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Nudge to nobesity II: Menu positions influence food orders

Dayan E, Bar-Hillel M

Judgment and Decision Making, Vol. 6, No. 4, June 2011, pp. 333–342

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“Very small but cumulated decreases in food intake may be sufficient to have significant effects, even erasing obesity over a period of years” (Rozin et al., 2011). In two studies, one a lab study and the other a real-world study, we examine the effect of manipulating the position of different foods on a restaurant menu. Items placed at the beginning or the end of the list of their category options were up to twice as popular as when they were placed in the center of the list. Given this effect, placing healthier menu items at the top or bottom of item lists and less healthy ones in their center (e.g.,sugared drinks vs. calorie-free drinks) should result in some increase in favor of healthier food choices.


Redesigning the ‘choice architecture’ of hospital prescription charts: a mixed methods study incorporating in situ simulation testing

King D, Jabbar A, Charani E

BMJ Open 2014

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Objectives To incorporate behavioural insights into the user-centred design of an inpatient prescription chart (Imperial Drug Chart Evaluation and Adoption Study, IDEAS chart) and to determine whether changes in the content and design of prescription charts could influence prescribing behaviour and reduce prescribing errors. Design A mixed-methods approach was taken in the development phase of the project; in situ simulation was used to evaluate the effectiveness of the newly developed IDEAS prescription chart. Setting A London teaching hospital. Interventions/methods A multimodal approach comprising (1) an exploratory phase consisting of chart reviews, focus groups and user insight gathering (2) the iterative design of the IDEAS prescription chart and finally (3) testing of final chart with prescribers using in situ simulation. Results Substantial variation was seen between existing inpatient prescription charts used across 15 different UK hospitals. Review of 40 completed prescription charts from one hospital demonstrated a number of frequent prescribing errors including illegibility, and difficulty in identifying prescribers. Insights from focus groups and direct observations were translated into the design of IDEAS chart. In situ simulation testing revealed significant improvements in prescribing on the IDEAS chart compared with the prescription chart currently in use in the study hospital. Medication orders on the IDEAS chart were significantly more likely to include correct dose entries (164/164 vs 166/174; p=0.0046) as well as prescriber's printed name (163/164 vs 0/174; p<0.0001) and contact number (137/164 vs 55/174; p<0.0001). Antiinfective indication (28/28 vs 17/29; p<0.0001) and duration (26/28 vs 15/29; p<0.0001) were more likely to be completed using the IDEAS chart. Conclusions In a simulated context, the IDEAS prescription chart significantly reduced a number of common prescribing errors including dosing errors and illegibility. Positive behavioural change was seen without prior education or support, suggesting that some common prescription writing errors are potentially rectifiable simply through changes in the content and design of prescription charts.


Stating Appointment Costs in SMS Reminders Reduces Missed Hospital Appointments: Findings from Two Randomised Controlled Trials

Hallsworth M, Berry D, Sanders M, Sallis A, King D, Vlaev I

PLoS ONE 10(9): e0137306. pmid:26366885

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Missed hospital appointments are a major cause of inefficiency worldwide. Healthcare providers are increasingly using Short Message Service reminders to reduce ‘Did Not Attend’ (DNA) rates. Systematic reviews show that sending such reminders is effective, but there is no evidence on whether their impact is affected by their content. Accordingly, we undertook two randomised controlled trials that tested the impact of rephrasing appointment reminders on DNA rates in the United Kingdom. Participants were outpatients with a valid mobile telephone number and an outpatient appointment between November 2013 and January 2014 (Trial One, 10,111 participants) or March and May 2014 (Trial Two, 9,848 participants). Appointments were randomly allocated to one of four reminder messages, which were issued five days in advance. Message assignment was then compared against appointment outcomes (appointment attendance, DNA, cancellation by patient). In Trial One, a message including the cost of a missed appointment to the health system produced a DNA rate of 8.4%, compared to 11.1% for the existing message (OR 0.74, 95% CI 0.61–0.89, P<0.01). Trial Two replicated this effect (DNA rate 8.2%), but also found that expressing the same concept in general terms was significantly less effective (DNA rate 9.9%, OR 1.22, 95% CI 1.00–1.48, P<0.05). Moving from the existing reminder to the more effective costs message would result in 5,800 fewer missed appointments per year in the National Health Service Trust in question, at no additional cost. The study’s main limitations are that it took place in a single location in England, and that it required accurate phone records, which were only obtained for 20% of eligible patients. We conclude that missed appointments can be reduced, for no additional cost, by introducing persuasive messages to appointment reminders. Future studies could examine the impact of varying reminder messages in other health systems.


Source Dispensers and Home Delivery of Chlorine in Kenya

Asman S, Casarotto C

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Researchers sought to examine the impact of factors including price, persuasion, promotion and the chlorination products themselves with a two-phase study. Prior to the study baseline surveys were administered to a random selection of households.In the first phase, households were given seven WaterGuard bottles, an individual water treatment product, each sufficient for one month’s supply of clean water. They were also provided with improved drinking water storage pots with a tap to prevent contamination and detailed instructions on use. One third of this group received twelve coupons for a 50 percent discount on WaterGuard bottles, each valid for one month during the next year, and calendars with reminders. Another third received additional verbal persuasion messages beyond the basic WaterGuard instructions, and another third received no additional coupons or messages. To estimate social networking effects, the free WaterGuard bottles were distributed in different percentages in each community, allowing researchers to see if higher community levels of use increased individual adoption. A follow-up survey was administered between 2 and 7 months after the free WaterGuard was distributed.In the second phase researchers compared six different treatments designed to increase WaterGuard adoption. For the first three treatments, scripted promotional messages were delivered at either the(1) household level, (2) community level, or (3) both. The second two treatments included repeated promotion of chlorination through a home visit by a community elected promoter. Despite volunteering to work for free, the promoter was paid either a (4) flat rate, or was (5) paid based on how many households had chlorinated water at follow-up visits. The last treatment (6) combined the incentivized promoter model with an unlimited supply of free WaterGuard delivered through a point-of-collection chlorine dispenser at the local water source. Follow-up surveys were conducted 3 weeks and 3-6 months after the start of the study.


Financial incentives for home-based health monitoring: a randomized controlled trial.

Volpp KG., Asch DA, Loewenstein G, Park JD, Zhu J, Tao Y, Hu MF, Bellamy SL, Stearman B, Riley EB, Sewell TB, Sen AP

J Gen Intern Med. 2014 May;29(5):770-7.

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BACKGROUND: Home wireless device monitoring could play an important role in improving the health of patients with poorly controlled chronic diseases, but daily engagement rates among these patients may be low. OBJECTIVE: To test the effectiveness of two different magnitudes of financial incentives for improving adherence to remote-monitoring regimens among patients with poorly controlled diabetes. DESIGN: Randomized, controlled trial. (Clinicaltrials.gov Identifier: NCT01282957). PARTICIPANTS: Seventy-five patients with a hemoglobin A1c greater than or equal to 7.5% recruited from a Primary Care Medical Home practice at the University of Pennsylvania Health System. INTERVENTIONS: Twelve weeks of daily home-monitoring of blood glucose, blood pressure, and weight (control group; n = 28); a lottery incentive with expected daily value of $2.80 (n = 26) for daily monitoring; and a lottery incentive with expected daily value of $1.40 (n = 21) for daily monitoring. MAIN MEASURES: Daily use of three home-monitoring devices during the three-month intervention (primary outcome) and during the three-month follow-up period and change in A1c over the intervention period (secondary outcomes). KEY RESULTS: Incentive arm participants used devices on a higher proportion of days relative to control (81% low incentive vs. 58%, P = 0.007; 77% high incentive vs. 58%, P = 0.02) during the three-month intervention period. There was no difference in adherence between the two incentive arms (P = 0.58). When incentives were removed, adherence in the high incentive arm declined while remaining relatively high in the low incentive arm. In month 6, the low incentive arm had an adherence rate of 62% compared to 35% in the high incentive arm (P = 0.015) and 27% in the control group (P = 0.002). CONCLUSIONS: A daily lottery incentive worth $1.40 per day improved monitoring rates relative to control and had significantly better efficacy once incentives were removed than a higher incentive.


The Impact of Text Message Reminders on Adherence to Antimalarial Treatment in Northern Ghana: A Randomized Trial

Raifman JR

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Background Low rates of adherence to artemisinin-based combination therapy (ACT) regimens increase the risk of treatment failure and may lead to drug resistance, threatening the sustainability of current anti-malarial efforts. We assessed the impact of text message reminders on adherence to ACT regimens. Methods Health workers at hospitals, clinics, pharmacies, and other stationary ACT distributors in Tamale, Ghana provided flyers advertising free mobile health information to individuals receiving malaria treatment. The messaging system automatically randomized self-enrolled individuals to the control group or the treatment group with equal probability; those in the treatment group were further randomly assigned to receive a simple text message reminder or the simple reminder plus an additional statement about adherence in 12-hour intervals. The main outcome was self-reported adherence based on follow-up interviews occurring three days after treatment initiation. We estimated the impact of the messages on treatment completion using logistic regression. Results 1140 individuals enrolled in both the study and the text reminder system. Among individuals in the control group, 61.5% took the full course of treatment. The simple text message reminders increased the odds of adherence (adjusted OR 1.45, 95% CI [1.03 to 2.04], p-value 0.028). Receiving an additional message did not result in a significant change in adherence (adjusted OR 0.77, 95% CI [0.50 to 1.20], p-value 0.252). Conclusion The results of this study suggest that a simple text message reminder can increase adherence to antimalarial treatment and that additional information included in messages does not have a significant impact on completion of ACT treatment. Further research is needed to develop the most effective text message content and frequency.


Mobile phone technologies improve adherence to antiretroviral treatment in a resource-limited setting: a randomized controlled trial of text message reminders

Pop-Eleches C

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Objective There is limited evidence on whether growing mobile phone availability in sub-Saharan Africa can be used to promote high adherence to antiretroviral therapy (ART). This study tested the efficacy of short message service (SMS) reminders on adherence to ART among patients attending a rural clinic in Kenya. Design A randomized controlled trial of four SMS reminder interventions with 48 weeks of follow-up. Methods Four hundred and thirty-one adult patients who had initiated ART within 3 months were enrolled and randomly assigned to a control group or one of the four intervention groups. Participants in the intervention groups received SMS reminders that were either short or long and sent at a daily or weekly frequency. Adherence was measured using the medication event monitoring system. The primary outcome was whether adherence exceeded 90% during each 12-week period of analysis and the 48-week study period. The secondary outcome was whether there were treatment interruptions lasting at least 48 h. Results In intention-to-treat analysis, 53% of participants receiving weekly SMS reminders achieved adherence of at least 90% during the 48 weeks of the study, compared with 40% of participants in the control group (P=0.03). Participants in groups receiving weekly reminders were also significantly less likely to experience treatment interruptions exceeding 48 h during the 48-week follow-up period than participants in the control group (81 vs. 90%, P = 0.03). Conclusion These results suggest that SMS reminders may be an important tool to achieve optimal treatment response in resource-limited settings.


Holding the Hunger Games Hostage at the Gym: An Evaluation of Temptation Bundling

Milkman KL, Minson JA, Volpp KG

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We introduce and evaluate the effectiveness of temptation bundling—a method for simultaneously tackling two types of self-control problems by harnessing consumption complementarities. We describe a field experiment measuring the impact of bundling instantly gratifying but guilt-inducing “want” experiences (enjoying page-turner audiobooks) with valuable “should” behaviors providing delayed rewards (exercising). We explore whether such bundles increase should behaviors and whether people would pay to create these restrictive bundles. Participants were randomly assigned to a full treatment condition with gym-only access to tempting audio novels, an intermediate treatment involving encouragement to restrict audiobook enjoyment to the gym, or a control condition. Initially, full and intermediate treatment participants visited the gym 51% and 29% more frequently, respectively, than control participants, but treatment effects declined over time (particularly following Thanksgiving). After the study, 61% of participants opted to pay to have gym-only access to iPods containing tempting audiobooks, suggesting demand for this commitment device.


Effect of Behavioral Interventions on Inappropriate Antibiotic Prescribing Among Primary Care Practices

Meeker D

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Importance Interventions based on behavioral science might reduce inappropriate antibiotic prescribing. Objective To assess effects of behavioral interventions and rates of inappropriate (not guideline-concordant) antibiotic prescribing during ambulatory visits for acute respiratory tract infections. Design, Setting, and Participants Cluster randomized clinical trial conducted among 47 primary care practices in Boston and Los Angeles. Participants were 248 enrolled clinicians randomized to receive 0, 1, 2, or 3 interventions for 18 months. All clinicians received education on antibiotic prescribing guidelines on enrollment. Interventions began between November 1, 2011, and October 1, 2012. Follow-up for the latest-starting sites ended on April 1, 2014. Adult patients with comorbidities and concomitant infections were excluded. Interventions Three behavioral interventions, implemented alone or in combination: suggested alternatives presented electronic order sets suggesting nonantibiotic treatments; accountable justification prompted clinicians to enter free-text justifications for prescribing antibiotics into patients’ electronic health records; peer comparison sent emails to clinicians that compared their antibiotic prescribing rates with those of “top performers” (those with the lowest inappropriate prescribing rates). Main Outcomes and Measures Antibiotic prescribing rates for visits with antibiotic-inappropriate diagnoses (nonspecific upper respiratory tract infections, acute bronchitis, and influenza) from 18 months preintervention to 18 months afterward, adjusting each intervention’s effects for co-occurring interventions and preintervention trends, with random effects for practices and clinicians. Results There were 14 753 visits (mean patient age, 47 years; 69% women) for antibiotic-inappropriate acute respiratory tract infections during the baseline period and 16 959 visits (mean patient age, 48 years; 67% women) during the intervention period. Mean antibiotic prescribing rates decreased from 24.1% at intervention start to 13.1% at intervention month 18 (absolute difference, −11.0%) for control practices; from 22.1% to 6.1% (absolute difference, −16.0%) for suggested alternatives (difference in differences, −5.0% [95% CI, −7.8% to 0.1%]; P = .66 for differences in trajectories); from 23.2% to 5.2% (absolute difference, −18.1%) for accountable justification (difference in differences, −7.0% [95% CI, −9.1% to −2.9%]; P < .001); and from 19.9% to 3.7% (absolute difference, −16.3%) for peer comparison (difference in differences, −5.2% [95% CI, −6.9% to −1.6%]; P < .001). There were no statistically significant interactions (neither synergy nor interference) between interventions. Conclusions and Relevance Among primary care practices, the use of accountable justification and peer comparison as behavioral interventions resulted in lower rates of inappropriate antibiotic prescribing for acute respiratory tract infections.


Nudging Guideline-Concordant Antibiotic Prescribing

Meeker D

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Importance “Nudges” that influence decision making through subtle cognitive mechanisms have been shown to be highly effective in a wide range of applications, but there have been few experiments to improve clinical practice. Objective To investigate the use of a behavioral “nudge” based on the principle of public commitment in encouraging the judicious use of antibiotics for acute respiratory infections (ARIs). Design, Setting, and Participants Randomized clinical trial in 5 outpatient primary care clinics. A total of 954 adults had ARI visits during the study timeframe: 449 patients were treated by clinicians randomized to the posted commitment letter (335 in the baseline period, 114 in the intervention period); 505 patients were treated by clinicians randomized to standard practice control (384 baseline, 121 intervention). Interventions The intervention consisted of displaying poster-sized commitment letters in examination rooms for 12 weeks. These letters, featuring clinician photographs and signatures, stated their commitment to avoid inappropriate antibiotic prescribing for ARIs. Main Outcomes and Measures Antibiotic prescribing rates for antibiotic-inappropriate ARI diagnoses in baseline and intervention periods, adjusted for patient age, sex, and insurance status. Results Baseline rates were 43.5% and 42.8% for control and poster, respectively. During the intervention period, inappropriate prescribing rates increased to 52.7% for controls but decreased to 33.7% in the posted commitment letter condition. Controlling for baseline prescribing rates, we found that the posted commitment letter resulted in a 19.7 absolute percentage reduction in inappropriate antibiotic prescribing rate relative to control (P = .02). There was no evidence of diagnostic coding shift, and rates of appropriate antibiotic prescriptions did not diminish over time. Conclusions and Relevance Displaying poster-sized commitment letters in examination rooms decreased inappropriate antibiotic prescribing for ARIs. The effect of this simple, low-cost intervention is comparable in magnitude to costlier, more intensive quality-improvement efforts.


Peer Mentoring and Financial Incentives to Improve Glucose Control in African American Veterans: A Randomized, Controlled Trial

Long JA

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Background Compared to whites, African Americans have a greater incidence of diabetes, decreased control, and higher rates of micro-vascular complications. A peer mentorship model could be a scalable approach to improving control in this population and reducing disparities in diabetic outcomes. Objective To determine whether peer mentors or financial incentives are superior to usual care in helping African American Veterans improve their glycosylated hemoglobin (HbA1c) levels. Design A six month randomized controlled trial. (ClinicalTrials.gov registration number: NCT01125956) Setting The Philadelphia VA Medical Center. Patients African American veterans, age 50-70 years old, with persistently poor diabetes control. Measurements Change in HbA1c at 6 months Intervention 118 participants were randomized to one of the three arms. Usual care participants were notified of their starting HbA1c and recommended goals for HbA1c. Those in the peer mentor arm were assigned a peer mentor who formerly had poor glycemic control but now had good control (HbA1c < 7.5%) who was asked to talk with the participant at least once a week. Peer mentors were matched on race, sex, and age. Those in the financial incentive arm could earn $100 by dropping their HbA1c by one point and $200 by dropping it by two points or to a HbA1c of 6.5%. Results Mentors and mentees talked the most in the first month (mean calls 4: range 0-30) and dropped to a mean of 2 calls (range 0-10) by the sixth month. HbA1c dropped from 9.9% to 9.8% in the control arm, 9.8% to 8.7% in the peer mentor arm and from 9.5% to 9.1% in the financial incentive arm. Mean change in HbA1c from baseline to 6 months relative to control was −1.07 (95% CI −1.84 to −0.31) in the peer mentor arm and −0.45 (95% CI −1.23 to 0.32) in the financial incentive arm. Limitations The study included only veterans and lasted only 6 months. Conclusions Peer mentorship improved glucose control in a cohort of African American Veterans with diabetes.


Habit formation in children: Evidence from incentives for healthy eating

Loewenstein G, Price J, Volpp K

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We present findings from a field experiment conducted at 40 elementary schools involving 8000 children and 400,000 child-day observations, which tested whether providing short-run incentives can create habit formation in children. Over a 3- or 5-week period, students received an incentive for eating a serving of fruits or vegetables during lunch. Relative to an average baseline rate of 39%, providing small incentives doubled the fraction of children eating at least one serving of fruits or vegetables. Two months after the end of the intervention, the consumption rate at schools remained 21% above baseline for the 3-week treatment and 44% above baseline for the 5-week treatment. These findings indicate that short-run incentives can produce changes in behavior that persist after incentives are removed.


Web-Based Access to Positive Airway Pressure Usage with or without an Initial Financial Incentive Improves Treatment Use in Patients with Obstructive Sleep Apnea.

Kuna ST

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We tested whether providing adults with obstructive sleep apnea (OSA) with daily Web-based access to their positive airway pressure (PAP) usage over 3 mo with or without a financial incentive in the first week improves adherence and functional outcomes.Academic- and community-based sleep centers.One hundred thirty-eight adults with newly diagnosed OSA starting PAP treatment.Participants were randomized to: usual care, usual care with access to PAP usage, or usual care with access to PAP usage and a financial incentive. PAP data were transmitted daily by wireless modem from the participants' PAP unit to a website where hours of usage were displayed. Participants in the financial incentive group could earn up to $30/day in the first week for objective PAP use ≥ 4 h/day.Mean hours of daily PAP use in the two groups with access to PAP usage data did not differ from each other but was significantly greater than that in the usual care group in the first week and over 3 mo (P < 0.0001). Average daily use (mean ± standard deviation) during the first week of PAP intervention was 4.7 ± 3.3 h in the usual care group, and 5.9 ± 2.5 h and 6.3 ± 2.5 h in the Web access groups with and without financial incentive respectively. Adherence over the 3-mo intervention decreased at a relatively constant rate in all three groups. Functional Outcomes of Sleep Questionnaire change scores at 3 mo improved within each group (P < 0.0001) but change scores of the two groups with Web access to PAP data were not different than those in the control group (P > 0.124).Positive airway pressure adherence is significantly improved by giving patients Web access to information about their use of the treatment. Inclusion of a financial incentive in the first week had no additive effect in improving adherence.


Individual- versus group-based financial incentives for weight loss: a randomized, controlled trial

Kullgren JT

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BACKGROUND: Data on the effectiveness of employer-sponsored financial incentives for employee weight loss are limited. OBJECTIVE: To test the effectiveness of 2 financial incentive designs for promoting weight loss among obese employees. DESIGN: Randomized, controlled trial. (ClinicalTrials.gov: NCT01208350) SETTING: Children's Hospital of Philadelphia. PARTICIPANTS: 105 employees with a body mass index between 30 and 40 kg/m2. INTERVENTION: 24 weeks of monthly weigh-ins (control group; n = 35); individual incentive, designed as $100 per person per month for meeting or exceeding weight-loss goals (n = 35); and group incentive, designed as $500 per month split among participants within groups of 5 who met or exceeded weight-loss goals (n = 35). MEASUREMENTS: Weight loss after 24 weeks (primary outcome) and 36 weeks and changes in behavioral mediators of weight loss (secondary outcomes). RESULTS: Group-incentive participants lost more weight than control participants (mean between-group difference, 4.4 kg [95% CI, 2.0 to 6.7 kg]; P < 0.001) and individual-incentive participants (mean between-group difference, 3.2 kg [CI, 0.9 to 5.5 kg]; P = 0.008). Twelve weeks after incentives ended and after adjustment for 3-group comparisons, group-incentive participants maintained greater weight loss than control group participants (mean between-group difference, 2.9 kg [CI, 0.5 to 5.3 kg]; P = 0.016) but not greater than individual-incentive participants (mean between-group difference, 2.7 kg [CI, 0.4 to 5.0 kg]; P = 0.024). LIMITATION: Single employer and short follow-up. CONCLUSION: A group-based financial incentive was more effective than an individual incentive and monthly weigh-ins at promoting weight loss among obese employees at 24 weeks.


Randomized trial of lottery-based incentives to improve warfarin adherence

Kimmel SE

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Background Poor adherence to medications is a major cause of morbidity and inadequate drug effectiveness. Efforts to improve adherence have typically been either ineffective or too complex to implement in clinical practice. Lottery-based incentive interventions could be a scalable approach to improving adherence.MethodsThis was a randomized, controlled clinical trial of a daily lottery-based incentive in patients on warfarin stratified by baseline international normalized ratio (INR). The trial randomized 100 patients to either a lottery-based incentive or no lottery intervention. Main outcome was out-of-range INRs.ResultsOver 6 months, the overall percentage of out-of-range INRs did not differ between the 2 arms (mean 23.0% in lottery arm and 25.9% in control arm, adjusted odds ratio[OR]0.93,95%CI0.62-1.41). However, among the a priori subgroup with a baseline INR below therapeutic range, there was a significant reduction in out-of-range INR in the lottery arm versus the control arm (adjusted OR 0.39, 95% CI 0.25-0.62), whereas there was no such effect among those with therapeutic INRs at baseline(adjusted OR 1.26, 95% CI, 0.76-2.09, P value for interaction = .0016). Among those with low INR at baseline, there was a nonsignificant 49% reduction in the odds of nonadherence with the intervention (OR 0.51, 95% CI 0.23-1.14).ConclusionsAlthough a lottery-based intervention was not associated with a significant improvement in anticoagulation control among all study participants, it improved control among an a priori group of patients at higher risk for poor adherence.(Am Heart J 2012;164:268-74.)


The Impact of Alternative Incentive Schemes on Completion of Health Risk Assessments

Haisley E, Volpp KG, Pellathy T, Loewenstein G

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Purpose. The biggest challenge for corporate wellness initiatives is low rates of employee participation. We test whether a behavioral economic approach to incentive design (i.e., a lottery) is more effective than a direct economic payment of equivalent monetary value (i.e., a grocery gift certificate) in encouraging employees to complete health risk assessments (HRAs). Design. Employees were assigned to one of three arms. Assignment to a treatment arm versus the nontreatment arm was determined by management. Assignment to an arm among those eligible for treatment was randomized by office. Setting. A large health care management and information technology consulting company. Patients. A total of 1299 employees across 14 offices participated. Intervention. All employees were eligible to receive $25 for completing the HRA. Those in the lottery condition were assigned to teams of four to eight people and, conditional on HRA completion, were entered into a lottery with a prize of $100 (expected value, $25) and a bonus value of an additional $25 if 80% of team members participated. Those in the grocery gift certificate condition who completed an HRA received a $25 grocery gift certificate. Those in the comparison condition received no additional incentive. Measures. HRA completion rates. Analysis. Logistic regression analysis. Results. HRA completion rates were significantly higher among participations in the lottery incentive condition (64%) than in both the grocery gift certificate condition (44%) and the comparison condition (40%). Effects were larger for lower-income employees, as indicated by a significant interaction between income and the lottery incentive. Conclusion. Lottery incentives that incorporate regret aversion and social pressure can provide higher impact for the same amount of money as simple economic incentives.


Heckle and Chide: Results of a randomized road safety intervention in Kenya

Habyarimana J, Jack W

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We report the results of a randomized field experiment aimed at improving the safety of long-distance mini-busses or matatus in Kenya. Our intervention combines evocative messages aimed at motivating passengers to speak up against bad driving with a lottery that rewards matatu drivers for keeping the stickers in place. Independent insurance claims data were collected for more than 2000 long-distance matatus before and after the intervention. Our results indicate that insurance claims fell by a half to two-thirds, from a baseline annual rate of about 10%, and that claims involving injury or death fell by 60%. While we are unable to identify the mechanism(s) underlying this effect, the intervention is more cost effective in reducing mortality than other documented public health interventions.


Encouraging Diabetics to Use Statins: Nudging for Long-Term Health


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For this controlled trial, we randomly divided our sample population of 2,324 diabetics into four groups and sent each a different type of letter from the Oklahoma Health Care Authority. To track and compare the responses of the different groups, we analyzed Medicaid claims data for each patient over the next year, noting payments for physician visits, blood tests and filled prescriptions. By the end of our one-year analysis period, the control group had caught up with the nudge recipients (not surprising in a population of diabetics, who are likely to have medical checkups over an extended period). There was no longer a significant difference in the number of prescriptions filled, whether as the result of physician visits or renewals of existing prescriptions. So it seems that the value of the nudge is actually in prompting recipients to act more quickly – which should have a positive effect on long-term health outcomes, particularly when extended across a population of millions.


Opioid prescribing decreases after learning of a patient’s fatal overdose

Doctor JN

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Most opioid prescription deaths occur among people with common conditions for which prescribing risks outweigh benefits. General psychological insights offer an explanation: People may judge risk to be low without available personal experiences, may be less careful than expected when not observed, and may falter without an injunction from authority. To test these hypotheses, we conducted a randomized trial of 861 clinicians prescribing to 170 persons who subsequently suffered fatal overdoses. Clinicians in the intervention group received notification of their patients’ deaths and a safe prescribing injunction from their county’s medical examiner, whereas physicians in the control group did not. Milligram morphine equivalents in prescriptions filled by patients of letter recipients versus controls decreased by 9.7% (95% confidence interval: 6.2 to 13.2%; P < 0.001) over 3 months after intervention. We also observed both fewer opioid initiates and fewer high-dose opioid prescriptions by letter recipients.


Risking it all for love? Resetting beliefs about HIV risk among low-income South African teens

Datta S

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Research suggests that the much higher HIV prevalence among young women in sub-Saharan Africa than among males of their age cohort is linked to the high prevalence of age-disparate sexual partnerships, and that incorrect beliefs about the relationship between age and HIV-risk are partly responsible. We report the results of an experiment that tests whether a simple, computer-based “HIV risk game” leads to better understanding of the relationship between HIV-risk and age among low-income South African adolescents than a version of the traditional “brochure approach” to dispensing information does. Our results are striking. The randomly assigned treatment group, which receives repeated doses of information about the link between age and HIV-risk as feedback to their own responses to simple questions about relative HIV-risk, is significantly more likely to correctly identify which of a pair of hypothetical men or women of different ages is more likely to have HIV than the control group. Subjects in the treatment group answer, on average, 1.65 times as many questions about HIV risk and age correctly as those in the control group. We also find that subjects’ (particularly female subjects’) beliefs about HIV risk among women are less accurate than their beliefs about HIV risk among men. Finally, a follow-up survey with no significant difference in attrition rates between those in the treatment and control groups, shows substantially higher information retention among treatment subjects than among control subjects.


Goals and Social Comparisons Promote Walking Behavior

Chapman GB, Colby H, Convery K, Coups EJ

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The effectiveness of a pedometer intervention was affectedby manipulating the goals given to participants and byproviding social comparison feedback about how partici-pants’ performance compared with others. In study 1(n= 148), university staff members received a low,medium, or high walking goal (10%, 50%, or 100%increase over baseline walking). Participants walked1358 more steps per day (95% confidence interval [CI],729, 1985), when receiving a high goal than when receiv-ing a medium goal, but a medium goal did not increasewalking relative to a low goal (554 more steps; 95% CI,–71,1179). In study 2 (n= 64), participants received individual feedback only or individual plus social com-parison feedback. Participants walked 1120 more stepsper day (95% CI, 538, 1703) when receiving social compar-ison feedback than when receiving only individual feed-back. Goals and the performance of others act asreference points and influence the effect that pedometerfeedback has on walking behavior, illustrating the applica-bility of the principles of behavioral economics and socialpsychology to the design of health behavior interventions.


