Dutch Young Adults Ratings of Behavior Change Techniques Applied in Mobile Phone Apps to Promote Physical Activity: A Cross-Sectional Survey.

Belmon Laura S, Middelweerd Anouk, Te Velde Saskia J, Brug Johannes

JMIR mHealth and uHealth [3:e103] (2015)

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Interventions delivered through new device technology, including mobile phone apps, appear to be an effective method to reach young adults. Previous research indicates that self-efficacy and social support for physical activity and self-regulation behavior change techniques (BCT), such as goal setting, feedback, and self-monitoring, are important for promoting physical activity; however, little is known about evaluations by the target population of BCTs applied to physical activity apps and whether these preferences are associated with individual personality characteristics. This study aimed to explore young adults' opinions regarding BCTs (including self-regulation techniques) applied in mobile phone physical activity apps, and to examine associations between personality characteristics and ratings of BCTs applied in physical activity apps. We conducted a cross-sectional online survey among healthy 18 to 30-year-old adults (N=179). Data on participants' gender, age, height, weight, current education level, living situation, mobile phone use, personality traits, exercise self-efficacy, exercise self-identity, total physical activity level, and whether participants met Dutch physical activity guidelines were collected. Items for rating BCTs applied in physical activity apps were selected from a hierarchical taxonomy for BCTs, and were clustered into three BCT categories according to factor analysis: "goal setting and goal reviewing," "feedback and self-monitoring," and "social support and social comparison." Most participants were female (n=146), highly educated (n=169), physically active, and had high levels of self-efficacy. In general, we observed high ratings of BCTs aimed to increase "goal setting and goal reviewing" and "feedback and self-monitoring," but not for BCTs addressing "social support and social comparison." Only 3 (out of 16 tested) significant associations between personality characteristics and BCTs were observed: "agreeableness" was related to more positive ratings of BCTs addressing "goal setting and goal reviewing" (OR 1.61, 95% CI 1.06-2.41), "neuroticism" was related to BCTs addressing "feedback and self-monitoring" (OR 0.76, 95% CI 0.58-1.00), and "exercise self-efficacy" was related to a high rating of BCTs addressing "feedback and self-monitoring" (OR 1.06, 95% CI 1.02-1.11). No associations were observed between personality characteristics (ie, personality, exercise self-efficacy, exercise self-identity) and participants' ratings of BCTs addressing "social support and social comparison." Young Dutch physically active adults rate self-regulation techniques as most positive and techniques addressing social support as less positive among mobile phone apps that aim to promote physical activity. Such ratings of BCTs differ according to personality traits and exercise self-efficacy. Future research should focus on which behavior change techniques in app-based interventions are most effective to increase physical activity.

Interventions to increase condom use among middle-aged and older adults: A systematic review of theoretical bases, behaviour change techniques, modes of delivery and treatment fidelity.

MacDonald Jennifer, Lorimer Karen, Knussen Christina, Flowers Paul

Journal of health psychology [:Array] (2015)

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This systematic review collates, examines and syntheses condom use interventions for middle-aged and older adults. Associations between effectiveness and theoretical basis, behaviour change techniques, mode of delivery and treatment fidelity were explored. Five interventions were included; one was effective. Compared to interventions with non-significant findings, the effective telephone-administered intervention used theory to a greater extent, had a higher number of behaviour change techniques and employed more treatment fidelity strategies. There is a need to develop theory-based interventions targeting condom use among this population and evaluate these in randomised controlled trials that are rigorously designed and reported. Health psychologists have a key role in this endeavour.

Computerized cognitive training for older diabetic adults at risk of dementia: Study protocol for a randomized controlled trial.

Bloom Rachel, Schnaider-Beeri Michal, Ravona-Springer Ramit, Heymann Anthony, Dabush Hai, Bar Lior, Slater Shirel, Rassovsky Yuri, Bahar-Fuchs Alex

Alzheimer's & dementia (New York, N. Y.) [3:636-650] (2017)

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Older adults with type 2 diabetes are at high risk of cognitive decline and dementia and form an important target group for dementia risk reduction studies. Despite evidence that computerized cognitive training (CCT) may benefit cognitive performance in cognitively healthy older adults and those with mild cognitive impairment, whether CCT may benefit cognitive performance or improve disease self-management in older diabetic adults has not been studied to date. In addition, whether adaptive difficulty levels and tailoring of interventions to individuals' cognitive profile are superior to generic training remains to be established. Ninety community-dwelling older (age ≥ 65) diabetic adults are recruited and randomized into a tailored and adaptive computerized cognitive training condition or to a generic, nontailored, or adaptive CCT condition. Both groups complete an 8-week training program using the commercially available CogniFit program. The intervention is augmented by a range of behavior-change techniques, and participants in each condition are further randomized into a global or cognition-specific phone-based self-efficacy (SE) condition, or a no-SE condition. The primary outcome is global cognitive performance immediately after the intervention. Secondary outcomes include diabetes self-management, meta-memory, mood, and SE. This pilot study is the first trial evaluating the potential benefits of home-based tailored and adaptive CCT in relation to cognitive and disease self-management in older diabetic adults. Methodological strengths of this trial include the double-blind design, the clear identification of the proposed active ingredients of the intervention, and the use of evidence-based behavior-change techniques. Results from this study will indicate whether CCT has the potential to lower the risk of diabetes-related cognitive decline. The outcomes of the trial will also advance our understanding of essential intervention parameters required to improve or maintain cognitive function and enhance disease self-management in this at-risk group.

Tailored and Adaptive Computerized Cognitive Training in Older Adults at Risk for Dementia: A Randomized Controlled Trial.

Bahar-Fuchs Alex, Webb Shannon, Bartsch Lauren, Clare Linda, Rebok George, Cherbuin Nicolas, Anstey Kaarin J

Journal of Alzheimer's disease : JAD [60:889-911] (2017)

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Computerized Cognitive Training (CCT) has been shown to improve cognitive function in older adults with mild cognitive impairment (MCI) or mood-related neuropsychiatric symptoms (MrNPS), but many questions remain unresolved. To evaluate the extent to which CCT benefits older adults with both MCI and MrNPS, and its effects on meta-cognitive and non-cognitive outcomes, as well as establish whether adapting difficulty levels and tailoring to individuals' profile is superior to generic training. Older adults with MCI (n = 9), MrNPS (n = 11), or both (MCI+, n = 25) were randomized into a home-based individually-tailored and adaptive CCT (n = 21) or an active control condition (AC; n = 23) in a double-blind design. Interventions lasted 8-12 weeks and outcomes were assessed after the intervention, and at a 3-month follow-up. Participants in both conditions reported greater satisfaction with their everyday memory following intervention and at follow-up. However, participants in the CCT condition showed greater improvement on composite measures of memory, learning, and global cognition at follow-up. Participants with MrNPS in the CCT condition were also found to have improved mood at 3-month follow-up and reported using fewer memory strategies at the post-intervention and follow-up assessments. There was no evidence that participants with MCI+ were disadvantaged relative to the other diagnostic conditions. Finally, informant-rated caregiver burden declined at follow-up assessment in the CCT condition relative to the AC condition. Home-based CCT with adaptive difficulty and personal tailoring appears superior to more generic CCT in relation to both cognitive and non-cognitive outcomes. Mechanisms of treatment effect and future directions are discussed.

Specifying the content of home-based health behaviour change interventions for older people with frailty or at risk of frailty: an exploratory systematic review.

Gardner Benjamin, Jovicic Ana, Belk Celia, Kharicha Kalpa, Iliffe Steve, Manthorpe Jill, Goodman Claire, Drennan Vari M, Walters Kate

BMJ open [7:e014127] (2017)

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To identify trials of home-based health behaviour change interventions for frail older people, describe intervention content and explore its potential contribution to intervention effects. 15 bibliographic databases, and reference lists and citations of key papers, were searched for randomised controlled trials of home-based behavioural interventions reporting behavioural or health outcomes. Participants' homes. Community-dwelling adults aged ≥65 years with frailty or at risk of frailty. Trials were coded for effects on thematically clustered behavioural, health and well-being outcomes. Intervention content was described using 96 behaviour change techniques, and 9 functions (eg, education, environmental restructuring). 19 eligible trials reported 22 interventions. Physical functioning was most commonly assessed (19 interventions). Behavioural outcomes were assessed for only 4 interventions. Effectiveness on most outcomes was limited, with at most 50% of interventions showing potential positive effects on behaviour, and 42% on physical functioning. 3 techniques (instruction on how to perform behaviour, adding objects to environment, restructuring physical environment) and 2 functions (education and enablement) were more commonly found in interventions showing potential than those showing no potential to improve physical function. Intervention content was not linked to effectiveness on other outcomes. Interventions appeared to have greatest impact on physical function where they included behavioural instructions, environmental modification and practical social support. Yet, mechanisms of effects are unclear, because impact on behavioural outcomes has rarely been considered. Moreover, the robustness of our findings is also unclear, because interventions have been poorly reported. Greater engagement with behavioural science is needed when developing and evaluating home-based health interventions. ID=CRD42014010370.

A scoping review on interventions to promote physical activity among adults with disabilities

Castro O, Ng K, Novoradovskaya E, Bosselut G, Hassandra M

Disability and Health Journal (2017)

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Despite the strong evidence that physical activity (PA) is a key determinant of health, there is limited knowledge on the content and outcomes of PA promotion interventions among individuals with disabilities. To conduct a scoping review in order to examine the published literature on PA promotion interventions among adults with disabilities. A scoping review following the methodological framework provided by Arksey and O'Malley used electronic databases (MEDLINE, PsycINFO, and CINAHL), reference lists, and journals to locate studies. Inclusion criteria were based on study aim, outcome measures, and a disability definition by the WHO International Classification of Functioning, Disability and Health. The Behavior Change Techniques Taxonomy version 1 and Furlan and collaborators' risk of bias assessment were utilized during the data charting stage. Thirty-eight articles met the inclusion criteria. Most of the studies (70%) reported a significant increase in PA behavior immediately following intervention. However, less than half of the studies (46%) examined the maintenance of pre-/post-test differences. The number of identified behavior change techniques was significantly higher for successful PA promotion interventions than for interventions with no effects on PA. Approximately one-third of studies (32%) were rated as having a high risk of bias. Although findings support the idea that PA promotion interventions produce positive changes in PA behavior for a variety of disability conditions, risk of bias assessment calls for prudence. There are opportunities for continued development of the area of PA promotion among individuals with disabilities through systematic reviews and meta-analyses.

A scoping review on interventions to promote physical activity among adults with disabilities.

Castro Oscar, Ng Kwok, Novoradovskaya Elizaveta, Bosselut Grégoire, Hassandra Mary

Disability and health journal [11:174-183] (2018)

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Despite the strong evidence that physical activity (PA) is a key determinant of health, there is limited knowledge on the content and outcomes of PA promotion interventions among individuals with disabilities. To conduct a scoping review in order to examine the published literature on PA promotion interventions among adults with disabilities. A scoping review following the methodological framework provided by Arksey and O'Malley used electronic databases (MEDLINE, PsycINFO, and CINAHL), reference lists, and journals to locate studies. Inclusion criteria were based on study aim, outcome measures, and a disability definition by the WHO International Classification of Functioning, Disability and Health. The Behavior Change Techniques Taxonomy version 1 and Furlan and collaborators' risk of bias assessment were utilized during the data charting stage. Thirty-eight articles met the inclusion criteria. Most of the studies (70%) reported a significant increase in PA behavior immediately following intervention. However, less than half of the studies (46%) examined the maintenance of pre-/post-test differences. The number of identified behavior change techniques was significantly higher for successful PA promotion interventions than for interventions with no effects on PA. Approximately one-third of studies (32%) were rated as having a high risk of bias. Although findings support the idea that PA promotion interventions produce positive changes in PA behavior for a variety of disability conditions, risk of bias assessment calls for prudence. There are opportunities for continued development of the area of PA promotion among individuals with disabilities through systematic reviews and meta-analyses.

