight, waist measurements, blood pressure, pulse and A1C testing.

Participants are considered screen failures if they have any of the following, prompting a 
requirement for further review by their healthcare provider:
o
‘Yes’ response to any question on the PAR-Q & You, OR
o
B/P > 160 systolic or > 100 diastolic, OR
o
Type 1 diabetes diagnosis, OR
o
Type 2 diabetes diagnosis and have an A1C > 9.0%, OR
o
No prior diagnosis of diabetes and during the study screening are identified to have an 
A1C > 6.5%
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
If a participant is deemed a screen failure, the participant’s healthcare provider will need to 
determine if it is safe for her to participate 
o
The participant will be given a Clearance Letter for the healthcare provider that 
describes the study, as well as a PARmed-X form that will need to be completed and 
returned to the research team, providing a recommendation regarding physical 
activity  
o
If it is safe for her to participate, she will then be deemed eligible to continue further 
screening into the study

Participants are considered eligible if they meet all of the following criteria:
o
‘No’ response to the PAR-Q & You questions
o
B/P < 160 systolic and < 100 diastolic
o
No need for a referral for a B/P or diabetes evaluation, OR 

Have been deemed safe to participate following a visit with their healthcare 
provider and have a completed PARmed-X form with sign-off from their 
healthcare provider

Participants that are eligible will complete a fitness assessment – Step Test

Eligible participants will be given two physical activity monitors:
o
A Fitbit with the display monitor temporarily taped or settings adjusted  so that the 
participant cannot see the display and so that their physical activity is not influenced 
by their ability to observe their step count data  

The Fitbit program application will be installed onto each participant’s 
smartphone, in order to sync Fitbit data

Participants will need to wear the Fitbit for a minimum of four 10-hour days, 
one of which is a weekend day
o
An Actigraph GT3X-BT (hereafter referred to as an Actigraph) 

The Actigraph accelerometer is to be worn during all waking hours on the 
right hip, in line with the right armpit  

Participants will need to wear the Actigraph for a minimum of four 10-hour 
days, one of which is a weekend day

Participants will complete an Actigraph Log when they are wearing an 
Actigraph during study assessments.

Participants will be given instructions on how to wear their two physical activity monitors, 
manage daily usage of their devices, and return to verify sedentary step criteria
o
The research team will stress the importance of wearing both monitors at the same 
time, when the participant is awake
o
The research team will also emphasize with the participant it is very important that 
they do not change their typical physical activity behavior while wearing their Fitbit 
and Actigraph during this screening assessment
o
An appointment will be given for participants to bring their two physical activity 
monitors one week later, to the Physical Activity Lab housed in the Armour 
Academic Center, in order to obtain physical activity data from the monitors
o
Because of changes related to COVID-19, participants that are eligible for the study 
will be asked to keep their Fitbit physical activity monitor (the Fitbit will be 
reintroduced at an on-line Program Orientation appointment) and will be given a 
Physical Activity manual.
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o
Participants will be asked to sign a Physical Activity Monitors Loan Agreement form
Participants will be given a handout regarding Actigraph Instructions and a handout regarding 
Fitbit Screening Use Instructions. 
Returning Physical Activity Monitors and Determination of Final Eligibility

Participants will drop off their physical activity monitors.

The research team will assure that the most recent steps from the Fitbit are synced to the 
participant’s phone. 

Research team staff members will analyze the data from the Actigraph to determine final 
eligibility for participation in the study
o
Participants that are deemed to be too active for the study (> 7,500 steps per day on 
average) will be contacted and told that they are ineligible for continuation and 
provided an electronic copy of the Step it Up! informational booklet from the Surgeon 
General’s office
o
Participants that are identified to have had issues with the monitors (e.g. they were 
not using them as instructed) will be asked to wear them for an additional week of 
wear time to re-evaluate their eligibility
o
Participants that are screened eligible based on their step count data will be contacted 
for scheduling their Baseline Interview 
Baseline Interview and Randomization (D1)

Because of changes related to COVID-19, participants will complete the D1 questionnaire 
online using a secure REDCap survey link

D1 data collection will include the following:
o
Questionnaire completion:

Demographics (age, ethnicity, marital status, children, caregiver status, 
education, income/hardship, job, shift)

Neighborhood Environment Walkability Scale (NEWS)

28 items assessing respondent’s perceptions of characteristics in their 
neighborhood that are conducive to walking

Exercise Benefits/Barriers Scale (Revised for PA)

43 items about statements that relate to positive/negative PA ideas

McAuley’s Self-Efficacy for Overcoming Barriers to PA

17 items reflecting beliefs in ability to continue to be physically active 
in the face of barriers

Social Support and Exercise (Revised for PA)

13 items assessing scale of family and friend support

Outcome expectations

11 items measuring expected change due to becoming more physically 
active

International Physical Activity Questionnaire (IPAQ) long-form

27 items assessing days per week and hours/minutes per day of sitting, 
occupational, light, moderate, and vigorous leisure-time PA 

Sedentary Behavior:

Time spent sitting participating in 9 sitting behaviors in past 7 days 
resulting in total minutes per week of sedentary behavior
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
Emotional Distress-Depression Short Form 8b

8 items measuring depressive symptoms over the past 7 days

PROMIS Scale v 1.2

10 items assessing general health, PA, emotional problems, and fatigue

PROMIS Sleep Impact Short Form

10 items, assessing past 7 days of sleep

Participants will be asked to sign an Oath of Confidentiality agreement that notes that they 
will not discuss their experience with the physical activity program with anyone else in their 
workplace until after the participation in the study ends. 

Participants will be thanked for their time, and will schedule their program orientation 
appointment to occur within a target two-week window.

