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Effectiveness of a website and mobile phone based physical activity and nutrition intervention for middle-aged… Duncan, Mitch J; Vandelanotte, Corneel; Rosenkranz, Richard R; Caperchione, Cristina M; Ding, Hang; Ellison, Marcus; George, Emma S; Hooker, Cindy; Karunanithi, Mohan; Kolt, Gregory S; Maeder, Anthony; Noakes, Manny; Tague, Rhys; Taylor, Pennie; Viljoen, Pierre; Mummery, W K Aug 15, 2012

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STUDY PROTOCOL Open AccessEffectiveness of a website and mobile phonebased physical activity and nutrition interventionfor middle-aged males: Trial protocol andbaseline findings of the ManUp StudyMitch J Duncan1*, Corneel Vandelanotte1, Richard R Rosenkranz2, Cristina M Caperchione3, Hang Ding4,Marcus Ellison1, Emma S George5, Cindy Hooker1, Mohan Karunanithi4, Gregory S Kolt5, Anthony Maeder6,Manny Noakes7, Rhys Tague6, Pennie Taylor7, Pierre Viljoen8 and W Kerry Mummery9AbstractBackground: Compared to females, males experience higher rates of chronic disease and mortality, yet few healthpromotion initiatives are specifically aimed at men. Therefore, the aim of the ManUp Study is to examine theeffectiveness of an IT-based intervention to increase the physical activity and nutrition behaviour and literacy inmiddle-aged males (aged 35–54 years).Method/Design: The study design was a two-arm randomised controlled trial, having an IT-based (applyingwebsite and mobile phones) and a print-based intervention arm, to deliver intervention materials and to promoteself-monitoring of physical activity and nutrition behaviours. Participants (n = 317) were randomised on a 2:1 ratio infavour of the IT-based intervention arm. Both intervention arms completed assessments at baseline, 3, and9 months. All participants completed self-report assessments of physical activity, sitting time, nutrition behaviours,physical activity and nutrition literacy, perceived health status and socio-demographic characteristics. A randomlyselected sub-sample in the IT-based (n = 61) and print-based (n = 30) intervention arms completed objectivemeasures of height, weight, waist circumference, and physical activity as measured by accelerometer (ActigraphGT3X). The average age of participants in the IT-based and print-based intervention arm was 44.2 and 43.8 yearsrespectively. The majority of participants were employed in professional occupations (IT-based 57.6%, Print-based54.2%) and were overweight or obese (IT-based 90.8%, Print-based 87.3%). At baseline a lower proportion ofparticipants in the IT-based (70.2%) group agreed that 30 minutes of physical activity each day is enough toimprove health compared to the print-based (82.3%) group (p= .026). The IT-based group consumed a significantlylower number of serves of red meat in the previous week, compared to the print-based group (p= .017). No othersignificant between-group differences were observed at baseline.(Continued on next page)* Correspondence: m.duncan@cqu.edu.au1Central Queensland University, Institute for Health and Social ScienceResearch, Centre for Physical Activity Studies, Bruce Highway, Rockhampton,QLD 4700, AustraliaFull list of author information is available at the end of the article© 2012 Duncan et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the CreativeCommons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly cited.Duncan et al. BMC Public Health 2012, 12:656http://www.biomedcentral.com/1471-2458/12/656(Continued from previous page)Discussion: The ManUp Study will examine the effectiveness of an IT-based approach to improve physical activityand nutrition behaviour and literacy. Study outcomes will provide much needed information on the efficacy of thisapproach in middle aged males, which is important due to the large proportions of males at risk, and the potentialreach of IT-based interventions.Trial registration: ACTRN12611000081910Keywords: Physical activity, Nutrition, Males, Website, Internet, Online, Mobile phone, Self-monitoring, Literacy,InterventionBackgroundReducing disease and the prevalence of avoidable riskfactors associated with poor health in males is attractingconsiderable attention within the public health agenda.This is evidenced in both developed and developingcountries by the advancement of several recent policyinitiatives and other strategies dedicated to improvingthe health of males [1,2]. These initiatives are based on arecognition that, compared to females, males experiencehigher rates of overall premature mortality, cardiovascu-lar disease related mortality, suicide, diabetes, and obes-ity [2,3]. These health outcomes are linked to males’high levels of behavioural risk factors including highlevels of physical inactivity, poor nutrition behaviours,high risk drinking and smoking [2,3].Improving the physical activity levels of males is vitalto improving their health, as physical inactivity is one ofthe most significant risk factors for the leading causes ofpreventable death and burden of disease in Australianmales [2]. Physical inactivity is characterized by highlevels of sedentary behaviours, such as sitting, and/orlow levels of participation in moderate-to-vigorous in-tensity physical activity, such as walking. Australian sur-veillance data indicate that males report more than3 hours of occupational sitting, and 5.5 hours of total sit-ting per day [4,5]. Although approximately 53% of malesreport engaging in sufficient levels of physical activityfor health benefit, the proportion of males engaging insufficient physical activity has not increased in recentyears [6].Improving nutrition behaviours is similarly importantfor improving male health, as poor nutrition behavioursalso rank highly among risk factors for the leadingcauses of preventable death and disease in Australianmales [2]. Poor nutrition behaviours are characterized bylow consumption of fruits, fibre, vegetables, and fish,and high consumption of saturated fat and alcohol. Fruitand vegetable consumption is low in males, with fewerthan 6.5% of males consuming recommended dailyserves of fruit and vegetables [7,8] and 15% reportingthat they consumed alcohol at high-risk levels [9]. Fur-thermore, approximately half of adult males consumefull-cream milk on a usual basis and takeaway food atleast once per week, which is indicative of high saturatedfat intake [10].Despite ample evidence of demonstrated need forimprovement in health and related behavioural risk fac-tors, males are frequently underrepresented in