Integrating a Parenting Intervention With Routine Primary Health Care: A Cluster Randomized Trial

Chang SM

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OBJECTIVE: More than 200 million children globally do not attain their developmental potential. We hypothesized that a parent training program could be integrated into primary health center visits and benefit child development. METHODS: We conducted a cluster randomized trial in the Caribbean (Jamaica, Antigua, and St Lucia). Fifteen centers were randomly assigned to the control (n = 250 mother-child pairs) and 14 to the intervention (n = 251 mother-child pairs) groups. Participants were recruited at the 6- to 8-week child health visit. The intervention used group delivery at 5 routine visits from age 3 to 18 months and comprised short films of child development messages, which were shown in the waiting area; discussion and demonstration led by community health workers; and mothers’ practice of activities. Nurses distributed message cards and a few play materials. Primary outcomes were child cognition, language, and hand-eye coordination and secondary outcomes were caregiver knowledge, practices, maternal depression, and child growth, measured after the 18-month visit. RESULTS: Eight-five percent of enrolled children were tested (control = 210, intervention = 216). Loss did not differ by group. Multilevel analyses showed significant benefits for cognitive development (3.09 points; 95% confidence interval: 1.31 to 4.87 points; effect size: 0.3 SDs). There were no other child benefits. There was a significant benefit to parenting knowledge (treatment effect: 1.59; 95% confidence interval: 1.01 to 2.17; effect size: 0.4). CONCLUSIONS: An innovative parenting intervention, requiring no additional clinic staff or mothers’ time, was integrated into health services, with benefits to child cognitive development and parent knowledge. This is a promising strategy that merits further evaluation at scale.


Did you get your shots? Experimental evidence on the role of reminders

Busso, Cristia, Humpage

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Many families fail to vaccinate their children despite the supply of these services at no cost. This study tests whether personal reminders can increase demand for vaccination. A field experiment was conducted in rural Guatemala in which timely reminders were provided to families whose children were due for a vaccine. The six-month intervention increased the probability of vaccination completion by 2.2 percentage points among all children in treatment communities. Moreover, for children in treatment communities who were due to receive a vaccine, and whose parents were expected to be reminded about that due date, the probability of vaccination completion increased by 4.6 percentage points. The cost of an additional child with complete vaccination due to the intervention is estimated at about $7.50.


Attention, intentions, and follow-through in preventive health behavior: Field experimental evidence on flu vaccination

Bronchetti ET

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Preventive health behaviors like flu vaccination have important benefits, but compliance is poor, and the reasons are not fully understood. We conducted a large study across six colleges (N = 9358), with a methodology that offers an unusual opportunity to look at three potential factors: inattention to information, informed intentions to not comply, and problems following through on intentions. We also tested three interventions in an RCT. We find that inattention to information is not the primary driver of low take-up, while informed decisions to not get the vaccine, but also lack of follow-through, are important factors. A financial intervention increased take-up and had persistent, positive effects on intentions for vaccination in future years. Two low-cost “nudges” did not increase vaccination rates, although the peer endorsement nudge increased exposure to information, especially if aligned with social networks.


Behavioral Emails Increase Flu Vaccine Uptake among City Employees


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SUMMARY To increase uptake of flu vaccines and maintain a healthy workforce during the 2016-17 flu season, New York City’s Behavioral Design Team (NYC BDT) partnered with WorkWell NYC to design behaviorally informed emails to encourage New York City employees to visit a worksite flu clinic. One version of the redesigned email used the strategy of “enhanced active choice,” whereby employees were prompted to make a choice that had a clear right answer. IMPACT Behavioral emails more than doubled click-through rates and statistically increased appointment sign-ups. Most importantly, the enhanced active choice version of the email increased vaccine uptake by 5 percent at worksite locations.


Improving immunisation coverage in rural India: clustered randomised controlled evaluation of immunisation campaigns with and without incentives

Banerjee AV, Duflo, Glennerster, Kothari

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Objective To assess the efficacy of modest non-financial incentives on immunisation rates in children aged 1-3 and to compare it with the effect of only improving the reliability of the supply of services. Design Clustered randomised controlled study. Setting Rural Rajasthan, India. Participants 1640 children aged 1-3 at end point. Interventions 134 villages were randomised to one of three groups: a once monthly reliable immunisation camp (intervention A; 379 children from 30 villages); a once monthly reliable immunisation camp with small incentives (raw lentils and metal plates for completed immunisation; intervention B; 382 children from 30 villages), or control (no intervention, 860 children in 74 villages). Surveys were undertaken in randomly selected households at baseline and about 18 months after the interventions started (end point). Main outcome measures Proportion of children aged 1-3 at the end point who were partially or fully immunised. Results Among children aged 1-3 in the end point survey, rates of full immunisation were 39% (148/382, 95% confidence interval 30% to 47%) for intervention B villages (reliable immunisation with incentives), 18% (68/379, 11% to 23%) for intervention A villages (reliable immunisation without incentives), and 6% (50/860, 3% to 9%) for control villages. The relative risk of complete immunisation for intervention B versus control was 6.7 (4.5 to 8.8) and for intervention B versus intervention A was 2.2 (1.5 to 2.8). Children in areas neighbouring intervention B villages were also more likely to be fully immunised than those from areas neighbouring intervention A villages (1.9, 1.1 to 2.8). The average cost per immunisation was $28 (1102 rupees, about £16 or €19) in intervention A and $56 (2202 rupees) in intervention B. Conclusions Improving reliability of services improves immunisation rates, but the effect remains modest. Small incentives have large positive impacts on the uptake of immunisation services in resource poor areas and are more cost effective than purely improving supply.


Effect of Financial Incentives to Physicians, Patients, or Both on Lipid Levels: A Randomized Clinical Trial

Asch DA

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Importance Financial incentives to physicians or patients are increasingly used, but their effectiveness is not well established. Objective To determine whether physician financial incentives, patient incentives, or shared physician and patient incentives are more effective than control in reducing levels of low-density lipoprotein cholesterol (LDL-C) among patients with high cardiovascular risk. Design, Setting, and Participants Four-group, multicenter, cluster randomized clinical trial with a 12-month intervention conducted from 2011 to 2014 in 3 primary care practices in the northeastern United States. Three hundred forty eligible primary care physicians (PCPs) were enrolled from a pool of 421. Of 25 627 potentially eligible patients of those PCPs, 1503 enrolled. Patients aged 18 to 80 years were eligible if they had a 10-year Framingham Risk Score (FRS) of 20% or greater, had coronary artery disease equivalents with LDL-C levels of 120 mg/dL or greater, or had an FRS of 10% to 20% with LDL-C levels of 140 mg/dL or greater. Investigators were blinded to study group, but participants were not. Interventions Primary care physicians were randomly assigned to control, physician incentives, patient incentives, or shared physician-patient incentives. Physicians in the physician incentives group were eligible to receive up to $1024 per enrolled patient meeting LDL-C goals. Patients in the patient incentives group were eligible for the same amount, distributed through daily lotteries tied to medication adherence. Physicians and patients in the shared incentives group shared these incentives. Physicians and patients in the control group received no incentives tied to outcomes, but all patient participants received up to $355 each for trial participation. Main Outcomes and Measures Change in LDL-C level at 12 months. Results Patients in the shared physician-patient incentives group achieved a mean reduction in LDL-C of 33.6 mg/dL (95% CI, 30.1-37.1; baseline, 160.1 mg/dL; 12 months, 126.4 mg/dL); those in physician incentives achieved a mean reduction of 27.9 mg/dL (95% CI, 24.9-31.0; baseline, 159.9 mg/dL; 12 months, 132.0 mg/dL); those in patient incentives achieved a mean reduction of 25.1 mg/dL (95% CI, 21.6-28.5; baseline, 160.6 mg/dL; 12 months, 135.5 mg/dL); and those in the control group achieved a mean reduction of 25.1 mg/dL (95% CI, 21.7-28.5; baseline, 161.5 mg/dL; 12 months, 136.4 mg/dL; P < .001 for comparison of all 4 groups). Only patients in the shared physician-patient incentives group achieved reductions in LDL-C levels statistically different from those in the control group (8.5 mg/dL; 95% CI, 3.8-13.3; P = .002). Conclusions and Relevance In primary care practices, shared financial incentives for physicians and patients, but not incentives to physicians or patients alone, resulted in a statistically significant difference in reduction of LDL-C levels at 12 months. This reduction was modest, however, and further information is needed to understand whether this approach represents good value.


Using implementation intentions prompts to enhance influenza vaccination rates

Milkman KL

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A randomized evaluation found that writing both a date and time increased the number of employees getting their flu shots.. Employees who received the more detailed "time plan" mailer were 4 percentage points more likely than those who received the standard mailer to get their shot (37.1% compared to 33.1%).


Goals and Social Comparisons Promote Walking Behavior

Chapman GB, Colby H, Convery K, Coups EJ

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A randomized evaluation found that staff members assigned a high goal walked an average of 1,358 more steps per day than their colleagues who were assigned a medium goal, and 1,912 more steps per day than those assigned a low goal.


Default Options In Advance Directives Influence How Patients Set Goals For End-Of-Life Care

Halpern SD

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A randomized evaluation found that presenting patients with a default, preselected influenced the type of end-of-life care patients chose. When the advance directed had no preselected option, 61% percent of patients chose comfort-oriented care.


Enhanced active choice: A new method to motivate behavior change

Keller PA, Harlam B, Loewenstein G, Volpp KG

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Not adhering to medication regimens has individual, public health, and economic consequences. While helpful automatic prescription refill programs are widely available, few individuals enroll.


Do-Gooders and Go-Getters: Selection and Performance in Public Service Delivery

Ashraf, Bandiera, Lee

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Project Summary. Posters and brochures emphasizing career incentives—especially the opportunity to move up to higher and better-paid positions—helped recruit new, more effective community health workers.


Cash vs. food assistance to improve adherence to antiretroviral therapy among HIV-infected adults in Tanzania

McCoy SI

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Good adherence to HIV medication is crucial to extend the length and quality of life and to eliminate transmission of HIV to others. However, in sub-Saharan Africa, only 29% of people living with HIV (PLHIV) have viral suppression, the ultimate goal of treatment.


Facilitating Sunscreen Use Among Chinese Young Adults: Less-Motivated Persons Benefit from a Planning Intervention.

Zhou Guangyu, Zhang Liang, Knoll Nina, Schwarzer Ralf

International journal of behavioral medicine [22:443-51] (2015)

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The effect of a self-regulatory intervention with its focus on planning sunscreen use is evaluated in comparison to a standard educational condition. This paper studied whether planning mediates between the experimental conditions and the behavioral outcome. Further, it is examined who benefits more: already motivated or unmotivated individuals. College students (N = 253) were randomly assigned to two groups: a self-regulatory and a standard-care condition. Sunscreen use, intention to use sunscreen, and planning were assessed at two points in time, 1 month apart. The self-regulatory intervention improved planning to use sunscreen but not the behavior directly. Planning emerged as the mediator between conditions and later sunscreen use, controlling for baseline behavior. Moreover, participants who were less motivated benefited more from the intervention. Although it is generally assumed that planning interventions are best designed for already motivated persons, the present findings suggest that less prepared individuals might have more to gain from a brief self-regulatory intervention.


Randomized trial testing a worksite sun protection program in an outdoor recreation industry.

Buller David B, Andersen Peter A, Walkosz Barbara J, Scott Michael D, Cutter Gary R, Dignan Mark B, Zarlengo Elizabeth M, Voeks Jenifer H, Giese Aimee J

Health education & behavior : the official publication of the Society for Public Health Education [32:514-35] (2005)

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Health communication campaigns intended to reduce chronic and severe exposure to ultraviolet radiation in sunlight and prevent skin cancer are a national priority. Outdoor workers represent an unaddressed, high-risk population. Go Sun Smart (GSS), a worksite sun safety program largely based on the diffusion-of-innovations theory, was evaluated in a pair-matched, group-randomized, pretest-posttest controlled design enrolling employees at 26 ski areas in Western North America. Employees at the intervention ski areas were more aware of GSS (odds ratio [OR] = 8.27, p < .05) and reported less sunburning (adjusted OR = 1.63, p < .05) at posttest than employees at the control areas. A dose response was evident (OR = 1.46, p < .05) with greater observed program implementation associated with fewer sunburns among employees. Program awareness per se was not predictive (p > .05) of reduced sunburning in a mediational analysis. Analyses of nonrespondents, including intent-to-treat analyses, further supported the success of GSS.


A brief intervention changing oral self-care, self-efficacy, and self-monitoring.

Schwarzer Ralf, Antoniuk Agata, Gholami Maryam

British journal of health psychology [20:56-67] (2015)

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The roles of self-efficacy and self-monitoring as proximal predictors of dental flossing frequency are studied in the context of an oral health intervention. A study among 287 university students, aged 19 to 26 years, compared an intervention group that received a brief self-regulatory treatment, with a passive and an active control group. Dental flossing, self-efficacy, and self-monitoring were assessed at baseline and 3 weeks later. The intervention led to an increase in dental flossing regardless of experimental condition. However, treatment-specific gains were documented for self-efficacy and self-monitoring. Moreover, changes in the latter two served as mediators in a path model, linking the intervention with subsequent dental flossing and yielding significant indirect effects. Self-efficacy and self-monitoring play a mediating role in facilitating dental flossing. Interventions that aim at an improvement in oral self-care should consider using these constructs. Statement of contribution What is already known on this subject? The adoption and maintenance of oral self-care can be facilitated by a number of social-cognitive variables. Interventions that include planning, action control, or self-efficacy components have been shown to improve dental flossing. In one recent study on flossing in adolescent girls, planning intervention effects were mediated by self-efficacy. What does this study add? Self-monitoring is associated with better oral self-care. A 10-min intervention improves self-efficacy and self-monitoring. Self-efficacy and self-monitoring operate as mediators between treatment and flossing.


Perceived control and intrinsic vs. extrinsic motivation for oral self-care: a full factorial experimental test of theory-based persuasive messages.

Staunton Liam, Gellert Paul, Knittle Keegan, Sniehotta Falko F

Annals of behavioral medicine : a publication of the Society of Behavioral Medicine [49:258-68] (2015)

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Correlational evidence suggests that perceived control (PC) and intrinsic motivation (IM), key constructs in social cognitive and self-determination theories, may interact to reinforce behavior change. This proof-of-principle study examines the independent and synergistic effects of interventions to increase PC and IM upon dental flossing frequency. University students (n = 185) were randomized in a 2 × 2 full factorial design to receive two computer-based interventions: one to either increase or decrease PC and another to increase either IM or extrinsic motivation. These constructs were measured immediately post-intervention; flossing behavior was measured 1 week later. The interventions to increase PC and PC/IM had main and interaction effects on flossing, respectively. The PC/IM interaction effect was mediated by increases in PC and IM. Combining interventions to increase PC and IM seems to be a promising avenue of research, which has implications for both theory and intervention development.


The use of a mobile app to motivate evidence-based oral hygiene behaviour.

Underwood, B Birdsall, J Kay

British dental journal [219:166-7] (2015)

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Mobile apps are software programmes that run on smartphones and other mobile devices. Mobile health apps can help people manage their own health and wellness, promote healthy living and gain access to useful information when and where they need it. The Brush DJ oral health app was developed to use the opportunity mobile apps offer to motivate an evidence-based oral hygiene routine. A literature review has found no research investigating the use of a mobile app to motivate evidence-based oral hygiene behaviour. The objective of this preliminary investigation was to assess user perception of an oral health app to give a basis for future research and development of app technology in relation to oral health. A cross-sectional qualitative user perception questionnaire. One hundred and eighty-nine people responded to the questionnaire. Seventy percent (n = 113) of respondents reported that their teeth felt cleaner since using the app. Eighty-eight percent (n = 133) reported the app motivated them to brush their teeth for longer and 92.3% (n = 144) would recommend the app to their friends and family. Four broad themes relating to how the app helped toothbrushing were reported. These themes were motivation, education, compliance and perceived benefits. A mobile app is a promising tool to motivate an evidence-based oral hygiene routine.


An oral care self-management support protocol (OrCaSS) to reduce oral mucositis in hospitalized patients with acute myeloid leukemia and allogeneic hematopoietic stem cell transplantation: a randomized controlled pilot study.

Leppla Lynn, De Geest Sabina, Fierz Katharina, Deschler-Baier Barbara, Koller Antje

Supportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer [24:773-82] (2016)

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Oral mucositis (OM) is a common and debilitating side effect of chemoradiotherapy in patients awaiting allogeneic hematopoietic stem cell transplantation (aHSCT). The aim of this pilot RCT was to compare an oral care self-management support protocol (OrCaSS) to usual pre-aHSCT care. Feasibility was tested, effect sizes calculated for OM (primary outcome), and patient adherence was measured (secondary outcome). Eighteen AML patients awaiting aHSCT and hospitalized between August 2012 and April 2013 were randomized 1:1 to usual care (UCG) and intervention (IG) groups. The OrCaSS protocol consisted of two sessions of educational and behavioral interventions, the first delivered 1 week pre-admission (T1), the second on admission day (T2). Via field notes, practicability and acceptability were evaluated to explore the feasibility of intervention and study procedures. OM data were collected at T1, T2, and daily for 28 days using the WHO scale. The effect size r was calculated (r less than -0.1 ≙ small and greater than or equal to -0.3 ≙ medium). Patients' adherence to the protocol was assessed at T1, T2, and 8-10 days post-HSCT (T3). Research and intervention procedures were feasible. OM incidence was 100 %. The IG's median highest OM grade was 2.0 (IQR = 2); the UCGs was 3.0 (IQR = 2; r = -0.1). Median OM durations were 12 days in the IG and 14 days in the UCG (r = -0.1). OM onset was 2 days later in the IG than in the UCG (r = -0.1). Over the course of the study, patient adherence decreased in both groups. OrCaSS is a promising intervention to delay and reduce OM. These results can serve to plan a larger RCT.


Self-efficacy, planning and action control in an oral self-care intervention.

Zhou Guangyu, Sun Caiyun, Knoll Nina, Hamilton Kyra, Schwarzer Ralf

Health education research [30:671-81] (2015)

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To evaluate a theory-guided intervention on oral self-care and examine the possible mechanisms among self-regulatory factors, two brief intervention arms were compared, an information-based education treatment and a self-regulation treatment focusing on planning and action control. Young adults (N = 284; aged 18-29 years) were assessed at baseline and 1 month later. The self-regulation intervention improved levels of oral self-care, dental planning and action control. Moreover, a moderated mediation model with planning as the mediator between experimental conditions and dental outcome, and self-efficacy as well as action control as moderators elucidated the mechanism of change. More self-efficacious participants in the self-regulation condition benefitted in terms of more planning, and those who monitored their actions yielded higher levels of oral hygiene. Dental self-efficacy, dental planning and action control are involved in the improvement of oral self-care. Their joint consideration may contribute to a better understanding of health behavior change.


Psychological, behavioral, and clinical effects of intra-oral camera: a randomized control trial on adults with gingivitis.

Araújo Mário-Rui, Alvarez Maria-João, Godinho Cristina A, Pereira Cícero

Community dentistry and oral epidemiology (2016)

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To evaluate the effects of using an intra-oral camera (IOC) during supportive periodontal therapy (SPT), on the psychological, behavioral, and clinical parameters of patients with gingivitis, outlined by evidence and a theory-based framework. A group of 78 adult patients with gingivitis receiving an SPT was randomized into two groups: IOC and control. Bleeding on Marginal Probing (BOMP), self-reported dental hygiene behaviors, and psychological determinants of behavior change (outcome expectancies, self-efficacy, and planning) and IOC opinion were evaluated 1 week before or during the appointment and 4 months later. Repeated-measures anova was used to compare groups over time. Almost all the patients brushed their teeth daily, while 78% either never or hardly ever used dental floss. The IOC group showed significant improvements in BOMP index (P < 0.001), self-reported flossing (P < 0.05), and self-efficacy (P < 0.05) compared to the control group. The use of IOC significantly improves clinical, behavioral, and psychological determinants of periodontal health 4 months after treatment.


Train the trainer? A randomized controlled trial of a multi-tiered oral health education programme in community-based residential services for adults with intellectual disability.

Mac Giolla, Phadraig Caoimhin, Guerin Suzanne, Nunn June

Community dentistry and oral epidemiology [41:182-92] (2013)

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To assess the impact of a multi-tiered oral health education programme on care staff caring for people with intellectual disability (ID). Postal questionnaires were sent to all care staff of a community-based residential care service for adults, randomly assigned to control and intervention groups. A specifically developed training programme was delivered to residential staff nominees, who then trained all staff within the intervention group. The control group received no training. Post-test questionnaires were sent to both groups. Paired-samples t-test was used to compare oral health-related knowledge (K) and behaviour, attitude and self-efficacy (BAS) scores. Of the initial 219 respondents, 154 (response rate between 40% and 35.8%, with attrition rate of 29.7% from baseline to repeat) returned completed questionnaires at post-test (M=8.5 months, range=6.5-11 months). Control and intervention groups were comparable for general training, employment and demographic variables. In the intervention group, mean Knowledge Index score rose from K=7.2 to K=7.9 (P<0.001) and mean BAS scale score rose from BAS=4.7 to BAS=5.4 (P<0.001). There was no statistically significant increase in mean scores from test (K=7.0, BAS=4.7) to post-test (K=7.2, BAS=4.9) for the control group. Mean scores regarding knowledge, attitude, self-efficacy and reported behaviour increased significantly at 8.5 months in staff where training was provided. The results indicate that a multi-tiered training programme improved knowledge, attitude, self-efficacy and reported behaviour amongst staff caring for people with ID.


Using intervention mapping to develop a home-based parental-supervised toothbrushing intervention for young children.

Gray-Burrows K A, Day P F, Marshman Z, Aliakbari E, Prady S L, McEachan R R C

Implementation science : IS [11:61] (2016)

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Dental caries in young children is a major public health problem impacting on the child and their family in terms of pain, infection and substantial financial burden on healthcare funders. In the UK, national guidance on the prevention of dental caries advises parents to supervise their child's brushing with fluoride toothpaste until age 7. However, there is a dearth of evidence-based interventions to encourage this practice in parents. The current study used intervention mapping (IM) to develop a home-based parental-supervised toothbrushing intervention to reduce dental caries in young children. The intervention was developed using the six key stages of the IM protocol: (1) needs assessment, including a systematic review, qualitative interviews, and meetings with a multi-disciplinary intervention development group; (2) identification of outcomes and change objectives following identification of the barriers to parental-supervised toothbrushing (PSB), mapped alongside psychological determinants outlined in the Theoretical Domains Framework (TDF); (3) selection of methods and practical strategies; (4) production of a programme plan; (5) adoption and implementation and (6) Evaluation. The comprehensive needs assessment highlighted key barriers to PSB, such as knowledge, skills, self-efficacy, routine setting and behaviour regulation and underlined the importance of individual, social and structural influences. Parenting skills (routine setting and the ability to manage the behaviour of a reluctant child) were emphasised as critical to the success of PSB. The multi-disciplinary intervention development group highlighted the need for both universal and targeted programmes, which could be implemented within current provision. Two intervention pathways were developed: a lower cost universal pathway utilising an existing national programme and an intensive targeted programme delivered via existing parenting programmes. A training manual was created to accompany each intervention to ensure knowledge and standardise implementation procedures. PSB is a complex behaviour and requires intervention across individual, social and structural levels. IM, although a time-consuming process, allowed us to capture this complexity and allowed us to develop two community-based intervention pathways covering both universal and targeted approaches, which can be integrated into current provision. Further research is needed to evaluate the acceptability and sustainability of these interventions.


A Brief Self-Regulatory Intervention Increases Dental Flossing in Adolescent Girls.

Gholami Maryam, Knoll Nina, Schwarzer Ralf

International journal of behavioral medicine [22:645-51] (2015)

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Oral diseases such as dental caries, periodontal disease, and tooth loss are a considerable public health problem. A review of the epidemiological data from many countries indicates that a global increase in dental caries prevalence affects children as well as adults. Despite the improvement in oral health of children in the last few decades, tooth decay remains one of the most common childhood diseases in both industrialized and developing countries. The study evaluates the effects of a self-regulatory intervention to increase dental flossing among adolescents and examines the mediating mechanisms underlying behavioral changes. A cluster randomized controlled trial compared a brief intervention arm with a control arm in 166 girls aged 11-15 years. Planning, self-efficacy, and behavioral intention were specified as mediators between treatment conditions and follow-up dental flossing frequency. At baseline, the intervention group received theory-guided materials on oral hygiene. Four weeks later, changes in behavior and social-cognitive variables were assessed. The brief self-regulatory intervention led to an increase in dental flossing and social-cognitive constructs. A sequential mediator model was identified in which first changes in intention and afterwards changes in self-efficacy mediated between treatment conditions and behavioral outcomes. Intention formation and self-efficacy seem to play an instrumental role in the mechanism that facilitates dental flossing among adolescent girls. Oral self-care interventions should consider the application of intention formation strategies combined with building confidence in one's ability to adhere to the regimen.


Efficacy of a brief behavioral intervention to promote condom use among female sex workers in Tijuana and Ciudad Juarez, Mexico.

Patterson Thomas L, Mausbach Brent, Lozada Remedios, Staines-Orozco Hugo, Semple Shirley J, Fraga-Vallejo Miguel, Orozovich Prisci, Abramovitz Daniela, de la Torre Adela, Amaro Hortensia, Martinez Gustavo, Magis-Rodríguez Carlos, Strathdee Steffanie A

American journal of public health [98:2051-7] (2008)

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We examined the efficacy of a brief behavioral intervention to promote condom use among female sex workers in Tijuana and Ciudad Juarez, Mexico. We randomized 924 female sex workers 18 years or older without known HIV infection living in Tijuana and Ciudad Juarez who had recently had unprotected sex with clients to a 30-minute behavioral intervention or a didactic control condition. At baseline and 6 months, women underwent interviews and testing for HIV, syphilis, gonorrhea, and chlamydia. We observed a 40% decline in cumulative sexually transmitted illness incidence (P = .049) in the intervention group. Incidence density for the intervention versus control groups was 13.8 versus 24.92 per 100 person-years for sexually transmitted illnesses combined (P = .034) and 0 versus 2.01 per 100 person-years for HIV (P < .001). There were concomitant increases in the number and percentage of protected sex acts and decreases in the number of unprotected sex acts with clients (P < .05). This brief behavioral intervention shows promise in reducing HIV and sexually transmitted illness risk behaviors among female sex workers and may be transferable to other resource-constrained settings.


Let's Talk About Sex: pilot study of an interactive CD-ROM to prevent HIV/STIS in female adolescents.

Ito Kristin E, Kalyanaraman Sri, Ford Carol A, Brown Jane D, Miller William C

AIDS education and prevention : official publication of the International Society for AIDS Education [20:78-89] (2008)

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The purpose of this study was to develop and pilot-test an interactive CD-ROM aimed at the prevention of sexually transmitted infections (STIs) in female adolescents. The CD-ROM includes prevention information, models skills for negotiating abstinence and consistent condom use, teaches media literacy, and allows the user to choose a culturally appropriate host to guide them through the CD-ROM. Forty-seven female adolescents attending a health department clinic were randomized to receive the CD-ROM plus an educator-led didactic session versus the didactic session alone. The CD-ROM was highly acceptable and feasible for use among female adolescents in the clinic setting. Hispanic and African American adolescents were more likely to choose hosts of the same race/ethnicity to guide them through the CD-ROM. HIV/STI knowledge increased significantly and nearly all adolescents intended to use condoms at next intercourse after viewing the CD-ROM. However, there were no significant differences measured between CD-ROM and comparison groups.


Multicentre RCT and economic evaluation of a psychological intervention together with a leaflet to reduce risk behaviour amongst men who have sex with men (MSM) prescribed post-exposure prophylaxis for HIV following sexual exposure (PEPSE): a protocol.

Llewellyn Carrie, Abraham Charles, Miners Alec, Smith Helen, Pollard Alex, Benn Paul, Fisher Martin

BMC infectious diseases [12:70] (2012)

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Post-exposure prophylaxis (PEP) following sexual exposure to HIV has been recommended as a method of preventing HIV infection in the UK. Men who have sex with men (MSM) are the group most affected by HIV in the UK and their sexual risk taking behaviour is reported to be increasing. One-to-one behavioural interventions, such as motivational interviewing (MI) have been recommended to reduce HIV in high risk groups. The Information, Motivation and Behavioral skills (IMB) model has been shown to provide a good basis for understanding and predicting HIV-relevant health behaviour and health behaviour change, however the IMB has yet to be applied to PEP after risky sexual exposure. The primary aim of this trial is to examine the impact of MI augmented with information provision and behavioural skills building (informed by the IMB Model), over and above usual care, on risky sexual behaviour in MSM prescribed PEP after potential sexual exposure. A secondary aim of this research is to examine the impact of the intervention on adherence to PEP. This study will also provide estimates of the cost-effectiveness of the intervention. A manualised parallel group randomised controlled trial with economic evaluation will be conducted. The primary outcome is the proportion of risky sexual practices. Secondary outcomes include: i) Levels of adherence to PEP treatment; ii) Number of subsequent courses of PEP; iii) Levels of motivation to avoid risky sexual behaviours; iv) Levels of HIV risk-reduction information/knowledge; v) Levels of risk reduction behavioural skills; vi) Diagnosis of anal gonorrhoea, Chlamydia and/or HIV. 250 participants will be asked to self-complete a questionnaire at four time points during the study (at 0,3,6,12 months). The intervention will consist of a two-session, fixed duration, telephone administered augmented MI intervention based on the IMB model. A newly developed treatment manual will guide the selection of persuasive communication strategies as appropriate for each participant and will be based on underlying change mechanisms specified by the IMB theoretical framework. Information provision and skills building will also be included in the intervention package through the use of information leaflets and tailored action plans. Fidelity of intervention delivery will be assessed. The results from this NIHR funded study will identify whether it is appropriate and cost-effective to intervene using one-to-one telephone calls with MSM seeking PEP. If the intervention is effective, further work will be needed on training staff to deliver the intervention competently. UKCRN ID:11436; ISRCTN00746242.