Toward the optimal strategy for sustained weight loss in overweight cancer survivors: a systematic review of the literature.

Hoedjes Meeke, van Stralen Maartje M, Joe Sheena Tjon A, Rookus Matti, van Leeuwen Flora, Michie Susan, Seidell Jacob C, Kampman Ellen

Journal of cancer survivorship : research and practice (2017)

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To gain more insight into the optimal strategy to achieve weight loss and weight loss maintenance in overweight and obese cancer survivors after completion of initial treatment, this systematic review aimed to provide an overview of the literature on intervention effects on weight, to describe intervention components used in effective interventions, to identify and synthesize behaviour change techniques (BCTs) and to assess the frequency with which these BCTs were used in effective interventions. Six databases were searched for original research articles describing weight changes in adult overweight cancer survivors after participation in a lifestyle intervention initiated after completion of initial treatment. Two researchers independently screened the retrieved papers and extracted BCTs using the BCT Taxonomy version 1. Thirty-two papers describing 27 interventions were included. Interventions that were evaluated with a robust study design (n = 8) generally showed <5% weight loss and did not evaluate effects at ≥12 months after intervention completion. Effective interventions promoted both diet and physical activity and used the BCTs 'goal setting (behaviour)', 'action planning', 'social support (unspecified)' and 'instruction on how to perform the behaviour'. The results of this first review on intervention components of effective interventions could be used to inform intervention development and showed a need for future publications to report long-term effects, a detailed intervention description and an extensive process evaluation. This study contributed to increasing knowledge on the optimal strategy to achieve weight loss, which is recommended for overweight cancer survivors to improve health outcomes.

Characterizing Active Ingredients of eHealth Interventions Targeting Persons With Poorly Controlled Type 2 Diabetes Mellitus Using the Behavior Change Techniques Taxonomy: Scoping Review.

Kebede Mihiretu M, Liedtke Tatjana P, Möllers Tobias, Pischke Claudia R

Journal of medical Internet research [19:e348] (2017)

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The behavior change technique taxonomy v1 (BCTTv1; Michie and colleagues, 2013) is a comprehensive tool to characterize active ingredients of interventions and includes 93 labels that are hierarchically clustered into 16 hierarchical clusters. The aim of this study was to identify the active ingredients in electronic health (eHealth) interventions targeting patients with poorly controlled type 2 diabetes mellitus (T2DM) and relevant outcomes. We conducted a scoping review using the BCTTv1. Randomized controlled trials (RCTs), studies with or pre-post-test designs, and quasi-experimental studies examining efficacy and effectiveness of eHealth interventions for disease management or the promotion of relevant health behaviors were identified by searching PubMed, Web of Science, and PsycINFO. Reviewers independently screened titles and abstracts for eligibility using predetermined eligibility criteria. Data were extracted following a data extraction sheet. The BCTTv1 was used to characterize active ingredients of the interventions reported in the included studies. Of the 1404 unique records screened, 32 studies fulfilled the inclusion criteria and reported results on the efficacy and or or effectiveness of interventions. Of the included 32 studies, 18 (56%) were Web-based interventions delivered via personal digital assistant (PDA), tablet, computer, and/or mobile phones; 7 (22%) were telehealth interventions delivered via landline; 6 (19%) made use of text messaging (short service message, SMS); and 1 employed videoconferencing (3%). Of the 16 hierarchical clusters of the BCTTv1, 11 were identified in interventions included in this review. Of the 93 individual behavior change techniques (BCTs), 31 were identified as active ingredients of the interventions. The most common BCTs identified were instruction on how to perform behavior, adding objects to the environment, information about health consequences, self-monitoring of the outcomes and/or and prefers to be explicit to avoid ambiguity. Response: Checked and avoided of a certain behavior Author: Please note that the journal discourages the use of parenthesis to denote either and/or and prefers to be explicit to avoid ambiguity. Response: Checked and avoided "and/or" and prefers to be explicit to avoid ambiguity. Response: Checked and avoided, and feedback on outcomes of behavior. Our results suggest that the majority of BCTs employed in interventions targeting persons with T2DM revolve around the promotion of self-regulatory behavior to manage the disease or to assist patients in performing health behaviors necessary to prevent further complications of the disease. Detailed reporting of the BCTs included in interventions targeting this population may facilitate the replication and further investigation of such interventions.

Using a behaviour change techniques taxonomy to identify active ingredients within trials of implementation interventions for diabetes care.

Presseau Justin, Ivers Noah M, Newham James J, Knittle Keegan, Danko Kristin J, Grimshaw Jeremy M

Implementation science : IS [10:55] (2015)

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Methodological guidelines for intervention reporting emphasise describing intervention content in detail. Despite this, systematic reviews of quality improvement (QI) implementation interventions continue to be limited by a lack of clarity and detail regarding the intervention content being evaluated. We aimed to apply the recently developed Behaviour Change Techniques Taxonomy version 1 (BCTTv1) to trials of implementation interventions for managing diabetes to assess the capacity and utility of this taxonomy for characterising active ingredients. Three psychologists independently coded a random sample of 23 trials of healthcare system, provider- and/or patient-focused implementation interventions from a systematic review that included 142 such studies. Intervention content was coded using the BCTTv1, which describes 93 behaviour change techniques (BCTs) grouped within 16 categories. We supplemented the generic coding instructions within the BCTTv1 with decision rules and examples from this literature. Less than a quarter of possible BCTs within the BCTTv1 were identified. For implementation interventions targeting providers, the most commonly identified BCTs included the following: adding objects to the environment, prompts/cues, instruction on how to perform the behaviour, credible source, goal setting (outcome), feedback on outcome of behaviour, and social support (practical). For implementation interventions also targeting patients, the most commonly identified BCTs included the following: prompts/cues, instruction on how to perform the behaviour, information about health consequences, restructuring the social environment, adding objects to the environment, social support (practical), and goal setting (behaviour). The BCTTv1 mapped well onto implementation interventions directly targeting clinicians and patients and could also be used to examine the impact of system-level interventions on clinician and patient behaviour. The BCTTv1 can be used to characterise the active ingredients in trials of implementation interventions and provides specificity of content beyond what is given by broader intervention labels. Identification of BCTs may provide a more helpful means of accumulating knowledge on the content used in trials of implementation interventions, which may help to better inform replication efforts. In addition, prospective use of a behaviour change techniques taxonomy for developing and reporting intervention content would further aid in building a cumulative science of effective implementation interventions.

Diet Behavior Change Techniques in Type 2 Diabetes: A Systematic Review and Meta-analysis.

Cradock Kevin A, ÓLaighin Gearóid, Finucane Francis M, McKay Rhyann, Quinlan Leo R, Martin Ginis Kathleen A, Gainforth Heather L

Diabetes care [40:1800-1810] (2017)

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Dietary behavior is closely connected to type 2 diabetes. The purpose of this meta-analysis was to identify behavior change techniques (BCTs) and specific components of dietary interventions for patients with type 2 diabetes associated with changes in HbA and body weight. The Cochrane Library, CINAHL, Embase, PubMed, PsycINFO, and Scopus databases were searched. Reports of randomized controlled trials published during 1975-2017 that focused on changing dietary behavior were selected, and methodological rigor, use of BCTs, and fidelity and intervention features were evaluated. In total, 54 studies were included, with 42 different BCTs applied and an average of 7 BCTs used per study. Four BCTs-"problem solving," "feedback on behavior," "adding objects to the environment," and "social comparison"-and the intervention feature "use of theory" were associated with >0.3% (3.3 mmol/mol) reduction in HbA. Meta-analysis revealed that studies that aimed to control or change the environment showed a greater reduction in HbA of 0.5% (5.5 mmol/mol) (95% CI -0.65, -0.34), compared with 0.32% (3.5 mmol/mol) (95% CI -0.40, -0.23) for studies that aimed to change behavior. Limitations of our study were the heterogeneity of dietary interventions and poor quality of reporting of BCTs. This study provides evidence that changing the dietary environment may have more of an effect on HbA in adults with type 2 diabetes than changing dietary behavior. Diet interventions achieved clinically significant reductions in HbA, although initial reductions in body weight diminished over time. If appropriate BCTs and theory are applied, dietary interventions may result in better glucose control.

Behaviour change techniques targeting both diet and physical activity in type 2 diabetes: A systematic review and meta-analysis.

Cradock Kevin A, ÓLaighin Gearóid, Finucane Francis M, Gainforth Heather L, Quinlan Leo R, Ginis Kathleen A Martin

The international journal of behavioral nutrition and physical activity [14:18] (2017)

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Changing diet and physical activity behaviour is one of the cornerstones of type 2 diabetes treatment, but changing behaviour is challenging. The objective of this study was to identify behaviour change techniques (BCTs) and intervention features of dietary and physical activity interventions for patients with type 2 diabetes that are associated with changes in HbA1c and body weight. We performed a systematic review of papers published between 1975-2015 describing randomised controlled trials (RCTs) that focused exclusively on both diet and physical activity. The constituent BCTs, intervention features and methodological rigour of these interventions were evaluated. Changes in HbA1c and body weight were meta-analysed and examined in relation to use of BCTs. Thirteen RCTs were identified. Meta-analyses revealed reductions in HbA1c at 3, 6, 12 and 24 months of -1.11 % (12 mmol/mol), -0.67 % (7 mmol/mol), -0.28 % (3 mmol/mol) and -0.26 % (2 mmol/mol) with an overall reduction of -0.53 % (6 mmol/mol [95 % CI -0.74 to -0.32, P < 0.00001]) in intervention groups compared to control groups. Meta-analyses also showed a reduction in body weight of -2.7 kg, -3.64 kg, -3.77 kg and -3.18 kg at 3, 6, 12 and 24 months, overall reduction was -3.73 kg (95 % CI -6.09 to -1.37 kg, P = 0.002). Four of 46 BCTs identified were associated with >0.3 % reduction in HbA1c: 'instruction on how to perform a behaviour', 'behavioural practice/rehearsal', 'demonstration of the behaviour' and 'action planning', as were intervention features 'supervised physical activity', 'group sessions', 'contact with an exercise physiologist', 'contact with an exercise physiologist and a dietitian', 'baseline HbA1c >8 %' and interventions of greater frequency and intensity. Diet and physical activity interventions achieved clinically significant reductions in HbA1c at three and six months, but not at 12 and 24 months. Specific BCTs and intervention features identified may inform more effective structured lifestyle intervention treatment strategies for type 2 diabetes.

The impact of an innovative web-based school nutrition intervention to increase fruits and vegetables and milk and alternatives in adolescents: a clustered randomized trial.