Participants will be randomly assigned to one of the first two initial treatments (physical 
activity monitor, or physical activity monitor+text message)
o
See section IX. Randomization for further details on the randomization process
Program Orientation Appointment

Because of changes related to COVID-19, the Program Orientation Appointment will now be 
done using Zoom or Webex

All participants will be asked to have their Fitbit available for this appointment, and will be 
provided guidance on general device usage throughout the study 
o
Participants will be asked to refer to their Physical Activity Manual for information 
about the Fitbit and about walking
o
Participants will be asked to wear their Fitbit when they are awake, preferably all of 
the time they are awake
o
Participants will be instructed on how to review their daily and weekly steps on their 
Fitbit

Participants will be provided guidance on setting their physical activity goal (See Section V. 
Physical Activity Goal for more details)

All participants will be shown an instructional video related to walking, proper stretching, 
and using a Fitbit
o
All participants will be reminded that they can contact research team members during 
the study with any questions or concerns

A research team member will complete a Behavioral Competencies Checklist, documenting 
that the participant can demonstrate skills correctly regarding the Fitbit Charge 2 and setting 
their Step Goal

Participants who have been assigned to the physical activity monitor+text message initial 
treatment will also receive the following:
o
Instructions on what to expect regarding receiving text messages
o
A brief motivational interviewing session to identify motivational text messaging 
strategies to overcome their perceived barriers to increasing their daily steps

During this session, participants will suggest their own text messages and 
have the opportunity to select from an existing physical activity text 
messaging database

Monitoring of physical activity will start immediately after completion of the program 
orientation. Evaluation of response/non-response for each participant will take place 8 weeks 
after the orientation date.
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o
Participants will be reminded that the research team will remotely monitor their 
progress to ensure the following:

Adequate wear-time of the device 

Proper syncing of data between Fitbit and iCardia

All participants will be thanked for their time, and will schedule their appointment for the 
next study visit in 9-10 weeks
Decision Point 1: Week 8

This aspect of protocol procedures does not entail an in-person visit with the research team

At week 8, the research team will remotely determine if participants are deemed responders 
or non-responders to their initial treatment assignment based on their daily Fitbit step count 
synced to iCardia at UIC.  A participant is considered a Responder to the initial treatment if 
she meets both of the following criteria for two of the three weeks during weeks 6-8 of the 
initial intervention phase:
1)
Have 3 or more valid days, defined as either 10 hours of wear time or steps greater than baseline 
average steps, and
2)
Average at least 600 steps above baseline steps for the valid days. 

If she is deemed a responder, she will continue her initial treatment (physical activity monitor 
or physical activity monitor+text messages)

If she is deemed a non-responder, she will continue her initial treatment (physical activity 
monitor or physical activity monitor+text messages) and, in addition, be randomly assigned 
to receive either of the two augmented treatment conditions
o
Personal calls 
o
Group meetings

See section IX. Randomization for further details on the randomization 
process
Data Collection Weeks 9-10 and Augmented Treatment Appointment (D2)

Participants will be notified of whether they have been deemed a responder or non-responder 
to their initial treatment, and, if deemed a non-responder, will receive the results of their 
second randomization

Because of changes related to COVID-19, participants will complete the D questionnaire 
online using a secure REDCap survey link

D2 data collection will include the following:
o
Questionnaires:

Exercise Benefits/Barriers Scale (Revised for PA)

McAuley’s Self-Efficacy for Overcoming Barriers to PA

Social Support and Exercise (Revised for PA)

International Physical Activity Questionnaire (IPAQ) long-form

Sedentary Behavior

Emotional Distress-Depression Short Form 8b

PROMIS Scale v 1.2

PROMIS Sleep Impact Short Form

Outcome Realizations

11 items measuring realized change due to becoming more physically 
active
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
Program Orientation Satisfaction Tool

7 items measuring satisfaction with the Program Orientation Process

Fitbit Satisfaction Tool 

21 items measuring satisfaction with the Fitbit Process

Physical Activity Text Messaging Satisfaction Tool 

4 items measuring satisfaction with the text messaging intervention 
component
o
Participants will be asked to come to the Physical Activity lab for a brief appointment 
to obtain:

Physical measures including:

Three blood pressure readings, pulse, weight and waist circumference 
(a Physical Measures handout will be given to the participant that 
records these findings)

Fitness assessment:

Step fitness test 

The research team will give the participant a new step goal, based on their average daily step 
count (See V. Physical Activity Goal for more information about goal adjustment)

For the second time in the study, participants will be given an Actigraph to wear for one 
week along with instructions for use 
o
Participants will be instructed to continue to wear their Fitbit monitor every day 

Participants will only be wearing both monitors, the Actigraph and the Fitbit, 
simultaneously for one week during the prescribed Actigraph wear time

Arrangements will be made by the research team staff to pick up participants’ physical 
activity monitors one week later, or participants will have the option of returning their 
monitors to the College of Nursing using a secured metal drop-box on the outside of the main 
office door 

If a participant has been randomly assigned to receive the augmented Personal Calls 
Component of the study (See VII. Personal Calls Component for more information):
o
The research team will explain to the participant that they will be receiving five brief 
motivational interviewing telephone calls made by an interventionist 

The research team will arrange a schedule for the participant to receive 
personal calls every two to three weeks over the upcoming 24 weeks 

If a participant has been randomly assigned to receive the augmented Group Meeting 
Component of the study (See VIII. Group Meeting Component for more information):
o
The research team will explain to the participant that they will be participating in five, 
45-60 minute group meetings held every 4-6 weeks over the next 6 months

Participants will be asked about their best available times to meet, and the 
group leader (trained interventionist) will develop a schedule, based on the 
participants' collective input of best available times to meet, and will send it 
out to by Week 11 of the study to better ensure that enough group members 
are available for the meetings

Participants will be thanked for their time, and will schedule their Data Collection Weeks 35-
36 (D3) appointment
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Data Collection Weeks 35-36 Appointment (D3)