Comparing theory-based condom interventions: health belief model versus theory of planned behavior.

Montanaro Erika A, Bryan Angela D

Health psychology : official journal of the Division of Health Psychology, American Psychological Association [33:1251-60] (2014)

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This study sought to experimentally manipulate the core constructs of the Health Belief Model (HBM) and the Theory of Planned Behavior (TPB) in order to compare the success of interventions to increase preparatory condom use behavior (i.e., purchasing condoms, talking to a boyfriend or girlfriend about using condoms, and carrying condoms) based on these theories. A total of 258 participants were randomly assigned to one of three computer-based interventions (HBM, TPB, or information-only control). A total of 204 (79.1%) completed follow-up assessments 1 month later. Regression analyses were conducted to determine which set of theoretical constructs accounted for the most variance in behavior at baseline. A series of structural equation models were estimated to determine which constructs were the "active ingredients" of change. The TPB accounted for 32.8% of the variance in risky sexual behavior at baseline, while the HBM only explained 1.6% of the variance. Mediational analyses revealed differential intervention effects on perceived susceptibility, perceived benefits, and attitudes toward condom use. However, it was attitudes toward condom use and condom use self-efficacy that were associated with intentions, which then predicted preparatory condom use behavior at follow-up. Except for attitudes, the mediators that were successfully manipulated by the interventions (i.e., perceived susceptibility, perceived severity, and attitudes) were not the same constructs that predicted intentions (i.e., attitudes and condom use self-efficacy), and subsequently predicted behavior. This suggests that the constructs that explain behavior are not the same as those that produce behavior change.


SafeTalk, a multicomponent, motivational interviewing-based, safer sex counseling program for people living with HIV/AIDS: a qualitative assessment of patients' views.

Golin Carol E, Davis Rebecca A, Przybyla Sarahmona M, Fowler Beth, Parker Sharon, Earp Jo Anne, Quinlivan E Byrd, Kalichman Seth C, Patel Shilpa N, Grodensky Catherine A

AIDS patient care and STDs [24:237-45] (2010)

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With the continued transmission of HIV each year, novel approaches to HIV prevention are needed. Since 2003, the U.S. HIV prevention focus has shifted from primarily targeting HIV-negative at-risk persons to including safer sex programs for people already infected with HIV. At least 20-30% of people infected with HIV engage in risky sexual practices. Based on these data, policymakers have recommended that interventionists develop strategies to help HIV-infected people reduce their risky sexual behaviors. In the past, the few safer sex interventions that targeted HIV-infected people met with limited success because they basically adapted strategies previously used with HIV-uninfected individuals. In addition, often these adaptations did not address issues of serostatus disclosure, HIV stigma, or motivation to protect others from HIV. We had previously tested, in a demonstration project named the Start Talking About Risks (STAR) Program, a monthly three-session motivational interviewing (MI)-based intervention to help people living with HIV practice safer sex. In this study, we refined that program by enhancing its frequency and intensity and adding written and audio components to support the counseling. We theorized that an intervention such as MI, which is tailored to each individual's circumstances more than standardized prevention messages, would be more successful when supplemented with other components. We qualitatively assessed participants' perceptions, reactions, and preferences to the refined prevention with positives counseling program we called SafeTalk and learned that participants found the SafeTalk MI counseling and educational materials appealing, understandable, and relevant to their lives.


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.


Integrating psychological theory into the design of an online intervention for sexual health: the sexunzipped website.

Carswell Kenneth, McCarthy Ona, Murray Elizabeth, Bailey Julia V

JMIR research protocols [1:e16] (2012)

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The Internet can provide a confidential and convenient medium for sexual health promotion for young people. This paper describes the development of an interactive, theory-based website (Sexunzipped) aimed at increasing safe sexual behavior of young people, as well as an outline of the evaluation protocol. The website focuses on safer sex, relationships, and sexual pleasure. An overview of the site is provided, including a description of the theoretical constructs which form the basis of the site development. An integrated behavioral model was chosen as the guiding theory for the Sexunzipped intervention. A randomized trial design will be used to evaluate the site quantitatively. The content of the site is described in detail with examples of the main content types: information pages, quizzes, and decision-making activities. We describe the protocol for quantitative evaluation of the website using a randomized trial design and discuss the principal challenges involved in developing the site, including the challenge of balancing the requirements of theory with young people's views on website content and design. Considerations for future interventions are discussed. Developing an online behavior-change intervention is costly and time consuming. Given the large public health potential, the cost involved in developing online interventions, and the need for attractive design, future interventions may benefit from collaborating with established sites that already have a user base, a brand, and a strong Internet presence. It is vital to involve users in decisions about intervention content, design, and features, paying attention to aspects that will attract and retain users' interest. A central challenge in developing effective Internet-based interventions for young people is to find effective ways to operationalize theory in ways that address the views and perspectives of young people.


Increasing condom use in heterosexual men: development of a theory-based interactive digital intervention.

Webster R, Michie S, Estcourt C, Gerressu M, Bailey J V

Translational behavioral medicine [6:418-27] (2016)

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Increasing condom use to prevent sexually transmitted infections is a key public health goal. Interventions are more likely to be effective if they are theory- and evidence-based. The Behaviour Change Wheel (BCW) provides a framework for intervention development. To provide an example of how the BCW was used to develop an intervention to increase condom use in heterosexual men (the MenSS website), the steps of the BCW intervention development process were followed, incorporating evidence from the research literature and views of experts and the target population. Capability (e.g. knowledge) and motivation (e.g. beliefs about pleasure) were identified as important targets of the intervention. We devised ways to address each intervention target, including selecting interactive features and behaviour change techniques. The BCW provides a useful framework for integrating sources of evidence to inform intervention content and deciding which influences on behaviour to target.


Talking parents, healthy teens: a worksite-based program for parents to promote adolescent sexual health.

Eastman Karen L, Corona Rosalie, Schuster Mark A

Preventing chronic disease [3:A126] (2006)

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Parents play an important role in the sexual health of their adolescent children. Based on previous research, formative research, and theories of behavioral change, we developed Talking Parents, Healthy Teens, an intervention designed to help parents improve communication with their adolescent children, promote healthy adolescent sexual development, and reduce adolescent sexual risk behaviors. We conduct the parenting program at worksites to facilitate recruitment and retention of participants. The program consists of 8 weekly 1-hour sessions during the lunch hour. In this article, we review the literature that identifies parental influences on adolescent sexual behavior, summarize our formative research, present the theoretical framework we used to develop Talking Parents, Healthy Teens, describe the program's components and intervention strategies, and offer recommendations based on our experiences developing the program. By targeting parents at their worksites, this program represents an innovative approach to promoting adolescent sexual health. This article is intended to be helpful to health educators and clinicians designing programs for parents, employers implementing health-related programs, and researchers who may consider designing and evaluating such worksite-based programs.


The Men's Safer Sex project: intervention development and feasibility randomised controlled trial of an interactive digital intervention to increase condom use in men.

Bailey Julia V, Webster Rosie, Hunter Rachael, Griffin Mark, Freemantle Nicholas, Rait Greta, Estcourt Claudia, Michie Susan, Anderson Jane, Stephenson Judith, Gerressu Makeda, Ang Chee Siang, Murray Elizabeth

Health technology assessment (Winchester, England) [20:1-124] (2016)

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This report details the development of the Men's Safer Sex website and the results of a feasibility randomised controlled trial (RCT), health economic assessment and qualitative evaluation. (1) Develop the Men's Safer Sex website to address barriers to condom use; (2) determine the best design for an online RCT; (3) inform the methods for collecting and analysing health economic data; (4) assess the Sexual Quality of Life (SQoL) questionnaire and European Quality of Life-5 Dimensions, three-level version (EQ-5D-3L) to calculate quality-adjusted life-years (QALYs); and (5) explore clinic staff and men's views of online research methodology. (1) Website development: we combined evidence from research literature and the views of experts (n = 18) and male clinic users (n = 43); (2) feasibility RCT: 159 heterosexually active men were recruited from three sexual health clinics and were randomised by computer to the Men's Safer Sex website plus usual care (n = 84) or usual clinic care only (n = 75). Men were invited to complete online questionnaires at 3, 6, 9 and 12 months, and sexually transmitted infection (STI) diagnoses were recorded from clinic notes at 12 months; (3) health economic evaluation: we investigated the impact of using different questionnaires to calculate utilities and QALYs (the EQ-5D-3L and SQoL questionnaire), and compared different methods to collect resource use; and (4) qualitative evaluation: thematic analysis of interviews with 11 male trial participants and nine clinic staff, as well as free-text comments from online outcome questionnaires. (1) Software errors and clinic Wi-Fi access presented significant challenges. Response rates for online questionnaires were poor but improved with larger vouchers (from 36% with £10 to 50% with £30). Clinical records were located for 94% of participants for STI diagnoses. There were no group differences in condomless sex with female partners [incidence rate ratio (IRR) 1.01, 95% confidence interval (CI) 0.52 to 1.96]. New STI diagnoses were recorded for 8.8% (7/80) of the intervention group and 13.0% (9/69) of the control group (IRR 0.75, 95% CI 0.29 to 1.89). (2) Health-care resource data were more complete using patient files than questionnaires. The probability that the intervention is cost-effective is sensitive to the source of data used and whether or not data on intended pregnancies are included. (3) The pilot RCT fitted well around clinical activities but 37% of the intervention group did not see the Men's Safer Sex website and technical problems were frustrating. Men's views of the Men's Safer Sex website and research procedures were largely positive. It would be feasible to conduct a large-scale RCT using clinic STI diagnoses as a primary outcome; however, technical errors and a poor response rate limited the collection of online self-reported outcomes. The next steps are (1) to optimise software for online trials, (2) to find the best ways to integrate digital health promotion with clinical services, (3) to develop more precise methods for collecting resource use data and (4) to work out how to overcome barriers to digital intervention testing and implementation in the NHS. Current Controlled Trials ISRCTN18649610. This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 91. See the NIHR Journals Library website for further project information.


The effects of two AIDS risk-reduction interventions on heterosexual college women's AIDS-related knowledge, attitudes and condom use.

Ploem C, Byers ES

Journal of psychology & human sexuality [9:1-24] (1997)

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An intervention combining AIDS information with condom eroticization, condom normalization, and communication skills training was found to increase both AIDS-related knowledge and condom use among Canadian college students. 112 unmarried female undergraduates (mean age, 18 years) were randomly assigned to this combination intervention (n = 49), an information-only intervention (n = 44), or a pre-test/post-test control group (n = 19). 80% of students had engaged in vaginal intercourse and 14% in anal intercourse. 84% of coitally active women had engaged in unprotected intercourse in the past year and 48% had not used condoms consistently with any sexual partner. Condom use in the pre-intervention period was associated with positive attitudes toward the method and the perception that condom use was normative among peers. One month after the interventions, both the combination and information groups, but not controls, showed an increase over baseline in AIDS-related knowledge. However, among the 36 students who were coitally active in the 1-month periods before and after the intervention, only the combination intervention was associated with increased condom use. In the combination group, the percentage of episodes of intercourse protected by condoms increased from an average of 21.8% in the month preceding the study to 50% during the 4-week follow-up period. Due to the small sample size and design of the study, it was not possible to determine which component of the multifaceted educational intervention was most responsible for this change.


A behavioural intervention to reduce persistence of bacterial vaginosis among women who report sex with women: results of a randomised trial.

Marrazzo Jeanne M, Thomas Katherine K, Ringwood Kathleen

Sexually transmitted infections [87:399-405] (2011)

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Bacterial vaginosis (BV) is common in lesbians, and treatment fails in up to 28%. Risks include sexual behaviours that transmit vaginal fluid. The authors measured efficacy of a behavioural intervention to reduce sexual transfer of vaginal fluid between female sex partners in reducing BV persistence. Women aged 16-35 years with BV who reported sex with women (prior year) were eligible. Participants were randomised to intervention (motivational interviewing designed to reduce sharing of vaginal fluid on hands or sex toys post-treatment, by provision of condoms, gloves and water-based lubricant) or control (general STI education) arms. All were treated with vaginal metronidazole and underwent computer-assisted self-interview to ascertain sexual behaviours, with test-of-cure at 30 days. Of 129 women with BV, 108 (84%) were eligible; 89 (69%) agreed to enrol. 43 were randomised to control and 46 to intervention; 81 (91%) returned for test-of-cure. BV persisted in 12 (27.9%) of 43 women in intervention and 8 (21.1%) of 38 women in control arms (p1/40.6). Digital-vaginal sex was common post-treatment (50% intervention and 68% control); women randomised to the intervention were less likely to report receptive digital-vaginal sex without gloves than control (31% vs 61%; p1/40.01), without reported lower frequency of other sexual practices. Shared vaginal use of sex toys was infrequent. Although the intervention effected a significant increase in glove use during digital-vaginal sex post-BV treatment, this was not associated with reduction in BV persistence. Shared use of vaginal sex toys was infrequent, suggesting that other mechanisms promote BV in lesbians.


Community-level HIV intervention in 5 cities: final outcome data from the CDC AIDS Community Demonstration Projects.


American journal of public health [89:336-45] (1999)

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This study evaluated a theory-based community-level intervention to promote progress toward consistent condom and bleach use among selected populations at increased risk for HIV infection in 5 US cities. Role-model stories were distributed, along with condoms and bleach, by community members who encouraged behavior change among injection drug users, their female sex partners, sex workers, non-gay-identified men who have sex with men, high-risk youth, and residents in areas with high sexually transmitted disease rates. Over a 3-year period, cross-sectional interviews (n = 15,205) were conducted in 10 intervention and comparison community pairs. Outcomes were measured on a stage-of-change scale. Observed condom carrying and intervention exposure were also measured. At the community level, movement toward consistent condom use with main (P < .05) and nonmain (P < .05) partners, as well as increased condom carrying (P < .0001), was greater in intervention than in comparison communities. At the individual level, respondents recently exposed to the intervention were more likely to carry condoms and to have higher stage-of-change scores for condom and bleach use. The intervention led to significant communitywide progress toward consistent HIV risk reduction.


HIV/STD risk reduction interventions for African American and Latino adolescent girls at an adolescent medicine clinic: a randomized controlled trial.

Jemmott John B, Jemmott Loretta Sweet, Braverman Paula K, Fong Geoffrey T

Archives of pediatrics & adolescent medicine [159:440-9] (2005)

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Adolescent girls in the United States and around the world are at a heightened risk for sexually transmitted diseases (STDs), including human immunodeficiency virus (HIV). To determine the efficacy of a skill-based HIV/STD risk-reduction intervention in reducing self-reported unprotected sexual intercourse among African American and Latino adolescent girls. Randomized controlled trial with 3-, 6-, and 12-month follow-ups. Sexually experienced African American and Latino adolescent girls recruited from the adolescent medicine clinic of a children's hospital serving a low-income inner-city community (N = 682, mean age, 15.5 years); 88.6% were retained at the 12-month follow-up. Three 250-minute interventions based on cognitive-behavioral theories and elicitation research: an information-based HIV/STD intervention provided information necessary to practice safer sex; a skill-based HIV/STD intervention provided information and taught skills necessary to practice safer sex; or a health-promotion control intervention concerned with health issues unrelated to sexual behavior. Primary outcome measure was self-reported frequency of unprotected sexual intercourse; secondary outcomes included the frequency of sexual intercourse while intoxicated, the number of sexual partners, biologically confirmed STDs, and theoretical mediator variables, including the intention to use condoms, beliefs about using condoms, and condom-use knowledge. No differences between the information intervention and the health control intervention were statistically significant. Skills-intervention participants (mean [SE], 2.27 [0.81]) reported less unprotected sexual intercourse at the 12-month follow-up than did information-intervention participants (mean [SE], 4.04 [0.80]; P = .03), or health control-intervention participants (mean [SE], 5.05 [0.81]; P = .002). At the 12-month follow-up, skills-intervention participants (mean [SE], 0.91 [0.05]) reported fewer sexual partners (P = .04) compared with health control-intervention participants (mean [SE], 1.04 [0.05]) and were less likely to test positive for STD (mean [SE], 10.5% [2.9%]) than were health control-intervention participants (mean [SE], 18.2% [2.8%]; P = .05). No differences in the frequency of unprotected sexual intercourse, the number of partners, or the rate of STD were observed at the 3- or 6-month follow-up between skill-intervention participants and information-intervention or health control-intervention participants. Skill-based HIV/STD interventions can reduce sexual risk behaviors and STD rate among African American and Latino adolescent girls in clinic settings.


School-based, randomised controlled trial of an evidence-based condom promotion leaflet.

Hill CA, Abraham C

Psychology & health [23:41-56] (2008)

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A condom use promotion leaflet was designed for use with older teenagers in schools. The text targeted a series of cognitive and behavioural antecedents of condom use identified in the literature. Given previous evidence that motivational incentives can enhance the effectiveness of health promotion leaflets, the leaflet was presented in conjunction with a quiz and prize draw. Students were randomly assigned to either the intervention condition or a (no leaflet or incentive) control condition. Measures were taken immediately, pre-intervention and 4 weeks later from 404 students. The 20-min intervention successfully promoted six of the eight measured cognitions, namely (1) attitude towards using condoms with a new partner (2) attitude towards using condoms with a steady partner (3) normative beliefs in relation to preparatory actions (4) self-efficacy in relation to both preparatory actions and (5) condom use (6) intention to use condoms, as well as three measured preparatory actions, that is, purchasing condoms, carrying condoms and discussing condom use. The intervention did not increase condom use with steady or new partners but power to test intervention impact on condom use was curtailed.


Interactive video behavioral intervention to reduce adolescent females' STD risk: a randomized controlled trial.

Downs Julie S, Murray Pamela J, Bruine de Bruin Wändi, Penrose Joyce, Palmgren Claire, Fischhoff Baruch

Social science & medicine (1982) [59:1561-72] (2004)

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A longitudinal randomized design was used to evaluate the impact of a theoretically based, stand-alone interactive video intervention on 300 urban adolescent girls' (a) knowledge about sexually transmitted diseases (STDs), (b) self-reported sexual risk behavior, and (c) STD acquisition. It was compared to two controls, representing high-quality informational interventions. One used the same content in book form; the other used commercially available brochures. Following randomization, the interventions were administered at baseline, with booster sessions at 1, 3, and 6 months. Self-reports revealed that those assigned to the interactive video were significantly more likely to be abstinent in the first 3 months following initial exposure to the intervention, and experienced fewer condom failures in the following 3 months, compared to controls. Six months after enrollment, participants in the video condition were significantly less likely to report having been diagnosed with an STD. A non-significant trend in data from a clinical PCR assay of Chlamydia trachomatis was consistent with that finding.


Defining the Content of an Online Sexual Health Intervention: The MenSS Website.

Webster Rosie, Gerressu Makeda, Michie Susan, Estcourt Claudia, Anderson Jane, Ang Chee Siang, Murray Elizabeth, Rait Greta, Stephenson Judith, Bailey Julia V

JMIR research protocols [4:e82] (2015)

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Health promotion and risk reduction are essential components of sexual health care. However, it can be difficult to prioritize these within busy clinical services. Digital interventions may provide a new method for supporting these. The MenSS (Men's Safer Sex) website is an interactive digital intervention developed by a multidisciplinary team, which aims to improve condom use in men who have sex with women (MSW). This paper describes the content of this intervention, and the rationale for it. Content was informed by a literature review regarding men's barriers to condom use, workshops with experts in sexual health and technology (N=16) and interviews with men in sexual health clinics (N=20). Data from these sources were analyzed thematically, and synthesized using the Behavior Change Wheel framework. The MenSS intervention is a website optimized for delivery via tablet computer within a clinic waiting room setting. Key targets identified were condom use skills, beliefs about pleasure and knowledge about risk. Content was developed using behavior change techniques, and interactive website features provided feedback tailored for individual users. This paper provides a detailed description of an evidence-based interactive digital intervention for sexual health, including how behavior change techniques were translated into practice within the design of the MenSS website. Triangulation between a targeted literature review, expert workshops, and interviews with men ensured that a range of potential influences on condom use were captured.


Randomized trial of group interventions to reduce HIV/STD risk and change theoretical mediators among detained adolescents.

Schmiege Sarah J, Broaddus Michelle R, Levin Michael, Bryan Angela D

Journal of consulting and clinical psychology [77:38-50] (2009)

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Criminally involved adolescents engage in high levels of risky sexual behavior and alcohol use, and alcohol use may contribute to lack of condom use. Detained adolescents (n = 484) were randomized to (1) a theory-based sexual risk reduction intervention (GPI), (2) the GPI condition with a group-based alcohol risk reduction motivational enhancement therapy component (GPI + GMET), or (3) an information-only control (INFO). All interventions were presented in same-sex groups in single sessions lasting from 2 to 4 hr. Changes to putative theoretical mediators (attitudes, perceived norms, self-efficacy, and intentions) were measured immediately following intervention administration. The primary outcomes were risky sexual behavior and sexual behavior while drinking measured 3 months later (65.1% retention). The GPI + GMET intervention demonstrated superiority over both other conditions in influencing theoretical mediators and over the INFO control in reducing risky sexual behavior. Self-efficacy and intentions were significant mediators between condition and later risky sexual behavior. This study contributes to an understanding of harm reduction among high-risk adolescents and has implications for understanding circumstances in which the inclusion of GMET components may be effective.


Effectiveness of HIV/STD sexual risk reduction groups for women in substance abuse treatment programs: results of NIDA Clinical Trials Network Trial.

Tross Susan, Campbell Aimee N C, Cohen Lisa R, Calsyn Donald, Pavlicova Martina, Miele Gloria M, Hu Mei-Chen, Haynes Louise, Nugent Nancy, Gan Weijin, Hatch-Maillette Mary, Mandler Raul, McLaughlin Paul, El-Bassel Nabila, Crits-Christoph Paul, Nunes Edward V

Journal of acquired immune deficiency syndromes (1999) [48:581-9] (2008)

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Because drug-involved women are among the fastest growing groups with AIDS, sexual risk reduction intervention for them is a public health imperative. To test effectiveness of HIV/STD safer sex skills building (SSB) groups for women in community drug treatment. Randomized trial of SSB versus standard HIV/STD Education (HE); assessments at baseline, 3 and 6 months. Women recruited from 12 methadone or psychosocial treatment programs in Clinical Trials Network of National Institute on Drug Abuse. Five hundred fifteen women with >or=1 unprotected vaginal or anal sex occasion (USO) with a male partner in the past 6 months were randomized. In SSB, five 90-minute groups used problem solving and skills rehearsal to increase HIV/STD risk awareness, condom use, and partner negotiation skills. In HE, one 60-minute group covered HIV/STD disease, testing, treatment, and prevention information. Number of USOs at follow-up. A significant difference in mean USOs was obtained between SSB and HE over time (F = 67.2, P < 0.0001). At 3 months, significant decrements were observed in both conditions. At 6 months, SSB maintained the decrease and HE returned to baseline (P < 0.0377). Women in SSB had 29% fewer USOs than those in HE. Skills building interventions can produce ongoing sexual risk reduction in women in community drug treatment.


Pilot study of a brief intervention based on the theory of planned behaviour and self-identity to increase chlamydia testing among young people living in deprived areas.

Booth Amy R, Norman Paul, Goyder Elizabeth, Harris Peter R, Campbell Michael J

British journal of health psychology [19:636-51] (2014)

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This study sought to estimate the effects of a novel intervention, compared with usual chlamydia testing promotion, on chlamydia test uptake and intentions among young people living in deprived areas. The intervention was based on the theory of planned behaviour, augmented with self-identity, and targeted the significant predictors of chlamydia testing intentions identified in the previous research. Cluster randomization was used to allocate college tutor groups (intervention n = 10; control n = 11) to the intervention or control group. The sample comprised 253 participants (intervention n = 145, control n = 108). The primary outcome was test offer uptake at the end of the session. Other outcomes measured at immediate follow-up were intention, attitude, subjective norm, perceived behavioural control, and self-identity. Generalized estimating equations, controlling for cluster effects and sexual activity, found a small but non-significant effect of condition on test offer uptake, OR = 1.65 (95% CI 0.70, 3.88) p = .25, with 57.5% of intervention participants accepting the offer of a test compared with 40.2% of control participants. Using the same analysis procedure, small-to-medium intervention effects were found on other outcome variables, including a significant effect on attitudes towards chlamydia testing, OR = 1.37 (95% CI 1.00, 1.87), p = .05. The results provide encouraging initial evidence that this theory-based intervention, targeting the key determinants of chlamydia testing, may help to improve chlamydia testing uptake in a high-risk group. They support the conduct of a larger trial to evaluate the effectiveness of the intervention. What is already known on this subject? Young people living in areas of increased socio-economic deprivation have been identified as a high-risk group for chlamydia. Previous research within an extended model of the theory of planned behaviour (TPB) found that attitude, subjective norm, perceived behavioural control, and self-identity all significantly predicted chlamydia testing intentions in this high-risk group. What does this study add? Development and testing of a novel, TPB-based intervention targeting predictors of chlamydia testing intentions. The intervention led to significantly more positive attitudes towards chlamydia testing. Preliminary indication that a TPB-based intervention may help to improve chlamydia testing in a high-risk group.


All4You! A randomized trial of an HIV, other STDs, and pregnancy prevention intervention for alternative school students.

Coyle Karin K, Kirby Douglas B, Robin Leah E, Banspach Stephen W, Baumler Elizabeth, Glassman Jill R

AIDS education and prevention : official publication of the International Society for AIDS Education [18:187-203] (2006)

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This study evaluated All4You!, a theoretically based curriculum designed to reduce sexual risk behaviors associated with HIV, other STDs, and unintended pregnancy among students in alternative schools. The study featured a randomized controlled trial involving 24 community day schools in northern California. A cohort of 988 students was assessed four times during an 18-month period using a self report questionnaire. At the 6-month follow-up, the intervention reduced the frequency of intercourse without a condom during the previous 3 months, the frequency of intercourse without a condom with steady partners, and the number of times students reported having intercourse in the previous 3 months. It also increased condom use at last intercourse. These behavioral effects were no longer statistically significant at the 12- and 18-month follow-ups. The All4You! intervention was effective in reducing selected sexual risk behaviors among students in alternative school settings; however, the effects were modest and short term.


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.


Preventing college women's sexual victimization through parent based intervention: a randomized controlled trial.

Testa Maria, Hoffman Joseph H, Livingston Jennifer A, Turrisi Rob

Prevention science : the official journal of the Society for Prevention Research [11:308-18] (2010)

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A randomized controlled trial, using parent-based intervention (PBI) was designed to reduce the incidence of alcohol-involved sexual victimization among first-year college students. The PBI, adapted from Turrisi et al. (2001), was designed to increase alcohol-specific and general communication between mother and daughter. Female graduating high school seniors and their mothers were recruited from the community and randomly assigned to one of four conditions: Alcohol PBI (n = 305), Enhanced Alcohol + Sex PBI (n = 218), Control (n = 288) or Unmeasured Control (n = 167). Mothers in the intervention conditions were provided an informational handbook and encouraged to discuss its contents with their daughters prior to college matriculation. Consistent with hypotheses, PBI, either standard or enhanced, was associated with lower incidence of incapacitated rape in the first year of college relative to controls. Path analysis revealed support for a hypothesized indirect effects model, by which intervention increased mother-daughter communication, which predicted lower frequency of first semester heavy episodic drinking, resulting in lower rates of alcohol-involved sexual victimization in the first year of college.


Can safer-sex promotion leaflets change cognitive antecedents of condom use? An experimental evaluation.

Krahé Barbara, Abraham Charles, Scheinberger-Olwig Renate

British journal of health psychology [10:203-20] (2005)

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An experimental evaluation of a safer sex promotion leaflet was undertaken to assess its capacity to change antecedent cognitions of condom use. The leaflet was identified in a previous study as addressing research-based cognitive antecedents of condom use. A pre-post-test experimental study including three conditions was conducted: (a) presentation of the leaflet; (b) presentation of the leaflet plus incentive for systematic processing; (c) no-leaflet control. The leaflet was evaluated in terms of its capacity to change eight cognitive correlates of condom use identified in a recent meta-analysis. The sample consisted of 230 tenth-grade students. Following baseline assessments, leaflet-induced change was measured immediately following the intervention and at a follow up 4 weeks post-intervention. The target leaflet alone did not result in significant changes in the cognitive antecedents of condom use compared with the control condition. However, in combination with an incentive for systematic processing, the target leaflet had a greater impact on cognitive antecedents than the no-leaflet control condition. The findings are discussed with regard to the development and evaluation of research-based health-promotion materials.