Chamberland Karine, Sanchez Marina, Panahi Shirin, Provencher Véronique, Gagnon Jocelyn, Drapeau Vicky

The international journal of behavioral nutrition and physical activity [14:140] (2017)

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The increase in overweight and obesity in adolescents and its health-related consequences highlight the need to develop strategies, which could help them adopt healthy eating habits. The objective of this study was to evaluate the impact of an innovative web-based school nutrition intervention (Team Nutriathlon) aimed at promoting the consumption of vegetables and fruit (V/F) and milk and alternatives (M/A) in high school students and to identify facilitators and/or barriers influencing its success. Ten classes of first and second year secondary students (grades 7 and 8) from the Québec City region were randomized into two groups (control n = 89 and intervention n = 193). Participants in the intervention (Team Nutriathlon) were to increase their consumption of V/F and M/A using an innovative web-based platform, developed for this study, over 6 weeks. The control group followed the regular school curriculum. The number of servings of V/F and M/A consumed by students per day was compared between the two groups before, during, immediately after and 10 weeks after the intervention using a web-based platform. Main outcome measures included V/F and M/A servings and facilitators and/or barriers of program success. Repeated measures linear fixed effects models were used to assess the impact of Team Nutriathlon on V/F and M/A consumption. A P-value of <0.05 was considered significant. Students in the intervention reported a significant increase of 3 servings and 1.8 servings per day of V/F and M/A, respectively, compared to the control group (P < 0.05); however, this was only observed in the short-term. Some factors contributing to the success of Team Nutriathlon included the team aspect of the program, use of the technology and recording results outside of classroom hours. Team Nutriathlon represents an innovative web-based nutrition program which positively impacts V/F and M/A consumption among high school students. Using web-based or technological platforms may help youth adopt healthy eating habits that will have implications later in adulthood; however, further studies are needed to determine their long-term effects. NCT03117374 (retrospectively registered).

The effectiveness of motivational interviewing for health behaviour change in primary care settings: a systematic review.

Morton Katie, Beauchamp Mark, Prothero Anna, Joyce Lauren, Saunders Laura, Spencer-Bowdage Sarah, Dancy Bernadette, Pedlar Charles

Health psychology review [9:205-23] (2015)

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Motivational interviewing (MI) is a patient-centred approach to behaviour change that was originally developed in the addiction field but has increasingly been applied to public health settings with a focus on health promotion. The purpose of this review was to examine the evidence base for MI interventions in primary care settings with non-clinical populations to achieve behaviour change for physical activity, dietary behaviours and/or alcohol intake. We also sought to explore the specific behaviour change techniques included in MI interventions within primary care. Electronic databases were searched for relevant articles and 33 papers met inclusion criteria and were included. Approximately 50% of the included studies (n = 18) demonstrated positive effects in relation to health behaviour change. The efficacy of MI approaches is unclear given the inconsistency of MI descriptions and intervention components. Furthermore, research designs that do not isolate the effects of MI make it difficult to determine the effectiveness of such approaches. We offer a number of recommendations for researchers and practitioners seeking to include MI within behaviour change interventions to help improve the quality of the research and the effectiveness of MI-based interventions within primary care settings.

Counseling for health behavior change in people with COPD: systematic review.

Williams Marie T, Effing Tanja W, Paquet Catherine, Gibbs Carole A, Lewthwaite Hayley, Li Lok Sze Katrina, Phillips Anna C, Johnston Kylie N

International journal of chronic obstructive pulmonary disease [12:2165-2178] (2017)

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Counseling has been suggested as a promising approach for facilitating changes in health behavior. The aim of this systematic review of counseling interventions for people with COPD was to describe: 1) counseling definitions, 2) targeted health behaviors, 3) counseling techniques and 4) whether commonalities in counseling techniques were associated with improved health behaviors. Ten databases were searched for original randomized controlled trials which included adults with COPD, used the term "counseling" as a sole or component of a multifaceted intervention and were published in the previous 10 years. Data extraction, study appraisal and coding for behavior change techniques (BCTs) were completed by two independent reviewers. Data were synthesized descriptively, with meta-analysis conducted where possible. Of the 182 studies reviewed as full-text, 22 were included. A single study provided a definition for counseling. Two key behaviors were the main foci of counseling: physical activity (n=9) and smoking cessation (n=8). Six studies (27%) reported underlying models and/or theoretical frameworks. Counseling was the sole intervention in 10 studies and part of a multicomponent intervention in 12. Interventions targeting physical activity included a mean of 6.3 (±3.1) BCTs, smoking cessation 4.9 (±2.9) BCTs and other behaviors 6.5 (±3.9) BCTs. The most frequent BCTs were social support unspecified (n=22; 100%), goal setting behavior (n=11), problem-solving (n=11) and instructions on how to perform the behavior (n=10). No studies shared identical BCT profiles. Counseling had a significant positive effect for smoking cessation and positive but not significant effect for physical activity. Counseling for health behavior change was rarely defined and effectiveness varied by target behavior. Provision of specific details when reporting studies of counseling interventions (definition, BCTs, dosage) would allow clarification of the effectiveness of counseling as an approach to health behavior change in people with COPD.

Can Communicating Personalised Disease Risk Promote Healthy Behaviour Change? A Systematic Review of Systematic Reviews.

French David P, Cameron Elaine, Benton Jack S, Deaton Christi, Harvie Michelle

Annals of behavioral medicine : a publication of the Society of Behavioral Medicine (2017)

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The assessment and communication of disease risk that is personalised to the individual is widespread in healthcare contexts. Despite several systematic reviews of RCTs, it is unclear under what circumstances that personalised risk estimates promotes change in four key health-related behaviours: smoking, physical activity, diet and alcohol consumption. The present research aims to systematically identify, evaluate and synthesise the findings of existing systematic reviews. This systematic review of systematic reviews followed published guidance. A search of four databases and two-stage screening procedure with good reliability identified nine eligible systematic reviews. The nine reviews each included between three and 15 primary studies, containing 36 unique studies. Methods of personalising risk feedback included imaging/visual feedback, genetic testing, and numerical estimation from risk algorithms. The reviews were generally high quality. For a broad range of methods of estimating and communicating risk, the reviews found no evidence that risk information had strong or consistent effects on health-related behaviours. The most promising effects came from interventions using visual or imaging techniques and with smoking cessation and dietary behaviour as outcomes, but with inconsistent results. Few interventions explicitly used theory, few targeted self-efficacy or response efficacy, and a limited range of Behaviour Change Techniques were used. Presenting risk information on its own, even when highly personalised, does not produce strong effects on health-related behaviours or changes which are sustained. Future research in this area should build on the existing knowledge base about increasing the effects of risk communication on behaviour.

Maintaining abstinence from smoking after a period of enforced abstinence - systematic review, meta-analysis and analysis of behaviour change techniques with a focus on mental health.

Brose L S, Simonavicius E, McNeill A

Psychological medicine (2017)

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Smoking prevalence is doubled among people with mental health problems and reaches 80% in inpatient, substance misuse and prison settings, widening inequalities in morbidity and mortality. As more institutions become smoke-free but most smokers relapse immediately post-discharge, we aimed to review interventions to maintain abstinence post-discharge. MEDLINE, EMBASE, PsycINFO, CINAHL and Web of Science were searched from inception to May 2016 and randomised controlled trials (RCTs) and cohort studies conducted with adult smokers in prison, inpatient mental health or substance use treatment included. Risk of bias (study quality) was rated using the Effective Public Health Practice Project Tool. Behaviour change techniques (BCTs) were coded from published papers and manuals using a published taxonomy. Mantel-Haenszel random effects meta-analyses of RCTs used biochemically verified point-prevalence smoking abstinence at (a) longest and (b) 6-month follow-up. Five RCTs (n = 416 intervention, n = 415 control) and five cohort studies (n = 471) included. Regarding study quality, four RCTs were rated strong, one moderate; one cohort study was rated strong, one moderate and three weak. Most common BCTs were pharmacotherapy (n = 8 nicotine replacement therapy, n = 1 clonidine), problem solving, social support, and elicitation of pros and cons (each n = 6); papers reported fewer techniques than manuals. Meta-analyses found effects in favour of intervention [(a) risk ratio (RR) = 2.06, 95% confidence interval (CI) 1.30-3.27; (b) RR = 1.86, 95% CI 1.04-3.31]. Medication and/or behavioural support can help maintain smoking abstinence beyond discharge from smoke-free institutions with high mental health comorbidity. However, the small evidence base tested few different interventions and reporting of behavioural interventions is often imprecise.

A systematic review of randomised control trials of sexual health interventions delivered by mobile technologies.

Burns Kara, Keating Patrick, Free Caroline

BMC public health [16:778] (2016)

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Sexually transmitted infections (STIs) pose a serious public health problem globally. The rapid spread of mobile technology creates an opportunity to use innovative methods to reduce the burden of STIs. This systematic review identified recent randomised controlled trials that employed mobile technology to improve sexual health outcomes. The following databases were searched for randomised controlled trials of mobile technology based sexual health interventions with any outcome measures and all patient populations: MEDLINE, EMBASE, PsycINFO, Global Health, The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Cochrane Methodology Register, NHS Health Technology Assessment Database, and Web of Science (science and social science citation index) (Jan 1999-July 2014). Interventions designed to increase adherence to HIV medication were not included. Two authors independently extracted data on the following elements: interventions, allocation concealment, allocation sequence, blinding, completeness of follow-up, and measures of effect. Trials were assessed for methodological quality using the Cochrane risk of bias tool. We calculated effect estimates using intention to treat analysis. A total of ten randomised trials were identified with nine separate study groups. No trials had a low risk of bias. The trials targeted: 1) promotion of uptake of sexual health services, 2) reduction of risky sexual behaviours and 3) reduction of recall bias in reporting sexual activity. Interventions employed up to five behaviour change techniques. Meta-analysis was not possible due to heterogeneity in trial assessment and reporting. Two trials reported statistically significant improvements in the uptake of sexual health services using SMS reminders compared to controls. One trial increased knowledge. One trial reported promising results in increasing condom use but no trial reported statistically significant increases in condom use. Finally, one trial showed that collection of sexual health information using mobile technology was acceptable. The findings suggest interventions delivered by SMS interventions can increase uptake of sexual health services and STI testing. High quality trials of interventions using standardised objective measures and employing a wider range of behavioural change techniques are needed to assess if interventions delivered by mobile phone can alter safer sex behaviours carried out between couples and reduce STIs.

Mobile Technology Interventions for Asthma Self-Management: Systematic Review and Meta-Analysis.

Miller Lisa, Schüz Benjamin, Walters Julia, Walters E Haydn

JMIR mHealth and uHealth [5:e57] (2017)

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Mobile technology interventions (MTI) are becoming increasingly popular in the management of chronic health behaviors. Most MTI allow individuals to monitor medication use, record symptoms, or store and activate disease-management action plans. Therefore, MTI may have the potential to improve low adherence to medication and action plans for individuals with asthma, which is associated with poor clinical outcomes. A systematic review and meta-analysis were conducted to evaluate the efficacy of MTI on clinical outcomes as well as adherence in individuals with asthma. As the use of evidence-based behavior change techniques (BCT) has been shown to improve intervention effects, we also conducted exploratory analyses to determine the role of BCT and engagement with MTI as moderators of MTI efficacy. We searched electronic databases for randomized controlled trials up until June 2016. Random effect models were used to assess the effect of MTI on clinical outcomes as well as adherence to preventer medication or symptom monitoring. Mixed effects models assessed whether the features of the MTI (ie, use of BCT) and how often a person engaged with MTI moderated the effects of MTI. The literature search located 11 studies meeting the inclusion criteria, with 9 providing satisfactory data for meta-analysis. Compared with standard treatment, MTI had moderate to large effect sizes (Hedges g) on medication adherence and clinical outcomes. MTI had no additional effects on adherence or clinical outcomes when compared with paper-based monitoring. No moderator effects were found, and the number of studies was small. A narrative review of the two studies, which are not included in the meta-analysis, found similar results. This review indicated the efficacy of MTI for self-management in individuals with asthma and also indicated that MTI appears to be as efficacious as paper-based monitoring. This review also suggested a need for robust studies to examine the effects of BCT use and engagement on MTI efficacy to inform the evidence base for MTI in individuals with asthma.