health-promotion and chronic disease prevention interventionefforts [11,12], and report that the interventions that arefrequently adopted by females do not appeal to them [13].Thus, there is a need to develop interventions that specif-ically target physical activity and nutrition behaviours ofmales in a way that is tailored to their preferences. Theformat of the messages, presentation of information deliv-ered, mode of information delivery, and methods to en-gage participants are key intervention strategies than canbe tailored to males. Website-delivered interventions canbe tailored to specific user preferences and needs, areviewed favourably by males, and can positively alter levelsof overweight, physical activity, and selected dietary beha-viours [12,14,15]. The accessibility of such website-delivered interventions may also be more appealing tomales who cannot attend face-to-face interventions due toclashes with work, family responsibilities, and other sche-dules [16]. Additionally the capacity of website-deliveredinterventions to be accessed by large numbers of males inneed of health behaviour change is beneficial. Theprovision of educational materials, goal setting strategies,and tools to promote self-monitoring have been shown tobe effective methods to change physical activity and nutri-tion behaviours [12,17-19]. Our formative research onthese issues demonstrated that males are somewhatknowledgeable on the levels of physical activity andhealthy eating required to promote health, but that theyalso want information on these topics provided in a clearand simple way to avoid confusion associated with mul-tiple media campaigns and messages [20,21]. Tailoringhealth promotion messages in this way is important as thematerials not only need to provide information in an ‘eas-ily digestible’ format for males, but must also empowermales to use this information to positively change theirbehaviours [22]. This process of applying knowledge tochange behaviour, or health literacy, plays an importantrole in health promotion and is relatively low in manypopulations [22]. Males also acknowledge the importanceDuncan et al. BMC Public Health 2012, 12:656 Page 2 of 14http://www.biomedcentral.com/1471-2458/12/656of self-monitoring behaviours, but want this to be com-pleted in a time-efficient and user-friendly manner [21].As such, website-delivered interventions that incorporatethese characteristics and features may be useful to posi-tively change physical activity and nutrition behaviours.Self-monitoring of health behaviour is a common be-haviour change strategy implemented in many healthpromotion interventions [23], and is positively associatedwith greater behaviour change across a range of healthbehaviours [17,18]. Mobile (cell) phones that store datalocally and/or connect to the internet offer participantsa modern and technologically sophisticated way to self-monitor behaviour, may offer greater convenience whencompared to more traditional self-monitoring methods,and allow transfer of data to a website that containsother intervention materials and components [21].However, the use of websites and/or mobile phones, toself-monitor physical activity or nutrition behaviours,specifically targeted at males, remains largely untested.This manuscript describes the rationale, design, andbaseline findings from the ManUp Study, which aims toexamine the effectiveness of an information technology(IT) based intervention that uses both websites andmobile phones to improve the physical activity andnutrition behaviour and literacy in middle-aged males.Methods/DesignThe ManUp Study design is a two-arm randomised con-trolled trial with assessment points at baseline, three,and nine months. One intervention arm used an IT-based approach (website and mobile phones) to deliverphysical activity and healthy eating promotion materials,and to promote self-monitoring of these behaviours. Thesecond intervention arm used a more conventionalprint-based approach to deliver the same health promo-tion materials. Both intervention arms provided partici-pants with the same materials and ability to self-monitortheir behaviours, although the IT-based interventionadditionally provided participants with automated feed-back on their progress towards completing physical ac-tivity and nutrition goals, and the ability to interact withother participants on the website platform as a socialsupport mechanism (Table 1). The IT-based interventionallowed participants to self-monitor physical activity andnutrition behaviours using either the website or mobilephone platform. A print-based comparison group wasselected rather than a wait-list control group as it has beendemonstrated that print-based interventions are effective[24,25]. Participants provided informed consent prior toparticipation and the study was approved by CentralQueensland University, and the University of WesternSydney’s Human Research Ethics Committees. The studywas registered with the Australian New Zealand ClinicalTrials Registry (ACTRN12611000081910).Participants, recruitment and group allocationEligible participants were males aged 35 to 54 years oldwho (1) owned a mobile telephone, (2) had access to theinternet, (3) did not have a mobility impairment, (4)resided in the cities of Gladstone or Rockhampton(Queensland, Australia), and (5) were classified as lowrisk to commence an exercise regime [26]. Participants(n= 317) were recruited using a variety of techniques in-cluding advertisements via local newspapers, tradingmagazines, face-to-face information sessions with localbusinesses, and distribution of leaflets and posters to localbusinesses, medical clinics, and offices of allied health pro-fessionals. Rolling participant recruitment occurred fromOctober 2010 to September 2011. Following initial screen-ing for inclusion criteria, participants were randomly allo-cated to an intervention arm. Group assignment wasconducted on a two-to-one ratio in favour of the IT-basedintervention arm. Unequal group allocation was con-ducted to maximize the number of participants allocatedto the intervention arm that is less frequently examined inmale populations [19]. Randomization lists were generatedusing freely available software (www.randomization.com).Participants were blinded to group allocation until base-line assessments were completed.ManUp interventionThe study was labeled “ManUp” to have men identifywith the intervention and also to challenge men to takeresponsibility for their health. Similarities and differencesin intervention