Because of changes related to COVID-19, participants will complete the D3 questionnaire 
online using a secure REDCap survey link

D3 data collection will include the following:
o
Questionnaires:

Exercise Benefits/Barriers Scale (Revised for PA)

McAuley’s Self-Efficacy for Overcoming Barriers to PA

Social Support and Exercise (Revised for PA)

Outcome Realizations

International Physical Activity Questionnaire (IPAQ) long-form

Sedentary Behavior

Emotional Distress-Depression Short Form 8b

PROMIS Scale v 1.2

PROMIS Sleep Impact Short Form

Fitbit Satisfaction Tool 

Physical Activity Text Messaging Satisfaction Tool 

For those in the Personal Call Condition only:

13 items measuring satisfaction with receiving personal calls

For those in the Group Meetings Condition only:

12 items measuring satisfaction with participating in the Group Visits

Social Provisions Scale
o
24 items, 6 sub-scales each comprised of 4 questions scaled 
from 1 strongly disagree to 4 strongly agree reflecting:

Social provisions of attachment

Social integration

Reassurance of worth

Reliable alliance

Guidance

Opportunity for nurturance
o
Participants will be asked to come to the Physical Activity lab for a brief appointment 
to obtain:

Physical measures:

Three blood pressure readings, pulse, weight and waist circumference 
(a Physical Measures handout will be given to the participant that 
records these findings)

Fitness assessment:

Step fitness test

The research team will give the participant a new step goal, based on their average daily step 
count (See V. Physical Activity Goal for more information about goal adjustment)

For the third time in the study, participants will be given an Actigraph to wear for one week 
to assess their average daily steps
o
Participants will be instructed to continue to wear their Fitbit monitor every day 

Participants will only be wearing both monitors, the Actigraph and the Fitbit, 
simultaneously for one week during the prescribed Actigraph wear time
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
Arrangements will be made by the research team to pick up participants’ physical activity 
monitors one week later, or participants will have the option of returning their monitors to the 
College of Nursing using a secured metal drop-box on the outside of the main office door

All participants will return to using only their Fitbit, and participants who received text 
messages or personal calls or group visits will be told that they have completed that part of 
the study 

Participants will be thanked for their time, and will schedule their final study visit, the Data 
Collection Weeks 51-52 (D4) appointment
Final Data Collection Weeks 51-52 Appointment (D4)

Because of changes related to COVID-19, participants will complete the D3 questionnaire 
online using a secure REDCap survey link

D4 data collection will include the following:
o
Questionnaires:

Exercise Benefits/Barriers Scale (Revised for PA)

McAuley’s Self-Efficacy for Overcoming Barriers to PA

Social Support and Exercise (Revised for PA)

Outcome Realizations

International Physical Activity Questionnaire (IPAQ) long-form

Sedentary Behavior

Emotional Distress-Depression Short Form 8b

PROMIS Scale v 1.2

PROMIS Sleep Impact Short Form

Fitbit Satisfaction Tool

Diffusion Effects Measure

2-part questionnaire that determines the degree to which participation 
in the program has influenced other Rush employees

For those in the Group Meetings Condition only:

Social Provisions Scale

Participant Satisfaction Tool

12 items, five-point Likert Scale (Strongly agree to Strongly disagree) 
that asks questions related to satisfaction with the study.
o
Participants will be asked to come to the Physical Activity lab for a brief appointment 
to obtain:

Physical measures:

Three blood pressure readings, pulse, weight and waist circumference 
(a Physical Measures handout will be given to the participant that 
records these findings)

Fitness assessment

Step fitness test

For the fourth time in the study, participants will be given an Actigraph to wear for one week
o
Participants will be instructed to continue to wear their Fitbit monitor every day 

Participants will only be wearing both monitors, the Actigraph and the Fitbit, 
simultaneously for one week during the prescribed Actigraph wear time
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
Arrangements will be made for research staff to pick up the Actigraph at an agreed upon 
time at their worksite, or participants will also have the option of returning the Actigraph to 
the Physical Activity Lab housed in the Armour Academic Center, at an agreed upon time

After returning their Actigraph, participants will be allowed to keep their Fitbits, and the 
Fitbit property (formerly owned by Rush University) will be signed over to them. 
Instructions will be provided on how to use their Fitbit on their own, since they have 
completed with the study. 