Self-management in temporomandibular disorders: a systematic review of behavioural components.

Story W P, Durham J, Al-Baghdadi M, Steele J, Araujo-Soares V

Journal of oral rehabilitation [43:759-70] (2016)

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The aim of this qualitative systematic review was to identify the behaviour change techniques most frequently employed in published temporomandibular disorder (TMD) self-management (SM) programmes. The reviewers matched the components of SM programmes into the relevant behaviour change technique domains according to the definitions of the behaviour change taxonomy (version 1). Electronic databases were searched for randomised controlled trials assessing an SM programme for TMD. Manual searches were also conducted for potentially important journals. Eligibility criteria for the review included: the type of study, the participants, the intervention utilised and the comparators/control. Fifteen randomised controlled trials with 554 patients were included in this review. The review concludes a minority of the available behaviour change techniques are currently employed in SM programmes. Other behaviour change techniques should be examined to see whether there is a theoretical underpinning that might support their inclusion in self-management programmes in TMD. Further trials are required to conclude that SM programmes are more effective than no treatment at all and or placebo. With more structured SM programmes, greater therapeutic benefits might be achieved, and certainly if SM programmes published in the literature define their components through use of the behaviour change taxonomy, it would be easier for clinicians to replicate efficacious programmes.

Using computer, mobile and wearable technology enhanced interventions to reduce sedentary behaviour: a systematic review and meta-analysis.

Stephenson Aoife, McDonough Suzanne M, Murphy Marie H, Nugent Chris D, Mair Jacqueline L

The international journal of behavioral nutrition and physical activity [14:105] (2017)

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High levels of sedentary behaviour (SB) are associated with negative health consequences. Technology enhanced solutions such as mobile applications, activity monitors, prompting software, texts, emails and websites are being harnessed to reduce SB. The aim of this paper is to evaluate the effectiveness of such technology enhanced interventions aimed at reducing SB in healthy adults and to examine the behaviour change techniques (BCTs) used. Five electronic databases were searched to identify randomised-controlled trials (RCTs), published up to June 2016. Interventions using computer, mobile or wearable technologies to facilitate a reduction in SB, using a measure of sedentary time as an outcome, were eligible for inclusion. Risk of bias was assessed using the Cochrane Collaboration's tool and interventions were coded using the BCT Taxonomy (v1). Meta-analysis of 15/17 RCTs suggested that computer, mobile and wearable technology tools resulted in a mean reduction of -41.28 min per day (min/day) of sitting time (95% CI -60.99, -21.58, I2 = 77%, n = 1402), in favour of the intervention group at end point follow-up. The pooled effects showed mean reductions at short (≤ 3 months), medium (>3 to 6 months), and long-term follow-up (>6 months) of -42.42 min/day, -37.23 min/day and -1.65 min/day, respectively. Overall, 16/17 studies were deemed as having a high or unclear risk of bias, and 1/17 was judged to be at a low risk of bias. A total of 46 BCTs (14 unique) were coded for the computer, mobile and wearable components of the interventions. The most frequently coded were "prompts and cues", "self-monitoring of behaviour", "social support (unspecified)" and "goal setting (behaviour)". Interventions using computer, mobile and wearable technologies can be effective in reducing SB. Effectiveness appeared most prominent in the short-term and lessened over time. A range of BCTs have been implemented in these interventions. Future studies need to improve reporting of BCTs within interventions and address the methodological flaws identified within the review through the use of more rigorously controlled study designs with longer-term follow-ups, objective measures of SB and the incorporation of strategies to reduce attrition. The review protocol was registered with PROSPERO: CRD42016038187.

The Effect of the Move More Pack on the Physical Activity of Cancer Survivors: Protocol for a Randomized Waiting List Control Trial with Process Evaluation.

Webb Justin, Fife-Schaw Chris, Ogden Jane, Foster Jo

JMIR research protocols [6:e220] (2017)

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Physical activity can improve many common side effects of cancer treatment as well as improve physical function and quality of life (QOL). In addition, physical activity can improve survival rate and reduce cancer recurrence. Despite these benefits, only 23% of cancer survivors in England are active to recommended levels. Cancer survivors are interested in lifestyle behavior change. Home-based interventions offer a promising means for changing physical activity behavior. Prediagnosis levels of physical activity and self-efficacy have been reported to be predictors of physical activity behavior change. The Move More Pack, which has undergone revision, is a printed resource with supporting Internet-based tools that aims to increase the physical activity of cancer survivors in the United Kingdom. The revised Move More Pack is underpinned by the theory of planned behavior and the social cognitive theory. The aim of this proposed study was to investigate the effect of the revised Move More Pack, supported by Internet-based tools, on physical activity, self-efficacy, and health-related QOL (HRQOL) of cancer survivors in the United Kingdom. This study is a two-arm waiting list randomized control trial with embedded process evaluation. A sample of 99 participants per arm will be recruited by invitation through an email database of cancer survivors held by UK charity Macmillan Cancer Support and an advert placed on the Macmillan Cancer Support Facebook page. Each participant is randomized to receive brief physical activity information and the UK guidelines for physical activity, or brief physical activity information and the revised Move More Pack with supporting Internet-based tools. The intervention and control arm will be followed up at 12 weeks to identify changes in self-reported physical activity, self-efficacy, and HRQOL based on Web-based questionnaires. The control arm will receive the revised Move More Pack at 12 weeks with follow-up at 24 weeks. The intervention arm is followed up at 24 weeks to determine maintenance of reported changes. Subgroup analyses will be completed based on participants' prediagnosis level of physical activity and baseline self-efficacy as possible predictors of positive changes. Use of each component of the revised Move More Pack will be assessed using a 4-point Likert scale. Semistructured phone interviews will evaluate the use and perceived usefulness of the revised Move More Pack. Participant recruitment started in March 2017. Projected completion of this study is October 2018. This study's findings will identify if the proposed low-cost broad reach intervention improves physical activity, self-efficacy, and the HRQOL of cancer survivors. The process evaluation is designed to contextualize the use and perceived usefulness of the revised Move More Pack, help augment its efficient distribution, and identify potential improvements to its design.

Implementation of behavior change techniques in mobile applications for physical activity.

Yang Chih-Hsiang, Maher Jaclyn P, Conroy David E

American journal of preventive medicine [48:452-5] (2015)

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Mobile applications (apps) for physical activity are popular and hold promise for promoting behavior change and reducing non-communicable disease risk. App marketing materials describe a limited number of behavior change techniques (BCTs), but apps may include unmarketed BCTs, which are important as well. To characterize the extent to which BCTs have been implemented in apps from a systematic user inspection of apps. Top-ranked physical activity apps (N=100) were identified in November 2013 and analyzed in 2014. BCTs were coded using a contemporary taxonomy following a user inspection of apps. Users identified an average of 6.6 BCTs per app and most BCTs in the taxonomy were not represented in any apps. The most common BCTs involved providing social support, information about others' approval, instructions on how to perform a behavior, demonstrations of the behavior, and feedback on the behavior. A latent class analysis of BCT configurations revealed that apps focused on providing support and feedback as well as support and education. Contemporary physical activity apps have implemented a limited number of BCTs and have favored BCTs with a modest evidence base over others with more established evidence of efficacy (e.g., social media integration for providing social support versus active self-monitoring by users). Social support is a ubiquitous feature of contemporary physical activity apps and differences between apps lie primarily in whether the limited BCTs provide education or feedback about physical activity.

mHealth Technologies to Influence Physical Activity and Sedentary Behaviors: Behavior Change Techniques, Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Direito Artur, Carraça Eliana, Rawstorn Jonathan, Whittaker Robyn, Maddison Ralph

Annals of behavioral medicine : a publication of the Society of Behavioral Medicine (2016)

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mHealth programs offer potential for practical and cost-effective delivery of interventions capable of reaching many individuals. To (1) compare the effectiveness of mHealth interventions to promote physical activity (PA) and reduce sedentary behavior (SB) in free-living young people and adults with a comparator exposed to usual care/minimal intervention; (2) determine whether, and to what extent, such interventions affect PA and SB levels and (3) use the taxonomy of behavior change techniques (BCTs) to describe intervention characteristics. A systematic review and meta-analysis following PRISMA guidelines was undertaken to identify randomized controlled trials (RCTs) comparing mHealth interventions with usual or minimal care among individuals free from conditions that could limit PA. Total PA, moderate-to-vigorous intensity physical activity (MVPA), walking and SB outcomes were extracted. Intervention content was independently coded following the 93-item taxonomy of BCTs. Twenty-one RCTs (1701 participants-700 with objectively measured PA) met eligibility criteria. SB decreased more following mHealth interventions than after usual care (standardised mean difference (SMD) -0.26, 95 % confidence interval (CI) -0.53 to -0.00). Summary effects across studies were small to moderate and non-significant for total PA (SMD 0.14, 95 % CI -0.12 to 0.41); MVPA (SMD 0.37, 95 % CI -0.03 to 0.77); and walking (SMD 0.14, 95 % CI -0.01 to 0.29). BCTs were employed more frequently in intervention (mean = 6.9, range 2 to 12) than in comparator conditions (mean = 3.1, range 0 to 10). Of all BCTs, only 31 were employed in intervention conditions. Current mHealth interventions have small effects on PA/SB. Technological advancements will enable more comprehensive, interactive and responsive intervention delivery. Future mHealth PA studies should ensure that all the active ingredients of the intervention are reported in sufficient detail.

Secondary prevention lifestyle interventions initiated within 90 days after TIA or 'minor' stroke: a systematic review and meta-analysis of rehabilitation programmes.

Heron Neil, Kee Frank, Cardwell Christopher, Tully Mark A, Donnelly Michael, Cupples Margaret E

The British journal of general practice : the journal of the Royal College of General Practitioners [67:e57-e66] (2017)

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Strokes are often preceded by a transient ischaemic attack (TIA) or 'minor' stroke. The immediate period after a TIA/minor stroke is a crucial time to initiate secondary prevention. However, the optimal approach to prevention, including non-pharmacological measures, after TIA is not clear. To systematically review evidence about the effectiveness of delivering secondary prevention, with lifestyle interventions, in comprehensive rehabilitation programmes, initiated within 90 days of a TIA/minor stroke. Also, to categorise the specific behaviour change techniques used. The review identified randomised controlled trials by searching the Cochrane Library, Ovid MEDLINE, Ovid EMBASE, Web of Science, EBSCO CINAHL and Ovid PsycINFO. Two review authors independently screened titles and abstracts for eligibility (programmes initiated within 90 days of event; outcomes reported for TIA/minor stroke) and extracted relevant data from appraised studies; a meta-analysis was used to synthesise the results. A total of 31 potentially eligible papers were identified and four studies, comprising 774 patients post-TIA or minor stroke, met the inclusion criteria; two had poor methodological quality. Individual studies reported increased aerobic capacity but meta-analysis found no significant change in resting and peak systolic blood pressure, resting heart rate, aerobic capacity, falls, or mortality. The main behaviour change techniques were goal setting and instructions about how to perform given behaviours. There is limited evidence of the effectiveness of early post-TIA rehabilitation programmes with preventive lifestyle interventions. Further robust randomised controlled trials of comprehensive rehabilitation programmes that promote secondary prevention and lifestyle modification immediately after a TIA are needed.