components between the IT and printgroups are summarized in Table 1 and reflected the abil-ity of the IT-based intervention to include componentsrelated to automated feedback and participant inter-action in an online environment. The ManUp interven-tion was designed on the basis of our review of physicalactivity interventions in males [12], formative researchthat identified the enablers and barriers that males facedin engaging in more physical activity and healthy eating[20] and the specific requirements for the IT-based com-ponents suggested by males [21].Both intervention arms were designed to engage parti-cipants in making healthy changes to their physical ac-tivity and nutrition behaviours, and improve their healthliteracy about these behaviours. This was achieved bythe provision of educational materials, increasing thefrequency of participation in physical activity andhealthy eating by the completion of a series of “chal-lenges”, and self-monitoring progress towards the com-pletion of each challenge. Participants were able toaccess their group’s intervention materials throughoutthe nine-month study period. Educational materials werespecifically designed to be clear and uncomplicated inthe presentation of the benefits of physical activity andhealthy eating, the amount or type required to achieveDuncan et al. BMC Public Health 2012, 12:656 Page 3 of 14http://www.biomedcentral.com/1471-2458/12/656Table 1 Components of the ManUp interventionMajor Component Sub-component Description IT-basedInterventionArmPrint-basedInterventionArmEducationalMaterialsPhysical ActivityWhat is physicalactivityDescription of✓ ✓- What is ‘physical activity’✓ ✓- The different intensities of physical activity✓ ✓- The physical activity guidelines for Australian adultsBenefits of physicalactivitySummary of the health, social and economicbenefits of physical activity participation✓ ✓Where to be active Summary of the locations to be physically activein the study area, including parks, communityfacilities, commercial recreation centres.✓ ✓Getting started Summary of the steps people should do tominimise risk when commencing a physicalactivity regime, including link to pre-exercisescreening tool. Includes information onselecting the correct equipment for theactivity, warming up, stretching, cooling down,progressively increasing activity, hydration andsun safety.✓ ✓Further information URLs of other health promotion websites andresources for further information on physicalactivity✓ ✓Healthy EatingWhat is healthyeatingDescription of- What is ‘healthy eating’ ✓ ✓- Where appropriate a serving size is defined ✓ ✓- The healthy eating guidelines for Australian adults ✓ ✓Benefits of healthyeatingSummary of the health benefits of healthy eating ✓ ✓Where to eathealthilySummary of the outlets that provide fresh foodoptions in the study area✓ ✓Getting started Summary of strategies to make choosing healthyeating a part of daily routines✓ ✓Further information URL addresses of other health promotionwebsites and resources for further informationon healthy eating✓ ✓Body WeightWhat is a healthybody weightDescription of how a healthy body weight isdefined using BMI and waist circumference✓ ✓Benefits of ahealthybody weightSummary of the health benefits of maintaining ahealthy body weight✓ ✓How to achieve ahealthy bodyweightSummary of the strategies that can be used tomaintain and/or achieve a healthy body weight✓ ✓Further information URL addresses of other health promotionwebsites and resources to assist in maintainingand/or achieving a healthy body weight✓ ✓Self-monitoring - Ability to record progress towards completingany of the challenges✓ ✓- Ability to record body weight, height andwaist circumference✓Duncan et al. BMC Public Health 2012, 12:656 Page 4 of 14http://www.biomedcentral.com/1471-2458/12/656health benefit, and how to achieve the amounts requiredfor health benefits [12,20,21]. Educational materials werealso designed to encourage males to change their healthbehaviours by recognizing how physical inactivity andpoor nutrition can adversely affect health and by usingthis recognition as a stimulus to set goals to make posi-tive changes to these behaviours [27]. The ManUp phys-ical activity and healthy eating “challenges” wereinformed by Social Cognitive Theory and Self RegulationTheory, and developed to change target behaviours byhaving participants engage in goal setting and self-monitoring behaviours based on these challenges[28,29]. Goal setting and self-monitoring was operatio-nalised by having participants select a challenge and rec-ord their progress towards completing the challenge.ManUp physical activity and healthy eating challengesThe “ManUp challenges” varied in duration and theamount of activity or healthy eating that males were askedto achieve. The challenges were designed to increase theoverall levels of physical activity and healthy eating, ratherthan achieving any particular guideline for the behaviours.Variation in the duration and requirements for each chal-lenge are described below. The challenge concept wasadopted in ManUp based on our formative research[12,20,21]. Challenges were constructed to provide partici-pants with specific, measureable, and time-based goals toachieve, which is consistent with established goal settingstrategies [30], by specifying the weekly and total volumeof activity across the duration of the challenge.In total, six ManUp physical activity challenges (seeTable 2) and a single ManUp healthy eating challenge wereprovided for participants to select from. For each challenge,participants could select from three different ‘strengths’ toparticipate in: light strength (three weeks), mid strength (sixweeks) and full strength (12 weeks). The different strengthchallenges also varied in the weekly volume of physical ac-tivity and healthy eating to be completed and could becompleted in any order. ManUp physical activity challengesincluded the activities of walking, cycling, swimming,Table 2 Description of the ManUp physical activity and healthy eating challengesActivity Light Strength (3 weeks) Mid Strength (6 weeks) Full strength (12 weeks)Walking 1.5 hrs/week or 2.5 hrs/week or 3.5 hrs/week or7500 steps/day 10000 steps/day 12000 steps/dayCycling 1 hr/week or 2 hrs/week 4 hrs/week25 km/week or 50 km/week or 100 km/weekSwimming 0.5 hr/week or 1 hr/week or 1.5 hrs/week or1 km/week 2 km/week 3 km/weekRunning 0.5 hr/week or 1 hr/week or 2.0 hrs/week or5 km/week 10 km/week 20 km/weekSport & Recreation 0.5 hr/week 1 hr/week 1.5 hrs/weekStrengthening