A brief, low-cost, theory-based intervention to promote dual method use by black and Latina female adolescents: a randomized clinical trial.

Roye Carol, Perlmutter Silverman Paula, Krauss Beatrice

Health education & behavior : the official publication of the Society for Public Health Education [34:608-21] (2007)

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HIV/AIDS disproportionately affects young women of color. Young women who use hormonal contraception are less likely to use condoms. Brief, inexpensive HIV-prevention interventions are needed for high-volume clinics. This study was a randomized clinical trial of two interventions: (a) a video made for this study and (b) an adaptation of Project RESPECT counseling. Four hundred Black and Latina teenage women completed a questionnaire about their sexual behaviors and were randomly assigned to (a) see the video, (b) get counseling, (c) see the video and get counseling, or (d) receive usual care. At 3-month follow-up, those who saw the video and received counseling were 2.5 times more likely to have used a condom at last intercourse with their main partner than teens in the usual care group. These differences did not persist at 12-month follow-up. This suggests that a brief intervention can positively affect condom use in the short term.


Brief motivational interventions for heavy college drinkers: A randomized controlled trial.

Carey Kate B, Carey Michael P, Maisto Stephen A, Henson James M

Journal of consulting and clinical psychology [74:943-54] (2006)

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In this randomized controlled trial, the authors evaluated brief motivational interventions (BMIs) for at-risk college drinkers. Heavy drinking students (N = 509; 65% women, 35% men) were randomized into 1 of 6 intervention conditions formed by crossing the baseline Timeline Followback (TLFB) interview (present versus absent) and intervention type (basic BMI, BMI enhanced with a decisional balance module, or none). Assessments completed at baseline, 1, 6, and 12 months measured typical and risky drinking as well as drinking-related problems. Relative to controls, the TLFB interview reduced consumption but not problems at 1 month. The basic BMI improved all drinking outcomes beyond the effects of the TLFB interview at 1 month, whereas the enhanced BMI did not. Risk reduction achieved by brief interventions maintained throughout the follow-up year.


Efficacy of counselor vs. computer-delivered intervention with mandated college students.

Barnett Nancy P, Murphy James G, Colby Suzanne M, Monti Peter M

Addictive behaviors [32:2529-48] (2007)

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The purpose of this study was to evaluate the efficacy of two brief interventions and the inclusion of a 1-month booster session with college students who were referred to attend alcohol education following an alcohol-related incident. Participants (N=225; 48.9% male) were randomly assigned to receive one session of a Brief Motivational Interview (BMI) or computer-delivered intervention (CDI) with the Alcohol 101 CD-ROM. Participants were also randomly assigned to booster/no booster. At 3-month follow up, participants in BMI reported greater help seeking and use of behavioral strategies to moderate drinking. At 12-month follow up, BMI participants were drinking more frequently and CDI participants were consuming a greater number of drinks per occasion than at baseline. Mediation analyses showed that the use of specific behavioral strategies mediated the effect of the BMI condition on drinking volume. There was no intervention effect on alcohol problems, and the booster condition did not significantly affect outcomes. Promoting specific behaviors in the context of in-person brief interventions may be a promising approach to reducing drinking volume among identified at-risk students.


Reducing high-risk drinking in mandated college students: evaluation of two personalized normative feedback interventions.

Doumas Diana M, Workman Camille, Smith Diana, Navarro Anabel

Journal of substance abuse treatment [40:376-85] (2011)

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This study evaluated the efficacy of two brief personalized normative feedback interventions aimed at reducing heavy drinking among mandated college students (N = 135). Students were randomly assigned to one of two conditions: Web-based assessment with self-guided personalized normative feedback (SWF) or Web-based assessment with counselor-guided personalized normative feedback (CWF). Results indicated that students in the CWF condition reported significantly greater reductions in weekly drinking quantity and binge drinking frequency than those in the SWF group at follow-up (M = 8 months). Students in the CWF group also reported significantly greater reductions in estimates of peer drinking from baseline to the follow-up assessment than students in the SWF group. In addition, changes in estimates of peer drinking partially mediated the effect of the intervention on changes in drinking. Results suggest that counselor-guided feedback may be more effective in reducing drinking among mandated students relative to self-guided feedback in the long term.


Assessing the effectiveness of peer-facilitated interventions addressing high-risk drinking among judicially mandated college students.

Cimini M Dolores, Martens Matthew P, Larimer Mary E, Kilmer Jason R, Neighbors Clayton, Monserrat Joseph M

Journal of studies on alcohol and drugs. Supplement (2009)

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This study examined the effectiveness of three peer-facilitated brief alcohol interventions-small group motivational interviewing, motivationally enhanced peer theater, and an interactive alcohol-education program-with students engaging in high-risk drinking who were referred for alcohol policy violations. Undergraduate students referred for alcohol policy violations (N = 695) at a large northeastern public university were randomized to one of the three conditions. Six-month follow-up data were collected on drinking frequency and quantity, negative consequences, use of protective behaviors, and perceptions of peers' drinking norms. There were no statistically significant overall pre-post effects or treatment effects. However, exploratory analyses indicated that decreases in perceived norms and increases in use of protective behavioral strategies were associated with reductions in alcohol use and alcohol-related problems at follow-up (p < .01). The presence of nonsignificant pre-post or main effects is, in part, consistent with recent research indicating that sanctioned college students may immediately reduce drinking in response to citation and that brief interventions may not contribute to additional behavioral change. The presence of statistically significant correlations between alcohol use and related problems with corrections in norms misperceptions and increased use of protective behaviors at the individual level holds promise for both research and practice. The integration of elements addressing social norms and use of protective behaviors within brief cognitive-behavioral intervention protocols delivered by trained peer facilitators warrants further study using randomized clinical trials.


Internet-based personalized feedback to reduce 21st-birthday drinking: a randomized controlled trial of an event-specific prevention intervention.

Neighbors Clayton, Lee Christine M, Lewis Melissa A, Fossos Nicole, Walter Theresa

Journal of consulting and clinical psychology [77:51-63] (2009)

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This article presents an initial randomized controlled trial of an event-specific prevention intervention. Participants included 295 college students (41.69% male, 58.31% female) who intended to consume 2 or more drinks on their 21st birthday. Participants completed a screening/baseline assessment approximately 1 week before they turned 21 and were randomly assigned to receive Web-based personalized feedback or assessment only. Feedback included normative information, protective behaviors, and personalized blood alcohol concentration information. A follow-up assessment was completed approximately 1 week after a student's birthday. Results indicated a significant intervention effect in reducing estimated blood alcohol concentration (d = 0.33). The intervention effect was moderated by 21st-birthday drinking intentions, and the intervention was primarily effective among those who intended to reach higher levels of intoxication. Results provide some support for normative information as a mediator of intervention efficacy. Overall results provide support for Web-based personalized feedback as an intervention approach for specific events associated with extreme drinking.


A randomized controlled trial of event-specific prevention strategies for reducing problematic drinking associated with 21st birthday celebrations.

Neighbors Clayton, Lee Christine M, Atkins David C, Lewis Melissa A, Kaysen Debra, Mittmann Angela, Fossos Nicole, Geisner Irene M, Zheng Cheng, Larimer Mary E

Journal of consulting and clinical psychology [80:850-62] (2012)

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While research has documented heavy drinking practices and associated negative consequences of college students turning 21, few studies have examined prevention efforts aimed at reducing high-risk drinking during 21st birthday celebrations. The present study evaluated the comparative efficacy of a general prevention effort (i.e., Brief Alcohol Screening and Intervention for College Students, or BASICS) and event-specific prevention in reducing 21st birthday drinking and related negative consequences. Furthermore, this study evaluated inclusion of peers in interventions and mode of intervention delivery (i.e., in-person vs. via the Web). Participants included 599 college students (46% male): men who intended to consume at least 5 drinks and women who intended to consume at least 4 drinks on their 21st birthday. After completing a screening/baseline assessment approximately 1 week before turning 21, participants were randomly assigned to 1 of 6 conditions: 21st birthday in-person BASICS, 21st birthday web BASICS, 21st birthday in-person BASICS plus friend intervention, 21st birthday web BASICS plus friend intervention, BASICS, or an attention control. A follow-up assessment was completed approximately 1 week after students' birthdays. Results indicated a significant intervention effect for BASICS in reducing blood alcohol content reached and number of negative consequences experienced. All 3 in-person interventions reduced negative consequences experienced. Results for the web-based interventions varied by drinking outcome and whether a friend was included. Overall, results provide support for both general intervention and ESP approaches across modalities for reducing extreme drinking and negative consequences associated with turning 21. These results suggest there are several promising options for campuses seeking to reduce both use and negative consequences associated with 21st birthday celebrations.


Perceived Norms Mediate Effects of a Brief Motivational Intervention for Sanctioned College Drinkers.

Carey Kate B, Henson James M, Carey Michael P, Maisto Stephen A

Clinical psychology : a publication of the Division of Clinical Psychology of the American Psychological Association [17:58-71] (2010)

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The present study is a secondary analysis of a randomized trial of brief motivational interventions (BMIs) for 198 college students sanctioned for alcohol-related violations of school policy (Carey, Henson, Carey, & Maisto, 2009). Using multivariate latent growth curve models, we evaluated theoretically-derived mediators of the observed BMI effect: motivation to change (readiness-to-change, costs and benefits of drinking), and drinking norms (injunctive norms for peers, and descriptive norms for friends, local peers, and national peers). Results provided partial support for mediation by changes in perceptions of descriptive but not injunctive norms, a pattern that varied by gender and norm type. We found no evidence of a mediating role for any of the motivational variables.


Optimizing personalized normative feedback: the use of gender-specific referents.

Lewis Melissa A, Neighbors Clayton

Journal of studies on alcohol and drugs [68:228-37] (2007)

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Many brief interventions include personalized normative feedback (PNF) using gender-specific or gender-neutral referents. Several theories suggest that information pertaining to more socially proximal referents should have greater influence on one's behavior compared with more socially distal referents. The current research evaluated whether gender specificity of the normative referent employed in PNF related to intervention efficacy. Following baseline assessment, 185 college students (45.2% women) were randomly assigned to one of three intervention conditions: gender-specific feedback, gender-neutral feedback, or assessment-only control. Immediately after completing measures of perceived norms, alcohol consumption, and gender identity, participants in the gender-neutral and gender-specific intervention conditions were provided with computerized information detailing their own drinking behavior, their perceptions of student drinking, and actual student drinking. After a 1-month follow-up, the results indicated that normative feedback was effective in changing perceived norms and reducing alcohol consumption for both intervention groups for women and men. The results provide support, however, for changes in perceived gender-specific norms as a mediator of the effects of normative feedback on reduced drinking behavior for women only. Additionally, gender-specific feedback was found to be more effective for women higher in gender identity, relative to the gender-neutral feedback. A post-assessment follow-up telephone survey administered to assess potential demand characteristics corroborated the intervention effects. Results extend previous research documenting efficacy of computer delivered PNF. Gender specificity and gender identity appear to be important elements to consider for PNF intervention efficacy for women.


Effectiveness of a Web-based alcohol-misuse and harm-prevention course among high- and low-risk students.

Bersamin Melina, Paschall Mallie J, Fearnow-Kenney Melodie, Wyrick David

Journal of American college health : J of ACH [55:247-54] ()

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In the current study, the authors assessed whether a new online alcohol-misuse prevention course (College Alc) is more effective at reducing alcohol use and related consequences among drinkers and nondrinkers. The authors compared incoming college freshmen who reported any past 30-day alcohol use before the beginning of the semester with those who did not. The authors randomly assigned students who completed a precollege baseline survey to either complete a 3-hour noncredit version of College Alc or serve as members of a control group. The authors conducted a follow-up survey 3 months later. Findings indicated that among freshmen who were regular drinkers before college, College Alc appeared to reduce the frequency of heavy drinking, drunkenness, and negative alcohol-related consequences. Among freshmen who did not report any past-30-day alcohol use before college, College Alc did not appear to have any beneficial effects. Results suggest that College Alc may be an effective program for students with a history of alcohol use.


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


Computerized versus motivational interviewing alcohol interventions: impact on discrepancy, motivation, and drinking.

Murphy James G, Dennhardt Ashley A, Skidmore Jessica R, Martens Matthew P, McDevitt-Murphy Meghan E

Psychology of addictive behaviors : journal of the Society of Psychologists in Addictive Behaviors [24:628-39] (2010)

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The authors conducted two randomized clinical trials with ethnically diverse samples of college student drinkers in order to determine (a) the relative efficacy of two popular computerized interventions versus a more comprehensive motivational interview approach (BASICS) and (b) the mechanisms of change associated with these interventions. In Study 1, heavy drinking participants recruited from a student health center (N = 74, 59% women, 23% African American) were randomly assigned to receive BASICS or the Alcohol 101 CD-ROM program. BASICS was associated with greater post-session motivation to change and self-ideal and normative discrepancy relative to Alcohol 101, but there were no group differences in the primary drinking outcomes at 1-month follow-up. Pre to post session increases in motivation predicted lower follow-up drinking across both conditions. In Study 2, heavy drinking freshman recruited from a core university course (N = 133, 50% women, 30% African American) were randomly assigned to BASICS, a web-based feedback program (e-CHUG), or assessment-only. BASICS was associated with greater post-session self-ideal discrepancy than e-CHUG, but there were no differences in motivation or normative discrepancy. There was a significant treatment effect on typical weekly and heavy drinking, with participants in BASICS reporting significantly lower follow-up drinking relative to assessment only participants. In Study 2, change in the motivation or discrepancy did not predict drinking outcomes. Across both studies, African American students assigned to BASICS reported medium effect size reductions in drinking whereas African American students assigned to Alcohol 101, e-CHUG, or assessment did not reduce their drinking.


Personalized mailed feedback for college drinking prevention: a randomized clinical trial.

Larimer Mary E, Lee Christine M, Kilmer Jason R, Fabiano Patricia M, Stark Christopher B, Geisner Irene M, Mallett Kimberly A, Lostutter Ty W, Cronce Jessica M, Feeney Maggie, Neighbors Clayton

Journal of consulting and clinical psychology [75:285-93] (2007)

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The current study was designed to evaluate the efficacy of a mailed feedback and tips intervention as a universal prevention strategy for college drinking. Participants (N = 1,488) were randomly assigned to feedback or assessment-only control conditions. Results indicated that the mailed feedback intervention had a preventive effect on drinking rates overall, with participants in the feedback condition consuming less alcohol at follow-up in comparison with controls. In addition, abstainers in the feedback condition were twice as likely to remain abstinent from alcohol at follow-up in comparison with control participants (odds ratio = 2.02), and feedback participants were significantly more likely to refrain from heavy episodic drinking (odds ratio = 1.43). Neither gender nor severity of baseline drinking moderated the efficacy of the intervention in these analyses, but more conservative analyses utilizing last-observation carryforward suggested women and abstainers benefited more from this prevention approach. Protective behaviors mediated intervention efficacy, with participants who received the intervention being more likely to use strategies such as setting limits and alternating alcohol with nonalcoholic beverages. Implications of these findings for universal prevention of college drinking are discussed.


Brief motivational and parent interventions for college students: a randomized factorial study.

Wood Mark D, Fairlie Anne M, Fernandez Anne C, Borsari Brian, Capone Christy, Laforge Robert, Carmona-Barros Rosa

Journal of consulting and clinical psychology [78:349-61] (2010)

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Using a randomized factorial design, we examined the efficacy of a brief motivational intervention (BMI) and a parent-based intervention (PBI) as universal preventive interventions to reduce alcohol use among incoming college students. Participants (N = 1,014) were assessed prior to matriculation and at 10 months and 22 months postbaseline. Two-part latent growth modeling was used to simultaneously examine initiation and growth in heavy episodic drinking and alcohol-related consequences. This study retained 90.8% (n = 921) of randomized students at the 10-month follow-up and 84.0% (n = 852) of randomized students at the 22-month follow-up. BMI participants were significantly less likely than non-BMI participants to initiate heavy episodic drinking and to begin experiencing alcohol-related consequences. Effect sizes were minimal at 10 months (Cohen's h ranged from 0.02 to 0.07) and were small at 22 months (hs ranged from 0.15 to 0.22). A significant BMI x PBI interaction revealed that students receiving both the BMI and the PBI were significantly less likely to report the onset of consequences beyond the sum of the individual intervention effects (h = 0.08 at 10 months, and h = 0.21 at 22 months). Hypothesized direct BMI effects for reductions in heavy episodic drinking and consequences were not observed. Significant mediated effects via changes in descriptive norms were present for both growth and initiation of heavy episodic drinking and consequences. To our knowledge, the current study is the first to provide support for BMI as a universal preventive intervention for incoming college students. Although hypothesized PBI main effects were not found, mediation analyses suggest future refinements could enhance PBI effectiveness.


Using a mobile health application to reduce alcohol consumption: a mixed-methods evaluation of the drinkaware track & calculate units application.

Attwood Sophie, Parke Hannah, Larsen John, Morton Katie L

BMC public health [17:394] (2017)

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Smartphone applications ("apps") offer promise as tools to help people monitor and reduce their alcohol consumption. To date, few evaluations of alcohol reduction apps exist, with even fewer considering apps already available to the public. The aim of this study was to evaluate an existing publically available app, designed by Drinkaware, a UK-based alcohol awareness charity. We adopted a mixed-methods design, analysing routinely collected app usage data to explore user characteristics and patterns of usage. Following this, in-depth interviews were conducted with a sub-sample of app users to examine perceptions of acceptability, usability and perceived effectiveness, as well as to provide recommendations on how to improve the app. One hundred nineteen thousand seven hundred thirteen people downloaded and entered data into the app over a 13-month period. High attrition was observed after 1 week. Users who engaged with the app tended to be "high risk" drinkers and to report being motivated "to reduce drinking" at the point of first download. In those who consistently engaged with the app over time, self-reported alcohol consumption levels reduced, with most change occurring in the first week of usage. Our qualitative findings indicate satisfaction with the usability of the app, but mixed feedback was given regarding individual features. Users expressed conflicting views concerning the type of feedback and notifications that the app currently provides. A common preference was expressed for more personalised content. The Drinkaware app is a useful tool to support behaviour change in individuals who are already motivated and committed to reducing their alcohol consumption. The Drinkaware app would benefit from greater personalisation and tailoring to promote longer term use. This evaluation provides insight into the usability and acceptability of various app features and contains a number of recommendations for improving user satisfaction and the potential effectiveness of apps designed to encourage reductions in alcohol consumption.


Motivational interventions for heavy drinking college students: examining the role of discrepancy-related psychological processes.

McNally Abigail M, Palfai Tibor P, Kahler Christopher W

Psychology of addictive behaviors : journal of the Society of Psychologists in Addictive Behaviors [19:79-87] (2005)

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The authors examined the effects of a brief motivational intervention for heavy, episodic alcohol use on discrepancy-related psychological processes. Heavy-drinking college students (N=73) were randomly assigned to a motivationally based intervention (MBI) or an assessment-only control (AC) condition. Cognitive (actual-ideal discrepancy) and affective (2 forms of cognitive dissonance) discrepancy processes were assessed at baseline and immediately following the experimental manipulation. At 6-week follow-up, MBI participants demonstrated significantly greater reductions in problematic drinking than AC participants. Moreover, actual-ideal discrepancy and negative, self-focused dissonance were significantly increased following the intervention (discomfort-related dissonance was not) and were correlated with outcome alcohol involvement. These discrepancy processes did not, however, mediate the relationship between condition and outcome. The findings lend some support to the role of discrepancy enhancement in drinking-related behavior change among college students.


Social-norms interventions for light and nondrinking students.

Neighbors Clayton, Jensen Megan, Tidwell Judy, Walter Theresa, Fossos Nicole, Lewis Melissa A

Group processes & intergroup relations : GPIR [14:651-669] (2011)

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Social-norms approaches to alcohol prevention are based on consistent findings that most students overestimate the prevalence of drinking among their peers. Most interventions have been developed for heavy-drinking students, and the applicability of social-norms approaches among abstaining or light-drinking students has yet to be evaluated. The present research aimed to evaluate the impact of two types of online social-norms interventions developed for abstaining or light-drinking students. Identification with other students was evaluated as a moderator. Participants included 423 freshmen and sophomore college students who reported never or rarely drinking at screening. Students were randomly assigned to one of three conditions: (a) personalized-norms feedback, (b) social-norms marketing ads, or (c) attention control. Data were analyzed using generalized linear mixed models. Results provided some support for both interventions but were stronger for social-norms marketing ads, particularly among participants who identified more closely with other students.


Being controlled by normative influences: self-determination as a moderator of a normative feedback alcohol intervention.

Neighbors Clayton, Lewis Melissa A, Bergstrom Rochelle L, Larimer Mary E

Health psychology : official journal of the Division of Health Psychology, American Psychological Association [25:571-9] (2006)

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The objectives of this research were to evaluate the efficacy of computer-delivered personalized normative feedback among heavy drinking college students and to evaluate controlled orientation as a moderator of intervention efficacy. Participants (N = 217) included primarily freshman and sophomore, heavy drinking students who were randomly assigned to receive or not to receive personalized normative feedback immediately following baseline assessment. Perceived norms, number of drinks per week, and alcohol-related problems were the main outcome measures. Controlled orientation was specified as a moderator. At 2-month follow-up, students who received normative feedback reported drinking fewer drinks per week than did students who did not receive feedback, and this reduction was mediated by changes in perceived norms. The intervention also reduced alcohol-related negative consequences among students who were higher in controlled orientation. These results provide further support for computer-delivered personalized normative feedback as an empirically supported brief intervention for heavy drinking college students, and they enhance the understanding of why and for whom normative feedback is effective.


Alcohol screening and brief interventions for offenders in the probation setting (SIPS Trial): a pragmatic multicentre cluster randomized controlled trial.

Newbury-Birch Dorothy, Coulton Simon, Bland Martin, Cassidy Paul, Dale Veronica, Deluca Paolo, Gilvarry Eilish, Godfrey Christine, Heather Nick, Kaner Eileen, McGovern Ruth, Myles Judy, Oyefeso Adenekan, Parrott Steve, Patton Robert, Perryman Katherine, Phillips Tom, Shepherd Jonathan, Drummond Colin

Alcohol and alcoholism (Oxford, Oxfordshire) [49:540-8] ()

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To evaluate the effectiveness of different brief intervention strategies at reducing hazardous or harmful drinking in the probation setting. Offender managers were randomized to three interventions, each of which built on the previous one: feedback on screening outcome and a client information leaflet control group, 5 min of structured brief advice and 20 min of brief lifestyle counselling. A pragmatic multicentre factorial cluster randomized controlled trial. The primary outcome was self-reported hazardous or harmful drinking status measured by Alcohol Use Disorders Identification Test (AUDIT) at 6 months (negative status was a score of


Efficacy of web-based personalized normative feedback: a two-year randomized controlled trial

Neighbors Clayton, Lewis Melissa A, Atkins David C, Jensen Megan M, Walter Theresa, Fossos Nicole, Lee Christine M, Larimer Mary E

Journal of consulting and clinical psychology [78:898-911] (2010)

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Web-based brief alcohol interventions have the potential to reach a large number of individuals at low cost; however, few controlled evaluations have been conducted to date. The present study was designed to evaluate the efficacy of gender-specific versus gender-nonspecific personalized normative feedback (PNF) with single versus biannual administration in a 2-year randomized controlled trial targeting a large sample of heavy-drinking college students. Participants included 818 freshmen (57.6% women; 42% non-Caucasian) who reported 1 or more heavy-drinking episodes in the previous month at baseline. Participants were randomly assigned in a 2 (gender-specific vs. gender-nonspecific PNF) × 2 (single vs. biannual administration of PNF) + 1 (attention control) design. Assessments occurred every 6 months for a 2-year period. Results from hierarchical generalized linear models provided modest effects on weekly drinking and alcohol-related problems but not on heavy episodic drinking. Relative to control, gender-specific biannual PNF was associated with reductions over time in weekly drinking (d = -0.16, 95% CI [-0.02, -0.31]), and this effect was partially mediated by changes in perceived norms. For women, but not men, gender-specific biannual PNF was associated with reductions over time in alcohol-related problems relative to control (d = -0.29, 95% CI [-0.15, -0.58]). Few other effects were evident. The present research provides modest support for the use of biannually administered web-based gender-specific PNF as an alternative to more costly indicated prevention strategies.


Evaluating personal alcohol feedback as a selective prevention for college students with depressed mood.

Geisner Irene Markman, Neighbors Clayton, Lee Christine M, Larimer Mary E

Addictive behaviors [32:2776-87] (2007)

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This research evaluated a brief mailed intervention for alcohol use as an adjunct to a brief treatment for college students with depression symptoms. The intervention aimed to correct normative misperceptions and reduce students' drinking and related consequences. One hundred seventy seven college students (70% Female) with elevated scores on the Beck Depression Inventory were randomly assigned to intervention or control group. Participants in the intervention were mailed feedback and information detailing their reported alcohol use, moderation strategies, and accurate normative information regarding student drinking. Results indicated no main effects of the intervention on drinking or related problems but students receiving feedback showed significant reductions in their perception of drinking norms compared to the control group. Furthermore, students whose normative perceptions reduced showed significant reductions in total drinks per week and total alcohol related problems compared to those whose norms did not reduce. Results support the importance of correcting normative perceptions and provide direction for selective prevention of alcohol use and related problems among college students with depressed mood.


21st birthday celebratory drinking: evaluation of a personalized normative feedback card intervention.

Lewis Melissa A, Neighbors Clayton, Lee Christine M, Oster-Aaland Laura

Psychology of addictive behaviors : journal of the Society of Psychologists in Addictive Behaviors [22:176-85] (2008)

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This research was designed to evaluate a personalized normative feedback birthday card intervention aimed at reducing normative perceptions, alcohol consumption, and negative consequences associated with 21st birthday celebrations among college students (N=281; 59.15% women). Students were randomly assigned to receive or not receive a birthday card about 1 week prior to their 21st birthday. Approximately 1 week following their birthday, students were asked to complete a brief survey concerning their birthday celebration activities. Findings indicated that the birthday card intervention was not successful at reducing drinking or consequences; however, the card did reduce normative misperceptions. Additional findings indicated that many students experienced negative consequences, such as passing out or driving after consuming alcohol. Combined, these findings suggest that prevention is needed for drinking associated with turning 21. However, prevention efforts should consist of more than a birthday card.


The effect of brief interventions on alcohol consumption among heavy drinkers in a general hospital setting.

Holloway Aisha S, Watson Hazel E, Arthur Antony J, Starr George, McFadyen Angus K, McIntosh Jean

Addiction (Abingdon, England) [102:1762-70] (2007)

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(i) To evaluate the effect of receiving one of two brief interventions in reducing alcohol consumption among general hospital patients compared with usual care. (ii) To assess whether a brief intervention of self-efficacy enhancement was superior to a self-help booklet in reducing alcohol consumption. A three-arm cluster randomized controlled trial. Seven general medical, six general surgical, one dermatology and two otolaryngology wards of a large teaching hospital covering a large urban and rural area. A total of 215 of 789 in-patients aged 18-75 years, who screened positive for alcohol consumption in excess of national recommended limits according to a 7-day retrospective drinking diary. Participants were allocated to receive one of three interventions: (i) face-to-face self-efficacy enhancement; (ii) a self-help booklet; or (iii) usual care. The primary outcome measure was change in reported alcohol consumption at 6-month follow-up as measured by a 7-day retrospective drinking diary. Secondary outcomes were change in: number of alcohol drinking days in last week; the maximum units of alcohol consumed on any one day in last week; and Drinking Refusal Self-efficacy Expectancy Questionnaire score. Compared to the usual care group the self-efficacy enhancement group (-10.1 units 95% CI -16.1 to -4.1) and the self-help booklet group (-10.0 units 95% CI -16.0 to -3.9) had greater reductions in self-reported weekly alcohol consumption. There was no evidence that self-efficacy enhancement was superior to the self-help booklet (P = 0.96). Brief interventions delivered in hospital offer simple means of helping heavy drinkers to reduce their alcohol consumption.


Self-affirmation, intentions and alcohol consumption in students: a randomized exploratory trial

Scott Jenn L, Brown Alexandra C, Phair Jessica K, Westland Josh N, Schüz Benjamin

Alcohol and alcoholism (Oxford, Oxfordshire) [48:458-63] ()

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This study tests whether enhancing alcohol risk messages with self-affirmation, the process of focusing on cherished aspects of oneself, increases intentions to reduce alcohol consumption and reduces actual alcohol consumption. It was also examined whether these effects differed by risk status as indicated by standard drinks consumed in an average week. Participants (n = 121) were randomly allocated to a self-affirmation or matched control condition before viewing emotive graphic alcohol warning posters in a questionnaire-based study. There were significant increases in intentions to reduce alcohol consumption in self-affirmed participants, and these effects were stronger in participants with higher behavioural risk. Intentions in turn significantly predicted a reduction in self-reported alcohol consumption. These findings support the use of self-affirmation to enhance alcohol awareness campaigns, particularly in individuals with high behavioural risk.


RCT of web-based personalized normative feedback for college drinking prevention: are typical student norms good enough?