Behaviour change interventions to promote physical activity in rheumatoid arthritis: a systematic review.

Larkin Louise, Gallagher Stephen, Cramp Fiona, Brand Charles, Fraser Alexander, Kennedy Norelee

Rheumatology international [35:1631-40] (2015)

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Research has shown that people who have rheumatoid arthritis (RA) do not usually participate in enough physical activity to obtain the benefits of optimal physical activity levels, including quality of life, aerobic fitness and disease-related characteristics. Behaviour change theory underpins the promotion of physical activity. The aim of this systematic review was to explore behaviour change interventions which targeted physical activity behaviour in people who have RA, focusing on the theory underpinning the interventions and the behaviour change techniques utilised using specific behaviour change taxonomy. An electronic database search was conducted via EBSCOhost, PubMed, Cochrane Central Register of Controlled Trials and Web of Science databases in August 2014, using Medical Subject Headings and keywords. A manual search of reference lists was also conducted. Randomised control trials which used behaviour change techniques and targeted physical activity behaviour in adults who have RA were included. Two reviewers independently screened studies for inclusion. Methodological quality was assessed using the Cochrane risk of bias tool. Five studies with 784 participants were included in the review. Methodological quality of the studies was mixed. The studies consisted of behaviour change interventions or combined practical physical activity and behaviour change interventions and utilised a large variety of behaviour change techniques. Four studies reported increased physical activity behaviour. All studies used subjective methods of assessing physical activity with only one study utilising an objective measure. There has been varied success of behaviour change interventions in promoting physical activity behaviour in people who have RA. Further studies are required to develop and implement the optimal behaviour change intervention in this population.

Behavior change techniques implemented in electronic lifestyle activity monitors: a systematic content analysis.

Lyons Elizabeth J, Lewis Zakkoyya H, Mayrsohn Brian G, Rowland Jennifer L

Journal of medical Internet research [16:e192] (2014)

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Electronic activity monitors (such as those manufactured by Fitbit, Jawbone, and Nike) improve on standard pedometers by providing automated feedback and interactive behavior change tools via mobile device or personal computer. These monitors are commercially popular and show promise for use in public health interventions. However, little is known about the content of their feedback applications and how individual monitors may differ from one another. The purpose of this study was to describe the behavior change techniques implemented in commercially available electronic activity monitors. Electronic activity monitors (N=13) were systematically identified and tested by 3 trained coders for at least 1 week each. All monitors measured lifestyle physical activity and provided feedback via an app (computer or mobile). Coding was based on a hierarchical list of 93 behavior change techniques. Further coding of potentially effective techniques and adherence to theory-based recommendations were based on findings from meta-analyses and meta-regressions in the research literature. All monitors provided tools for self-monitoring, feedback, and environmental change by definition. The next most prevalent techniques (13 out of 13 monitors) were goal-setting and emphasizing discrepancy between current and goal behavior. Review of behavioral goals, social support, social comparison, prompts/cues, rewards, and a focus on past success were found in more than half of the systems. The monitors included a range of 5-10 of 14 total techniques identified from the research literature as potentially effective. Most of the monitors included goal-setting, self-monitoring, and feedback content that closely matched recommendations from social cognitive theory. Electronic activity monitors contain a wide range of behavior change techniques typically used in clinical behavioral interventions. Thus, the monitors may represent a medium by which these interventions could be translated for widespread use. This technology has broad applications for use in clinical, public health, and rehabilitation settings.

Effectiveness of physical activity interventions in achieving behaviour change maintenance in young and middle aged adults: A systematic review and meta-analysis.

Murray Jennifer M, Brennan Sarah F, French David P, Patterson Christopher C, Kee Frank, Hunter Ruth F

Social science & medicine (1982) [192:125-133] (2017)

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Physical activity (PA) interventions are generally effective in supporting short-term behaviour change, but increases are not always maintained. This review examined the effectiveness of PA interventions for behaviour change maintenance in young and middle-aged adults, and investigated which Behaviour Change Techniques (BCTs) and other intervention features were associated with maintenance. Six databases (Medline, EMBASE, PsycINFO, Cochrane Database of Systematic Reviews, CINAHL, Web of Science) were systematically searched. Eligibility criteria were controlled trials investigating the effectiveness of PA interventions with adult (mean age 18-64 years) non-clinical populations using validated measures of PA behaviour at baseline and ≥six months' post-baseline. Results were pooled in meta-analyses using standardised mean differences (SMD) at five time intervals (6-9, 9-15, 15-21, 21-24, >24 months). Moderator analyses investigated the influence of sample and intervention characteristics on PA maintenance at 6-9 months. Sixty-two studies were included. PA interventions had a significant effect on behaviour maintenance 6-15 months post-baseline relative to controls. Interventions had a larger effect on maintenance at 6-9 months (SMD = 0.28; 95% CI: 0.20, 0.35; I2 = 73%) compared to 9-15 months (SMD = 0.20; 95% CI: 0.13, 0.26; I2 = 70%). Beyond 15 months, PA measurements were infrequent with little evidence supporting maintenance. Moderator analyses showed some BCTs and intervention settings moderated PA outcomes at 6-9 months. A multivariable meta-regression model showed interventions using the BCTs 'Prompt self-monitoring of behavioural outcome' (b = 1.46, p < 0.01) and 'Use of follow-up prompts' (b = 0.38, p < 0.01) demonstrated greater effectiveness at promoting PA maintenance at 6-9 months. Interventions implemented in primary care (versus community or workplace/university) settings (b = -0.13, p = 0.10) tended to demonstrate less effectiveness. This review provides evidence of some effective BCTs for maintaining behaviour to 15 months. Greater consideration must be given to how future interventions encourage and measure maintenance of changes, and investigate broader psychological, social and environmental influences of PA behaviour. PROSPERO 2015:CRD42015025462.

Behavior Change Techniques in Physical Activity eHealth Interventions for People With Cardiovascular Disease: Systematic Review.

Duff Orlaith Mairead, Walsh Deirdre Mj, Furlong Bróna A, O'Connor Noel E, Moran Kieran A, Woods Catherine B

Journal of medical Internet research [19:e281] (2017)

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Cardiovascular disease (CVD) is the leading cause of premature death and disability in Europe, accounting for 4 million deaths per year and costing the European Union economy almost €196 billion annually. There is strong evidence to suggest that exercise-based secondary rehabilitation programs can decrease the mortality risk and improve health among patients with CVD. Theory-informed use of behavior change techniques (BCTs) is important in the design of cardiac rehabilitation programs aimed at changing cardiovascular risk factors. Electronic health (eHealth) is the use of information and communication technologies (ICTs) for health. This emerging area of health care has the ability to enhance self-management of chronic disease by making health care more accessible, affordable, and available to the public. However, evidence-based information on the use of BCTs in eHealth interventions is limited, and particularly so, for individuals living with CVD. The aim of this systematic review was to assess the application of BCTs in eHealth interventions designed to increase physical activity (PA) in CVD populations. A total of 7 electronic databases, including EBSCOhost (MEDLINE, PsycINFO, Academic Search Complete, SPORTDiscus with Full Text, and CINAHL Complete), Scopus, and Web of Science (Core Collection) were searched. Two authors independently reviewed references using the software package Covidence (Veritas Health Innovation). The reviewers met to resolve any discrepancies, with a third independent reviewer acting as an arbitrator when required. Following this, data were extracted from the papers that met the inclusion criteria. Bias assessment of the studies was carried out using the Cochrane Collaboration's tool for assessing the risk of bias within Covidence; this was followed by a narrative synthesis. Out of the 987 studies that were identified, 14 were included in the review. An additional 9 studies were added following a hand search of review paper references. The average number of BCTs used across the 23 studies was 7.2 (range 1-19). The top three most frequently used BCTs included information about health consequences (78%, 18/23), goal setting (behavior; 74%, 17/23), and joint third, self-monitoring of behavior and social support (practical) were included in 11 studies (48%, 11/23) each. This systematic review is the first to investigate the use of BCTs in PA eHealth interventions specifically designed for people with CVD. This research will have clear implications for health care policy and research by outlining the BCTs used in eHealth interventions for chronic illnesses, in particular CVD, thereby providing clear foundations for further research and developments in the area.

Community-based intervention to promote physical activity in rheumatoid arthritis (CIPPA-RA): a study protocol for a pilot randomised control trial.

Larkin Louise, Gallagher Stephen, Fraser Alexander, Kennedy Norelee

Rheumatology international [37:2095-2103] (2017)

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Rheumatoid arthritis (RA) is a chronic, inflammatory condition which may cause pain, stiffness and fatigue. People who have RA have reduced levels of physical activity due to these symptoms. Interventions targeting physical activity behaviour in this population have had limited efficacy. This paper describes a protocol for a pilot randomised controlled trial (RCT) of a theory-based intervention delivered in a community setting designed to promote physical activity in people who have RA. The aim of the pilot study is to assess the impact of the intervention on moderate-intensity physical activity in people with RA. The objectives are to obtain reliable estimates regarding recruitment rates; participant retention, protocol adherence and generate potential effect size estimates to inform sample size calculations for a main trial on physical activity participation. Semi-structured interviews will be conducted with a selected sample of participants to explore their experiences. Participants will be recruited from direct referrals from the rheumatology clinics in a public hospital. Participants meeting inclusion criteria will be randomised into a 6 week physical activity intervention (four sessions delivered over a 6-week period by a trained physiotherapist) or a control group (physical activity information leaflet). Results of the pilot study will provide data to determine if a larger RCT is feasible. Qualitative data will inform intervention design and delivery. The findings will be disseminated to health professionals, in peer-reviewed journals and conference presentations.

Behaviour change techniques in physical activity interventions for men with prostate cancer: A systematic review.

Hallward Laura, Patel Nisha, Duncan Lindsay R

Journal of health psychology (2018)

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Physical activity interventions can improve prostate cancer survivors' health. Determining the behaviour change techniques used in physical activity interventions can help elucidate the mechanisms by which an intervention successfully changes behaviour. The purpose of this systematic review was to identify and evaluate behaviour change techniques in physical activity interventions for prostate cancer survivors. A total of 7 databases were searched and 15 studies were retained. The studies included a mean 6.87 behaviour change techniques (range = 3-10), and similar behaviour change techniques were implemented in all studies. Consideration of how behaviour change techniques are implemented may help identify how behaviour change techniques enhance physical activity interventions for prostate cancer survivors.

The effectiveness of interventions aimed at increasing physical activity in adults with persistent musculoskeletal pain: a systematic review and meta-analysis.