Set 8 exercises Set 8 exercises Set 8 exercises1 x set (8–10 reps) 2 x set (8–10 reps) 3 x set (8–10 reps)2 x/week 2 x/week 2 x/weekHealthy Eating ≥3 healthy eating goals/day ≥5 healthy eating goals/day ≥7 healthy eating goals/dayTable 1 Components of the ManUp intervention (Continued)- Automatically generated summary of all datarecorded✓- Ability to schedule an activity and receivetext or email reminder✓- Visual summary of progress towardscompleting ManUp challenges✓ ✓Social-support - Ability to view ‘mates’ progress ✓- Ability to comment on a the profile page ofa mate✓- Ability to complete group based challenges ✓ManUp challenges Light, Mid and Full Strength Physical Activityand Healthy Eating Challenges✓ ✓Duncan et al. BMC Public Health 2012, 12:656 Page 5 of 14http://www.biomedcentral.com/1471-2458/12/656running, strengthening, sport and recreation, and wereselected based on recreation activities that Australian malesfrequently participate in [31]. The strengthening challengeincluded any resistance-based exercises such as freeweights, machine weights, and body weight exercises. Thesport and recreation challenge included any team-based ac-tivity or individual activity (i.e. soccer, football or group-based fitness class) not covered by the remaining five phys-ical activity challenges.The ManUp healthy eating challenges were based onachieving a number of daily healthy eating goals: in totalthere were ten healthy eating goals that could be achieved.The goals were based on the Dietary Guidelines forAustralian Adults, which promote eating a diverse dietthat includes fruits, vegetables, grains, cereals, lean meatand fish while limiting the consumption of saturated fat,salt, alcohol and foods that contain added sugars [32]. TheManUp daily healthy eating goals were to: (1) eat twoserves of fruit, (2) eat five serves of vegetables, (3) eat aserve of fish, (4) choose whole-grain bread instead ofwhite bread, (5) choose low-fat dairy products, (6) have asoft drink- (soda-) free day, (7) have an alcohol-free day,(8) have an red-meat-free day, (9) have an unhealthy-snack-free day, and (10) have a fast-food-free day. To pro-mote dietary diversity, participants were not constrainedto pre-selecting any specific ManUp healthy eating goalsfor the duration of a healthy eating challenge. Rather, par-ticipants were encouraged to achieve any of the tenManUp healthy eating goals on a daily basis and in orderto complete a challenge successfully the number ofhealthy eating goals needed to be achieved varied by thestrength of the challenge selected (Table 2).Differences in challenge strengths were designed tocater for varying levels of initial physical activity and nu-trition behaviours, to generate confidence to achieve arealistic target for behaviour change and to provide theopportunity to progressively increase changes to physicalactivity and dietary habits. Concise information on the‘why’, ‘how’, and ‘where’ for each physical activity andhealthy eating goal was provided to participants. The‘why’ focused on the health, social, or economic benefitsof engaging in the activity or achieving the healthy eat-ing goal. The ‘how’ provided tips on how to integrate theactivity or healthy eating goal into the daily routine toovercome barriers associated with participation. The‘where’ provided participants with local information inthe Gladstone and Rockhampton areas on where to en-gage in the activity or purchase the food or healthy alter-natives to unhealthy dietary choices.Intervention armsIT-based intervention armThe IT-based intervention arm included access to thepassword-protected ManUp website. The website containedsix sections that participants could navigate, including:My Profile, My Progress, My Mates, My Groups, MyWeight, and Information Centre. The My Profile sectionsummarized each participant’s progress in their currentchallenges, allowed participants to record their progresstowards any current challenges and post personalupdates to their profile, schedule future activities, anddisplayed their groups and a list of their ‘mates’ (onlinefriends on the website). The My Progress page allowedparticipants to examine their progress graphs towardstheir current challenges. The website allowed participantsto search for and view mates on the My Mates sectionof the website. The My Groups section allowed partici-pants to create a group and view the progress of groupsthey were part of. The My Weight section provided in-formation on the benefits of achieving a healthy weightand allowed participants to record their height, weightand waist circumference. This information was used toprovide automatically generated classifications of healthrisk based on waist circumference and body mass index(BMI). The Information Centre provided participantswith summaries of information related to physical activ-ity and healthy eating, as described in Table 1, and alsoinformation about the physical activity and healthy eat-ing challenges.The IT-based intervention arm promoted social sup-port, and friendly competition among male peers(group-based challenges) as these have been reported aseffective strategies to promote engagement in physicalactivity and healthy eating [12]. Social support was oper-ationalised by allowing men to ‘challenge’ their mates tocompete with them to achieve a goal either in a one-on-one basis, or as part of a larger group. Men were alsoable to view the progress of their mates in any challengethey were enrolled in and to comment on their mates'My Profile page.A mobile phone web application was developed as anadditional tool to facilitate quick and convenient record-ing of progress towards the ManUp challenges, ratherthan as a platform to deliver educational material [21]. Amobile phone web application, rather than an “installed”application specific to a mobile platform (Apple, An-droid, Windows), was developed to maximize access tothis additional self-monitoring tool. Any participant inthe IT-based intervention arm who owned a mobilephone capable of accessing the internet had access tothe mobile phone web application. The mobile phoneweb application allowed participants to enter their bodyweight, start a new ManUp physical activity or healthyeating challenge, record progress and view progress to-wards completing challenges. Both platforms were con-nected through protocols that enable data entry to beautomatically synchronized between platforms on a fre-quently scheduled period.Duncan et al. BMC Public Health 2012, 12:656 Page 6 of 