Labrie Joseph W, Lewis Melissa A, Atkins David C, Neighbors Clayton, Zheng Cheng, Kenney Shannon R, Napper Lucy E, Walter Theresa, Kilmer Jason R, Hummer Justin F, Grossbard Joel, Ghaidarov Tehniat M, Desai Sruti, Lee Christine M, Larimer Mary E

Journal of consulting and clinical psychology [81:1074-86] (2013)

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Personalized normative feedback (PNF) interventions are generally effective at correcting normative misperceptions and reducing risky alcohol consumption among college students. However, research has yet to establish what level of reference group specificity is most efficacious in delivering PNF. This study compared the efficacy of a web-based PNF intervention using 8 increasingly specific reference groups against a Web-BASICS intervention and a repeated-assessment control in reducing risky drinking and associated consequences. Participants were 1,663 heavy-drinking Caucasian and Asian undergraduates at 2 universities. The referent for web-based PNF was either the typical same-campus student or a same-campus student at 1 (either gender, race, or Greek affiliation), or a combination of 2 (e.g., gender and race), or all 3 levels of specificity (i.e., gender, race, and Greek affiliation). Hypotheses were tested using quasi-Poisson generalized linear models fit by generalized estimating equations. The PNF intervention participants showed modest reductions in all 4 outcomes (average total drinks, peak drinking, drinking days, and drinking consequences) compared with control participants. No significant differences in drinking outcomes were found between the PNF group as a whole and the Web-BASICS group. Among the 8 PNF conditions, participants receiving typical student PNF demonstrated greater reductions in all 4 outcomes compared with those receiving PNF for more specific reference groups. Perceived drinking norms and discrepancies between individual behavior and actual norms mediated the efficacy of the intervention. Findings suggest a web-based PNF intervention using the typical student referent offers a parsimonious approach to reducing problematic alcohol use outcomes among college students.


Brief motivational intervention and alcohol expectancy challenge with heavy drinking college students: a randomized factorial study.

Wood Mark D, Capone Christy, Laforge Robert, Erickson Darin J, Brand Nancy H

Addictive behaviors [32:2509-28] (2007)

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This study is the first reported test of the unique and combined effects of Brief Motivational Intervention (BMI) and Alcohol Expectancy Challenge (AEC) with heavy drinking college students. Three hundred and thirty-five participants were randomly assigned in a 2x2 factorial design to either: BMI, AEC, BMI and AEC, and assessment only conditions. Follow-ups occurred at 1, 3, and 6 months. Unconditional latent curve analyses suggested that alcohol use (Q-F), heavy episodic drinking, and alcohol problems were best modeled as quadratic effects. BMI produced significant decreases in Q-F, heavy drinking, and problems, while AEC produced significant decreases in Q-F and heavy drinking. There was no evidence of an additive effect of combining the interventions. Intervention effects decayed somewhat for BMI and completely for AEC over 6 months. Multi-group analyses suggested similar intervention effects for men and women. BMI effects on alcohol problems were mediated by perceived norms. These findings extend previous research with BMI and AEC but do not support their utility as a combined preventive intervention to reduce collegiate alcohol abuse.


Targeting misperceptions of descriptive drinking norms: efficacy of a computer-delivered personalized normative feedback intervention.

Neighbors Clayton, Larimer Mary E, Lewis Melissa A

Journal of consulting and clinical psychology [72:434-47] (2004)

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The authors evaluated the efficacy of a computer-delivered personalized normative feedback intervention in reducing alcohol consumption among heavy-drinking college students. Participants included 252 students who were randomly assigned to an intervention or control group following a baseline assessment. Immediately after completing measures of reasons for drinking, perceived norms, and drinking behavior, participants in the intervention condition were provided with computerized information detailing their own drinking behavior, their perceptions of typical student drinking, and actual typical student drinking. Results indicated that normative feedback was effective in changing perceived norms and alcohol consumption at 3- and 6-month follow-up assessments. In addition, the intervention was somewhat more effective at 3-month follow-up among participants who drank more for social reasons.


Effects of a brief motivational intervention with college student drinkers.

Borsari B, Carey K B

Journal of consulting and clinical psychology [68:728-33] (2000)

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This study consisted of a randomized controlled trial of a 1-session motivational intervention for college student binge drinkers. Sixty students who reported binge drinking 2 or more times in the past 30 days were randomly assigned to either a no-treatment control or a brief intervention group. The intervention provided students with feedback regarding personal consumption, perceived drinking norms, alcohol-related problems, situations associated with heavy drinking, and alcohol expectancies. At 6-week follow-up, the brief intervention group exhibited significant reductions on number of drinks consumed per week, number of times drinking alcohol in the past month, and frequency of binge drinking in the past month. Estimates of typical student drinking mediated these reductions. This study replicates earlier research on the efficacy of brief interventions with college students and extends previous work regarding potential mechanisms of change.


A mobile phone intervention to reduce binge drinking among disadvantaged men: study protocol for a randomised controlled cost-effectiveness trial.

Crombie Iain K, Irvine Linda, Williams Brian, Sniehotta Falko F, Petrie Dennis, Evans Josie Mm, Emslie Carol, Jones Claire, Ricketts Ian W, Humphris Gerry, Norrie John, Rice Peter, Slane Peter W

Trials [15:494] (2014)

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Socially disadvantaged men are at a substantially higher risk of developing alcohol-related problems. The frequency of heavy drinking in a single session is high among disadvantaged men. Brief alcohol interventions were developed for, and are usually delivered in, healthcare settings. The group who binge drink most frequently, young to middle-aged disadvantaged men, have less contact with health services and there is a need for an alternative method of intervention delivery. Text messaging has been used successfully to modify other adverse health behaviours. This study will test whether text messages can reduce the frequency of binge drinking by disadvantaged men. Disadvantaged men aged 25 to 44 years who drank >8 units of alcohol at least twice in the preceding month will be recruited from the community. Two recruitment strategies will be used: contacting men listed in primary care registers, and a community outreach method (time-space sampling). The intended sample of 798 men will be randomised to intervention or control, stratifying by recruitment method. The intervention group will receive a series of text messages designed to reduce the frequency of binge drinking through the formation of specific action plans. The control group will receive behaviourally neutral text messages intended to promote retention in the study. The primary outcome measure is the proportion of men consuming >8 units on at least three occasions in the previous 30 days. Secondary outcomes include total alcohol consumption and the frequency of consuming more than 16 units of alcohol in one session in the previous month. Process measures, developed during a previous feasibility study, will monitor engagement with the key behaviour change components of the intervention. The study will incorporate an economic evaluation comparing the costs of recruitment and intervention delivery with the benefits of reduced alcohol-related harm. This study will assess the effectiveness of a brief intervention, delivered by text messages, aimed at reducing the frequency of binge drinking in disadvantaged men. The process measures will identify components of the intervention which contribute to effectiveness. The study will also determine whether any benefit of the intervention is justified by the costs of intervening. ISRCTN07695192. Date assigned: 14 August 2013.


An intervention to reduce alcohol consumption in undergraduate students using implementation intentions and mental simulations: a cross-national study.

Hagger Martin S, Lonsdale Adam, Koka Andre, Hein Vello, Pasi Heidi, Lintunen Taru, Chatzisarantis Nikos L D

International journal of behavioral medicine [19:82-96] (2012)

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Excessive alcohol consumption has been linked to deleterious health consequences among undergraduate students. There is a need to develop theory-based and cost-effective brief interventions to attenuate alcohol consumption in this population. The present study tested the effectiveness of an integrated theory-based intervention in reducing undergraduates' alcohol consumption in excess of guideline limits in national samples from Estonia, Finland, and the UK. A 2 (volitional: implementation intention vs. no implementation intention) × 2 (motivation: mental simulation vs. no mental simulation) × 3 (nationality: Estonia vs. Finland vs. UK) randomized-controlled design was adopted. Participants completed baseline psychological measures and self-reported number of alcohol units consumed and binge-drinking frequency followed by the intervention manipulation. One month later, participants completed follow-up measures of the psychological variables and alcohol consumption. Results revealed main effects for implementation intention and nationality on units of alcohol consumed at follow-up and an implementation intention × nationality interaction. Alcohol consumption was significantly reduced in the implementation intention condition for the Estonian and UK samples. There was a significant main effect for nationality and an implementation intention × nationality interaction on binge-drinking frequency. Follow-up tests revealed significant reductions in binge-drinking occasions in the implementation intention group for the UK sample only. Results support the implementation intention component of the intervention in reducing alcohol drinking in excess of guideline limits among Estonian and UK undergraduates. There was no support for the motivational intervention or the interaction between the strategies. Results are discussed with respect to intervention design based on motivational and volitional approaches.


Outcomes of a technology-based social norms intervention to deter alcohol use in freshman residence halls.

Thombs Dennis L, Olds R Scott, Osborn Cynthia J, Casseday Sarah, Glavin Kevin, Berkowitz Alan D

Journal of American college health : J of ACH [55:325-32] ()

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The authors tested a prototype intervention designed to deter alcohol use in residence halls. Approximately 384 freshmen participated in the study over a 2-year period. The authors devised a feedback method that assessed residents' blood alcohol concentration (BAC) at night and allowed the readings to be retrieved the next day via the Web. Residents in an intervention hall received their BAC readings as well as normative feedback. In a comparison hall, residents could retrieve only the BAC readings. The authors found statistically significant hall differences, but they were small in size and not meaningful. Qualitative findings suggest the intervention had an overall positive impact, but the actions of a subgroup of rebellious drinkers might have obscured the effect. Social norms interventions could provoke some episodes of excessive drinking in students who find these messages objectionable. More research is needed to evaluate delayed BAC feedback.


Decreasing hospital-associated rotavirus infection: a multidisciplinary hand hygiene campaign in a children's hospital.

Zerr Danielle M, Allpress Amanda L, Heath Joan, Bornemann Rena, Bennett Elizabeth

The Pediatric infectious disease journal [24:397-403] (2005)

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Hand hygiene is an effective means of preventing hospital-associated infection, but compliance among health care workers is poor. Few studies aimed at increasing hand hygiene in the hospital setting have shown sustained improvement and concurrent decreases in hospital-associated infections, and even fewer have been performed in the pediatric setting. We implemented a hand hygiene program with the hopes of improving hand hygiene and decreasing hospital-associated rotavirus infection rates. A multidisciplinary group developed a hospital supported, house-wide campaign. Opportunities for hand hygiene were observed during 5 periods. The frequency of hospital-associated rotavirus infection was tracked over time by review of laboratory records. Correlates of hand hygiene were investigated with the use of multivariate logistic regression. Overall hand hygiene compliance improved from 62% in period 1 to 81% in period 5 (P < 0.001). Soap and water was the most common method for practicing hand hygiene, and alcohol hand gel use increased from 4% to 29% between the first and last observation periods (P < 0.001). The rate of hospital-associated rotavirus infection decreased from 5.9 episodes per 1000 discharged patients in 2001 to 2.2 episodes per 1000 discharged patients in 2004 (P = 0.01). Period of observation, hospital ward, type of care provider and type of care performed were all independently associated with hand hygiene (adjusted P < or = 0.02 for all). Improving hand hygiene is an important goal for health care institutions. These data can be useful for development of interventions aimed at improving hand hygiene.


Health care workers' hand decontamination practices: an Irish study.

Creedon SA

Clinical nursing research [15:6-26] (2006)

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The primary purpose of this quasi-experimental research is to observe health care workers' compliance with hand-hygiene guidelines during patient care in an intensive care unit in Ireland before (pretest) and after (posttest) implementation of a multifaceted hand-hygiene program. Health care workers' attitudes, beliefs, and knowledge in relation to compliance with handwashing guidelines were also investigated. A convenience sample of nurses, doctors, physiotherapists, and care assistants (n = 73 observational participants, n = 62 questionnaire respondents) was used. Data (N = 314 observations, 62 questionnaires) were analyzed descriptively and cross-tabulated using chi-square (Pearson's) and Mann-Whitney statistical tests. Results revealed that a significant shift (32%) occurred in health care workers' compliance with handwashing guidelines (pretest 51%, posttest 83%, p < .001) following the interventional hand-hygiene program. Significant changes were also found in relation to health care workers' attitudes, beliefs, and knowledge (p < .05).


Improving hand hygiene behaviour among adolescents by a planning intervention.

Zhou Guangyu, Jiang Tingting, Knoll Nina, Schwarzer Ralf

Psychology, health & medicine [20:824-31] (2015)

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To improve regular hand hygiene in adolescents, educational messages based on medical information have not been very successful. Therefore, a theory-guided self-regulatory intervention has been designed with a particular focus on planning strategies. A randomised controlled trial with 307 adolescents, aged 12-18 years, was conducted in high schools. The control group received educational hand hygiene leaflets, whereas the experimental group received a self-regulatory treatment which required them to generate specific action plans and coping plans. Three times during one month, both groups received verbal reminder messages about planning to wash their hands properly. At one-month follow-up, hand hygiene behaviour as well as planning to practise hand hygiene were higher in the self-regulation than in the education group (p < .01). Moreover, changes in planning levels operated as a mediator between experimental conditions and changes in behavioural outcomes. Teaching self-regulatory planning strategies may constitute a superior approach than educational messages to improve regular hand hygiene practice in adolescents.


Evaluating brief motivational and self-regulatory hand hygiene interventions: a cross-over longitudinal design.

Lhakhang Pempa, Lippke Sonia, Knoll Nina, Schwarzer Ralf

BMC public health [15:79] (2015)

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Frequent handwashing can prevent infections, but non-compliance to hand hygiene is pervasive. Few theory- and evidence-based interventions to improve regular handwashing are available. Therefore, two intervention modules, a motivational and a self-regulatory one, were designed and evaluated. In a longitudinal study, 205 young adults, aged 18 to 26 years, were randomized into two intervention groups. The Mot-SelfR group received first a motivational intervention (Mot; risk perception and outcome expectancies) followed by a self-regulatory intervention (SelfR; perceived self-efficacy and planning) 17 days later. The SelfR-Mot group received the same two intervention modules in the opposite order. Follow-up data were assessed 17 and 34 days after the baseline. Both intervention sequences led to an increase in handwashing frequency, intention, self-efficacy, and planning. Also, overall gains were found for the self-regulatory module (increased planning and self-efficacy levels) and the motivational module (intention). Within groups, the self-regulatory module appeared to be more effective than the motivational module, independent of sequence. Self-regulatory interventions can help individuals to exhibit more handwashing. Sequencing may be important as a motivation module (Mot) first helps to set the goal and a self-regulatory module (SelfR) then helps to translate this goal into actual behavior, but further research is needed to evaluate mechanisms.


Promoting Hand Hygiene Compliance.

von Lengerke Thomas, Lutze Bettina, Krauth Christian, Lange Karin, Stahmeyer Jona Theodor, Chaberny Iris Freya

Deutsches Arzteblatt international [114:29-36] (2017)

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The German "Clean Hands Campaign" (an adaptation of the WHO "Clean Care is Safer Care" programme) to promote hand hygiene among hospital personnel at Hannover Medical School (MHH, Medizinische Hochschule Hannover), known as Aktion Saubere Hände (ASH), met with initial success. By 2013, however, compliance rates with hygienic hand disinfection in the hospital's ten intensive care units (ICUs) and two hematopoietic stem cell transplantation units (HSCTUs) had relapsed to their initial levels (physicians: 48%; nurses: 56%). The cluster- randomized controlled trial PSYGIENE was conducted to investigate whether interventions tai - lored in ways suggested by research in behavioral psychology might bring about more sustainable improvements than the ASH. The "Health Action Process Approach" (HAPA) compliance model specifies key psychological determinants of compliance. These determinants were assessed among health care workers in the ICUs and HSCTUs of the MHH by questionnaire (response rates: physicians: 71%; nurses: 63%) and by interviews of the responsible ward physicians and head nurses (100%). In 2013, 29 tailored behavior change techniques were implemented in educational training sessions and feedback discussions in the six wards that constituted the intervention arm of the trial, while ASH training sessions were provided in the control arm. The compliance rates for 2014 and 2015 (the primary outcomes of the trial) were determined by nonparticipating observation of hygienic hand disinfection, in accordance with the World Health Organization's gold standard. The two groups did not differ in their baseline compliance rates in 2013 (intervention: 54%, control: 55%, p = 0.581). The tailored interventions led to increased compliance in each of the two follow-up years (2014: 64%, p<0.001; 2015: 70%, p = 0.001), while the compliance in the control arm increased to 68% in 2014 (p<0.001) but fell back to 64% in 2015 (p = 0.007). The compliance increases from 2013-2015 and the compliance rate in 2015 were higher in the intervention arm (p<0.005). This was mainly attributable to the nurses' behavior, as the corresponding parameters for physicians did not differ significantly between the two study arms in stratified analysis. Tailored interventions based on behavioral psychology principles led to more sustainable increases in compliance with hand hygiene guidelines than ASH training sessions did. This was true among nurses, and thus also for hospital ward personnel as a whole (i.e., nurses and physicians combined). Further studies are needed to identify more target group-specific interventions that may improve compliance among physicians.


A brief report on the development of a theoretically-grounded intervention to promote patient autonomy and self-management of physiotherapy patients: face validity and feasibility of implementation.

Matthews James, Hall Amanda M, Hernon Marian, Murray Aileen, Jackson Ben, Taylor Ian, Toner John, Guerin Suzanne, Lonsdale Chris, Hurley Deirdre A

BMC health services research [15:260] (2015)

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Clinical practice guidelines for the treatment of low back pain suggest the inclusion of a biopsychosocial approach in which patient self-management is prioritized. While many physiotherapists recognise the importance of evidence-based practice, there is an evidence practice gap that may in part be due to the fact that promoting self-management necessitates change in clinical behaviours. Evidence suggests that a patient's motivation and maintenance of self-management behaviours can be positively influenced by the clinician's use of an autonomy supportive communication style. Therefore, the aim of this study was to develop and pilot-test the feasibility of a theoretically derived implementation intervention to support physiotherapists in using an evidence-based autonomy supportive communication style in practice for promoting patient self-management in clinical practice. A systematic process was used to develop the intervention and pilot-test its feasibility in primary care physiotherapy. The development steps included focus groups to identify barriers and enablers for implementation, the theoretical domains framework to classify determinants of change, a behaviour change technique taxonomy to select appropriate intervention components, and forming a testable theoretical model. Face validity and acceptability of the intervention was pilot-tested with two physiotherapists and monitoring their communication with patients over a three-month timeframe. Using the process described above, eight barriers and enablers for implementation were identified. To address these barriers and enablers, a number of intervention components were selected ranging from behaviour change techniques such as, goal-setting, self-monitoring and feedback to appropriate modes of intervention delivery (i.e. continued education meetings and audit and feedback focused coaching). Initial pilot-testing revealed the acceptability of the intervention to recipients and highlighted key areas for refinement prior to scaling up for a definitive trial. The development process utilised in this study ensured the intervention was theory-informed and evidence-based, with recipients signalling its relevance and benefit to their clinical practice. Future research should consider additional intervention strategies to address barriers of social support and those beyond the clinician level.


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.


Managing fatigue after cancer treatment: development of RESTORE, a web-based resource to support self-management.

Foster C, Calman L, Grimmett C, Breckons M, Cotterell P, Yardley L, Joseph J, Hughes S, Jones R, Leonidou C, Armes J, Batehup L, Corner J, Fenlon D, Lennan E, Morris C, Neylon A, Ream E, Turner L, Richardson A

Psycho-oncology [24:940-9] (2015)

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The aim of this study is to co-create an evidence-based and theoretically informed web-based intervention (RESTORE) designed to enhance self-efficacy to live with cancer-related fatigue (CRF) following primary cancer treatment. A nine-step process informed the development of the intervention: (1) review of empirical literature; (2) review of existing patient resources; (3) establish theoretical framework; (4) establish design team with expertise in web-based interventions, CRF and people affected by cancer; (5) develop prototype intervention; (6) user testing phase 1; (7) refinement of prototype; (8) user testing phase 2; and (9) develop final intervention. Key stakeholders made a critical contribution at every step of intervention development, and user testing, which involved an iterative process and resulted in the final intervention. The RESTORE intervention has five sessions; sessions 1 and 2 include an introduction to CRF and goal setting. Sessions 3-5 can be tailored to user preference and are designed to cover areas of life where CRF may have an impact: home and work life, personal relationships and emotional adjustment. It is feasible to systematically 'co-create' an evidence-based and theory-driven web-based self-management intervention to support cancer survivors living with the consequences of cancer and its treatment. This is the first account of the development of a web-based intervention to support self-efficacy to manage CRF. An exploratory trial to test the feasibility and acceptability of RESTORE is now warranted.


Using intervention mapping to develop a theory-driven, group-based complex intervention to support self-management of osteoarthritis and low back pain (SOLAS).

Hurley Deirdre A, Murphy Laura Currie, Hayes David, Hall Amanda M, Toomey Elaine, McDonough Suzanne M, Lonsdale Chris, Walsh Nicola E, Guerin Suzanne, Matthews James

Implementation science : IS [11:56] (2016)

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The Medical Research Council framework provides a useful general approach to designing and evaluating complex interventions, but does not provide detailed guidance on how to do this and there is little evidence of how this framework is applied in practice. This study describes the use of intervention mapping (IM) in the design of a theory-driven, group-based complex intervention to support self-management (SM) of patients with osteoarthritis (OA) and chronic low back pain (CLBP) in Ireland's primary care health system. The six steps of the IM protocol were systematically applied to develop the self-management of osteoarthritis and low back pain through activity and skills (SOLAS) intervention through adaptation of the Facilitating Activity and Self-management in Arthritis (FASA) intervention. A needs assessment including literature reviews, interviews with patients and physiotherapists and resource evaluation was completed to identify the programme goals, determinants of SM behaviour, consolidated definition of SM and required adaptations to FASA to meet health service and patient needs and the evidence. The resultant SOLAS intervention behavioural outcomes, performance and change objectives were specified and practical application methods selected, followed by organised programme, adoption, implementation and evaluation plans underpinned by behaviour change theory. The SOLAS intervention consists of six weekly sessions of 90-min education and exercise designed to increase participants' physical activity level and use of evidence-based SM strategies (i.e. pain self-management, pain coping, healthy eating for weight management and specific exercise) through targeting of individual determinants of SM behaviour (knowledge, skills, self-efficacy, fear, catastrophizing, motivation, behavioural regulation), delivered by a trained physiotherapist to groups of up to eight individuals using a needs supportive interpersonal style based on self-determination theory. Strategies to support SOLAS intervention adoption and implementation included a consensus building workshop with physiotherapy stakeholders, development of a physiotherapist training programme and a pilot trial with physiotherapist and patient feedback. The SOLAS intervention is currently being evaluated in a cluster randomised controlled feasibility trial. IM is a time-intensive collaborative process, but the range of methods and resultant high level of transparency is invaluable and allows replication by future complex intervention and trial developers.


Self-Monitoring Utilization Patterns Among Individuals in an Incentivized Program for Healthy Behaviors.

Kim Ju Young, Wineinger Nathan E, Taitel Michael, Radin Jennifer M, Akinbosoye Osayi, Jiang Jenny, Nikzad Nima, Orr Gregory, Topol Eric, Steinhubl Steve

Journal of medical Internet research [18:e292] (2016)

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The advent of digital technology has enabled individuals to track meaningful biometric data about themselves. This novel capability has spurred nontraditional health care organizations to develop systems that aid users in managing their health. One of the most prolific systems is Walgreens Balance Rewards for healthy choices (BRhc) program, an incentivized, Web-based self-monitoring program. This study was performed to evaluate health data self-tracking characteristics of individuals enrolled in the Walgreens' BRhc program, including the impact of manual versus automatic data entries through a supported device or apps. We obtained activity tracking data from a total of 455,341 BRhc users during 2014. Upon identifying users with sufficient follow-up data, we explored temporal trends in user participation. Thirty-four percent of users quit participating after a single entry of an activity. Among users who tracked at least two activities on different dates, the median length of participating was 8 weeks, with an average of 5.8 activities entered per week. Furthermore, users who participated for at least twenty weeks (28.3% of users; 33,078/116,621) consistently entered 8 to 9 activities per week. The majority of users (77%; 243,774/315,744) recorded activities through manual data entry alone. However, individuals who entered activities automatically through supported devices or apps participated roughly four times longer than their manual activity-entering counterparts (average 20 and 5 weeks, respectively; P<.001). This study provides insights into the utilization patterns of individuals participating in an incentivized, Web-based self-monitoring program. Our results suggest automated health tracking could significantly improve long-term health engagement.


Evidence suggesting that a chronic disease self-management program can improve health status while reducing hospitalization: a randomized trial.

Lorig K R, Sobel D S, Stewart A L, Brown B W, Bandura A, Ritter P, Gonzalez V M, Laurent D D, Holman H R

Medical care [37:5-14] (1999)

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This study evaluated the effectiveness (changes in health behaviors, health status, and health service utilization) of a self-management program for chronic disease designed for use with a heterogeneous group of chronic disease patients. It also explored the differential effectiveness of the intervention for subjects with specific diseases and comorbidities. The study was a six-month randomized, controlled trial at community-based sites comparing treatment subjects with wait-list control subjects. Participants were 952 patients 40 years of age or older with a physician-confirmed diagnosis of heart disease, lung disease, stroke, or arthritis. Health behaviors, health status, and health service utilization, as determined by mailed, self-administered questionnaires, were measured. Treatment subjects, when compared with control subjects, demonstrated improvements at 6 months in weekly minutes of exercise, frequency of cognitive symptom management, communication with physicians, self-reported health, health distress, fatigue, disability, and social/role activities limitations. They also had fewer hospitalizations and days in the hospital. No differences were found in pain/physical discomfort, shortness of breath, or psychological well-being. An intervention designed specifically to meet the needs of a heterogeneous group of chronic disease patients, including those with comorbid conditions, was feasible and beneficial beyond usual care in terms of improved health behaviors and health status. It also resulted in fewer hospitalizations and days of hospitalization.


An Internet-based diabetes self-care intervention tailored to self-efficacy.

Wangberg SC

Health education research [23:170-9] (2008)

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The main objective of this study was to assess whether self-efficacy (SE) could function as a moderator of the effect of a tailored Internet-based intervention aimed at increasing self-reported diabetes self-care behaviours. In a two-group, 1-month interval pre-test-post-test randomized controlled trial, participants (N = 64) were assigned at random to either a group that received an intervention on the area of self-care (blood glucose monitoring, diet management or physical activity) for which the reported SE was lowest (LSE group) or to a group that received an intervention on area of self-care for which the reported SE was highest (HSE group). Improvements in self-care were observed for both groups, but the HSE group improved more. Self-care also increased for those areas that the intervention did not target. Furthermore, SE levels decreased from baseline to follow-up. This study suggests that SE can function as a moderator in a behavioural intervention for diabetes self-care, and hence that initial level of SE provides relevant information for tailoring such interventions.


A user-centred approach to developing bWell, a mobile app for arm and shoulder exercises after breast cancer treatment.

Harder Helena, Holroyd Patrick, Burkinshaw Lynn, Watten Phil, Zammit Charles, Harris Peter R, Good Anna, Jenkins Val

Journal of cancer survivorship : research and practice (2017)

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The study aim was to develop a mobile application (app) supported by user preferences to optimise self-management of arm and shoulder exercises for upper-limb dysfunction (ULD) after breast cancer treatment. Focus groups with breast cancer patients were held to identify user needs and requirements. Behaviour change techniques were explored by researchers and discussed during the focus groups. Concepts for content were identified by thematic analysis. A rapid review was conducted to inform the exercise programme. Preliminary testing was carried out to obtain user feedback from breast cancer patients who used the app for 8 weeks post surgery. Breast cancer patients' experiences with ULD and exercise advice and routines varied widely. They identified and prioritised several app features: tailored information, video demonstrations of the exercises, push notifications, and tracking and progress features. An evidence-based programme was developed with a physiotherapist with progressive exercises for passive and active mobilisation, stretching and strengthening. The exercise demonstration videos were filmed with a breast cancer patient. Early user testing demonstrated ease of use, and clear and motivating app content. bWell, a novel app for arm and shoulder exercises, was developed by breast cancer patients, health care professionals and academics. Further research is warranted to confirm its clinical effectiveness. Mobile health has great potential to provide patients with information specific to their needs. bWell is a promising way to support breast cancer patients with exercise routines after treatment and may improve future self-management of clinical care.


Details of development of the resource for adults with asthma in the RAISIN (randomized trial of an asthma internet self-management intervention) study.

Morrison Deborah, Mair Frances S, Chaudhuri Rekha, McGee-Lennon Marilyn, Thomas Mike, Thomson Neil C, Yardley Lucy, Wyke Sally

BMC medical informatics and decision making [15:57] (2015)

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Around 300 million people worldwide have asthma and prevalence is increasing. Self-management can be effective in improving a range of outcomes and is cost effective, but is underutilised as a treatment strategy. Supporting optimum self-management using digital technology shows promise, but how best to do this is not clear. We aimed to develop an evidence based, theory informed, online resource to support self-management in adults with asthma, called 'Living well with Asthma', as part of the RAISIN (Randomized Trial of an Asthma Internet Self-Management Intervention) study. We developed Living well with Asthma in two phases. Phase 1: A low fidelity prototype (paper-based) version of the website was developed iteratively through input from a multidisciplinary expert panel, empirical evidence from the literature, and potential end users via focus groups (adults with asthma and practice nurses). Implementation and behaviour change theories informed this process. Phase 2: The paper-based designs were converted to a website through an iterative user centred process. Adults with asthma (n = 10) took part in think aloud studies, discussing the paper based version, then the web-based version. Participants considered contents, layout, and navigation. Development was agile using feedback from the think aloud sessions immediately to inform design and subsequent think aloud sessions. Think aloud transcripts were also thematically analysed, further informing resource development. The website asked users to aim to be symptom free. Key behaviours targeted to achieve this include: optimising medication use (including inhaler technique); attending primary care asthma reviews; using asthma action plans; increasing physical activity levels; and stopping smoking. The website had 11 sections, plus email reminders, which promoted these behaviours. Feedback on the contents of the resource was mainly positive with most changes focussing on clarification of language, order of pages and usability issues mainly relating to navigation difficulties. Our multifaceted approach to online intervention development underpinned by theory, using evidence from the literature, co-designed with end users and a multidisciplinary panel has resulted in a resource which end users find relevant to their needs and easy to use. Living well with Asthma is undergoing evaluation within a randomized controlled trial.