Marley Joanne, Tully Mark A, Porter-Armstrong Alison, Bunting Brendan, O'Hanlon John, Atkins Lou, Howes Sarah, McDonough Suzanne M

BMC musculoskeletal disorders [18:482] (2017)

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Individuals with persistent musculoskeletal pain (PMP) have an increased risk of developing co-morbid health conditions and for early-mortality compared to those without pain. Despite irrefutable evidence supporting the role of physical activity in reducing these risks; there has been limited synthesis of the evidence, potentially impacting the optimisation of these forms of interventions. This review examines the effectiveness of interventions in improving levels of physical activity and the components of these interventions. Randomised and quasi-randomised controlled trials were included in this review. The following databases were searched from inception to March 2016: CENTRAL in the Cochrane Library, Cochrane Database of Systematic Reviews (CDSR), MEDLINE, Embase, CINAHL, PsycINFO and AMED. Two reviewers independently screened citations, assessed eligibility, extracted data, assessed risk of bias and coded intervention content using the behaviour change taxonomy (BCTTv1) of 93 hierarchically clustered techniques. GRADE was used to rate the quality of the evidence. The full text of 276 articles were assessed for eligibility, twenty studies involving 3441 participants were included in the review. Across the studies the mean number of BCTs coded was eight (range 0-16); with 'goal setting' and 'instruction on how to perform the behaviour' most frequently coded. For measures of subjective physical activity: interventions were ineffective in the short term, based on very low quality evidence; had a small effect in the medium term based on low quality evidence (SMD 0.25, 95% CI 0.01 to 0.48) and had a small effect in the longer term (SMD 0.21 95% CI 0.08 to 0.33) based on moderate quality evidence. For measures of objective physical activity: interventions were ineffective - based on very low to low quality evidence. There is some evidence supporting the effectiveness of interventions in improving subjectively measured physical activity however, the evidence is mostly based on low quality studies and the effects are small. Given the quality of the evidence, further research is likely/very likely to have an important impact on our confidence in effect estimates and is likely to change the estimates. Future studies should provide details on intervention components and incorporate objective measures of physical activity.

Digital health behaviour change interventions targeting physical activity and diet in cancer survivors: a systematic review and meta-analysis.

Roberts Anna L, Fisher Abigail, Smith Lee, Heinrich Malgorzata, Potts Henry W W

Journal of cancer survivorship : research and practice (2017)

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The number of cancer survivors has risen substantially due to improvements in early diagnosis and treatment. Health behaviours such as physical activity (PA) and diet can reduce recurrence and mortality, and alleviate negative consequences of cancer and treatments. Digital behaviour change interventions (DBCIs) have the potential to reach large numbers of cancer survivors. We conducted a systematic review and meta-analyses of relevant studies identified by a search of Medline, EMBASE, PubMed and CINAHL. Studies which assessed a DBCI with measures of PA, diet and/or sedentary behaviour were included. Fifteen studies were identified. Random effects meta-analyses showed significant improvements in moderate-vigorous PA (seven studies; mean difference (MD) = 41 min per week; 95% CI 12, 71) and body mass index (BMI)/weight (standardised mean difference (SMD) = -0.23; 95% CI -0.41, -0.05). There was a trend towards significance for reduced fatigue and no significant change in cancer-specific measures of quality of life (QoL). Narrative synthesis revealed mixed evidence for effects on diet, generic QoL measures and self-efficacy and no evidence of an effect on mental health. Two studies suggested improved sleep quality. DBCIs may improve PA and BMI among cancer survivors, and there is mixed evidence for diet. The number of included studies is small, and risk of bias and heterogeneity was high. Future research should address these limitations with large, high-quality RCTs, with objective measures of PA and sedentary time. Digital technologies offer a promising approach to encourage health behaviour change among cancer survivors.

How to reduce sitting time? A review of behaviour change strategies used in sedentary behaviour reduction interventions among adults.

Gardner Benjamin, Smith Lee, Lorencatto Fabiana, Hamer Mark, Biddle Stuart Jh

Health psychology review [10:89-112] (2016)

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Sedentary behaviour - i.e., low energy-expending waking behaviour while seated or lying down - is a health risk factor, even when controlling for physical activity. This review sought to describe the behaviour change strategies used within interventions that have sought to reduce sedentary behaviour in adults. Studies were identified through existing literature reviews, a systematic database search, and hand-searches of eligible papers. Interventions were categorised as 'very promising', 'quite promising', or 'non-promising' according to observed behaviour changes. Intervention functions and behaviour change techniques were compared across promising and non-promising interventions. Twenty-six eligible studies reported thirty-eight interventions, of which twenty (53%) were worksite-based. Fifteen interventions (39%) were very promising, eight quite promising (21%), and fifteen non-promising (39%). Very or quite promising interventions tended to have targeted sedentary behaviour instead of physical activity. Interventions based on environmental restructuring, persuasion, or education were most promising. Self-monitoring, problem solving, and restructuring the social or physical environment were particularly promising behaviour change techniques. Future sedentary reduction interventions might most fruitfully incorporate environmental modification and self-regulatory skills training. The evidence base is, however, weakened by low-quality evaluation methods; more RCTs, employing no-treatment control groups, and collecting objective data are needed.

Systematic review of behaviour change techniques to promote participation in physical activity among people with dementia.

Nyman Samuel R, Adamczewska Natalia, Howlett Neil

British journal of health psychology [23:148-170] (2018)

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The objective of this study was to systematically review the evidence for the potential promise of behaviour change techniques (BCTs) to increase physical activity among people with dementia (PWD). PsychINFO, MEDLINE, CINAHL, and the Cochrane Central Register of Controlled Trials databases were searched 01/01/2000-01/12/2016. Randomized controlled/quasi-randomized trials were included if they recruited people diagnosed/suspected to have dementia, used at least one BCT in the intervention arm, and had at least one follow-up measure of physical activity/adherence. Studies were appraised using the Cochrane Collaboration Risk of Bias Tool, and BCTs were coded using Michie et al., 2013, Annals of Behavioral Medicine, 46, 81. taxonomy. Intervention findings were narratively synthesized as either 'very promising', 'quite promising', or 'non-promising', and BCTs were judged as having potential promise if they featured in at least twice as many very/quite promising than non-promising interventions (as per Gardner et al., 2016, Health Psychology Review, 10, 89). Nineteen articles from nine trials reported physical activity findings on behavioural outcomes (two very promising, one quite promising, and two non-promising) or intervention adherence (one quite promising and four non-promising). Thirteen BCTs were used across the interventions. While no BCT had potential promise to increase intervention adherence, three BCTs had potential promise for improving physical activity behaviour outcomes: goal setting (behaviour), social support (unspecified), and using a credible source. Three BCTs have potential promise for use in future interventions to increase physical activity among PWD. Statement of contribution What is already known on this subject? While physical activity is a key lifestyle factor to enhance and maintain health and wellbeing amongst the general population, adults rarely participate in sufficient levels to obtain these benefits. Systematic reviews suggest that specific behaviour change techniques can increase physical activity, although one review suggested that self-regulatory techniques may be counterproductive when promoting physical activity among older people. Until now, no systematic review has been conducted to assess which behaviour change techniques may be associated with greater participation in physical activity among people with dementia. What does this study add? Interventions showed mixed promise for increasing physical activity and little effect on participant adherence. Goal setting (behaviour), social support (unspecified), and using a credible source are promising approaches. No technique showed promise for increasing adherence to physical activity interventions among people with dementia.

Gamification for health promotion: systematic review of behaviour change techniques in smartphone apps.

Edwards E A, Lumsden J, Rivas C, Steed L, Edwards L A, Thiyagarajan A, Sohanpal R, Caton H, Griffiths C J, Munafò M R, Taylor S, Walton R T

BMJ open [6:e012447] (2016)

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Smartphone games that aim to alter health behaviours are common, but there is uncertainty about how to achieve this. We systematically reviewed health apps containing gaming elements analysing their embedded behaviour change techniques. Two trained researchers independently coded apps for behaviour change techniques using a standard taxonomy. We explored associations with user ratings and price. We screened the National Health Service (NHS) Health Apps Library and all top-rated medical, health and wellness and health and fitness apps (defined by Apple and Google Play stores based on revenue and downloads). We included free and paid English language apps using 'gamification' (rewards, prizes, avatars, badges, leaderboards, competitions, levelling-up or health-related challenges). We excluded apps targeting health professionals. 64 of 1680 (4%) health apps included gamification and met inclusion criteria; only 3 of these were in the NHS Library. Behaviour change categories used were: feedback and monitoring (n=60, 94% of apps), reward and threat (n=52, 81%), and goals and planning (n=52, 81%). Individual techniques were: self-monitoring of behaviour (n=55, 86%), non-specific reward (n=49, 82%), social support unspecified (n=48, 75%), non-specific incentive (n=49, 82%) and focus on past success (n=47, 73%). Median number of techniques per app was 14 (range: 5-22). Common combinations were: goal setting, self-monitoring, non-specific reward and non-specific incentive (n=35, 55%); goal setting, self-monitoring and focus on past success (n=33, 52%). There was no correlation between number of techniques and user ratings (p=0.07; rs=0.23) or price (p=0.45; rs=0.10). Few health apps currently employ gamification and there is a wide variation in the use of behaviour change techniques, which may limit potential to improve health outcomes. We found no correlation between user rating (a possible proxy for health benefits) and game content or price. Further research is required to evaluate effective behaviour change techniques and to assess clinical outcomes. CRD42015029841.

The effects of care bundles on patient outcomes: a systematic review and meta-analysis.

Lavallée Jacqueline F, Gray Trish A, Dumville Jo, Russell Wanda, Cullum Nicky

Implementation science : IS [12:142] (2017)

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Care bundles are a set of three to five evidence-informed practices performed collectively and reliably to improve the quality of care. Care bundles are used widely across healthcare settings with the aim of preventing and managing different health conditions. This is the first systematic review designed to determine the effects of care bundles on patient outcomes and the behaviour of healthcare workers in relation to fidelity with care bundles. This systematic review is reported in line with the PRISMA statement for reporting systematic reviews and meta-analyses. A total of 5796 abstracts were retrieved through a systematic search for articles published between January 1, 2001, to February 4, 2017, in the Cochrane Central Register for Controlled Trials, MEDLINE, EMBASE, British Nursing Index, CINAHL, PsychInfo, British Library, Conference Proceeding Citation Index, OpenGrey trials (including cluster-randomised trials) and non-randomised studies (comprising controlled before-after studies, interrupted time series, cohort studies) of care bundles for any health condition and any healthcare settings were considered. Following the removal of duplicated studies, two reviewers independently screen 3134 records. Three authors performed data extraction independently. We compared the care bundles with usual care to evaluate the effects of care bundles on the risk of negative patient outcomes. Random-effect models were used to further explore the effects of subgroups. In total, 37 studies (6 randomised trials, 31 controlled before-after studies) were eligible for inclusion. The effect of care bundles on patient outcomes is uncertain. For randomised trial data, the pooled relative risk of negative effects between care bundle and control groups was 0.97 [95% CI 0.71 to 1.34; 2049 participants]. The relative risk of negative patient outcomes from controlled before-after studies favoured the care bundle treated groups (0.66 [95% CI 0.59 to 0.75; 119,178 participants]). However, using GRADE, we assessed the certainty of all of the evidence to be very low (downgraded for risk of bias, inconsistency, indirectness). Very low quality evidence from controlled before-after studies suggests that care bundles may reduce the risk of negative outcomes when compared with usual care. By contrast, the better quality evidence from six randomised trials is more uncertain. PROSPERO, CRD42016033175.

Theories Applied to m-Health Interventions for Behavior Change in Low- and Middle-Income Countries: A Systematic Review.

Cho Yoon-Min, Lee Seohyun, Islam Sheikh Mohammed Shariful, Kim Sun-Young

Telemedicine journal and e-health : the official journal of the American Telemedicine Association (2018)

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Recently there has been dramatic increase in the use of mobile technologies for health (m-Health) in both high and low- and middle-income countries (LMICs). However, little is known whether m-Health interventions in LMICs are based on relevant theories critical for effective implementation of such interventions. This review aimed to systematically identify m-Health studies on health behavioral changes in LMICs and to examine how each study applied behavior change theories. A systematic review was conducted using the standard method from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. By searching electronic databases (MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials [CENTRAL]), we identified eligible studies published in English from inception to June 30, 2017. For the identified m-Health studies in LMICs, we examined their theoretical bases, use of behavior change techniques (BCTs), and modes of delivery. A total of 14 m-Health studies on behavioral changes were identified and, among them, only 5 studies adopted behavior change theory. The most frequently cited theory was the health belief model, which was adopted in three studies. Likewise, studies have applied only a limited number of BCTs. Among the seven BCTs identified, the most frequently used one was the social support (practical) technique for medication reminder and medical appointment. m-Health studies in LMICs most commonly used short messaging services and phone calls as modes of delivery for behavior change interventions. m-Health studies in LMICs are suboptimally based on behavior change theory yet. To maximize effectiveness of m-Health, rigorous delivery methods as well as theory-based intervention designs will be needed.