14http://www.biomedcentral.com/1471-2458/12/656Print-based intervention armParticipants in the print-based group received a hard copybooklet that provided the same educational materials andManUp challenges as those received by participants in theIT-based intervention. Participants in the print-basedgroup were not provided with information on their peersin this group. The print-based booklet also included logsheets that could be used to monitor their progress and/orsuccessful completion of any of the ManUp physical activ-ity or healthy eating challenges.MeasuresAll participants completed an online questionnaire atbaseline and completed follow-up online questionnairesat 3 months and 9 months after they began the interven-tion. A randomly selected sub-sample (n = 91, 61 fromIT-based intervention arm, 30 from print-based inter-vention arm) of participants also attended one of thetrial centres (CQUniversity Gladstone or RockhamptonCampus) for an in-person assessment at each time point.During in-person assessments, participants completedthe online survey, received an accelerometer for the ob-jective measurement of physical activity, and had theirheight, weight and waist circumference measured by atrained research assistant.Demographic characteristicsParticipants self-reported the following demographiccharacteristics: age, employment status, level of employ-ment, industry of employment, number of hours of workper week, household income, years of education, numberof children (aged <18 years) living in the household, liv-ing situation, and presence of any chronic diseases diag-nosed by a doctor.Perceived health statusParticipants reported on several aspects of perceivedhealth status that have been identified as risk factors forhealth behaviours and chronic disease [16,33]. Two itemswere used to assess risk perception in relation to physicalactivity and body weight, consistent with previous re-search [16]. The items are “I believe that I am doingenough exercise/physical activity to achieve health bene-fits” and “I believe that my current body weight is a risk tomy health.” Responses were measured on a five-pointLikert type scale from strongly agree to strongly disagree[16]. The self-rated health item from the Healthy DaysModule of the Behavioral Risk Factor Surveillance Survey(BRFSS) was used to assess self-rated health, and responseoptions were excellent, very good, good, fair or poor [34].WeightAll participants self-reported current height (cm), weight(kg), and waist circumference (cm) during the onlinesurvey. For those individuals selected for in-person assess-ments, these measures are also measured by project staff.During in-person assessments, participant height to thenearest 0.1 cm (PE087, Mentone Educational, Victoria,Australia), weight to the nearest 0.1 kg (Tanita BF-681,Tanita Corp., Tokyo, Japan) and waist circumference tothe nearest 0.1 cm (Lufkin Executive W606PM) are mea-sured at each assessment point, in triplicate. Participantsare asked to wear light clothing and to remove shoes priorto the assessment. Waist circumference is measured hori-zontally at the umbilicus, after normal expiration, by atrained research assistant.Activity related behavioursPhysical activity was assessed in all participants usingthe Active Australia Questionnaire, which assesses thefrequency and duration of transport and recreationalwalking, moderate and vigorous intensity physical activ-ity [35]. The Active Australia Questionnaire has demon-strated acceptable levels of test re-test reliability andvalidity in the Australian adult population, and has beenidentified as a useful measure to detect intervention-related change in physical activity behaviours [36-39].Participants (n=91) who selected to attend in-personmeasurement sessions were fitted with an ActiGraphGT3X (ActiGraph, Pensacola, FL) accelerometer to pro-vide objective measures of activity behaviours over afive-day period. Participants were instructed to wear theActiGraph, mounted on an elastic belt around the waistwith the unit positioned over the right hip during allwaking, non-contact activities (thus excluding activitieslike rugby league or rugby union) and non-water-basedactivities. The ActiGraph monitors were set to recordsteps, inclination, and acceleration counts in tri-axialmode, using a 10-second epoch. Accelerometer data wasanalysed using the MeterPlus program [40] in 10 secondepochs using previously reported cut-points for seden-tary, light and moderate-to-vigorous intensity physicalactivity [41]. Non wear time was assessed using a mini-mum of 60 minutes of consecutive zero counts allowingup to a 2 minute tolerance of non-zero counts. A mini-mum of 10 hours per day of wear time on at least fourdays was required to be included in analysis.Self-reported duration of sitting in occupational settingsover the previous seven days was assessed using twoitems. Adapted from an existing measure of occupationalsitting [5,42], the first item asked participants to reportthe amount of time sitting at work during meetings, lunchand at their desk. Using the same recall period the seconditem asked participants to report the amount of timespent driving at work. Both items asked participants toreport the duration of sitting in hours and minutes.Duration of sitting in leisure time was assessed usingitems adapted from a existing measure of nine leisure-Duncan et al. BMC Public Health 2012, 12:656 Page 7 of 14http://www.biomedcentral.com/1471-2458/12/656time sedentary behaviours with demonstrated acceptabletest-retest reliability [43]. The sedentary behaviours thatwere assessed included computer use, hobbies, televi-sion viewing, sitting and socializing, reading, sitting orlying down while listening to music, talking on the tele-phone, going for a recreational drive, and relaxing,thinking and resting [43]. These items were modified toexplicitly ask about time spent sitting while performingeach behaviour, instead of time spent engaged in eachbehaviour.Nutrition behavioursNutrition behaviours related to the healthy eatingguidelines for Australian adults [32] were assessedusing 19 items adapted from the National Health Sur-vey Australia and the Monitoring Food Habits Ques-tionnaire [44,45]. The number of daily serves of fruitand vegetables usually consumed in the previousweek was assessed using two separate items, based onthose used in the National Health Survey [44]; pos-sible response options were: one serve or less; two tothree serves; four to five serves; six or more; anddon’t consume this food. The number of times in