Participants will be thanked for their time and commitment to being part of the research 
study
V. Physical Activity Goal 
All participants will receive an enhanced physical activity monitor treatment, which includes 
goal setting with a physical activity prescription, and self-monitoring with a physical activity 
monitor. We will follow the physical activity prescription guidelines that were successfully used 
in our prior work. First, steps walked per week and per day (step counts) are obtained from the 
Fitbit, which is distributed during initial eligibility screening and worn for one week prior to the 
start of the intervention. The baseline step count per day is identified by averaging daily step 
counts over at least four days of valid data. Based on previously published step count data, 
counts per day have been classified as: < 5,000 = "sedentary"; 5,000-7,499 steps = “low active”; 
7,500-9,999 steps = “somewhat active”; 10,000-12,499 steps = “active”; and ≥ 12,500 steps = 
“high active”. Adults in the U.S. take an average of 5,117 steps per day. Adding 3,000 steps to 
5,117 steps per day would move an individual from the “low active” into the “somewhat active” 
category. Thus, each participant is given an overall goal to increase her steps above her baseline 
by a minimum of 3,000 steps per day, an increase that approximates 30 minutes of physical 
activity at a moderate walking pace.
To enhance self-efficacy, the research team will work with each woman to set an initial 
physical activity goal to gradually increase walking frequency, duration, and intensity. Gradually 
increasing frequency, duration, and intensity of physical activity promotes physical activity 
adherence and reduces risks of musculoskeletal injury and adverse cardiac events.  Participants 
may elect to only increase frequency without moving to increased duration and intensity. Thus, 
for activity progression, the research team will first emphasize frequency (walking more times 
throughout the day), then duration (walking for longer periods of time), and finally intensity 
(walking at a faster pace). Walking is initiated by beginning with incremental increases in 
routine/unplanned physical activity throughout the day. Participants will be given an initial goal 
of walking 600 steps/day over their baseline mean, by 8 weeks, to increase their frequency of 
walking. 
Depending on participant preferences, for participants who reach the “somewhat active” 
classification through their routine physical activity, they may begin structured physical activity 
(e.g., leisure-time walking), continue to increase their routine physical activity with a focus on 
walking for longer periods of time, or combine both strategies as additional sources of steps. The 
“somewhat active” classification was selected as the point to introduce structured/planned leisure 
physical activity because the “active” classification is associated with intentional (structured) 
activities. Thus, participants in the “somewhat active” classification who choose to add 
structured bouts of walking may gradually increase over four weeks structured activity to a 
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duration of 30 minutes, frequency of three to four times per week, consistent with American 
College of Sports Medicine. Participants who are able to reach the “active” classification should 
have the conditioning to assume moderate-intensity walking, per American College of Sports 
Medicine recommendations, either during 30 minutes of planned walking or physical activity 
bouts of ≥ 10  minutes.  Participants at this level are encouraged to walk faster. 
The initial step count goal will be entered electronically into a Fitbit, a slim wristband 
physical activity monitor to be worn at all times except during bathing and swimming, through a 
Fitbit application on a mobile device using the Fitbit.com website. The physical activity monitor 
allows participants to self-monitor their walking steps, distance, and intensity. Participants 
automatically receive notifications in relation to their PA as follows: The Fitbit PA monitor 
gently vibrates to notify the participant when she has achieved 100% of her daily step goals. 
Also, the Fitbit mobile app generates an automatic notification in the form of a friendly message, 
when a participant has achieved 75%, 100% or 125% of her daily step goal provided that the 
Fitbit mobile app is on or actively running in the background.
 
Fitbit data will be collected using the iCardia application and be presented on a virtual 
dashboard. The dashboard will show the research team real time participant physical activity 
data. These data will be used to provide suggested physical activity step goals at the end of the 
early adoption (Week 8) and late adoption (Week 34) phases. The iCardia application will be 
used to send text-messages based on the incoming physical activity data. 
Text message reminders are sent to all of the participants every Monday to remind them to 
sync their Fitbit. If the participant has not synced their Fitbit in 7 days, they receive a phone call. 
Participants will receive another phone call two days after that if they still have not synced their 
Fitbit. For the participants in the text message group, in addition to the Monday sync message, 
they receive an additional message later on Monday to sync if they have not already done so, and 
receive an additional text message to sync on Tuesday morning, if they still have not synced their 
Fitbit. The text message group is then given a step classification text message on Monday for 
those that have synced, and Tuesday afternoon for all remaining participants in this group, 
irrespective if they have synced or not. During Weeks 35-50 (maintenance), all participants will 
only be sent one text message weekly, and that will be a reminder every Monday to remind them 
to sync their Fitbit. 
The research team will create anonymous email and Fitbit accounts for all participants 
enrolled in the study. To ensure privacy and confidentiality, we will use unique Subject ID codes 
for the creation of online accounts. No personal or private identifiers will be stored in the Fitbit 
servers at any point in time. This account will be used only for the purpose of this study, where 
the email address will be used to communicate information about Fitbit data to the research team.
All participants will have a program orientation, which will include guidance on setting a 
physical activity goal and using their physical activity monitor, as well as viewing a video that 
will give information related to self-monitoring their steps, and proper walking and stretching 
techniques.
 