The Effectiveness of Prompts to Promote Engagement With Digital Interventions: A Systematic Review.

Alkhaldi Ghadah, Hamilton Fiona L, Lau Rosa, Webster Rosie, Michie Susan, Murray Elizabeth

Journal of medical Internet research [18:e6] (2016)

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Digital interventions have been effective in improving numerous health outcomes and health behaviors; furthermore, they are increasingly being used in different health care areas, including self-management of long-term conditions, mental health, and health promotion. The full potential of digital interventions is hindered by a lack of user engagement. There is an urgent need to develop effective strategies that can promote users' engagement with digital interventions. One potential method is the use of technology-based reminders or prompts. To evaluate the effectiveness of technology-based strategies for promoting engagement with digital interventions. Cochrane Collaboration guidelines on systematic review methodology were followed. The search strategy was executed across 7 electronic databases: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, Web of Science, the Education Resources Information Center (ERIC), PsycINFO, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL). Databases were searched from inception to September 13, 2013, with no language or publication type restrictions, using three concepts: randomized controlled trials, digital interventions, and engagement. Gray literature and reference lists of included studies were also searched. Titles and abstracts were independently screened by 2 authors, then the full texts of potentially eligible papers were obtained and double-screened. Data from eligible papers were extracted by one author and checked for accuracy by another author. Bias was assessed using the Cochrane risk of bias assessment tool. Narrative synthesis was performed on all included studies and, where appropriate, data were pooled using meta-analysis. All findings were reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A total of 14 studies were included in the review with 8774 participants. Of the 14 studies, 9 had sufficient data to be included in the meta-analyses. The meta-analyses suggested that technology-based strategies can potentially promote engagement compared to no strategy for dichotomous outcomes (relative risk [RR] 1.27, 95% CI 1.01-1.60, I(2)=71%), but due to considerable heterogeneity and the small sample sizes in most studies, this result should be treated with caution. No studies reported adverse or economic outcomes. Only one study with a small sample size compared different characteristics; the study found that strategies promoting new digital intervention content and those sent to users shortly after they started using the digital intervention were more likely to engage users. Overall, studies reported borderline positive effects of technology-based strategies on engagement compared to no strategy. However, the results have to be interpreted with caution. More research is needed to replicate findings and understand which characteristics of the strategies are effective in promoting engagement and how cost-effective they are.

A systematic review investigating the behaviour change strategies in interventions to prevent misuse of anabolic steroids.

Bates Geoff, Begley Emma, Tod David, Jones Lisa, Leavey Conan, McVeigh Jim

Journal of health psychology (2017)

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We examined intervention effectiveness of strategies to prevent image- and performance-enhancing drug use. Comprehensive searches identified 14 interventions that met review inclusion criteria. Interventions were predominantly educational and delivered within school sport settings, but targeted a wide range of mediating factors. Identification of effective components was limited across studies by brief or imprecise descriptions of intervention content, lack of behavioural outcome measures and short-term follow-up times. However, studies with components in addition to information provision may be more promising. Interventions outside of sport settings are required to reflect the transition of this form of substance use to the general population.

A systematic review of techniques and effects of self-help interventions for tinnitus: Application of taxonomies from health psychology.

Greenwell Kate, Sereda Magdalena, Coulson Neil, El Refaie Amr, Hoare Derek J

International journal of audiology (2016)

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Self-help interventions are followed by people independently with minimal or no therapist contact. This review aims to assess the effectiveness of self-help interventions for adults with chronic tinnitus and systematically identify the self-help techniques used. Systematic review and application of health psychology taxonomies. Electronic database searches were conducted, supplemented by citation searching and hand-searching of key journals. Prospective controlled trials, which used measures of tinnitus distress, functional management, anxiety, depression, and quality of life, were included. Michie et al's behaviour change techniques (BCTs) taxonomy and Taylor et al's PRISMS taxonomy of self-management components were applied to describe interventions. Five studies were included, providing low-to-moderate levels of evidence. Randomized controlled trial studies were too few and heterogeneous for meta-analysis to be performed. Studies comparing self-help interventions to therapist-guided interventions and assessing non tinnitus-specific psychosocial outcomes and functional management were lacking. Fifteen BCTs and eight self-management components were identified across interventions. A lack of high-quality and homogeneous studies meant that confident conclusions could not be drawn regarding the efficacy of self-help interventions for tinnitus. Better reporting and categorization of intervention techniques is needed for replication in research and practice and to facilitate understanding of intervention mechanisms.

Stepped wedge randomised controlled trials: systematic review of studies published between 2010 and 2014.

Beard Emma, Lewis James J, Copas Andrew, Davey Calum, Osrin David, Baio Gianluca, Thompson Jennifer A, Fielding Katherine L, Omar Rumana Z, Ononge Sam, Hargreaves James, Prost Audrey

Trials [16:353] (2015)

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In a stepped wedge, cluster randomised trial, clusters receive the intervention at different time points, and the order in which they received it is randomised. Previous systematic reviews of stepped wedge trials have documented a steady rise in their use between 1987 and 2010, which was attributed to the design's perceived logistical and analytical advantages. However, the interventions included in these systematic reviews were often poorly reported and did not adequately describe the analysis and/or methodology used. Since 2010, a number of additional stepped wedge trials have been published. This article aims to update previous systematic reviews, and consider what interventions were tested and the rationale given for using a stepped wedge design. We searched PubMed, PsychINFO, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Web of Science, the Cochrane Library and the Current Controlled Trials Register for articles published between January 2010 and May 2014. We considered stepped wedge randomised controlled trials in all fields of research. We independently extracted data from retrieved articles and reviewed them. Interventions were then coded using the functions specified by the Behaviour Change Wheel, and for behaviour change techniques using a validated taxonomy. Our review identified 37 stepped wedge trials, reported in 10 articles presenting trial results, one conference abstract, 21 protocol or study design articles and five trial registrations. These were mostly conducted in developed countries (n = 30), and within healthcare organisations (n = 28). A total of 33 of the interventions were educationally based, with the most commonly used behaviour change techniques being 'instruction on how to perform a behaviour' (n = 32) and 'persuasive source' (n = 25). Authors gave a wide range of reasons for the use of the stepped wedge trial design, including ethical considerations, logistical, financial and methodological. The adequacy of reporting varied across studies: many did not provide sufficient detail regarding the methodology or calculation of the required sample size. The popularity of stepped wedge trials has increased since 2010, predominantly in high-income countries. However, there is a need for further guidance on their reporting and analysis.

Behaviour change techniques in home-based cardiac rehabilitation: a systematic review.

Heron Neil, Kee Frank, Donnelly Michael, Cardwell Christopher, Tully Mark A, Cupples Margaret E

The British journal of general practice : the journal of the Royal College of General Practitioners (2016)

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Cardiac rehabilitation (CR) programmes offering secondary prevention for cardiovascular disease (CVD) advise healthy lifestyle behaviours, with the behaviour change techniques (BCTs) of goals and planning, feedback and monitoring, and social support recommended. More information is needed about BCT use in home-based CR to support these programmes in practice. To identify and describe the use of BCTs in home-based CR programmes. Randomised controlled trials of home-based CR between 2005 and 2015 were identified by searching MEDLINE(®), Embase, PsycINFO, Web of Science, and Cochrane Database. Reviewers independently screened titles and abstracts for eligibility. Relevant data, including BCTs, were extracted from included studies. A meta-analysis studied risk factor change in home-based and comparator programmes. From 2448 studies identified, 11 of good methodological quality (10 on post-myocardial infarction, one on heart failure, 1907 patients) were included. These reported the use of 20 different BCTs. Social support (unspecified) was used in all studies and goal setting (behaviour) in 10. Of the 11 studies, 10 reported effectiveness in reducing CVD risk factors, but one study showed no improvement compared to usual care. This study differed from effective programmes in that it didn't include BCTs that had instructions on how to perform the behaviour and monitoring, or a credible source. Social support and goal setting were frequently used BCTs in home-based CR programmes, with the BCTs related to monitoring, instruction on how to perform the behaviour, and credible source being included in effective programmes. Further robust trials are needed to determine the relative value of different BCTs within CR programmes.

Identifying the barriers and enablers for a triage, treatment, and transfer clinical intervention to manage acute stroke patients in the emergency department: a systematic review using the theoretical domains framework (TDF).

Craig Louise E, McInnes Elizabeth, Taylor Natalie, Grimley Rohan, Cadilhac Dominique A, Considine Julie, Middleton Sandy

Implementation science : IS [11:157] (2016)

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Clinical guidelines recommend that assessment and management of patients with stroke commences early including in emergency departments (ED). To inform the development of an implementation intervention targeted in ED, we conducted a systematic review of qualitative and quantitative studies to identify relevant barriers and enablers to six key clinical behaviours in acute stroke care: appropriate triage, thrombolysis administration, monitoring and management of temperature, blood glucose levels, and of swallowing difficulties and transfer of stroke patients in ED. Studies of any design, conducted in ED, where barriers or enablers based on primary data were identified for one or more of these six clinical behaviours. Major biomedical databases (CINAHL, OVID SP EMBASE, OVID SP MEDLINE) were searched using comprehensive search strategies. The barriers and enablers were categorised using the theoretical domains framework (TDF). The behaviour change technique (BCT) that best aligned to the strategy each enabler represented was selected for each of the reported enablers using a standard taxonomy. Five qualitative studies and four surveys out of the 44 studies identified met the selection criteria. The majority of barriers reported corresponded with the TDF domains of "environmental, context and resources" (such as stressful working conditions or lack of resources) and "knowledge" (such as lack of guideline awareness or familiarity). The majority of enablers corresponded with the domains of "knowledge" (such as education for physicians on the calculated risk of haemorrhage following intravenous thrombolysis [tPA]) and "skills" (such as providing opportunity to treat stroke cases of varying complexity). The total number of BCTs assigned was 18. The BCTs most frequently assigned to the reported enablers were "focus on past success" and "information about health consequences." Barriers and enablers for the delivery of key evidence-based protocols in an emergency setting have been identified and interpreted within a relevant theoretical framework. This new knowledge has since been used to select specific BCTs to implement evidence-based care in an ED setting. It is recommended that findings from similar future reviews adopt a similar theoretical approach. In particular, the use of existing matrices to assist the selection of relevant BCTs.

Time for action-Improving the design and reporting of behaviour change interventions for antimicrobial stewardship in hospitals: Early findings from a systematic review.