theprevious week that red meat, fish, meat products(sausages, salami, meat pies, etc.), cooked cereals,bread, soft drink, chips, takeaway foods, and sweet orsavoury foods were consumed was assessed using anine-point scale from rarely/never to more than seventimes per week, each item also included a “don’t con-sume this food” response option. The volume of milkconsumed each day and the type of milk (whole milk,reduced fat, soy milk, condensed milk) was assessedusing two separate items [44].Health literacyHealth literacy can be defined as the acquisition of a setof skills and knowledge that can be applied to changebehaviours and improve health [22,46]. The five physicalactivity awareness items from the Active Australia Ques-tionnaire were used to assess health literacy related tophysical activity [35]. These items assess awarenessrelated to the health benefits of physical activity that in-clude the minimum amount of physical activity requiredfor health benefit, the appropriate intensity of physicalactivity to achieve benefit, and the pattern in whichphysical activity can be accumulated to receive healthbenefits [35]. The 28-item Nutritional Literacy Surveywas used to assess health literacy related to healthy eat-ing [47]. This instrument presents sentences to the re-spondent that contain one or more words removedfrom the sentence, the respondent is provided withfour possible response options and asked to select theresponse that best fits the sentence [47]. Topics cov-ered include food types that promote heart health, fatand cholesterol contents of food, and portion size[47].IT platform usageBoth the website and mobile platforms allow monitoringof the number of times a participant has logged in, thenumber and date of entries made, and the number ofchallenges created and completed. The website platformalso permits monitoring of which educational resourcepages have been viewed by participants. These measuresdescribe the level of participant engagement with theintervention components.Sample sizeThe study was powered to detect a 60-minute in-crease in moderate-to-vigorous intensity physical ac-tivity using a 0.05 alpha, with a power level of 90%.Based on these factors, it was estimated that 197 par-ticipants would be required [48]. Typical dropoutrates in IT based interventions are approximately 30%[16]. Given the difficulty in engaging and retainingthe target population (middle aged males) the esti-mated sample size was increased to account for a45% dropout rate. Methods described by Hsieh to accountfor the loss of power associated with the 2:1 group alloca-tion [49], the estimated sample size was further inflatedusing a variance inflation factor of (VIF= 1.125) resultingin a total estimated sample size of 321; 107 allocated tothe print-based group and 214 allocated to the IT-basedgroup.AnalysisComparison of sample baseline characteristics betweenintervention arms were examined using chi-square testsfor proportions, and either linear, gamma or Poissongeneralized linear models for continuous or count data.Examination of change in outcomes will be based ongroup allocation and the intention-to-treat principle.Linear mixed models and generalized estimating equa-tions will be used to compare intervention groups acrosstime points [50]. Statistical significance was set at ap-value of 0.05.Baseline characteristics of the sampleA total of 327 males contacted the research team aboutparticipation in the study, 10 males withdrew from thestudy prior to randomization to an intervention arm(Figure 1). The primary reason for not continuing par-ticipation in the study was being no longer interested inparticipation after having details of the study explainedto them. Following allocation to an intervention arm,nine participants in the IT-based intervention arm andseven participants in the print-based intervention armdid not complete a baseline assessment and wereDuncan et al. BMC Public Health 2012, 12:656 Page 8 of 14http://www.biomedcentral.com/1471-2458/12/656withdrawn from the trial (Figure 1). Participants wereasked how they learned about the existence of theManUp project (for which they could report multiplemethods); responses were classified into the followingcategories 1) project specific advertisements and promo-tional materials (n = 152), 2) word of mouth (n = 87), 3)information provided at their workplace (n = 75), 4) dir-ect contact with project staff (n = 49), and 5) not speci-fied (n = 1).Participant socio-demographic characteristics at base-line are provided in Table 3. The average age of IT-basedand print-based intervention arms was similar (44.2 vs.43.8 p= .656). In both intervention arms, the majority ofparticipants were classified as working in professionaloccupations; there were no significant differences be-tween intervention arms in the proportion of partici-pants employed in professional, white collar, blue collaror other occupation categories (p= .639). All participantsowned a mobile phone, however only 151 (73.2%) ofthose in the IT-based intervention arm owned a mobilephone that was capable of accessing the internet. Theaverage BMI (calculated from self-reported height andweight) was 30.9 and 30.4 in the IT-based and print-based intervention arms respectively (p= .434), whenclassifying BMI in established BMI categories, over 85%of participants in both intervention arms were classifiedas either overweight or obese (Table 3). The IT-basedand print-based intervention arms did not significantlydiffer on average for the in-person measured BMI(29.8 vs. 30.2, p= .712) and over 80% of participants wereclassified as overweight or obese when using in-personmeasured BMI. There were no significant between-groupdifferences for any socio-demographic variable examinedin Table 3.Table 4 shows that there were no significant between-group differences in: self-reported minutes or sessions ofphysical activity; sitting during leisure time; sitting atwork; or minutes of objectively determined minutes ofsedentary, light and moderate-to-vigorous intensity phys-ical activity. When examining physical activity literacy, theAssessed for eligibilityn = 327Eligiblen = 317Excluded prior torandomisation (n=10)Reason for exclusion:No mobile (n=1)Too young (n=2)No longer interested (n=7)Randomisedn = 317Allocated to “Print-based”N=103Allocated to “IT-based”N=214n=96(incl. Obj n:=30)n=205(incl. Obj n:=61)Baseline assessment3 month assessment9 month assessment(incl. Obj n:=) (incl. Obj n:=)n=(incl. Obj n:=) (incl. Obj n:=)n=n= n=Withdrawal from trial (n=9)Reason