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VI. Text Message Component
In addition to the enhanced physical activity monitor half of the participants will also receive 
motivational TMs.  Participants who receive an enhanced physical activity monitor + 
motivational text message treatment from Week 1 through Week 34 will participate in an initial 
brief motivational interviewing session to identify motivational text message strategies to 
overcome barriers. Motivational Interviewing is a client-centered counseling style that elicits 
behavior change by helping participants explore and resolve ambivalence. Motivational 
Interviewing will be used to elicit self-motivational statements that address the intervention 
targets of perceived benefits, perceived barriers, self-efficacy, and social support. This is 
accomplished by prompting participants to explore and resolve their own barriers to physical 
activity. After this step, permission will be asked to suggest and have participants select 
additional motivational text messages from a database of over 250 text messages previously 
generated with focus groups and tested in the worksite setting. A two-step process will be used to 
send text messages out. First, participants will choose motivational physical activity text 
messages that they want to receive three times a week over the course of the next 8 months. They 
will provide the three days of the week they want to receive those text messages, along with the 
time of day they want to receive them. Second, at the beginning of each week, the research team 
will review the physical activity data to determine a woman’s daily mean steps the previous 
week. Based on their steps, they will be informed of their step classification the past week, using 
these published step count data: < 5,000 = "sedentary"; 5,000-7,499 steps = “low active”; 7,500-
9,999 steps = “somewhat active”; 10,000-12,499 steps = “active”; and ≥ 12,500 steps = “high 
active”.  
VII. Personal Call Component
Motivational personal calls will be based on the model consisting of five brief 
(approximately 10 minute) Motivational Interviewing telephone calls, made by an 
interventionist, every two weeks during the first 10 weeks of late adoption, and five calls every 
three weeks for the following 14 weeks (total 10 personal calls in late adoption Weeks 11-34). 
Participants will be given feedback based on their step counts in the prior week in relation to 
their goal (obtained from iCardia). The interventionist, who will be trained in Motivational 
Interviewing methods/techniques, will explore the participant’s feelings toward behavior change, 
assist in articulating self-efficacy in overcoming problems/barriers to physical activity, identify 
benefits of physical activity, and assist in developing a plan to increase physical activity. Using 
Motivational Interviewing, the interventionist will tailor the discussion to match the participant’s 
needs, experiences, barriers, motivation, and confidence. Suggestions for addressing problems 
will only be provided after the participant has explored options and agreed to receive feedback. 
The interventionist will follow a semi-structured protocol that provides the basic flow of each 
call, allowing for discussion and reflective listening. The calls will emphasize how the 
participant can overcome barriers to obtain goal steps.
VIII. Group Meeting Component
The group meeting treatment consists of five 45-60 minute group meetings held every four to 
six weeks during late adoption (Weeks 9-34). Due to the time needed to schedule, group 
meetings will start at Week 12. Group meetings will be led by a trained interventionist, held in a 
private conference room on the worksite property, and scheduled between the day and evening 
shift times.  Participants will be able to attend in person or by using their own phones for 
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audioconferencing or Adobe Connect videoconferencing to interact and view group meeting 
materials. Technical support will be available to help navigate Webex.
The group meetings provide social support. The content for the first group meeting focuses 
on identifying realistic outcome expectations regarding the effects of physical activity, to ensure 
realistic short- and long-term goals. The second and third meetings address personal and 
environmental problems that can interfere with increasing physical activity. The fourth group 
meeting focuses on anticipating disincentives for physical activity and handling relapses. These 
group meetings are targeted to address participant’s common barriers to physical activity, and 
identify benefits of physical activity. At the final group meeting, participants will share their 
experiences.
The group begins with a seven minute video of women role modeling (vicarious experience) 
by demonstrating skills, sharing experiences, and sharing approaches to problem solving and 
overcoming challenges pertinent to each group meeting. Following the video, each group 
meeting will include a 30-minute group discussion facilitated by the interventionist to role 
model, provide guidance, and encourage participants to solve problems together. A customized 
manual, including content for each group meeting, will be used to guide the discussion. At the 
conclusion of each discussion, participants will examine their step counts from the prior week in 
relation to their goal, identify a strategy for meeting the goal, and rate their self-efficacy 
(confidence) to meet the goal on a scale of 0-10. If their confidence is <8, the interventionist will 
recommend that participants reset their goal to one in which they have higher confidence. At the 
End of each group meeting, participants will complete a Group Meeting Satisfaction Tool (4 
items assessing satisfaction with group meetings).
IX. Study Timeline and Compensation
Participants can expect to be involved in the study for 52 weeks from start to finish. At each 
visit except the final visit, participants will receive a $40 gift card as compensation. At the last 
visit, participants will receive a $20 gift card upon completion of the questionnaires, and a $20 
gift card when they return their Actigraph. Successful completion of all 4 in-person study visits 
would therefore entail a total possible compensation of $160 in gift cards for each participant 
that completes every required study visit. Participants will be given a receipt for the gift cards, 
using the Receipt for Working Women Walking Study form.
Research staff will stagger this study over 48 months. During the first 6 months, study 
preparation will occur. From Months 7 to 47, five waves of 51-66 participants each will be 
recruited, with a new wave beginning every 6 months. Data analysis and dissemination will be 
ongoing. The final 3 months will be dedicated to study completion. 
X. Data Management
Several electronic resources will be used for data management. The Microsoft Access system 
will be used to manage participant recruitment, scheduling, consort report building, 
randomization, and tracking. The REDCap database will be used for data collection. iCardia will 
be used under the guidance of Dr. Kitsiou at University of Illinois at Chicago to remotely collect 
all Fitbit data generated by study participants, and to manage the delivery of TMs. iCardia is 
password-protected and hosted in a HIPAA-compliant server. iCardia provides researchers with 
a user-friendly dashboard that allows them to view each study participant’s physical activity data 
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in the form of graphs, including battery level and time of last sync, and send personalized text-
messages based on the incoming data. All Fitbit data pertaining to steps and intensity of physical 
activity are exportable to SPSS in a de-identified fashion (i.e. using random ID codes) for further 
statistical analysis. Training of research assistants and familiarization with the iCardia 
application will be coordinated by Dr. Kitsiou.
XI. Randomization
At the conclusion of the baseline interview, participants will be randomized to one of two 
initial treatments (physical activity monitor, or physical activity monitor+text message) in a 1:1 
fashion.  The random allocation table will be integrated into the Baseline interview programmed 
in REDCap, allowing both participant and interviewer to be blind to initial treatment condition 
until the end of the consent process and baseline interview.
At the end of the 8-week initial treatment phase, non-responders (i.e., those with an average 
increases of <600 steps per day above baseline) will continue their initial treatment assignment 
(physical activity monitor, or physical activity monitor+text message) and be randomized to one 
of two augmented treatments (personal calls or group meetings) in a 1:1 fashion stratified by 
initial condition using a random allocation table integrated into the Access database.  Research 
staff will be blind to augmented treatment assignment until responder status has been entered 
into the Access database at the Decision Point 1 Week 8 time point. After their Week 9-10 (D2) 
follow-up appointment and after they return their ActiGraph, the participant will be notified if 
they are receiving an augmented treatment.  
XII. Hypotheses and Data Analysis
Under the direction of Dr. Schoeny, SAS (v9.3) and R will be used for statistical analysis. 
Dr. Nahum-Shani is a methodological expert with a focus on developing innovating 
experimental designs, including the Sequential Multiple Assignment Randomized Trial 
(SMART) and will consult with Dr. Schoeny and members of the research team on use of the 
SMART design during the study.  Because multiple outcomes are being evaluated in the primary 
aim, a two-tailed .01 significance level will be used for the statistical tests of these hypotheses. 
Secondary and exploratory aims will employ a standard two-tailed significance level of .05 for 
all statistical tests. All analyses will be performed on an intent-to-treat basis. A one-way analysis 
of variance will be conducted to look for potential diffusion effects. If significant differences are 
found, the estimated mean levels of diffusion will be used as weights in the efficacy analyses and 
cost analysis. Hypothesis testing will address four study aims. 
Aim 1. Aim 1 is to compare the two augmented treatments used for non-responders, personal 
calls and group meetings, in improving physical activity and cardiovascular health after 35 and 
50 weeks. 
Hypothesis: Group meetings will be more effective than personal calls in improving 
physical activity and cardiovascular health after 34 and 50 weeks, among non-responders to 
the initial treatment.
This hypothesis will be tested using a multilevel analysis with time nested within 
participant (i.e., non-responders only). The hypothesis of the study is that the non-responders 
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who receive group meetings will demonstrate greater improvement in physical activity (self-
report life-style and occupational physical activity: minutes of moderate/vigorous physical 
activity/weeks; device: number of steps/day, minutes of moderate/vigorous physical activity/ 
week) compared to those who receive personal calls. 
Aim 2a.  Aim 2a is to compare enhanced physical activity monitor with and without text 
messaging for improving the level of physical activity from baseline to 8 weeks. These analyses 
will parallel those used for Aim 1, but consider only two time points (baseline and 8 weeks) and 
include all participants. 
Hypothesis: Participants who receive enhanced physical activity monitor+text messaging 
as compared to those who receive enhanced physical activity monitor alone will show greater 
improvement on physical activity at the end of 8 weeks.
Aim 2b. Aim 2b is to compare the four adaptive interventions in improving physical activity 
and cardiovascular health from baseline to 8, 34, and 50 weeks. The analysis is parallel to that 
described in Aim 1, except that the participants are not assigned to treatment based on simple 
randomization. Instead, they are screened on the basis of response status, and, once it has been 
ascertained that they did not respond to the initial treatment, they are randomly assigned to a 