Davey Peter, Peden Claire, Charani Esmita, Marwick Charis, Michie Susan

International journal of antimicrobial agents [45:203-12] (2015)

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There is strong evidence that self-monitoring and feedback are effective behaviour change techniques (BCTs) across a range of healthcare interventions and that their effectiveness is enhanced by goal setting and action planning. Here we report a summary of the update of a systematic review assessing the application of these BCTs to improving hospital antibiotic prescribing. This paper includes studies with valid prescribing outcomes published before the end of December 2012. We used a structured method for reporting these BCTs in terms of specific characteristics and contacted study authors to request additional intervention information. We identified 116 studies reporting 123 interventions. Reporting of BCTs was poor, with little detail of BCT characteristics. Feedback was only reported for 17 (13.8%) of the interventions, and self-monitoring was used in only 1 intervention. Goals were reported for all interventions but were poorly specified, with only three of the nine characteristics reported for ≥50% of interventions. A goal threshold and timescale were specified for just 1 of the 123 interventions. Only 29 authors (25.0%) responded to the request for additional information. In conclusion, both the content and reporting of interventions for antimicrobial stewardship fell short of scientific principles and practices. There is a strong evidence base regarding BCTs in other contexts that should be applied to antimicrobial stewardship now if we are to further our understanding of what works, for whom, why and in what contexts.

Interventions to enhance effective communication during over-the-counter consultations in the community pharmacy setting: A systematic review.

Seubert Liza J, Whitelaw Kerry, Hattingh Laetitia, Watson Margaret C, Clifford Rhonda M

Research in social & administrative pharmacy : RSAP (2017)

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Easy access to effective over-the-counter (OTC) treatments allows self-management of some conditions, however inappropriate or incorrect supply or use of OTC medicines can cause harm. Pharmacy personnel should support consumers in their health-seeking behaviour by utilising effective communication skills underpinned by clinical knowledge. To identify interventions targeted towards improving communication between consumers and pharmacy personnel during OTC consultations in the community pharmacy setting. Systematic review and narrative analysis. Databases searched were MEDLINE, EMBASE, Psycinfo, Cochrane Central Register and Cochrane Database of Systematic Reviews for literature published between 2000 and 30 October 2014, as well as reference lists of included articles. The search was re-run on 18 January 2016 and 25 September 2017 to maximise the currency. Two reviewers independently screened retrieved articles for inclusion, assessed study quality and extracted data. Full publications of intervention studies were included. Participants were community pharmacy personnel and/or consumers involved in OTC consultations. Interventions which aimed to improve communication during OTC consultations in the community pharmacy setting were included if they involved a direct measurable communication outcome. Studies reporting attitudes and measures not quantifiable were excluded. The protocol was published on Prospero Database of Systematic Reviews. Of 4978 records identified, 11 studies met inclusion criteria. Interventions evaluated were: face-to-face training sessions (n = 10); role-plays (n = 9); a software decision making program (n = 1); and simulated patient (SP) visits followed by immediate feedback (n = 1). Outcomes were measured using: SP methodology (n = 10) and a survey (n = 1), with most (n = 10) reporting a level of improvement in some communication behaviours. Empirical evaluation of interventions using active learning techniques such as face-to-face training with role-play can improve some communication skills. However interventions that are not fully described limit the ability for replication and/or generalisability. This review identified interventions targeting pharmacy personnel. Future interventions to improve communication should consider the consumer's role in OTC consultations.

Effectiveness of brief nutrition interventions on dietary behaviours in adults: A systematic review.

Whatnall Megan C, Patterson Amanda J, Ashton Lee M, Hutchesson Melinda J

Appetite [120:335-347] (2018)

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Brief interventions are effective in improving health behaviours including alcohol intake, however the effectiveness of brief interventions targeting nutrition outcomes has not been determined. The aim of this systematic review was to determine the effectiveness of brief nutrition interventions in adults. Seven databases were searched for RCT/pseudo RCT studies published in English to April 2016, and evaluating brief interventions (i.e. single point of contact) designed to promote change in eating behaviours in healthy adults (≥18 years). Of 4849 articles identified, 45 studies met inclusion criteria. Most studies targeted fruit and/or vegetable intake (n = 21) or fat intake (n = 10), and few targeted diet quality (n = 2). Median follow-up was 3.5 months, with few studies (n = 4) measuring longer-term outcomes (≥12 months). Studies aimed to determine whether a brief intervention was more effective than another brief intervention (n = 30), and/or more effective than no intervention (n = 20), with 17 and 11 studies, respectively, reporting findings to that effect. Interventions providing education plus tailored or instructional components (e.g. feedback) were more effective than education alone or non-tailored advice. This review suggests that brief interventions, which are tailored and instructional, can improve short-term dietary behaviours, however evidence for longer-term behaviour change maintenance is limited.

Does changing social influence engender changes in alcohol intake? A meta-analysis.

Prestwich Andrew, Kellar Ian, Conner Mark, Lawton Rebecca, Gardner Peter, Turgut Liz

Journal of consulting and clinical psychology [84:845-60] (2016)

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Past research has suggested that social influences on drinking can be manipulated with subsequent reductions in alcohol intake. However, the experimental evidence for this and the best strategies to positively change these social influences have not been meta-analyzed. This research addressed these gaps. Randomized controlled trials testing social influence-based interventions on adults' drinking were systematically reviewed and meta-analyzed. The behavior change techniques used in each study were coded and the effect sizes showing the impact of each intervention on (a) social influence and (b) alcohol intake were calculated. Metaregressions identified the association between these effect sizes, as well as the effect of specific behavior change techniques on social influences. Forty-one studies comprising 17,445 participants were included. Changes in social influences were significantly associated with changes in alcohol intake. However, even moderate-to-large changes in social influences corresponded with only a small change in drinking behavior and changing social influences did not reduce alcohol-related problems. Providing normative information about others' behavior and experiences was the most effective technique to change social influences. Social influences and normative beliefs can be changed in drinkers, particularly by providing normative information about how much others' drink. However, even generating large changes in these constructs are likely to engender only small changes in alcohol intake. (PsycINFO Database Record

A systematic review of the effectiveness of interventions using the Common Sense Self-Regulatory Model to improve adherence behaviours.

Jones Christina J, Smith Helen E, Llewellyn Carrie D

Journal of health psychology (2015)

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This systematic review assessed the effectiveness of the Common Sense Self-Regulatory Model in the design of interventions to improve adherence behaviours. Of nine eligible studies, six reported improvements in adherence behaviours and three showed moderate to large effects on return to work and lifestyle recommendations. Four studies stated how Common Sense Self-Regulatory Model constructs were addressed in the intervention and five measured illness perceptions as outcomes. Evidence was found for targeting cure/control perceptions in studies aimed at improving adherence behaviours. Future studies need to measure illness perceptions pre- and post-intervention to enable mediational analyses to assess the effect of Common Sense Self-Regulatory Model interventions on improving health outcomes.

Automated telecommunication interventions to promote adherence to cardio-metabolic medications: meta-analysis of effectiveness and meta-regression of behaviour change techniques.

Kassavou A, Sutton S

Health psychology review (2017)

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Automated telecommunication interventions, including short message service and interactive voice response, are increasingly being used to promote adherence to medications prescribed for cardio-metabolic conditions. This systematic review aimed to comprehensively assess the effectiveness of such interventions to support medication adherence, and to identify the behaviour change techniques (BCTs) and other intervention characteristics that are positively associated with greater intervention effectiveness. Meta-analysis of 17 randomised controlled trials showed a small but statistically significant effect on medication adherence, OR = 1.89, 95% CI [1.51, 2.36], I(2) = 89%, N = 25,101. Multivariable meta-regression analysis including eight BCTs explained 88% of the observed variance in effect size (ES). The BCTs 'tailored' and 'information about health consequences' were positively and significantly associated with ES. Future studies could explore whether the inclusion of these and/or additional techniques (e.g., 'implementation intentions') would increase the effect of automated telecommunication interventions, using rigorous designs and objective outcome measures.

Healthcare provider-led interventions to support medication adherence following ACS: a meta-analysis.

Crawshaw Jacob, Auyeung Vivian, Ashworth Lucy, Norton Sam, Weinman John

Open heart [4:e000685] (2017)

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We conducted a systematic review and meta-analysis to determine the effectiveness of healthcare provider-led (HCPs) interventions to support medication adherence in patients with acute coronary syndrome (ACS). A systematic search of Cochrane Library, Medline, EMBASE, PsycINFO, Web of Science, IPA, CINAHL, ASSIA, OpenGrey, EthOS, WorldCat and PQDT was undertaken. Interventions were deemed eligible if they included adult ACS patients, were HCP-led, measured medication adherence and randomised participants to parallel groups. Intervention content was coded using the Behaviour Change Technique (BCT) Taxonomy and data were pooled for analysis using random-effects models. Our search identified 8870 records, of which 27 were eligible (23 primary studies). A meta-analysis (n=9735) revealed HCP-led interventions increased the odds of medication adherence by 54% compared to control interventions (k=23, OR 1.54, 95% CI 1.26 to 1.88, I=57.5%). After removing outliers, there was a 41% increase in the odds of medication adherence with moderate heterogeneity (k=21, OR 1.41, 95% CI 1.21 to 1.65, I=35.3%). Interventions that included phone contact yielded (k=12, OR 1.63, 95% CI 1.25 to 2.12, I=32.0%) a larger effect compared to those delivered exclusively in person. A total of 32/93 BCTs were identified across interventions (mean=4.7, SD=2.2) with 'information about health consequences' (BCT 5.1) (19/23) the most common. HCP-led interventions for ACS patients appear to have a small positive impact on medication adherence. While we were able to identify BCTs among interventions, data were insufficient to determine the impact of particular BCTs on study effectiveness. CRD42016037706.

Improving medication management in multimorbidity: development of the MultimorbiditY COllaborative Medication Review And DEcision Making (MY COMRADE) intervention using the Behaviour Change Wheel.

Sinnott Carol, Mercer Stewart W, Payne Rupert A, Duerden Martin, Bradley Colin P, Byrne Molly

Implementation science : IS [10:132] (2015)

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Multimorbidity, the presence of two or more chronic conditions, affects over 60 % of patients in primary care. Due to its association with polypharmacy, the development of interventions to optimise medication management in patients with multimorbidity is a priority. The Behaviour Change Wheel is a new approach for applying behavioural theory to intervention development. Here, we describe how we have used results from a review of previous research, original research of our own and the Behaviour Change Wheel to develop an intervention to improve medication management in multimorbidity by general practitioners (GPs), within the overarching UK Medical Research Council guidance on complex interventions. Following the steps of the Behaviour Change Wheel, we sought behaviours associated with medication management in multimorbidity by conducting a systematic review and qualitative study with GPs. From the modifiable GP behaviours identified, we selected one and conducted a focused behavioural analysis to explain why GPs were or were not engaging in this behaviour. We used the behavioural analysis to determine the intervention functions, behavioural change techniques and implementation plan most likely to effect behavioural change. We identified numerous modifiable GP behaviours in the systematic review and qualitative study, from which active medication review (rather than passive maintaining the status quo) was chosen as the target behaviour. Behavioural analysis revealed GPs' capabilities, opportunities and motivations relating to active medication review. We combined the three intervention functions deemed most likely to effect behavioural change (enablement, environmental restructuring and incentivisation) to form the MultimorbiditY COllaborative Medication Review And DEcision Making (MY COMRADE) intervention. MY COMRADE primarily involves the technique of social support: two GPs review the medications prescribed to a complex multimorbid patient together. Four other behavioural change techniques are incorporated: restructuring the social environment, prompts/cues, action planning and self-incentives. This study is the first to use the Behaviour Change Wheel to develop an intervention targeting multimorbidity and confirms the usability and usefulness of the approach in a complex area of clinical care. The systematic development of the MY COMRADE intervention will facilitate a thorough evaluation of its effectiveness in the next phase of this work.