for Exclusion:No longer interested (n=2)Moved away (n =1)Did not complete assessment (n=6)Withdrawal from trial (n=7)Reason for Exclusion: No longer interested (n=1)Unable to participate(n =1)Did not complete assessment (n=5)Figure 1 Flowchart describing the progress of participants through trial phases. Obj – Objective or ‘in person’ measurement completedwith randomly selected sub-sample of participants.Duncan et al. BMC Public Health 2012, 12:656 Page 9 of 14http://www.biomedcentral.com/1471-2458/12/656only significant between-group difference was that a lowerproportion of participants in the IT-based interventionarm agreed that 30 minutes each day is enough to im-prove health compared to the print-based interventionarm (70.2% vs. 82.3%, p= .026). No significant differenceswere observed between the IT-based intervention armand the print-based intervention arm on the proportion ofparticipants who reported eating at least two serves ofTable 3 Baseline comparisons of socio-demographic and anthropometric characteristics between ManUp interventiongroups (n = 301)Print-based IT-basedVariable N %, M (SE) N %, M (SE) pAge 96 43.8 (.6) 205 44.2 (.4) .656Occupational Classification% Professional 52 54.2% 118 57.6%% White Collar 8 8.3% 16 7.8%% Blue Collar 23 24.0% 37 18.0%% Otherb 13 13.5% 34 16.6% .639Education Level% Secondary School or Less 20 20.8% 45 22.0%% TAFE 25 26.0% 61 29.8%% University 51 53.1% 99 48.3% .719Self-Report Weight 96 96.3 (2.0) 205 98.3 (1.4) .389Self-Reported BMI 96 30.4 (.5) 205 30.9 (.4) .434Self-Reported BMI Classification% Healthy Weight 12 12.8% 19 9.3%% Overweight 40 42.6% 85 41.5%% Obese 42 44.7% 101 49.3% .588Self-Reported Waist Circumference 96 98.9 (2.0) 205 99.6 (1.4) .782Self-Reported Waist Circumference Classification% Healthy 33 34.4% 59 28.8%% Risky 28 29.2% 50 24.4%% High Risk 35 36.5% 96 46.8% .239Self-Rated Health Classification% Fair or Poor 25 26.0% 73 35.6%% Good 37 38.5% 83 40.5%% Very Good or Excellent 34 35.4% 49 23.9% .080Measured Weighta 30 94.7 (3.1) 61 93.3 (2.2) .719Measured BMIa 30 30.2 (.9) 61 29.8 (.6) .712Measured BMI Classificationa% Healthy Weight 3 10.0% 10 16.4%% Overweight 14 46.7% 26 42.6%% Obese 13 43.3% 25 41.0% .713Measured Waist Circumferencea 30 101.9 (2.3) 61 102.0 (1.6) .968Measured Waist Circumference Classificationa% Healthy 6 20.0% 15 24.6%% Risky 11 36.7% 19 31.1%% High Risk 13 43.3% 27 44.3% .830Note. a A randomly selected sub-sample (n = 91) of participants completed in person assessments of height, weight, waist circumference and physical activity(ActiGraph) these are referred to as “measured” outcomes.bOther category includes participants who were retired, students, unemployed or a pensioner.Duncan et al. BMC Public Health 2012, 12:656 Page 10 of 14http://www.biomedcentral.com/1471-2458/12/656Table 4 Baseline comparisons of physical activity and dietary behaviours between ManUp intervention groups (n=301)aPrint-based IT-basedN %, M (SE) or median(1st and 3rd quartile)N %, M (SE) or median(1st and 3rd quartile)pSelf-report physical activity behavioursWeekly minutes of physical activity 96 277.9 (34.0) 205 286.1 (23.3) .843Weekly session of physical activity 96 4 (1,8) 205 4 (1,7) .892Physical activity classification% None 19 19.8% 39 19.0%% Insufficient 36 37.5% 88 42.9%% Sufficient 41 42.7% 78 38.0% .655Daily minutes of sitting outside of work 96 520.1 (27.2) 205 492.9 (18.6) .409Daily minutes of sitting at work 96 411.0 (26.1) 205 452.4 (17.9) .191Objective Physical Activity BehavioursaDaily minutes of sedentary behaviour 25 631.0 (18.5) 52 670.6 (12.8) .079Daily minutes of light intensity physical activity 25 184.9 (8.4) 52 182.1 (5.8) .786Daily minutes of moderate-to-vigorous intensity physical activity 25 46.7 (4.9) 52 44.8 (3.2) .751Physical Activity Literacy (% Agree)> 30 minutes/day improves health 79 82.3% 144 70.2% .02630 minutes brisk walking improves health 79 82.3% 153 74.6% .14120 minutes of Vigorous activity 3 times a week is essential 54 56.3% 139 67.8% .05110 minute blocks of activity are okay 52 54.2% 106 51.7% .690Moderate activity can improve health 87 90.6% 177 86.3% .291Dietary Habits# Serves vegetables/day 96 2 (1,2) 205 2 (1,3) .793# Serves fruit/day 96 1 (1,2) 205 1 (1,2) .735# Serves of red meat last week 96 4 (3,6) 205 4 (3,5) .017# Soft drinks last week 96 2 (0,3) 205 1 (0,4) .783# Times fast food/takeaway 96 2 (0,2.75) 205 (1 (.5,2) .339Ave. Serves of Alcohol on a drinking day 96 2.78 (.3) 205 2.68 (.2) .761# Days of Harmful Drinking% 0 days 45 46.9% 102 49.8%% 1–2 days 29 30.2% 60 29.3%% ≥3 days 22 22.9% 43 21.0% .885Bread Type% White 40 42.6% 62 31.3%% Grain 53 56.4% 133 67.2%% Don’t Eat Bread 1 1.1% 3 1.5% .168Milk Type% Full Cream 37 38.5% 80 39.0%% Low Fat 50 52.1% 102 49.8%% Soy/Condensed 2 2.1% 5 2.4%% Don’t Drink Milk 2 2.1% 5 2.4%% Other 5 5.2% 13 6.3% .991Nutritional Literacy 96 25 (24, 26) 205 26 (24, 27) .656Note: a A randomly selected sub-sample (n=91) of participants completed in person assessments of height, weight, waist circumference and physical activity(ActiGraph). Variation in sample size is due to participants not fulfilling wear time criteria and were excluded from analysis of objective measures of physical activity.Duncan et al. BMC Public Health 2012, 12:656 Page 11 of 14http://www.biomedcentral.com/1471-2458/12/656fruit per day (38.5% vs. 35.4%, p= .602) and five or moreserves of vegetables per day (5.9% vs. 5.2%, p= .821). Theprint-based intervention arm consumed a higher numberof serves of red meat compared to the IT-based interven-tion arm (p= .017). No other significant differences wereobserved in nutrition behaviours or levels of nutrition lit-eracy between the intervention groups.DiscussionThis paper describes the intervention design, study proto-col and baseline characteristics of a sample of middle agedmales who took part in the ManUp Study. This study wasdesigned in an attempt to address some of the key issuesassociated with conducting research in the middle-agedmale population. These issues include specifically design-ing the intervention with the needs and preferences ofmales in mind to increase intervention appeal, and focus-ing on behavioural risk factors most relevant to men. Thestudy protocol will allow the efficacy of an IT-based deliv-ery of the intervention to be compared to a print-baseddelivery mode. If the IT-based delivery mode is found tobe efficacious, it will provide the foundation for similarinterventions that take advantage of the increased reach ofIT-based interventions to be