'Help for Hay Fever', a goal-focused intervention for people with intermittent allergic rhinitis, delivered in Scottish community pharmacies: study protocol for a pilot cluster randomized controlled trial.

Porteous Terry, Wyke Sally, Smith Sarah, Bond Christine, Francis Jill, Lee Amanda J, Lowrie Richard, Scotland Graham, Sheikh Aziz, Thomas Mike, Smith Lorraine

Trials [14:217] (2013)

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Despite the availability of evidence-based guidelines for managing allergic rhinitis in primary care, management of the condition in the United Kingdom (UK) remains sub-optimal. Its high prevalence and negative effects on quality of life, school performance, productivity and co-morbid respiratory conditions (in particular, asthma), and high health and societal costs, make this a priority for developing novel models of care. Recent Australian research demonstrated the potential of a community pharmacy-based 'goal-focused' intervention to help people with intermittent allergic rhinitis to self-manage their condition better, reduce symptom severity and improve quality of life. In this pilot study we will assess the transferability of the goal-focused intervention to a UK context, the suitability of the intervention materials, procedures and outcome measures and collect data to inform a future definitive UK randomized controlled trial (RCT). A pilot cluster RCT with associated preliminary economic analysis and embedded qualitative evaluation. The pilot trial will take place in two Scottish Health Board areas: Grampian and Greater Glasgow & Clyde. Twelve community pharmacies will be randomly assigned to intervention or usual care group. Each will recruit 12 customers seeking advice or treatment for intermittent allergic rhinitis. Pharmacy staff in intervention pharmacies will support recruited customers in developing strategies for setting and achieving goals that aim to avoid/minimize triggers for, and eliminate/minimize symptoms of allergic rhinitis. Customers recruited in non-intervention pharmacies will receive usual care. The co-primary outcome measures, selected to inform a sample size calculation for a future RCT, are: community pharmacy and customer recruitment and completion rates; and effect size of change in the validated mini-Rhinoconjunctivitis Quality of Life Questionnaire between baseline, one-week and six-weeks post-intervention. Secondary outcome measures relate to changes in symptom severity, productivity, medication adherence and self-efficacy. Quantitative data about accrual, retention and economic measures, and qualitative data about participants' experiences during the trial will be collected to inform the future RCT. This work will lay the foundations for a definitive RCT of a community pharmacy-based 'goal-focused' self-management intervention for people with intermittent allergic rhinitis. Results of the pilot trial are expected to be available in April 2013. Current Controlled Trials ISRCTN43606442.


The effectiveness of an enhanced invitation letter on uptake of National Health Service Health Checks in primary care: a pragmatic quasi-randomised controlled trial.

Sallis Anna, Bunten Amanda, Bonus Annabelle, James Andrew, Chadborn Tim, Berry Daniel

BMC family practice [17:35] (2016)

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The National Health Service Health Check (NHS HC) is a population level public health programme. It is a primary prevention initiative offering cardiovascular risk assessment and management for adults aged 40-74 years (every five years). It was designed to reduce the incidence of major vascular disease events by preventing or delaying the onset of diabetes, heart and kidney disease, stroke and vascular dementia . Effectiveness of the programme has been modelled on a national uptake of 75% however in 2012/13 uptake, nationally, was 49%. Ensuring a high percentage of those offered an NHS HC actually receive one is key to optimising the clinical and cost effectiveness of the programme. A pragmatic quasi-randomised controlled trial was conducted in four general practitioner practices in Medway, England with randomisation of 3511 patients. The aim was to compare attendance at the NHS HC using the standard national invitation template letter (control) compared to an enhanced invitation letter using insights from behavioural science (intervention). The intervention letter includes i) simplification - reducing letter content for less effortful processing ii) behavioural instruction - action focused language iii) personal salience - appointment due rather than invited and iv) addressing implementation intentions with a tear off slip to record the date, time and location of the appointment. Logistic Regression explored the association between control and intervention group and attendance at a health check. 29.3% of patients who received the control letter and 33.5% of those who received the intervention letter attended their NHS HC (adjusted odds ratio 1.26, 95% confidence interval 1.09-1.47, p < 0.01). This was an absolute difference in uptake of 4.2 percentage points for those receiving the intervention letter. An invitation letter applying behavioural insights was more effective than the existing national template letter at encouraging attendance at an NHS HC. Making small, no cost behaviourally informed changes to letter invitations can improve uptake of the NHS HC. Further research is required to replicate the effect with more robust methodology and powered for sub-group analysis including socio-economic status. Current Controlled Trials ISRCTN66757664 , date of registration 28/3/2014.


Testing the Implementation of a Pain Self-management Support Intervention for Oncology Patients in Clinical Practice: A Randomized Controlled Pilot Study (ANtiPain).

Koller Antje, Gaertner Jan, De Geest Sabina, Hasemann Monika, Becker Gerhild

Cancer nursing (2017)

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In oncology, pain control is a persistent problem. Significant barriers to cancer pain management are patient related. Pain self-management support interventions have shown to reduce pain intensity and patient-related barriers. Comparative effectiveness research is a suitable approach to test whether effects are sustained in clinical practice. In this pilot randomized controlled trial, the implementation of the ANtiPain intervention into clinical practice was tested to assess the effects on pain intensity, function-related outcomes, self-efficacy, and patient-related barriers to pain management to prepare a larger effectiveness trial. Within 14 months, 39 adult oncology patients with pain scores of 3 or higher on a 10-point numeric rating scale were recruited in an academic comprehensive cancer center in Southern Germany. Patients in the control group (n=19) received standard care. Patients in the intervention group (n=20) received ANtiPain, a cancer pain self-management support intervention based on 3 key strategies: provision of information, skill building, and nurse coaching. An intervention session was performed in-hospital. After discharge, follow-up was provided via telephone calls. Data were collected at baseline and 1 and 6 weeks after discharge. Effect sizes were calculated for all outcomes. Large effects were found for activity hindrance (Cohen d=0.90), barriers (d=0.91), and self-efficacy (d=0.90). Small to moderate effects were found for average and worst pain (Cohen d=0.17-0.45). Key findings of this study involved function-related outcomes and self-efficacy. Because these outcomes are particularly meaningful for patients, the integration of ANtiPain to routine clinical practice may be substantial. A larger study will be based on these findings.


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.


Hispanic chronic disease self-management: a randomized community-based outcome trial.

Lorig Kate R, Ritter Philip L, González Virginia M

Nursing research [52:361-9] ()

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In light of health disparities and the growing prevalence of chronic disease, there is a need for community-based interventions that improve health behaviors and health status. These interventions should be based on existing theory. This study aimed to evaluate the health and utilization outcomes of a 6-week community-based program for Spanish speakers with heart disease, lung disease, or type 2 diabetes. The treatment participants in this study (n = 327) took a 6-week peer-led program. At 4 months, they were compared with randomized wait-list control subjects (n = 224) using analyses of covariance. The outcomes for all the treatment participants were assessed at 1 year, as compared with baseline scores (n = 271) using t-tests. At 4 months, the participants, as compared with usual-care control subjects, demonstrated improved health status, health behavior, and self-efficacy, as well as fewer emergency room visits (p <.05). At 1 year, the improvements were maintained and remained significantly different from baseline condition. This community-based program has the potential to improve the lives of Hispanics with chronic illness while reducing emergency room use.


Improving coronary heart disease self-management using mobile technologies (Text4Heart): a randomised controlled trial protocol.

Dale Leila Pfaeffli, Whittaker Robyn, Jiang Yannan, Stewart Ralph, Rolleston Anna, Maddison Ralph

Trials [15:71] (2014)

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Cardiac rehabilitation (CR) is a secondary prevention program that offers education and support to assist patients with coronary heart disease (CHD) make lifestyle changes. Despite the benefits of CR, attendance at centre-based sessions remains low. Mobile technology (mHealth) has potential to reach more patients by delivering CR directly to mobile phones, thus providing an alternative to centre-based CR. The aim of this trial is to evaluate if a mHealth comprehensive CR program can improve adherence to healthy lifestyle behaviours (for example, physically active, fruit and vegetable intake, not smoking, low alcohol consumption) over and above usual CR services in New Zealand adults diagnosed with CHD. A two-arm, parallel, randomised controlled trial will be conducted at two Auckland hospitals in New Zealand. One hundred twenty participants will be randomised to receive a 24-week evidence- and theory-based personalised text message program and access to a supporting website in addition to usual CR care or usual CR care alone (control). The primary outcome is the proportion of participants adhering to healthy behaviours at 6 months, measured using a composite health behaviour score. Secondary outcomes include overall cardiovascular disease risk, body composition, illness perceptions, self-efficacy, hospital anxiety/depression and medication adherence. This study is one of the first to examine an mHealth-delivered comprehensive CR program. Strengths of the trial include quality research design and in-depth description of the intervention to aid replication. If effective, the trial has potential to augment standard CR practices and to be used as a model for other disease prevention or self-management programs. Australian New Zealand Clinical Trials Registry: ACTRN12613000901707.


Self-management support in routine primary care by nurses.

Westland Heleen, Schröder Carin D, de Wit Jessica, Frings Judith, Trappenburg Jaap C A, Schuurmans Marieke J

British journal of health psychology (2017)

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To examine how and to what extent self-management support, including behaviour change support, is provided by primary care nurses in routine consultations with chronically ill patients. Observational study design. Routine consultations of primary care nurses in the Netherlands with chronically ill patients were audio-taped and analysed. The analysis identified health topics addressed according to health care standards, self-management topics addressed using a validated set of topics, and behaviour change techniques (BCTs) using the Behaviour Change Techniques Taxonomy v1. Seventy-eight routine consultations of 17 primary care nurses with chronically ill patients were included in the analysis. Nurses addressed both health topics and self-management topics in brief, fragmented, and often inconsistent manners. Dietary intake and physical activity were the most frequently addressed topics. Nurses applied 21 BCTs to target behaviour change, but the use of these techniques was mainly inconsistent and implicit. The most consistently used BCTs were review behaviour goal(s) (56.4%) and feedback on behaviour (51.3%). Nurses addressed both health topics and self-management topics in their routine consultations. The duration, frequency, and number of addressed topics differed throughout the consultations. Nurses tended to prioritize the monitoring and optimization of patients' medical treatment and provided limited self-management support. Nurses seldom deepened their focus on behaviour change and infrequently used effective techniques to support this change. Adoption of self-management in primary care, including behaviour change, might be enhanced if nurses consistently and explicitly use effective BCTs in their consultations. Statement of contribution What is already known on this subject? Primary care nurses play a pivotal role in self-management support for patients with a chronic condition. Adequate self-management support requires nurses to activate patients and enhance behaviour change. Little is known regarding to what extent nurses provide self-management support in routine primary care. What does this study add? Self-management support is brief, fragmented, and inconsistently provided by nurses. Nurses tend to prioritize medical treatment optimization and seldom focus on behavioural change. Nurses' use of effective behaviour change techniques is low and should be enhanced.


Development and Validation of an Interactive Internet Platform for Older People: The Healthy Ageing Through Internet Counselling in the Elderly Study.

Jongstra Susan, Beishuizen Cathrien, Andrieu Sandrine, Barbera Mariagnese, van Dorp Matthijs, van de Groep Bram, Guillemont Juliette, Mangialasche Francesca, van Middelaar Tessa, Moll van Charante Eric, Soininen Hilkka, Kivipelto Miia, Richard Edo

Telemedicine journal and e-health : the official journal of the American Telemedicine Association (2016)

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A myriad of Web-based applications on self-management have been developed, but few focus on older people. In the face of global aging, older people form an important target population for cardiovascular prevention. This article describes the full development of an interactive Internet platform for older people, which was designed for the Healthy Ageing Through Internet Counselling in the Elderly (HATICE) study. We provide recommendations to design senior-friendly Web-based applications for a new approach to multicomponent cardiovascular prevention. The development of the platform followed five phases: (1) conceptual framework; (2) platform concept and functional design; (3) platform building (software and content); (4) testing and pilot study; and (5) final product. We performed a meta-analysis, reviewed guidelines for cardiovascular diseases, and consulted end users, experts, and software developers to create the platform concept and content. The software was built in iterative cycles. In the pilot study, 41 people aged ≥65 years used the platform for 8 weeks. Participants used the interactive features of the platform and appreciated the coach support. During all phases adjustments were made to incorporate all improvements from the previous phases. The final platform is a personal, secured, and interactive platform supported by a coach. When carefully designed, an interactive Internet platform is acceptable and feasible for use by older people with basic computer skills. To improve acceptability by older people, we recommend involving the end users in the process of development, to personalize the platform and to combine the application with human support. The interactive HATICE platform will be tested for efficacy in a multinational randomized controlled trial (ISRCTN48151589).


Development of a theory-informed implementation intervention to improve the triage, treatment and transfer of stroke patients in emergency departments using the Theoretical Domains Framework (TDF): the T(3) Trial.

Craig Louise E, Taylor Natalie, Grimley Rohan, Cadilhac Dominique A, McInnes Elizabeth, Phillips Rosemary, Dale Simeon, O'Connor Denise, Levi Chris, Fitzgerald Mark, Considine Julie, Grimshaw Jeremy M, Gerraty Richard, Cheung N Wah, Ward Jeanette, Middleton Sandy

Implementation science : IS [12:88] (2017)

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Theoretical frameworks and models based on behaviour change theories are increasingly used in the development of implementation interventions. Development of an implementation intervention is often based on the available evidence base and practical issues, i.e. feasibility and acceptability. The aim of this study was to describe the development of an implementation intervention for the T(3) Trial (Triage, Treatment and Transfer of patients with stroke in emergency departments (EDs)) using theory to recommend behaviour change techniques (BCTs) and drawing on the research evidence base and practical issues of feasibility and acceptability. A stepped method for developing complex interventions based on theory, evidence and practical issues was adapted using the following steps: (1) Who needs to do what, differently? (2) Using a theoretical framework, which barriers and enablers need to be addressed? (3) Which intervention components (behaviour change techniques and mode(s) of delivery) could overcome the modifiable barriers and enhance the enablers? A researcher panel was convened to review the list of BCTs recommended for use and to identify the most feasible and acceptable techniques to adopt. Seventy-six barriers were reported by hospital staff who attended the workshops (step 1: thirteen TDF domains likely to influence the implementation of the T(3) Trial clinical intervention were identified by the researchers; step 2: the researcher panellists then selected one third of the BCTs recommended for use as appropriate for the clinical context of the ED and, using the enabler workshop data, devised enabling strategies for each of the selected BCTs; and step 3: the final implementation intervention consisted of 27 BCTs). The TDF was successfully applied in all steps of developing an implementation intervention for the T(3) Trial clinical intervention. The use of researcher panel opinion was an essential part of the BCT selection process to incorporate both research evidence and expert judgment. It is recommended that this stepped approach (theory, evidence and practical issues of feasibility and acceptability) is used to develop highly reportable implementation interventions. The classifying of BCTs using recognised implementation intervention components will facilitate generalisability and sharing across different conditions and clinical settings.


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.


A novel behavioral intervention in adolescents with type 1 diabetes mellitus improves glycemic control: preliminary results from a pilot randomized control trial.

Maranda Louise, Lau May, Stewart Sunita M, Gupta Olga T

The Diabetes educator [41:224-30] (2015)

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The purpose of this study was to develop and pilot-test an innovative behavioral intervention in adolescents with type 1 diabetes mellitus (T1DM) incorporating structured care of a pet to improve glycemic control. Twenty-eight adolescents with A1C > 8.5% (69 mmol/mol) were randomly assigned to either the intervention group (care of a Betta splendens pet fish) or the control group (usual care). Adolescents in the intervention group were given instructions to associate daily and weekly fish care duties with diabetes self-management tasks, including blood glucose testing and parent-adolescent communication. After 3 months, the participants in the intervention group exhibited a statistically significant decrease in A1C level (-0.5%) compared with their peers in the control group, who had an increase in A1C level (0.8%) (P = .04). The younger adolescents (10-13 years of age) demonstrated a greater response to the intervention, which was statistically significant (-1.5% vs 0.6%, P = .04), compared with the older adolescents (14-17 years of age). Structured care of a pet fish can improve glycemic control in adolescents with T1DM, likely by providing cues to perform diabetes self-management behaviors.


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.


Intervention planning for a digital intervention for self-management of hypertension: a theory-, evidence- and person-based approach.

Band Rebecca, Bradbury Katherine, Morton Katherine, May Carl, Michie Susan, Mair Frances S, Murray Elizabeth, McManus Richard J, Little Paul, Yardley Lucy

Implementation science : IS [12:25] (2017)

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This paper describes the intervention planning process for the Home and Online Management and Evaluation of Blood Pressure (HOME BP), a digital intervention to promote hypertension self-management. It illustrates how a Person-Based Approach can be integrated with theory- and evidence-based approaches. The Person-Based Approach to intervention development emphasises the use of qualitative research to ensure that the intervention is acceptable, persuasive, engaging and easy to implement. Our intervention planning process comprised two parallel, integrated work streams, which combined theory-, evidence- and person-based elements. The first work stream involved collating evidence from a mixed methods feasibility study, a systematic review and a synthesis of qualitative research. This evidence was analysed to identify likely barriers and facilitators to uptake and implementation as well as design features that should be incorporated in the HOME BP intervention. The second work stream used three complementary approaches to theoretical modelling: developing brief guiding principles for intervention design, causal modelling to map behaviour change techniques in the intervention onto the Behaviour Change Wheel and Normalisation Process Theory frameworks, and developing a logic model. The different elements of our integrated approach to intervention planning yielded important, complementary insights into how to design the intervention to maximise acceptability and ease of implementation by both patients and health professionals. From the primary and secondary evidence, we identified key barriers to overcome (such as patient and health professional concerns about side effects of escalating medication) and effective intervention ingredients (such as providing in-person support for making healthy behaviour changes). Our guiding principles highlighted unique design features that could address these issues (such as online reassurance and procedures for managing concerns). Causal modelling ensured that all relevant behavioural determinants had been addressed, and provided a complete description of the intervention. Our logic model linked the hypothesised mechanisms of action of our intervention to existing psychological theory. Our integrated approach to intervention development, combining theory-, evidence- and person-based approaches, increased the clarity, comprehensiveness and confidence of our theoretical modelling and enabled us to ground our intervention in an in-depth understanding of the barriers and facilitators most relevant to this specific intervention and user population.


Web-based self-management with and without coaching for type 2 diabetes patients in primary care: design of a randomized controlled trial.

van Vugt Michael, de Wit Maartje, Hendriks Steven H, Roelofsen Yvonne, Bilo Henk Jg, Snoek Frank J

BMC endocrine disorders [13:53] (2013)

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Self-management is recognized as the cornerstone of overall diabetes management. Web-based self-management programs have the potential of supporting type 2 diabetes patients with managing their diabetes and reducing the workload for the care provider, where the addition of online coaching could improve patient motivation and reduce program attrition. This study aims to test the hypothesis that a web-based self-management program with coaching will prove more effective on improving patient self-management behavior and clinical outcome measures than a web-based self-management program without coaching. The effects of a web-based self-management program with and without coaching will be tested with a nested randomized controlled trial within a healthcare group in the Netherlands. In one year 220 type 2 diabetes patients will be randomized into an intervention group (n = 110) or a control group (n = 110). The control group will receive only the online self-management program. The intervention group will receive the online self-management program and additional online coaching. Participants will be followed for one year, with follow-up measurements at 6 and 12 months. The intervention being tested is set to support type 2 diabetes patients with their diabetes self-management and is expected to have beneficial effects on self-care activities, well being and clinical outcomes. When proven effective this self-management support program could be offered to other health care groups and their type 2 diabetes patients in the Netherlands. Nederlands Trial Register NTR4064.


Partner- and planning-based interventions to reduce fat consumption: randomized controlled trial.

Prestwich Andrew, Conner Mark T, Lawton Rebecca J, Ward Jane K, Ayres Karen, McEachan Rosemary R C

British journal of health psychology [19:132-48] (2014)

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The research tested the efficacy of partner- and planning-based interventions to reduce dietary fat intake over a 6-month period. Randomized controlled, blinded, parallel trial. A computer randomization feature was used to allocate council employees (N = 427, of which 393 completed baseline measures) to one of four conditions (partner + implementation intentions, partner-only, implementation intentions, and control group) before they completed measures at baseline and follow-ups at 1, 3, and 6 months post-baseline. Outcome measures were comprised of validated self-report measures of dietary fat intake (saturated fat intake, fat intake, ratio of 'good' fats to 'bad' fats); psychosocial mediators (enjoyment, intention, self-efficacy, social influence, partner support); weight and waist size (baseline and 6 months only). Data from 393 participants were analysed in accordance with intention-to-treat analyses. All intervention groups reported greater reductions in fat intake than the control group at 3 months. The partner-based groups increased the ratio of 'good' fats to 'bad' fats at 3 and 6 months and lost more inches on their waist, versus the non-partner groups. The impacts of the partner-based manipulations on outcomes were partially mediated by greater perceived social influences, partner support, and enjoyment of avoiding high-fat foods. The partner-based interventions also increased intention and self-efficacy. However, the effects in this study were typically small and generally marginally significant. Partner-based interventions had some positive benefits on dietary-related outcomes at 3 and 6 months. Support for implementation intentions was more limited.


The impact of a computer-tailored nutrition intervention.

Brug J, Steenhuis I, van Assema P, de Vries H

Preventive medicine [25:236-42] ()

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Nutrition education tailored to individual characteristics of people might be more effective than general nutrition education. Nowadays, the use of computers makes individualized feedback available for larger groups. The impact of tailored nutrition information on changes in fat, vegetable, and fruit consumption was tested in a randomized trial among 347 employees of a major oil company. Respondents in the experimental group received computer-generated feedback letters tailored to their personal dietary behavior, attitudes, perceived social influences, self-efficacy expectations, and awareness levels. Respondents in the control group received general nutrition information. Respondents in the experimental group decreased their fat consumption significantly more than the control group between baseline and posttest. A significant effect of tailoring was also found for changes in attitudes and intentions toward reducing fat intake and increasing fruit and vegetable consumption. Furthermore, respondents in the experimental group were more satisfied with the nutrition information they received and more often reported changing their diet or intention as a result of the information. It is concluded that computer-tailored nutrition information is a promising means of stimulating people to change their diet toward dietary recommendations.


The D-Net diabetes self-management program: long-term implementation, outcomes, and generalization results.

Glasgow Russell E, Boles Shawn M, McKay H Garth, Feil Edward G, Barrera Manuel

Preventive medicine [36:410-9] (2003)

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A prerequisite to translating research findings into practice is information on consistency of implementation, maintenance of results, and generalization of effects. This follow-up report is one of the few experimental studies to provide such information on Internet-based health education. We present follow-up data 10 months following randomization on the "Diabetes Network (D-Net)" Internet-based self-management project, a randomized trial evaluating the incremental effects of adding (1) tailored self-management training or (2) peer support components to a basic Internet-based, information-focused comparison intervention. Participants were 320 adult type 2 diabetes patients from participating primary care offices, mean age 59 (SD = 9.2), who were relatively novice Internet users. All intervention components were consistently implemented by staff, but participant website usage decreased over time. All conditions were significantly improved from baseline on behavioral, psychosocial, and some biological outcomes; and there were few differences between conditions. Results were robust across on-line coaches, patient characteristics, and participating clinics. The basic D-Net intervention was implemented well and improvements were observed across a variety of patients, interventionists, and clinics. There were, however, difficulties in maintaining usage over time and additions of tailored self-management and peer support components generally did not significantly improve results.


Nutrition intervention for high-risk auto workers: results of the Next Step Trial.

Tilley B C, Glanz K, Kristal A R, Hirst K, Li S, Vernon S W, Myers R

Preventive medicine [28:284-92] (1999)

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The Next Step Trial tested interventions encouraging prevention and early detection practices in automotive-industry employees at increased colorectal cancer risk. This article describes results of the nutrition intervention promoting low-fat, high-fiber eating patterns. Twenty-eight worksites (5,042 employees at baseline) were randomized to a 2-year nutrition intervention including classes, mailed self-help materials, and personalized dietary feedback. Control worksites received no intervention. Nutrition outcomes were assessed by mailed food frequency questionnaires (FFQs) Primary nutrition outcomes included percentage energy from fat and fiber density (g/1,000 kcal) at 1 year postrandomization. Secondary outcomes included servings of fruits/vegetables and dietary measures at 2 years postrandomization. Analyses were adjusted for within worksite correlations and baseline covariates. Fifty-eight percent of employees returned FFQs. At 1 year, there were modest but statistically significant intervention effects for fat (-0.9 %en), fiber (+0.5 g/1,000 kcal), and fruits/vegetables (+0.2 servings/day) (all P < 0.007). At 2 years, due to significant positive changes in control worksites, intervention effects were smaller, significant for fiber only. Intervention effects were larger in younger (<50 years), active employees and class attendees. The nutrition intervention produced significant but modest effects on dietary fat and fiber and fruits/vegetables in these high-risk employees. Age and dose effects suggest younger employees may be more responsive to this intervention.


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.


Cancer prevention for working class, multi-ethnic populations through health centers: the healthy directions study.

Emmons Karen M, Stoddard Anne M, Gutheil Caitlin, Suarez Elizabeth Gonzalez, Lobb Rebecca, Fletcher Robert

Cancer causes & control : CCC [14:727-37] (2003)

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This paper presents the study design and baseline data from Healthy Directions-Health Centers (HCs), a study designed to address social contextual factors in cancer prevention interventions for working class, multi-ethnic populations. This study is part of the Harvard Cancer Prevention Program Project. Ten community HCs were paired and randomly assigned to intervention or control. Patients who resided in low income, multi-ethnic neighborhoods were identified and approached for participation. This study targeted fruit and vegetable consumption, red meat consumption, multi-vitamin intake, and physical activity. The intervention components consisted of: (1) a brief in-person study endorsement from the participant's clinician at a scheduled routine care visit; (2) an initial in-person counseling session with a health advisor; (3) four follow-up telephone counseling sessions; (4) multiple mailings of tailored materials; and (5) linkages to relevant activities in the local community. Fifteen percent of the sample smoked, 86% reported eating fewer than five servings of fruits and vegetables per day, 50% reported eating more than the recommended amounts of red meat, 40% did not meet recommended physical activity levels, and 63% did not take a multi-vitamin on a daily basis. Although overall social support was high, participants reported low levels of social norms for the target prevention behaviors. Other social contextual mediators and modifying factors are reported. By examining the relationships between social contextual factors and health behaviors, it may be possible to enhance the effectiveness of interventions aimed at reducing social inequalities in risk behaviors.


The impact of self-efficacy and implementation intentions-based interventions on fruit and vegetable intake among adults.

Guillaumie Laurence, Godin Gaston, Manderscheid Jean-Claude, Spitz Elisabeth, Muller Laurent

Psychology & health [27:30-50] (2012)

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This study tested the effect of interventions designed for people who do not eat yet the recommended daily fruit and vegetable intake (FVI) but have a positive intention to do so. Adults (N = 163) aged 20-65 were randomised into four groups: implementation intentions (II group), self-efficacy (SE group), combination of II + SE group) and a control group receiving written information on nutrition. Study variables were measured at baseline, post-intervention and at 3-month follow-up. At follow-up, compared to the control group, FVI increased significantly in the II and II + SE groups (1.5 and 1.9 servings per day, respectively). Most psychosocial variables significantly increased compared to the control group, with the exception of SE for vegetable intake (VI). Moreover, at 3-month follow-up, change in FVI was mediated by changes in fruit intake (FI) intention and VI action planning. In conclusion, II interventions were efficient to increase FVI, with or without consideration for the development of SE. Thus, future studies should favour the adoption of this approach to bridge the intention-behaviour gap for FVI.


Demonstration of an E-mailed worksite nutrition intervention program.

Block Gladys, Block Torin, Wakimoto Patricia, Block Clifford H

Preventing chronic disease [1:A06] (2004)

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Dietary fat and low fruit and vegetable intake are linked to many chronic diseases, and U.S. population intake does not meet recommendations. Interventions are needed that incorporate effective behavior-change principles and that can be delivered inexpensively to large segments of the population. Employees at a corporate worksite were invited to participate in a program, delivered entirely by e-mail, to reduce dietary fat and increase fruit and vegetable intake. Behavior-change principles underlying the intervention included tailoring to the participant's dietary lifestyle, baseline assessment and feedback about dietary intake, family participation, and goal setting. Assessment, tailoring, and delivery was fully automated. The program was delivered weekly to participants' e-mail inboxes for 12 weeks. Each e-mail included information on nutrition or on the relationship between diet and health, dietary tips tailored to the individual, and small goals to try for the next week. In this nonrandomized pilot study, we assessed technical feasibility, acceptability to employees, improvement in Stage of Change, increase in fruit and vegetable consumption, and decrease in fat intake. Approximately one third (n = 84) of employees who were offered the 12-week program signed up for it, and satisfaction was high. There was significant improvement in Stage of Change: 74% of those not already at the top had forward movement (P < .001). In addition, results suggest significant increase in fruit and vegetable consumption (0.73 times/day, P < .001) and significant decrease in intake of fat sources (-0.39 times/day, P < .001). This inexpensive program is feasible and appears to be effective. A randomized controlled trial is needed.