treatment condition. Due to this design, the contrasts used to estimate the efficacy of these 
effects are nonorthogonal. The weights associated with the four interventions are then scored as a 
4 for non-responder subgroups and 2 for responder subgroups. This is because responder 
subgroups are used twice in the design matrix (e.g., subgroup A is used in adaptive interventions 
1 and 2; Figures 2 and 3). The estimation of these models is then based on a weighted multilevel 
linear regression model that has terms for change over time, the initial treatment, the augmented 
treatment, the interaction between the two treatments, and the effects of baseline and time-
varying characteristics. The critical effect in this model is the time-by-adaptive-intervention 
interaction term. The null hypothesis is that there will be no interaction effect at all, while the 
alternative hypothesis is that adaptive intervention 4 (enhanced physical activity monitor+text 
messaging [initial] and enhanced physical activity monitor+text messaging with group meetings 
[augmented for non-responders]) will produce the largest improvement rates. 
Aim 3. Aim 3 will identify mediators and moderators of the initial and augmented treatments 
on physical activity and cardiovascular health. Using analytic models parallel to those for Aims 1 
and 2, we will first test impact on intervention targets (benefits, barriers, self-efficacy, social 
support). 
Hypothesis: The intervention targets (benefits, barriers, self-efficacy, and social support) 
will mediate the effect of the initial and augmented treatments on physical activity (8, 34, and 
50 weeks) and cardiovascular health (34 and 50 weeks). 
Research Question: Do characteristics of participants (prior physical activity, demographics, 
BMI, depression) and their environment (walkability, crime) moderate the effects of the initial 
and augmented treatments on physical activity and cardiovascular health?
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Although we will test the impact of each treatment on all potential intervention targets, 
we anticipate variation in impact by treatment (e.g., initial treatment is less likely to impact 
social support). For intervention targets that are significantly impacted by treatment 
condition, we will test whether they serve as mediators of intervention effects on physical 
activity and health status outcomes using methods described by MacKinnon. Moderation 
effects will be tested by adding moderator main effects and interactions of the moderators 
with condition and time. Significant moderator effects (i.e., significant moderator-by-time-
by-treatment effects) will then be used to identify optimal decision rules for individual 
participants. The estimation of optimal decision rules will be achieved using a Q-Learning 
analysis, which is a modified regression analysis, adapted to address the SMART design. 
These optimal decision rules can then be cross-validated in future studies.
Aim 4. The cost-effectiveness analysis will be conducted from the societal perspective, 
including the program and participant costs. For the cost measurement, quantities of resources 
used and their associated prices will be collected for the program (either amounts paid or the 
value of the interventionist’s time), and participant (i.e., the value of the participant’s time to 
participate in the program). All costs will be valued in 2017 dollars. Program costs and 
participant costs will be calculated by summing their respective individual cost components, and 
these costs will be summed to calculate the total cost per participant. 
For the effectiveness measurement, effectiveness will be measured using physical activity 
and cardiovascular health outcomes for a total of six measures (physical activity steps, self-
reported light/moderate/vigorous physical activity, occupational physical activity, aerobic 
fitness, BMI, waist circumference). Cost-effectiveness will be evaluated by combining the 
mean total cost per participant with effectiveness (physical activity, cardiovascular health). 
We will calculate the incremental cost-effectiveness ratios (ICERs) for the four adaptive 
interventions: (1) enhanced physical activity monitor (initial) and enhanced physical activity 
monitor with personal calls (augmented); (2) enhanced physical activity monitor (initial) and 
enhanced physical activity monitor with group meetings (augmented); (3) enhanced physical 
activity monitor+text messaging (initial) and enhanced physical activity monitor+text 
messaging with personal calls (augmented); or (4) enhanced physical activity monitor+text 
messaging (initial) and enhanced physical activity monitor+text messaging with group 
meetings (augmented), such that the ICER = (Ci – Cj≠i)/(Ei – Ej≠i), where C denotes total 
cost and E denotes effectiveness. Effectiveness will be measured as the change in each 
outcome between baseline and study completion at 51-52 weeks. Subscript i denotes 1 of the 
4 adaptive interventions, and subscript j denotes the comparison intervention group. We will 
calculate six sets of ICERs, one for each effectiveness measure; 95% confidence intervals 
will be calculated to evaluate the uncertainty in these results. We will conduct one-way and 
multi-way sensitivity analyses for the key parameters to evaluate whether the ICERs are 
sensitive to plausible changes in their values. We will also plot acceptability curves based on 
varying threshold (willingness to pay) values for adherence and change in physical activity 
and cardiovascular health outcomes. Separate ICERs will be calculated from the program and 
participant perspectives.
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Appendix I. Text message examples
TM 
CODE 
English
TEXT MESSAGE LIST
101
Walk for peace of mind
102
Walk today for peace of mind
103
Get out to walk
104
Get up and start walking
105
Don't sit - walk
106
Take some me time - walk
107
Take care of the caretaker - walk
108
Don't sit still, time doesn't
109
Enjoy nature - walk
110
Enjoy nature - walk today
111
Walk and think about life
112
Open your eyes to life while you walk
113
Connect to your childhood by playing jump rope, hopscotch and tag
114
Revisit your childhood fun - jump rope, hula hoop
115
Let's explore - walk more
116
Activity begins with childhood and never ends
117
Walk around, look around and be safe
118
Walk and explore- ask others to  go
119
Encourage others to walk with you by exploring as you walk
120
Get in more steps with hiking at a park
121
Increase steps today - hike at a park
122
Active games matter - play volleyball, basketball and baseball
123
Walk with the family
124
Walk with a buddy
125
Walk with the kids
126
Encourage family walking
127
Take a walking break
128
A nature walk is a great idea
129
Try a nature walk
130
Dancing steps count
131
Get in steps by window shopping
132
Get up. Today is a good day to walk. 
133
Relax by walking
134
Walk while enjoying window shopping at your favorite stores. 
201
Walk to the shops
202
Eat less. Walk more
203
Let your spiritual light shine by reflecting while you walk
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204
Walk and reflect - increase your spiritual light
205
Push away from the table and pull in some activity
206
Don't just sit after eating - take a walk
207
Move after eating by walking
208
Add in movement to your holidays
209
Challenge yourself to walk more
210
Surprise yourself -learn more about your area – walk
211
Learn your area while you walk
212
Walk with a new eye and take in the scenery
213
It's ok to walk during vacations
214
Plan to walk while on vacation
215
While on vacation, take walks
216
Walking can be done before and after eating
217
Get out and move about
218
Warm-up by moving your feet
219
Beach walking can be relaxing
220
Get to know the culture by walking in different areas
221
Culture preview time - walk in new areas
222
Walk the trail
223
Go out and walk today - just do it
224
Just go out and walk
225
Get up and move daily
226
Get up and move – today
227
Park the car and move daily
228
You have to move your feet to stay healthy
229
Plan to increase steps the days BEFORE your hair appointment
230
Don't make a choice between your hair and walking - figure out a way to do both
301
Find your walking groove
302
Inner beauty starts with walking - be healthy on the inside
303
Be healthy on the inside - walk more
304
Beauty is living healthy - walking matters
305
Look better walk more
306
Why not exercise - start with walking
307
Walking is exercise - you can do this!!
308
Walk during your break
309
Stretch before and after you walk
310
Be sure to warm-up and cool down with brisk walks
311
Time to get healthy - why sit - walk instead
312
Time to get healthy - take a walk
313
Enjoy the fresh air - walk
314
Make leisure time a healthy time
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315
Walking more will help
316
Your kid's future depends on you staying healthy - so start walking more
317
Weave in walking today and everyday
318
Let's go - walk more
319
Take time to get healthy - move your feet while sitting 
320
Walk today- each step counts toward your health
321
Walking daily helps to maintain walking
322
Walk around instead of sitting down
323
Move with the players
324
Don't just watch the sports - move too
325
Take a walk between the plays at a game
326
Fit in moving every chance you can
327
Look for a chance to move more
328
Go the long way every chance you get
329
When you park, park further away
330
Park far - then walk
331
Halftime can be exercise time so step in place or walk around
332
Get up and move around
333
Don't sit through the whole game - walk and move
334
Fit in moving wherever you can
335
Anytime is a good time to walk
336
Walk around the neighborhood
401
Pick up the pace
402
Take the time to walk
403
Plan to meet your friends for a walk
404
Put some pep in your step
405
Pick up your pace and increase your steps weekly
406
Time to go walking
407
Put walking on the schedule
408
Schedule time to walk
409
Plan to meet your friend for a walk
410
Take a walk and clear your mind
411
Walk - take a break and refresh
412
Clear your schedule for walking
413
Walk during TV commercial breaks
414
Keep 30 minutes open to walk daily
415
You can always choose to walk in the mall
416
Walk in the mall of your choice
417
Try walking in the mall
418
Schedule time to walk by marking it on your calendar
419
Today mark your calendar to walk
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420
You can always walk around the house to get in shape
421
Take a short walk - this could improve your sleep
422
Take a short walk and sleep better
423
Don't just think about  it - actually go for a walk, even a short one
424
Walk faster
425
Walk faster and increase your steps weekly
426
Include walking in your day
427
Don´t take the elevator, take the stairs!
428
Find time to exercise during your busy day.
501
Don't miss out on walking benefits
502
Take a quick walking break
503
Don't just dream of walking - just do it
504
Just get up and move
505
Why wait - take the stairs
506
Push yourself - not the buttons to go up the stairs
507
Try walking the fairgrounds
508
Walk between laundry loads
509
Walk while you are cleaning
510
Make walking a priority
521
Walk while you mow the lawn
522
Walk with your pet
511
Check out what is going on outside and take a walk
512
Reenergize with a brief walk
513
Reenergize - take a brief walk
514
Walking breaks can reenergize you
515
Daily walks help to keep you healthy
516
Keeps the health provider at bay
517
A walk a day keeps the health care provider away
518
Take steps toward good health - take a walking break
519
Make an effort for yourself and those you love. Keep yourself health by walking
520
All your effort has its reward. Walk today.
601
Take a walking break - your health demands it
602
No excuses - walk more to feel better
603
A little walking goes a long way
604
Let's just get to walking
605
Look before you step and watch where you are going
606
Watch where you are going - but keep going
607
Watch where you tread
608
Give yourself the chance to be healthy. Start to walk. 
609
Give our bodies more days to live. Let´s walk
610
Walk. This will bring health to your life.
ORA: 17053108-IRB01   Date IRB Approved: 12/18/2019   Amendment Date: 7/21/2020