developed for this populationgroup. Within the IT-based intervention arm, it will bepossible to determine the presence of any relationships be-tween engagement with the platform and change in out-comes. This will provide much needed information in thisarea as reviews of such interventions have identified that alow proportion of males engage in these interventions[12,19]. The ManUp Study will also collect information onthe components of the IT-based intervention that are uti-lized, and this information can be used to refine the strat-egies adopted in future IT-based interventions by focusingattention on those that participants use most frequently.Males are frequently reported to have high levels of an-thropometric and behavioural risk factors of poor health,and this is the underlying rationale for the current study[2,3,8]. Baseline characteristics of the ManUp Study parti-cipants indicate, that like many males, they are generallyoverweight or obese, have poor nutrition behaviours andhave a low level of total physical activity. Over 85% and80% of participants are classified as overweight or obesewhen using self-reported and measured BMI respectively;this is higher than levels of self-reported overweight orobesity in Queensland and Australian adult males [3,8,51].The proportion of participants who self-reported physicalactivity at a level sufficient to meet guidelines in print-and IT-based intervention arms (42.7% and 38.0%) islower than that observed in population-based samplescovering similar geographical areas (52.8%) [6]. Further-more, in comparison to other available data [52], thecurrent sample spends more time in sedentary behaviourand less time in light intensity physical activity. Theaverage nutrition behaviours of the study sample werebelow that recommended for Australian adults, and theproportion of the sample who achieved the minimumguidelines for fruit and vegetables was lower than thatreported for other Australian males [8].Levels of physical activity literacy in the currentsample were lower than those previously reported inAustralian males [53], particularly for awareness that ac-cumulating physical activity in 10-minute blocks can stillprovide health benefits. Over a decade has passed andsignificant financial investment has been directed towardthe promotion of physical activity in Australia and thelevels of physical activity literacy in the current sampleare lower than those reported in 1999 [53]. While this isconcerning from a health promotion perspective, it alsoprovides a unique opportunity to intervene and attemptto address the issue in the current sample of participantsto inform subsequent promotion efforts. In contrast,levels of nutrition literacy were relatively high with themedian score of both intervention groups close to the max-imum level and comparable to levels reported in the samplethe instrument was developed in [47]. This is a positivefinding in the current study, and somewhat unexpectedgiven that males in our formative study reported confusionaround nutritional messages [20].Subsequent phases of the ManUp Study will evaluatechanges in physical activity, nutrition behaviours, andhealth literacy of those topics over the interventionperiod, and will compare the efficacy of the two inter-vention arms to change these outcomes.Competing interestsThe authors declare that they have no competing interests.Authors’ contributionsMJD drafted the manuscript and completed statistical analysis. AM, RT, MKand HD developed the IT platform. MJD, CV, CH and ME were responsiblefor participant recruitment and overseeing study implementation. All authorscontributed to the design of the overall study, development of interventionmaterials, read, edited and approved the final manuscript.AcknowledgementsQueensland Health provided funding to conduct this project. CV issupported by a National Health and Medical Research Council of Australia(#519778) and National Heart Foundation of Australia (#PH 07B 3303) post-doctoral research fellowship.Author details1Central Queensland University, Institute for Health and Social ScienceResearch, Centre for Physical Activity Studies, Bruce Highway, Rockhampton,QLD 4700, Australia. 2Kansas State University, Department of HumanNutrition, , Manhattan, Kansas 66506, United States. 3University of BritishColumbia, School of Health and Exercise Sciences, Kelowna, British ColumbiaV1V 1V7, Canada. 4CSIRO, The Australian eHealth Research Centre, ICT Centre,Level 5, UQ Health Sciences Building 901/16, Royal Brisbane and Women'sHospital, Herston QLD, 4029, Australia. 5University of Western Sydney, Schoolof Science and Health, Locked Bag 1797, Penrith NSW 2751, Australia.6University of Western Sydney, School of Computing, Engineering andMathematics, Tele-Health Research and Innovation Laboratory, Narellan Road,Campbelltown, NSW 2560, Australia. 7 CSIRO, Food and Nutritional Sciences,PO Box 10041, Adelaide, BC 5000, Australia. 8Central Queensland University,Duncan et al. BMC Public Health 2012, 12:656 Page 12 of 14http://www.biomedcentral.com/1471-2458/12/656Boundary Road, Mackay, QLD 4740, Australia. 9University of Alberta, Facultyof Physical Education and Recreation, Edmonton, Alberta, T6G 2H9, Canada.Received: 27 June 2012 Accepted: 2 August 2012Published: 15 August 2012References1. Wilkins D: Introduction. Belgium: European Men's Health Forum (EMHF0);2009.2. Department of Health and Aging: Building on the strengths of Australianmales - healthy routines. In National Male Health Policy. Edited byAustralian Government. Canberra: Canberra; 2010.3. Australian Bureau of Statistics: Men's Health: Australian Social Trends: 4102.Canberra: Australian Bureau of Statistics; 2010.4. Thorp AA, Healy GN, Owen N, Salmon J, Ball K, Shaw JE, Zimmet PZ,Dunstan DW: Deleterious associations of sitting time and televisionviewing time with cardiometabolic risk biomarkers: Australian diabetes,obesity and lifestyle (AusDiab) study 2004–2005. 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Canberra:Australian Institute of Health and Welfare; 2000.doi:10.1186/1471-2458-12-656Cite this article as: Duncan et al.: Effectiveness of a website and mobilephone based physical activity and nutrition intervention for middle-aged males: Trial protocol and baseline findings of the ManUp Study.BMC Public Health 2012 12:656.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submitDuncan et al. BMC Public Health 2012, 12:656 Page 14 of 14http://www.biomedcentral.com/1471-2458/12/656


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