ShopSmart 4 Health: results of a randomized controlled trial of a behavioral intervention promoting fruit and vegetable consumption among socioeconomically disadvantaged women.

Ball Kylie, McNaughton Sarah A, Le Ha Nd, Abbott Gavin, Stephens Lena D, Crawford David A

The American journal of clinical nutrition (2016)

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Behavioral interventions show potential for promoting increased fruit and vegetable consumption in the general population. However, little is known about their effectiveness or cost-effectiveness among socioeconomically disadvantaged groups, who are less likely to consume adequate fruit and vegetables. This study investigated the effects and costs of a behavior change intervention for increasing fruit and vegetable purchasing and consumption among socioeconomically disadvantaged women. ShopSmart 4 Health was a randomized controlled trial involving a 3-mo retrospective baseline data collection phase [time (T) 0], a 6-mo intervention (T1-T2), and a 6-mo no-intervention follow-up (T3). Socioeconomically disadvantaged women who were primary household shoppers in Melbourne, Australia, were randomly assigned to either a behavior change intervention arm (n = 124) or a control arm (n = 124). Supermarket transaction (sales) data and surveys measured the main outcomes: fruit and vegetable purchases and self-reported fruit and vegetable consumption. An analysis of supermarket transaction data showed no significant intervention effects on vegetable or fruit purchasing at T2 or T3. Participants in the behavior change intervention arm reported consumption of significantly more vegetables during the intervention (T2) than did controls, with smaller intervention effects sustained at 6 mo postintervention (T3). Relative to controls, vegetable consumption increased by ∼0.5 serving · participant(-1) · d(-1) from baseline to T2 and remained 0.28 servings/d higher than baseline at T3 among those who received the intervention. There was no intervention effect on reported fruit consumption. The behavior change intervention cost A$3.10 (in Australian dollars) · increased serving of vegetables(-1) · d(-1)Conclusions: This behavioral intervention increased vegetable consumption among socioeconomically disadvantaged women. However, the lack of observed effects on fruit consumption and on both fruit and vegetable purchasing at intervention stores suggests that further investigation of effective nutrition promotion approaches for this key target group is required. The ShopSmart 4 Health trial was registered at www.isrctn.com as ISRCTN48771770.


Randomized controlled trial of a brief research-based intervention promoting fruit and vegetable consumption.

Kellar I, Abraham C

British journal of health psychology [10:543-58] (2005)

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The present study sought to test the efficacy of a brief research-based, leaflet-like intervention to promote eating the recommended daily intake of fruit and vegetables (RDIFV). A controlled, pre- post-test experimental study with random allocation and a 1 week self-report behavioural follow-up was conducted. The intervention employed persuasive communication targeting self-efficacy and intention, and invited participants to form implementation intentions in relation to acquiring and preparing fruit and vegetables for consumption. Intervention participants had stronger post-intervention intentions to consume the RDIFV, and higher anticipated regret in relation to failing to do so, compared with controls, controlling for pre-intervention scores. At follow-up, the intervention group was found to have eaten more fruit and vegetables and to have consumed the RDIFV more frequently. It is concluded that this study supports the previously reported power of implementation intentions to prompt enactment of intentions, and that a brief research-based leaflet-like intervention could result in immediate enhancement of intentions and anticipated regret, and promote greater fruit and vegetable consumption.


Promoting healthy weight with "stability skills first": a randomized trial.

Kiernan Michaela, Brown Susan D, Schoffman Danielle E, Lee Katherine, King Abby C, Taylor C Barr, Schleicher Nina C, Perri Michael G

Journal of consulting and clinical psychology [81:336-46] (2013)

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Although behavioral weight-loss interventions produce short-term weight loss, long-term maintenance remains elusive. This randomized trial examined whether learning a novel set of "stability skills" before losing weight improved long-term weight management. Stability skills were designed to optimize individuals' current satisfaction with lifestyle and self-regulatory habits while requiring the minimum effort and attention necessary. Overweight/obese women (N = 267) were randomly assigned to one of two 6-month interventions and assessed at baseline and at 6, 12, and 18 months. Maintenance First women participated first in an 8-week stability skills maintenance module and then in a standard 20-week behavioral weight-loss program. Weight Loss First women participated first in a standard 20-week behavioral weight-loss program and then in a standard 8-week problem-solving skills maintenance module. There was no intervention staff contact during the 12-month follow-up period (6-18 months). As designed, Maintenance First participants lost the same percentage of initial weight during the 6-month intervention period as Weight Loss First participants (M = -8.6%, SD = 5.7, vs. M = -9.1%, SD = 6.9; t = -0.6, p = .52). However, Maintenance First participants regained significantly less weight during the 12-month follow-up period (6-18 months) than Weight Loss First participants (M = 3.2 lb, SD = 10.4, vs. M = 7.3 lb, SD = 9.9 [M = 1.4 kg, SD = 4.7, vs. M = 3.3 kg, SD = 4.5]; t = 3.3, p = .001, d = 0.4). Learning stability skills before losing weight was successful in helping women to maintain weight loss without intervention staff contact during follow-up. These results can inform the study design of future innovative interventions.


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.


Development of the SALdável programme to reduce salt intake among hypertensive Brazilian women: an intervention mapping approach.

Cornélio Marilia Estevam, Godin Gaston, Rodrigues Roberta, Agondi Rúbia, Spana Thaís, Gallani Maria-Cecilia

European journal of cardiovascular nursing : journal of the Working Group on Cardiovascular Nursing of the European Society of Cardiology [12:385-92] (2013)

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Despite strong evidence for a relationship between high salt intake and hypertension, plus the widespread recommendations for dietary salt restriction among hypertensive subjects, there are no nursing studies describing effective theory-based interventions. To describe a systematic process for development of a theory-based nursing intervention that is aimed at reducing salt intake among hypertensive women, by applying the 'intervention mapping' protocol. We developed our intervention following the six steps of the 'intervention mapping' protocol: assessing needs, creating a matrix of change objectives, selecting theoretical methods and practical applications, defining the intervention programme, organizing the adoption and implementation plan, and defining the evaluation plan. Addition of salt during cooking is identified as the main source for salt consumption, plus women are identified as the people responsible for cooking meals at home. In our study, the motivational predictors of this behaviour were self-efficacy and habit. Guided practice, verbal persuasion, coping barriers, consciousness-raising and counter-conditioning were the theoretical methods we selected for enhancing self-efficacy and promoting habit change, respectively. Brainstorming, role-playing, cookbook use, measuring spoon use, label reading, hands-on skill-building activities and reinforcement phone calls were the chosen practical applications. We designed our intervention programme, and then organized the adoption and implementation plans. Finally, we generated a plan to evaluate our intervention. 'Intervention mapping' was a feasible methodological framework to guide the development of a theory-based nursing intervention for dietary salt reduction among hypertensive women.


Pathway to health: cluster-randomized trial to increase fruit and vegetable consumption among smokers in public housing.

Ahluwalia Jasjit S, Nollen Nicole, Kaur Harsohena, James Aimee S, Mayo Matthew S, Resnicow Ken

Health psychology : official journal of the Division of Health Psychology, American Psychological Association [26:214-21] (2007)

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Examine the effectiveness of an intervention to increase fruits and vegetables (FV) consumption among smokers. Cluster-randomized trial of 20 public housing developments; 10 randomly assigned to an FV intervention and 10 to a smoking cessation intervention. Usual (past 7 days) and past 30 days change in daily FV intake at 8 weeks and 6 months postbaseline. Greater increases were seen in the FV group. At Week 8 and Month 6, the FV group had consumed 1.58 (p = .001) and 0.78 (p = .04), respectively, more daily FV servings in the past 7 days than the cessation group. At the same time points, the FV group had consumed 3.61 (p = .01) and 3.93 (p = .01), respectively, more FV servings in the past 30 days than the cessation group. Completing more motivational interviewing sessions (p = .02) and trying more recipes (p = .02) led to significantly greater increases at Month 6 among FV participants. Motivational interviewing counseling and lifestyle modification through trying out healthy recipes may be effective in helping a high-risk population increase their FV intake.


Development of an Evidence-Informed Blog to Promote Healthy Eating Among Mothers: Use of the Intervention Mapping Protocol.

Dumas Audrée-Anne, Lemieux Simone, Lapointe Annie, Provencher Véronique, Robitaille Julie, Desroches Sophie

JMIR research protocols [6:e92] (2017)

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Low adherence to dietary guidelines and a concurrent rise of obesity-related chronic diseases emphasize the need for effective interventions to promote healthy eating. There is growing recognition that behavior change interventions should draw on theories of behavior change. Online interventions grounded in theory lead to increased effectiveness for health behavior change; however, few theory-driven social media-based health promotion interventions have been described in the literature. The objective of this study was to describe the application of the Intervention Mapping (IM) protocol to develop an evidence-informed blog to promote healthy eating among French-Canadian mothers of preschool and school-aged children. The following six steps of the IM protocol were performed. In Step 1, a preliminary needs assessment included a literature search on theoretical domains predicting Vegetables and Fruits intakes and Milk and Alternatives intakes in adults (ie, knowledge, beliefs about capabilities, beliefs about consequences, intention/goals) and a qualitative study including focus groups to identify female Internet users' perceptions of their use of healthy eating blogs. In Step 2, two behavioral outcomes were selected (ie, increase daily intakes of Vegetables and Fruits and Milk and Alternatives of mothers to reach Canadian dietary recommendations) and subsequently divided into six performance objectives inspired by national and international dietary recommendations such as planning for healthy meals. A matrix of change objectives was then created by crossing performance objectives with theoretical domains predicting Vegetables and Fruits intakes and Milk and Alternatives intakes in adults. Step 3 consisted of selecting theory-based intervention methods (eg, modeling and goal setting) and translating them into practical applications for the context of a dietary intervention delivered through a blog. A 6-month intervention was developed in Step 4 in which we aimed to address one performance objective per month in weekly blog publications written by a registered dietitian. For Step 5, we sought to include engagement-promoting methods (eg, peer and counselor support) to promote mothers' use of the blog and adherence to the intervention. Finally in Step 6, a randomized controlled trial has been launched to evaluate the effects of the blog on dietary behaviors of French-Canadian mothers. The intervention study is expected to be completed in March 2018. An intervention mapping protocol allowed for effective decision making in the development of a novel knowledge translation tool to increase adherence to dietary recommendations among mothers of preschool and school-aged children.


Development and preliminary evaluation of an internet-based healthy eating program: randomized controlled trial.

Tapper Katy, Jiga-Boy Gabriela, Maio Gregory R, Haddock Geoffrey, Lewis Michael

Journal of medical Internet research [16:e231] (2014)

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The HealthValues Healthy Eating Programme is a standalone Internet-based intervention that employs a novel strategy for promoting behavior change (analyzing one's reasons for endorsing health values) alongside other psychological principles that have been shown to influence behavior. The program consists of phases targeting motivation (dietary feedback and advice, analyzing reasons for health values, thinking about health-related desires, and concerns), volition (implementation intentions with mental contrasting), and maintenance (reviewing tasks, weekly tips). The aim was to examine the effects of the program on consumption of fruit and vegetables, saturated fat, and added sugar over a 6-month period. A total of 82 females and 18 males were recruited using both online and print advertisements in the local community. They were allocated to an intervention or control group using a stratified block randomization protocol. The program was designed such that participants logged onto a website every week for 24 weeks and completed health-related measures. Those allocated to the intervention group also completed the intervention tasks at these sessions. Additionally, all participants attended laboratory sessions at baseline, 3 months, and 6 months. During these sessions, participants completed a food frequency questionnaire (FFQ, the Block Fat/Sugar/Fruit/Vegetable Screener, adapted for the UK), and researchers (blind to group allocation) measured their body mass index (BMI), waist-to-hip ratio (WHR), and heart rate variability (HRV). Data were analyzed using a series of ANOVA models. Per protocol analysis (n=92) showed a significant interaction for fruit and vegetable consumption (P=.048); the intervention group increased their intake between baseline and 6 months (3.7 to 4.1 cups) relative to the control group (3.6 to 3.4 cups). Results also showed overall reductions in saturated fat intake (20.2 to 15.6 g, P


What motivates maternal and child nutrition peer educators? Experiences of fathers and grandmothers in western Kenya.

Martin Stephanie L, Muhomah Teresia, Thuita Faith, Bingham Allison, Mukuria Altrena G

Social science & medicine (1982) [143:45-53] (2015)

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Peer-led dialogue groups (i.e., support or self-help groups) are a widely used community-based strategy to improve maternal and child health and nutrition. However, the experiences and motivation of peer educators who facilitate these groups are not well documented. We implemented eight father and ten grandmother peer dialogue groups in western Kenya to promote and support recommended maternal dietary and infant and young child feeding practices and sought to understand factors that influenced peer educator motivation. After four months of implementation, we conducted 17 in-depth interviews with peer educators as part of a process evaluation to understand their experiences as group facilitators as well as their motivation. We analyzed the interview transcripts thematically and then organized them by level: individual, family, peer dialogue group, organization, and community. Father and grandmother peer educators reported being motivated by multiple factors at the individual, family, dialogue group, and community levels, including increased knowledge, improved communication with their wives or daughters-in-law, increased respect and appreciation from their families, group members' positive changes in behavior, and increased recognition within their communities. This analysis also identified several organization-level factors that contributed to peer educator motivation, including clearly articulated responsibilities for peer educators; strong and consistent supportive supervision; opportunities for social support among peer educators; and working within the existing health system structure. Peer educator motivation affects performance and retention, which makes understanding and responding to their motivation essential for the successful implementation, sustainability, and scalability of community-based, peer-led nutrition interventions.


Psychosocial mediation of fruit and vegetable consumption in the body and soul effectiveness trial.

Fuemmeler Bernard F, Mâsse Louise C, Yaroch Amy L, Resnicow Ken, Campbell Marci Kramish, Carr Carol, Wang Terry, Williams Alexis

Health psychology : official journal of the Division of Health Psychology, American Psychological Association [25:474-83] (2006)

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In this study the authors examined psychosocial variables as mediators for fruit and vegetable (FV) intake in a clustered, randomized effectiveness trial conducted in African American churches. The study sample included 14 churches (8 intervention and 6 control) with 470 participants from the intervention churches and 285 participants from the control churches. The outcome of FV intake and the proposed mediators were measured at baseline and at 6-month follow-up. Structural equation modeling indicated that the intervention had direct effects on social support, self-efficacy, and autonomous motivation; these variables also had direct effects on FV intake. Applying the M. E. Sobel (1982) formula to test significant mediated effects, the authors confirmed that social support and self-efficacy were significant mediators but that autonomous motivation was not. Social support and self-efficacy partially mediated 20.9% of the total effect of the intervention on changes in FV intake. The results support the use of strategies to increase social support and self-efficacy in dietary intervention programs.


Healthy whole-grain choices for children and parents: a multi-component school-based pilot intervention.

Burgess-Champoux Teri L, Chan Hing Wan, Rosen Renee, Marquart Len, Reicks Marla

Public health nutrition [11:849-59] (2008)

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The aim of the present study was to pilot-test a school-based intervention designed to increase consumption of whole grains by 4th and 5th grade children. This multi-component school-based pilot intervention utilised a quasi-experimental study design (intervention and comparison schools) that consisted of a five-lesson classroom curriculum based on Social Cognitive Theory, school cafeteria menu modifications to increase the availability of whole-grain foods and family-oriented activities. Meal observations of children estimated intake of whole grains at lunch. Children and parents completed questionnaires to assess changes in knowledge, availability, self-efficacy, usual food choice and role modelling. Parent/child pairs from two schools in the Minneapolis metropolitan area; 67 in the intervention and 83 in the comparison school. Whole-grain consumption at the lunch meal increased by 1 serving (P < 0.0001) and refined-grain consumption decreased by 1 serving for children in the intervention school compared with the comparison school post-intervention (P < 0.001). Whole-grain foods were more available in the lunches served to children in the intervention school compared with the comparison school post-intervention (P < 0.0001). The ability to identify whole-grain foods by children in both schools increased, with a trend towards a greater increase in the intervention school (P = 0.06). Parenting scores for scales for role modelling (P < 0.001) and enabling behaviours (P < 0.05) were significantly greater for parents in the intervention school compared with the comparison school post-intervention. The multi-component school-based programme implemented in the current study successfully increased the intake of whole-grain foods by children.


Comparing the effectiveness of an enhanced MOtiVational intErviewing InTervention (MOVE IT) with usual care for reducing cardiovascular risk in high risk subjects: study protocol for a randomised controlled trial.

Bayley Adam, de Zoysa Nicole, Cook Derek G, Whincup Peter H, Stahl Daniel, Twist Katherine, Ridge Katie, McCrone Paul, Treasure Janet, Ashworth Mark, Greenough Anne, Blythe Clare, Winkley Kirsty, Ismail Khalida

Trials [16:112] (2015)

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Interventions targeting multiple risk factors for cardiovascular disease (CVD), including poor diet and physical inactivity, are more effective than interventions targeting a single risk factor. A motivational interviewing (MI) intervention can provide modest dietary improvements and physical activity increases, while adding cognitive behaviour therapy (CBT) skills may enhance the effects of MI. We designed a randomised controlled trial (RCT) to examine whether specific behaviour change techniques integrating MI and CBT result in favourable changes in weight and physical activity in those at high risk of CVD. A group and individual intervention will be compared to usual care. A group intervention offers potential benefits from social support and may be more cost effective. Individuals aged between 40 and 74 years in 11 South London Clinical Commissioning Groups who are at high risk of developing CVD (≥20%) in the next 10 years will be recruited. A sample of 1,704 participants will be randomised to receive the enhanced MI intervention, delivered by trained healthy lifestyle facilitators (HLFs), in group or individual formats, in 10 sessions (plus an introductory session) over one year, or usual care. Randomisation will be conducted by King's College London Clinical Trials Unit and researchers collecting outcome data will be blinded to treatment allocation. At 12-month and 24-month follow-up assessments, primary outcomes will be change in weight and physical activity (average steps per day). Secondary outcomes include changes in low-density lipoprotein cholesterol and CVD risk score. Incidence of CVD events since baseline will be recorded. A process evaluation will be conducted to evaluate factors which impact on delivery, adherence and outcome. An economic evaluation will estimate relative cost-effectiveness of each type of intervention delivery. This RCT assesses the effectiveness of a healthy lifestyle intervention for people at high risk of CVD. Benefits of the study include the ethnic and socioeconomic diversity of the study population and that, via social support within the group setting and long-term follow-up period, the intervention offers the potential to support maintenance of a healthy lifestyle. This trial is registered with the ISRCTN registry (identifier: ISRCTN84864870, registered 15 May 2012).


Nutrition education worksite intervention for university staff: application of the health belief model.

Abood Doris A, Black David R, Feral Diane

Journal of nutrition education and behavior [35:260-7] ()

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To evaluate the efficacy of an 8-week worksite nutrition education intervention for university staff using the Health Belief Model (HBM) to promote healthful dietary behaviors that reduce risks for cardiovascular disease and cancer. 2 3 2 repeated measures baseline/posttest ex post facto research design. Staff employees were randomly assigned to treatment (n = 28) and control groups (n = 25). The intervention focused on specific health beliefs, nutrition knowledge, and dietary practices to demonstrate treatment effect. Dependent variables were specific health beliefs, nutrition knowledge, and dietary behaviors. Independent variables were demographic characteristics and group assignment. Tests of parametric assumptions, power analyses, analysis of variance, and Kuder-Richardson and Pearson product-moment coefficients were computed and specificity of treatment effects was assessed. Perceived benefits of healthy nutrition practices and nutrition knowledge related to cardiovascular disease and cancer significantly improved among the treatment participants, P <.001. Treatment group participants also significantly reduced total calories, fat, saturated fat, and cholesterol intake (each P <.001). The intervention appears to be related to treatment effects and significantly increased nutrition knowledge and decreased energy, fat, saturated fat, and cholesterol intake to levels consistent with national recommendations.


RCT of a theory-based intervention promoting healthy eating and physical activity amongst out-patients older than 65 years.

Kelley K, Abraham C

Social science & medicine (1982) [59:787-97] (2004)

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A randomised controlled trial was used to evaluate a theory-based health promotion intervention. The intervention, a healthy living booklet, was designed to promote healthy eating and physical activity amongst people aged over 65 years attending hospital out-patient clinics. The booklet employed persuasive arguments targeting the most proximal cognitive antecedents of behaviour specified by the theory of planned behaviour, as well as goal setting prompts. Participants (N = 252, average age=82) were randomly allocated to a control (patient satisfaction questionnaire) or intervention (healthy living booklet) group. Cognitions and behaviour were measured pre-intervention and at a two week follow up. The intervention group made significantly higher gains in perceived behavioural control, intention and behaviour for both target behaviours, suggesting that the intervention was successful. Sixty three of those invited to set goals to eat more healthily (e.g., "to eat five portions of fruit and vegetables a day") did so, and 67% of those who set such goals reported 100% success in acting on them. By contrast, only 34% of intervention participants set an activity goal (e.g., "a five minute walk everyday"), and only 51% reported 100% success in enacting these goals. Results suggest that the observed behavioural effects of the healthy eating booklet could be attributed to goal setting as well as changes in perceived behavioural control and intention.


Promoting fruit and vegetable consumption. Testing an intervention based on the theory of planned behaviour.

Kothe E J, Mullan B A, Butow P

Appetite [58:997-1004] (2012)

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This study evaluated the efficacy of a theory of planned behaviour (TPB) based intervention to increase fruit and vegetable consumption. The extent to which fruit and vegetable consumption and change in intake could be explained by the TPB was also examined. Participants were randomly assigned to two levels of intervention frequency matched for intervention content (low frequency n=92, high frequency n=102). Participants received TPB-based email messages designed to increase fruit and vegetable consumption, messages targeted attitude, subjective norm and perceived behavioural control (PBC). Baseline and post-intervention measures of TPB variables and behaviour were collected. Across the entire study cohort, fruit and vegetable consumption increased by 0.83 servings/day between baseline and follow-up. Intention, attitude, subjective norm and PBC also increased (p<.05). The TPB successfully modelled fruit and vegetable consumption at both time points but not behaviour change. The increase of fruit and vegetable consumption is a promising preliminary finding for those primarily interested in increasing fruit and vegetable consumption. However, those interested in theory development may have concerns about the use of this model to explain behaviour change in this context. More high quality experimental tests of the theory are needed to confirm this result.


Correlational study and randomised controlled trial for understanding and changing red meat consumption: The role of eating identities.

Carfora V, Caso D, Conner M

Social science & medicine (1982) [175:244-252] (2017)

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The present studies aimed to contribute to the literature on psychological variables involved in reducing red meat consumption (RMC). Study 1 investigated whether the theory of planned behaviour (TPB), plus healthy-eating and meat-eating identities, could explain intentions to reduce RMC. Study 2 evaluated the effectiveness of an SMS text message intervention on self-monitoring to reduce RMC. In Study 1, data were collected daily using online food diaries for one week and a TPB questionnaire. Study 2 was a randomised controlled trial assessing pre- and post-RMC and TPB constructs by online food diaries and questionnaires over a one-week period. Participants were Italian undergraduates in each study (Study 1: N = 405; Study 2: N = 244). In Study 2, participants were randomly allocated to control and message condition groups. Participants in the message condition group received a daily SMS, which reminded them to monitor RMC, while participants in the control group did not receive any message. Only students who completed all measures were considered in the analyses (Study 1: N = 342; Study 2: N = 228). Study 1 showed that affective and instrumental attitudes, perceived behavioural control, and meat-eating identity explained intentions to reduce RMC, while subjective norm, past behaviour, and healthy-eating identity did not. Study 2 showed that an SMS intervention was effective in increasing intentions and reducing RMC. Mediation analyses indicated partial serial mediation through healthy-eating and meat-eating identities and intentions. The present studies provide support for the predictive validity of TPB in explaining intentions to reduce RMC and for the efficacy of an SMS intervention targeting self-monitoring in reducing RMC. Findings confirmed the important role of eating identities in explaining intentions to reduce RMC and in changing this behaviour.


Targeting Parents for Childhood Weight Management: Development of a Theory-Driven and User-Centered Healthy Eating App.

Curtis Kristina Elizabeth, Lahiri Sudakshina, Brown Katherine Elizabeth

JMIR mHealth and uHealth [3:e69] (2015)

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The proliferation of health promotion apps along with mobile phones' array of features supporting health behavior change offers a new and innovative approach to childhood weight management. However, despite the critical role parents play in children's weight related behaviors, few industry-led apps aimed at childhood weight management target parents. Furthermore, industry-led apps have been shown to lack a basis in behavior change theory and evidence. Equally important remains the issue of how to maximize users' engagement with mobile health (mHealth) interventions where there is growing consensus that inputs from the commercial app industry and the target population should be an integral part of the development process. The aim of this study is to systematically design and develop a theory and evidence-driven, user-centered healthy eating app targeting parents for childhood weight management, and clearly document this for the research and app development community. The Behavior Change Wheel (BCW) framework, a theoretically-based approach for intervention development, along with a user-centered design (UCD) philosophy and collaboration with the commercial app industry, guided the development process. Current evidence, along with a series of 9 focus groups (total of 46 participants) comprised of family weight management case workers, parents with overweight and healthy weight children aged 5-11 years, and consultation with experts, provided data to inform the app development. Thematic analysis of focus groups helped to extract information related to relevant theoretical, user-centered, and technological components to underpin the design and development of the app. Inputs from parents and experts working in the area of childhood weight management helped to identify the main target behavior: to help parents provide appropriate food portion sizes for their children. To achieve this target behavior, the behavioral diagnosis revealed the need for eliciting change in parents' capability, motivation, and opportunity in 10-associated Theoretical Domains Framework (TDF) domains. Of the 9 possible intervention functions, 6 were selected to bring about this change which guided the selection of 21 behavior change techniques. Parents' preferences for healthy eating app features revolved around four main themes (app features, time saving and convenience, aesthetics, and gamification) whereupon a criterion was applied to guide the selection on which preferences should be integrated into the design of the app. Collaboration with the app company helped to build on users' preferences for elements of gamification such as points, quizzes, and levels to optimize user engagement. Feedback from parents on interactive mock-ups helped to inform the final development of the prototype app. Here, we fully explicate a systematic approach applied in the development of a family-oriented, healthy eating health promotion app grounded in theory and evidence, and balanced with users' preferences to help maximize its engagement with the target population.


Why did soft drink consumption decrease but screen time not? Mediating mechanisms in a school-based obesity prevention program.

Chin AP, Marijke JM, Singh AS, Brug J, van Mechelen W

The international journal of behavioral nutrition and physical activity [5:41] (2008)

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This paper aims to identify the mediating mechanisms of a school-based obesity prevention program (DOiT). The DOiT-program was implemented in Dutch prevocational secondary schools and evaluated using a controlled, cluster-randomised trial (September 2003 to May 2004). We examined mediators of effects regarding (1) consumption of sugar containing beverages (SCB); (2) consumption of high caloric snacks; (3) screen-viewing behaviour; and (4) active commuting to school. To improve these behaviours the DOiT-program tried to influence the following potentially mediating variables: attitude, subjective norm, perceived behavioural control, and habit-strength. Both in boys (n = 418) and girls (n = 436) the DOiT-intervention reduced SCB consumption (between group difference in boys = -303.5 ml/day, 95% CI: -502.4;-104.5, between group difference in girls = -222.3 ml/day, 95% CI: -371.3;-73.2). The intervention did not affect the other examined behaviours. In girls, no intervention effect on hypothetical mediators was found nor evidence of any mediating mechanisms. Boys in intervention schools improved their attitude towards decreasing SCB consumption, while this behaviour became less of a habit. Indeed, attitude and habit strength were significant mediators of the DOiT-intervention's effect (4.5 and 3.8%, respectively) on SCB consumption among boys. Our findings imply that interventions aimed at EBRB-change should be gender-specific. Future studies aimed at reducing SCB consumption among boys should target attitude and habit strength as mediating mechanisms. Our study did not resolve the mediating mechanisms in girls. International Standard Randomised Controlled Trial Number Register ISRCTN87127361.


The feasibility phase of a community antenatal lifestyle programme [The Lifestyle Course (TLC)] for women with a body mass index (BMI)≥ 30 kg/m(2.).