24
611
Watch where you tread but keep going. You can do it!
701
Get out and enjoy the day
702
Make your walk exciting
703
Make your walk interesting by adding variety to it
704
Walk with a group
705
Walk with a group - for a change
706
Be aware of your environment when you walk
707
Wear reflective gear as needed when walking
708
Keep variety in your walking plan
709
Challenge yourself and walk a little further
710
Walk and be aware of your surroundings
711
Take the dog for a walk
712
Find reasons to walk more
713
Be prepared for the weather when you walk
714
Be safe when you walk at night - wear bright and reflective clothing
715
You can use a flashlight at night to promote safety
716
If walking alone, be extra observant
802
Treadmill steps DO count as regular steps
803
Steps on the treadmill count just like walking steps do
804
Walking CDs or apps can be used to add steps
805
Walking CDs or apps can make walking fun
806
Indoor walking choices are many such as the mall, field house, big stores and YMCA
807
Dress for the weather when you walk
808
When the weather is cold, layer your clothes
809
Plan ahead for safe walking 
810
Identify what it takes for you to be safe when you walk
811
Don't stop being physically active just because of the weather
812
Don't let the weather block your walk - blink and it will change
813
Wear the right clothing for the weather
814
Get your steps in by walking your pet
815
Get your steps in by walking someone else's pet
816
Check out the local school indoor track for getting in your steps
817
A little walking during the day is better than no extra walking
818
Even a little walking each day adds up
819
Appropriate head wear matters when you are walking
820
Head wear matters - especially when walking
821
Dressing for the weather matters - especially when walking
822
Remember to wear proper footwear for walking
823
Update your walking shoes and socks for comfort
824
Be sure to wear the right kind of socks with your tennis shoes when walking
825
If on the running track, take another lap
ORA: 17053108-IRB01   Date IRB Approved: 12/18/2019   Amendment Date: 7/21/2020

25
826
Be prepared to drink water before, during and after walking
827
 
Music can be used to motivate yourself to walk.
901
Breaks can be part of the walking process if needed
902
Be kind to yourself - add breaks to walk
903
Increase your walking gradually
904
Keep things interesting - find different places to walk
905
Be creative about finding ways to get in more steps throughout the day
906
Get creative about adding more steps to your day
907
Find walking opportunities throughout the day
908
Go ahead and try to keep up with the kids when walking
909
Take your kids for a walk
910
Take your child or grandchild for a walk
911
Walk the children or grandchildren to school
912
Don't just watch - participate when your kids are playing
913
When your kids are moving, move with them
914
Stay active - lead by example for the family
915
Get the whole family moving
916
Make a family plan to walk
917
Make walking dates with your friends
918
Before or after eating - make a walking date with some one
919
Encourage your friends to walk
920
Encourage friends to walk - with or without you
921
Have your business meeting while walking and not just in the office
922
Walk for a cause - sign up for charity walks
923
Walk for another cause - perhaps a charity?
924
Walk further - get healthier
925
Walk a little further each day - taking steps toward health
926
Add steps gradually day-by-day
927
Gradually add steps to your walk this week
928
Make walking appointments for yourself - stay consistent
929
Fit walking into your daily schedule
930
Walking can be a time of refreshment
931
Refresh yourself - walk today
932
Involve kids in your walking plan
933
Walk, skip, jump - all these movements count
934
Pedaling your bike also adds to your daily steps
935
Park far - plan to add to your daily steps
936
Park far - every chance you get to add more steps to your day
937
Let's start walking!
938
Participate in a variety of activities to add more steps to your day
ORA: 17053108-IRB01   Date IRB Approved: 12/18/2019   Amendment Date: 7/21/2020

26
939
Participate in sports that involve lots of movement
940
Alternate between fast and slow walking
941
Keep track of the time and the distance you are walking
942
Music helps when encouraging yourself to walk more
943
Encourage yourself to walk more
944
A simple way to add more steps is to walk twice around your car before you get in it
945
A simple walking plan is to increase daily steps with your activities
946
Count the stairs while you walk
947
Track your walking progress
948
Track your progress every day
949
Don't be still - move up, down and around, and keep moving
950
Take the stairs - step up to build a healthy heart
951
Walk - don't ride the elevator
952
Why wait for the elevator - walk, don't ride
953
Why wait for the elevator - use the stairs
954
Start slow with stair walking and increase as you go
955
Step counting matters - keep track of your progress
956
Step counting matters - share your progress with others
957
Walking is good for your heart
958
Walking is good for your heart and so cheap!!!
959
Walking in the sunshine brings life
960
Walk a little further each day, taking steps to improve your health
961
Walking can be a time for relaxing.
962
Rejuvenate - walk today
963
For your motivation, keep track of the time and distance you walk.
965
Walking is easy, just do it!
966
Take your kids to school by walking.
ORA: 17053108-IRB01   Date IRB Approved: 12/18/2019   Amendment Date: 7/21/2020