Smith Debbie M, Taylor Wendy, Whitworth Melissa K, Roberts Stephen, Sibley Colin, Lavender Tina

Midwifery [31:280-7] (2015)

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maternal obesity [body mass index (BMI)≥30kg/m(2)] is a cause for concern because of increasing rates and risk of associated complications. However, little is known about how to improve the health of women with a BMI≥30kg/m(2). a 10-week antenatal lifestyle programme (The Lifestyle Course - TLC), underpinned by behaviour change theory, was developed in a programme of research which included a prospective, multicentred, feasibility phase (n=227). Participants had a BMI≥30kg/m(2) at the start of their pregnancy, planned to deliver in two areas of Greater Manchester and were aged 18 or over. The objectives were to (1) assess the feasibility of the intervention and (2) to pilot the trial processes and outcome measures. (1) Trial intervention: only 22% of women in the feasibility phase had received gestational weight advice prior to the study. One or more TLC sessions were attended by 79% of women and 97% said they would recommend TLC to a friend due to the content suitability, perceived personal gains and extra care received. Changes to the TLC were suggested and implemented in the pilot phase. (2) Trial processes: recruitment rates (36%), retention rates (100%) and questionnaire completion rates up to one year (33%) were found. Daily general 'lifestyle' diaries and pedometers were not acceptable data collection tools (response rates of 32% and 16% respectively). However, specific food diaries were acceptable (response rates of 80-81%). The major challenge was the collection of maternal weight data at the follow-up points. the antenatal intervention (TLC) designed for this programme of work appears to suit the needs of women with a BMI≥30kg/m(2). The need for an antenatal intervention is clear from this study and also highlights reflections on effective communication with pregnant women with a BMI≥30kg/m(2). Lessons learnt for designing a future trial include effective ways to communicate with pregnant women with a BMI≥30kg/m(2). ISRCTN29860479.


A randomised controlled trial and mediation analysis of the 'Healthy Habits', telephone-based dietary intervention for preschool children.

Fletcher Amanda, Wolfenden Luke, Wyse Rebecca, Bowman Jenny, McElduff Patrick, Duncan Sarah

The international journal of behavioral nutrition and physical activity [10:43] (2013)

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Consumption of non-core foods in childhood is associated with excessive weight gain in childhood. Parents play a vital role in establishing healthy diet behaviours in young children. The aim of this study was to assess the effectiveness of a telephone-based intervention in reducing child consumption of non-core foods, and to examine parent and home food environment mediators of change in child consumption. The 'Healthy Habits' trial utilised a clustered randomised controlled design. Parents were recruited from 30 preschools (N=394 participants, mean age 35.2±5.6 years). Parents randomized to the intervention group received four telephone contacts and print materials. Parents allocated to the control condition receive generic print materials only. Non-core food consumption was assessed using a validated child dietary questionnaire at baseline, 2 and 6 months post recruitment in 2010. The intervention was effective in reducing child consumption of non-core foods at 2 months (intention to treat analysis: z=-2.83, p<.01), however this effect was not maintained at 6 months. Structural equation modelling using 2 month data indicated that child access to non-core foods in the home and child feeding strategies mediated the effect of the intervention. The telephone-based intervention shows promise in improving short term dietary behaviour in preschool age children, however further development is needed to sustain the effect in the long-term. Australian Clinical Trials Registry: ACTRN12609000820202.


A brief culturally tailored intervention for Puerto Ricans with type 2 diabetes.

Osborn Chandra Y, Amico K R, Cruz Noemi, O'Connell Ann A, Perez-Escamilla Rafael, Kalichman Seth C, Wolf Scott A, Fisher Jeffrey D

Health education & behavior : the official publication of the Society for Public Health Education [37:849-62] (2010)

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The information-motivation-behavioral skills (IMB) model of health behavior change informed the design of a brief, culturally tailored diabetes self-care intervention for Puerto Ricans with type 2 diabetes. Participants (n = 118) were recruited from an outpatient, primary care clinic at an urban hospital in the northeast United States. ANCOVA models evaluated intervention effects on food label reading, diet adherence, physical activity, and glycemic control (HbA1c). At follow-up, the intervention group was reading food labels and adhering to diet recommendations significantly more than the control group. Although the mean HbA1c values decreased in both groups ( 0.48% vs. 0.27% absolute decrease), only the intervention group showed a significant improvement from baseline to follow-up (p < .008), corroborating improvements in diabetes self-care behaviors. Findings support the use of the IMB model to culturally tailor diabetes interventions and to enhance patients' knowledge, motivation, and behavior skills needed for self-care.


Design and outcomes of a Mothers In Motion behavioral intervention pilot study.

Chang M, Nitzke S, Brown R

Journal of nutrition education and behavior [42:S11-21] ()

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This paper describes the design and findings of a pilot Mothers In Motion (P-MIM) program. A randomized controlled trial that collected data via telephone interviews and finger stick at 3 time points: baseline and 2 and 8 months post-intervention. Three Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) sites in southern Michigan. One hundred and twenty nine overweight and obese African-American and white mothers, 18-34 years old. The 10-week, theory-based, culturally sensitive intervention messages were delivered via a series of 5 chapters on a DVD and complemented by 5 peer support group teleconferences. Dietary fat, fruit, and vegetable intake; physical activity; stress; feelings; body weight; and blood glucose. General linear mixed model was applied to assess treatment effects across 2 and 8 months post-intervention. No significant effect sizes were found in primary and secondary outcome variables at 2 and 8 months post-intervention. However, changes in body weight and blood glucose showed apparent trends consistent with the study's hypotheses. The P-MIM showed promise for preventing weight gain in low-income overweight and obese women. However, a larger experimental trial is warranted to determine the effectiveness of this intervention.


Randomised controlled trial of a text messaging intervention for reducing processed meat consumption: The mediating roles of anticipated regret and intention.

Carfora V, Caso D, Conner M

Appetite [117:152-160] (2017)

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The present study aimed to extend the literature on text messaging interventions involved in promoting healthy eating behaviours. The theoretical framework was the Theory of Planned Behaviour (TPB). A randomized controlled trial was used to test the impact of daily text messages compared to no message (groups) for reducing processed meat consumption (PMC) over a 2 week period, testing the sequential mediation role of anticipated regret and intention on the relationship between groups and PMC reduction. PMC and TPB variables were assessed both at Time 1 and Time 2. Participants were Italian undergraduates (at Time 1 N = 124) randomly allocated to control and message condition groups. Undergraduates in the message condition group received a daily SMS, which focused on anticipated regret and urged them to self-monitor PMC. Participants in the control group did not receive any message. Those who completed all measures at both time points were included in the analyses (N = 112). Findings showed that a daily messaging intervention, controlling for participants' past behaviour, reduced self-reported consumption of PMC. Mediation analyses indicated partial serial mediation via anticipated regret and intentions. The current study provided support for the efficacy of a daily messaging intervention targeting anticipated regret and encouraging self-monitoring in decreasing PMC. Outcomes showed the important mediating role of anticipated regret and intentions for reducing PMC.


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.


Obesity reduction black intervention trial (ORBIT): six-month results.

Stolley Melinda R, Fitzgibbon Marian L, Schiffer Linda, Sharp Lisa K, Singh Vicky, Van Horn Linda, Dyer Alan

Obesity (Silver Spring, Md.) [17:100-6] (2009)

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The Obesity Reduction Black Intervention Trial (ORBIT) is a randomized controlled trial designed to assess the efficacy of a culturally proficient 6-month weight loss intervention followed by a 1-year maintenance intervention. This article describes the results of the 6-month weight loss intervention. Two hundred thirteen obese black women aged 30-65 years were randomized to the intervention group or a general health control group. The intervention consisted of a 6-month culturally adapted weight loss program that targeted changes in diet and physical activity patterns. Weight, dietary intake, and physical activity were measured at baseline and 6 months. A total of 198 women (93%) completed both the baseline and postintervention assessments. Women in the intervention group lost significantly more weight than women in the control group (P < 0.001). However, weight change was variable within the intervention group, with a maximum weight loss of 19.4% of initial body weight and a maximum weight gain of 6.4% of initial body weight. Women in the intervention group also showed significant improvements in fruit intake (P < 0.01), Healthy Eating Index score (P < 0.001), and moderate (P = 0.05), and vigorous (P < 0.001) physical activity compared to women in the control group. This study demonstrates that a culturally adapted program can successfully promote weight loss in obese black women. However, average weight loss was relatively modest, and weight change varied widely within the intervention group. Further research is needed in order to develop programs that will allow more black women to achieve their weight loss goals..


Augmenting fruit and vegetable consumption by an online intervention: Psychological mechanisms.

Keller Jan, Motter Susannah, Motter Mirjam, Schwarzer Ralf

Appetite [120:348-355] (2018)

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Fruit and vegetable (FV) intake was examined among men and women who participated in an online intervention. The psychological constructs involved were outcome expectancies, behavioral intention, planning, and self-efficacy. One purpose of the analyses was the evaluation of a self-efficacy treatment component. The other purpose of the analyses regarded the role of psychological mechanisms that might be responsible for individual differences in the process of behavior change. A two-arm online intervention with a standard and an enhanced intervention group focusing on FV planning was conducted to improve FV intake, followed up at two and four weeks. The intervention groups differed by the additional inclusion of a self-efficacy ingredient in the enhanced intervention. Linear mixed models examined the intervention effects, and a longitudinal structural equation model explored which psychological constructs were associated with changes in FV intake. Participants were N = 275 adults of whom n = 148 completed the four-week follow-up. Their age range was 18-81 years (Mage = 32.50, SDage = 14.00). Analyses yielded an overall increase in self-reported FV intake. Moreover, a triple interaction between time, sex, and experimental groups on self-efficacy emerged, indicating that men, independent of treatment conditions, reported an increase in their confidence to improve FV intake, whereas women developed higher FV self-efficacy when being in the enhanced group instead of the standard group. Planning, self-efficacy, and intention mediated between outcome expectancies, and follow-up FV intake. Both intervention arms produced overall improvements in FV intake. The enhanced intervention resulted in a steeper increase in self-efficacy in women compared to men, and compared to the standard intervention. A psychological mechanism transpired that included a sequence leading from initial outcome expectancies via planning, self-efficacy, and intention towards FV intake.


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).


Effects of a social cognitive theory-based hip fracture prevention web site for older adults.

Nahm Eun-Shim, Barker Bausell, Resnick Barbara, Covington Barbara, Magaziner Jay, Brennan Patricia Flatley

Computers, informatics, nursing : CIN [28:371-9] ()

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The purposes of this study were to develop a Social Cognitive Theory-based, structured Hip Fracture Prevention Web site for older adults and conduct a preliminary evaluation of its effectiveness. The Theory-based, structured Hip Fracture Prevention Web site is composed of learning modules and a moderated discussion board. A total of 245 older adults recruited from two Web sites and a newspaper advertisement were randomized into the Theory-based, structured Hip Fracture Prevention Web site and the conventional Web sites groups. Outcomes included (1) knowledge (hip fractures and osteoporosis), (2) self-efficacy and outcome expectations, and (3) calcium intake and exercise and were assessed at baseline, end of treatment (2 weeks), and follow-up (3 months). Both groups showed significant improvement in most outcomes. For calcium intake, only the Theory-based, structured Hip Fracture Prevention Web site group showed improvement. None of the group and time interactions were significant. The Theory-based, structured Hip Fracture Prevention Web site group, however, was more satisfied with the intervention. The discussion board usage was significantly correlated with outcome gains. Despite several limitations, the findings showed some preliminary effectiveness of Web-based health interventions for older adults and the use of a Theory-based, structured Hip Fracture Prevention Web site as a sustainable Web structure for online health behavior change interventions.


Long-term efficacy of a Web-based computer-tailored nutrition education intervention for adults including cognitive and environmental feedback: a randomized controlled trial.

Springvloet Linda, Lechner Lilian, de Vries Hein, Oenema Anke

BMC public health [15:372] (2015)

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Unhealthy diets are prevalent in Western countries, especially among low-educated people. To have an effect on health, it is important that dietary changes are sustained over time. This study examines long-term effects of a cognitive and environmental-feedback version of a Web-based computer-tailored (CT) nutrition education intervention targeting fruit, vegetables, high-energy snacks and saturated fat. A randomized controlled trial was conducted with a basic (tailored intervention targeting individual cognitions and self-regulation processes; n = 456), plus (additionally targeting environmental-level factors; n = 459) and control group (generic nutrition information; n = 434). Participants were recruited from the general population and randomly assigned to a study group. Online self-reported questionnaires assessed fruit, vegetable, high-energy snack and saturated fat intake, self-regulation, self-control, and Body Mass Index (BMI) at baseline and nine-months post-intervention. Linear mixed model analyses examined group differences in change over time. Educational differences were examined by 'group X time X education' interaction terms. Effects were examined in the total sample and among participants who did not comply with dietary- or BMI guidelines. The effects on vegetable intake in the total sample differed according to educational level (p = 02). Among low/moderate-educated participants, the basic version was significantly more effective in increasing vegetable intake than the control program (effect size (ES) = 0.32) and plus version (ES = 0.22). No effects were found for high-educated participants. Self-regulation change was significantly larger in the control group than in the basic (ES = 0.18) and plus (ES = 0.16) group. In general, both intervention versions did not result in long-term intervention effects. The exception was an effect of the basic version on self-reported vegetable intake among low/moderate-educated adults in the total sample. More research is needed on how targeting self-regulation processes and environmental-level factors in Web-based CT nutrition education interventions can increase long-term efficacy. Netherlands Trial Registry NTR3396 .


Using aversive images to enhance healthy food choices and implicit attitudes: An experimental test of evaluative conditioning.

Hollands Gareth J, Prestwich Andrew, Marteau Theresa M

Health psychology : official journal of the Division of Health Psychology, American Psychological Association [30:195-203] (2011)

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To examine the effect of communicating images of energy-dense snack foods paired with aversive images of the potential health consequences of unhealthy eating, on implicit and explicit attitudes and food choice behavior. Participants were randomly allocated to either an evaluative conditioning (EC) procedure that paired images of snack foods with images of potential adverse health consequences or a control condition that featured images of snack foods alone. Implicit attitudes were assessed pre- and post-intervention. Explicit attitudes and food choice behavior were assessed post-intervention. The conditioning intervention made implicit attitudes toward energy-dense snacks more negative, with this effect greatest in those with relatively more favorable implicit attitudes toward these snacks at baseline. Participants in the conditioning intervention were more likely to choose fruit rather than snacks in a behavioral choice task, a relationship mediated by changes in implicit attitudes. Presenting aversive images of potential health consequences with those of specific foodstuffs can change implicit attitudes, which impacts on subsequent food choice behavior.


Mechanisms of change of a novel weight loss programme provided by a third sector organisation: a qualitative interview study.

McMahon Naoimh E, Visram Shelina, Connell Louise A

BMC public health [16:378] (2016)

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There is a need for theory-driven studies that explore the underlying mechanisms of change of complex weight loss programmes. Such studies will contribute to the existing evidence-base on how these programmes work and thus inform the future development and evaluation of tailored, effective interventions to tackle overweight and obesity. This study explored the mechanisms by which a novel weight loss programme triggered change amongst participants. The programme, delivered by a third sector organisation, addressed both diet and physical activity. Over a 26 week period participants engaged in three weekly sessions (education and exercise in a large group, exercise in a small group and a one-to-one education and exercise session). Novel aspects included the intensity and duration of the programme, a competitive selection process, milestone physical challenges (e.g. working up to a 5 K and 10 K walk/run during the programme), alumni support (face-to-face and online) and family attendance at exercise sessions. Data were collected through interviews with programme providers (n = 2) and focus groups with participants (n = 12). Discussions were audio-recorded, transcribed and analysed using NVivo10. Published behaviour change frameworks and behaviour change technique taxonomies were used to guide the coding process. Clients' interactions with components of the weight loss programme brought about a change in their commitment, knowledge, beliefs about capabilities and social and environmental contexts. Intervention components that generated these changes included the competitive selection process, group and online support, family involvement and overcoming milestone challenges over the 26 week programme. The mechanisms by which these components triggered change differed between participants. There is an urgent need to establish robust interventions that can support people who are overweight and obese to achieve a healthy weight and maintain this change. Third sector organisations may be a feasible alternative to private and public sector weight loss programmes. We have presented findings from one example of a novel community-based weight loss programme and identified how the programme components resulted in change amongst the participants. Further research is needed to robustly test the effectiveness, and cost-effectiveness, of this programme.


Planning and self-efficacy interventions encouraging replacing energy-dense foods intake with fruit and vegetable: A longitudinal experimental study.

Luszczynska Aleksandra, Horodyska Karolina, Zarychta Karolina, Liszewska Natalia, Knoll Nina, Scholz Urte

Psychology & health [31:40-64] (2016)

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This longitudinal experimental study compared effects of self-efficacy, planning and education-based conditions, encouraging adolescents to eat fruit and vegetable in place of energy-dense foods. Data were collected among 506 adolescents (13-18 years old) who were randomly assigned to control (n = 181), planning (n = 153) or self-efficacy (n = 172) conditions. Measurements were taken at baseline (T1), at a 2-month follow-up (T2), and at a 14-month follow-up (T3). Interventions/control group procedures were delivered at T1 and T2. Self-reports of fruit and vegetable intake (FVI) and energy-dense foods intake were collected at three times. Cognitive mediators (self-efficacy and planning) were assessed at T1 and T2. Body weight and height were objectively measured at T1 and T3. Similar significant increases of FVI were found for planning and self-efficacy interventions (T3). The planning intervention did not influence energy-dense food intake (T3), but the self-efficacy intervention tended to result in stabilising intake (compared to an increase found in the control group). There were no effects on body weight. Similar patterns were found for the total sample and for a subsample of adolescents with overweight/obesity. The effects of interventions on FVI were mediated by respective cognitions.


Improving fruit and vegetable consumption: a self-efficacy intervention compared with a combined self-efficacy and planning intervention.

Luszczynska Aleksandra, Tryburcy Maciej, Schwarzer Ralf

Health education research [22:630-8] (2007)

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Effects of interventions targeting self-efficacy alone or combined with action plans were examined in the context of fruit and vegetable consumption. E-mail messages were sent to a self-efficacy group, a combined self-efficacy and action planning group and a control group. At a 6-month follow-up, 200 adults reported their fruit and vegetable consumption, along with current levels of self-efficacy and planning. The two experimental groups gained equally from the interventions, as documented by changes in behavior. In both intervention groups, change in respective cognitions predicted change in fruit and vegetable consumption. Parsimonious interventions might contribute to health behavior change.


Brief fruit and vegetable messages integrated within a community physical activity program successfully change behaviour.

Doerksen Shawna E, Estabrooks Paul A

The international journal of behavioral nutrition and physical activity [4:12] (2007)

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Consumption of the recommended amounts of fruits and vegetables is associated with several health benefits. Currently less than 25% of the American population meets the minimum recommendation of five servings a day. In order to change this health behaviour, interventions should be based on theory and include community-wide social support. A low intensity intervention was developed in which participants (n = 86) were randomly assigned to either the fruit and vegetable intervention (FVI) or standard control condition. The intervention was integrated into an ongoing community physical activity program and study participants were drawn from the sample of community members enrolled in the program. The FVI consisted of brief social cognitive theory-based messages delivered in nine weekly newsletters designed to improve participant outcome and self-efficacy expectations related to fruit and vegetable consumption. Participants in the FVI condition increased in their fruit and vegetable consumption by approximately one to one and one-third servings per day. The control condition showed no change in consumption. The effect of the intervention was enhanced when examined by the extent to which it was adopted by participants (i.e., the number of newsletters read). Those participants who read seven or more newsletters showed an increase of two servings per day. This intervention was effective at improving fruit and vegetable consumption among adults. Minimal interventions, such as newsletters, have the ability to reach large audiences and can be integrated into ongoing health promotion programs. As such, they have potential for a strong public health impact.


Short-term efficacy of a web-based computer-tailored nutrition intervention: main effects and mediators.

Oenema A, Tan F, Brug J

Annals of behavioral medicine : a publication of the Society of Behavioral Medicine [29:54-63] (2005)

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This study evaluates the short-term efficacy and respondents' evaluations of a Web-based computer-tailored nutrition intervention, aiming to decrease saturated fat intake and increase fruit and vegetable intake. Perceived personal relevance, individualization, and interestingness of the information were tested as mediators of the effects of the tailored intervention. The objective was to study the short-term effects of a Web-based computer-tailored nutrition intervention. Respondents (N = 782) were randomly assigned to a tailored intervention group, a generic nutrition information control group, or a no-information control group. Fat, fruit, and vegetable intakes and behavioral determinants were measured at baseline and at 3 weeks postintervention. Posttest group differences were determined by multiple linear regression analyses. The computer-tailored intervention produced significant effects for the determinants of fat, fruit, and vegetable intake and for vegetable and fruit intake. The tailored information was rated as more personally relevant, individualized, interesting, and new than the generic nutrition information. Perceived personal relevance, individualization, and interestingness were identified as mediators of some of the tailoring effects. The findings of this study indicate that Web-based, computer-tailored nutrition information can have a short-term effect on the determinants of fat, fruit, and vegetable intake. The effect of the tailored information may be partly explained by the perceived personal relevance and individualization of the information.


Can existing mobile apps support healthier food purchasing behaviour? Content analysis of nutrition content, behaviour change theory and user quality integration.

Flaherty Sarah-Jane, McCarthy Mary, Collins Alan, McAuliffe Fionnuala

Public health nutrition [21:288-298] (2018)

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To assess the quality of nutrition content and the integration of user quality components and behaviour change theory relevant to food purchasing behaviour in a sample of existing mobile apps. Descriptive comparative analysis of eleven mobile apps comprising an assessment of their alignment with existing evidence on nutrition, behaviour change and user quality, and their potential ability to support healthier food purchasing behaviour. Mobile apps freely available for public use in GoogePlay were assessed and scored according to agreed criteria to assess nutrition content quality and integration of behaviour change theory and user quality components. A sample of eleven mobile apps that met predefined inclusion criteria to ensure relevance and good quality. The quality of the nutrition content varied. Improvements to the accuracy and appropriateness of nutrition content are needed to ensure mobile apps support a healthy behaviour change process and are accessible to a wider population. There appears to be a narrow focus towards behaviour change with an overemphasis on behavioural outcomes and a small number of behaviour change techniques, which may limit effectiveness. A significant effort from the user was required to use the mobile apps appropriately which may negatively influence user acceptability and subsequent utilisation. Existing mobile apps may offer a potentially effective approach to supporting healthier food purchasing behaviour but improvements in mobile app design are required to maximise their potential effectiveness. Engagement of mobile app users and nutrition professionals is recommended to support effective design.


Increasing intention to cook from basic ingredients: A randomised controlled study.

Lavelle Fiona, Hollywood Lynsey, Caraher Martin, McGowan Laura, Spence Michelle, Surgenor Dawn, McCloat Amanda, Mooney Elaine, Raats Monique, Dean Moira

Appetite [116:502-510] (2017)

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The promotion of home cooking is a strategy used to improve diet quality and health. However, modern home cooking typically includes the use of processed food which can lead to negative outcomes including weight gain. In addition, interventions to improve cooking skills do not always explain how theory informed their design and implementation. The Behaviour Change Technique (BCT) taxonomy successfully employed in other areas has identified essential elements for interventions. This study investigated the effectiveness of different instructional modes for learning to cook a meal, designed using an accumulating number of BCTs, on participant's perceived difficulty, enjoyment, confidence and intention to cook from basic ingredients. 141 mothers aged between 20 and 39 years from the island of Ireland were randomised to one of four conditions based on BCTs (1) recipe card only [control condition]; (2) recipe card plus video modelling; (3) recipe card plus video prompting; (4) recipe card plus video elements. Participants rated their enjoyment, perceived difficulty, confidence and intention to cook again pre, mid and post experiment. Repeated one-way factorial ANOVAs, correlations and a hierarchical regression model were conducted. Despite no significant differences between the different conditions, there was a significant increase in enjoyment (P < 0.001), confidence (P < 0.001) and intention to cook from basics again (P < 0.001) and a decrease in perceived difficulty (P = 0.001) after the experiment in all conditions. Intention to cook from basics pre-experiment, and confidence and enjoyment (both pre and post experiment) significantly contributed to the final regression model explaining 42% of the variance in intention to cook from basics again. Cooking interventions should focus on practical cooking and increasing participants' enjoyment and confidence during cooking to increase intention to cook from basic ingredients at home.


Pounds Off Digitally study: a randomized podcasting weight-loss intervention.

Turner-McGrievy Gabrielle M, Campbell Marci K, Tate Deborah F, Truesdale Kimberly P, Bowling J Michael, Crosby Lelia

American journal of preventive medicine [37:263-9] (2009)

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As obesity rates rise, new weight-loss methods are needed. Little is known about the use of podcasting (audio files for a portable music player or computer) to promote weight loss, despite its growing popularity. A 12-week RCT was conducted. The study sample comprised overweight men and women (BMI=25-40 kg/m(2); n=78) in the Raleigh-Durham NC area. In 2008, participants were randomly assigned to receive 24 episodes of a currently available weight-loss podcast (control podcast) or a weight-loss podcast based on social cognitive theory (SCT) designed by the researchers (enhanced podcast) for 12 weeks. Weight was measured on a digital scale at baseline and follow-up. Both groups also completed questionnaires assessing demographic information, food intake, physical activity, and SCT constructs at the introductory and 12-week meetings. Additional questionnaires at the 12-week meeting assessed perceptions of the intervention. Data collection and analysis occurred in 2008 and intention-to-treat was used. Enhanced group participants (n=41) had a greater decrease in weight (-2.9+/-3.5 kg enhanced group vs -0.3+/-2.1 control group; p<0.001 between groups) and BMI (-1.0+/-1.2 kg/m(2) enhanced group vs -0.1+/-0.7 kg/m(2) control group; p<0.001 between groups) than the control group (n=37) and had greater weight-loss-related knowledge (p<0.05), elaboration (p<0.001), and user control (p<0.001) and less cognitive load (p<0.001). The results of this study suggest that the use of behavioral, theory-based podcasting may be an effective way to promote weight loss. NCT00771095.


How can self-efficacy be increased? Meta-analysis of dietary interventions.

Prestwich Andrew, Kellar Ian, Parker Richard, MacRae Siobhan, Learmonth Matthew, Sykes Bianca, Taylor Natalie, Castle Holly

Health psychology review [8:270-85] (2014)

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Targeting individuals' beliefs that they are able to eat healthily can improve dietary-related behaviours. However, the most effective behaviour change techniques (BCTs) to promote dietary self-efficacy have not been systematically reviewed. This research addressed this gap. Studies testing the effect of interventions on healthy eating and underlying dietary-related self-efficacy, within randomised controlled trials, were systematically reviewed in MEDLINE, EMBASE and PSYCINFO. Two reviewers independently coded intervention content in both intervention and comparison groups. Data pertaining to study quality were also extracted. Random effects meta-analysis was used to calculate an overall effect size on dietary self-efficacy for each study. The associations between 26 BCTs and self-efficacy effects were calculated using meta-regression. In some of the analyses, interventions that incorporated self-monitoring (tracking one's own food-related behaviour), provided feedback on performance, prompted review of behavioural goals, provided contingent rewards (rewarding diet success), or planned for social support/social change increased dietary self-efficacy significantly more than interventions that did not. Stress management was consistently associated with self-efficacy effects across all analyses. There was strong evidence for stress management and weaker evidence for a number of other BCTs. The findings can be used to develop more effective, theory- and evidence-based behavioural interventions.


A brief intervention increases fruit and vegetable intake. A comparison of two intervention sequences.

Lhakhang Pempa, Godinho Cristina, Knoll Nina, Schwarzer Ralf

Appetite [82:103-10] (2014)

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To evaluate the effectiveness of two subsequent intervention components (motivational and self-regulatory components), placed in different order, to promote fruit and vegetable (FV) intake. After baseline assessment, university students (N=205, aged 18-26 years) were allocated to two groups. One group received a motivational intervention (outcome expectancies, risk perception, and task self-efficacy) followed by a self-regulatory intervention (planning and dietary self-efficacy) after 17 days. The second group received the same intervention conditions in the opposite order. Follow-up assessments were done after another 17 days. Both intervention sequences yielded gains in terms of FV intake and self-efficacy. However, this gain was only due to the self-regulatory component whereas the motivational component did not contribute to the changes. Moreover, changes in intention and self-efficacy mediated between intervention sequence and follow-up behavior, suggesting that improving these proximal predictors of FV intake was responsible for the behavioral gains. Findings highlight the superiority of a self-regulatory intervention over a motivational intervention when it comes to dietary changes in this sample of young adults. Moreover, changes in dietary self-efficacy may drive nutritional changes.


Evaluating a small change approach to preventing long term weight gain in overweight and obese adults--Study rationale, design, and methods.

Ross Robert, Hill James O, Latimer Amy, Day Andrew G

Contemporary clinical trials [47:275-81] (2016)

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Despite the rapid rise in obesity worldwide, few strategies have been effective in treating this epidemic. An emerging strategy is to focus on preventing excessive weight gain rather than weight reduction. The proposed intervention, small change approach (SCA), is an innovative weight gain prevention strategy in which individuals monitor their usual nutrition and physical activity patterns and then make modest but sustainable alterations through behavioral intervention techniques (self-regulation, goal setting) enough to reduce overall energy balance by 100 to 200 kcal per day (e.g., reduce caloric intake by 100 kcal per day and/or increase daily step count by ~2000 steps (~100 kcal) per day). The primary aim of the trial is to determine whether small changes in energy expenditure and/or energy intake prevent weight gain in overweight and obese men and women long-term. The pre-specified primary and secondary assessments are at 2 and 3 years post-randomization respectively. The primary outcome is change in body weight. Secondary outcomes include body composition variables (adipose tissue distribution and lean mass distribution) and cardiorespiratory fitness (VO2peak). We randomized 320 primarily White (n=305) overweight and obese men and women to one of 2 conditions: 1) usual care (UC), 2) small change approach (SCA). Participant involvement in the study is 3 years; 2 year intervention with a 1 year follow-up. Our study findings will indicate whether there is value in clinicians adopting a SCA to lifestyle counseling for their patients who are overweight and obese.


Iterative development of Vegethon: a theory-based mobile app intervention to increase vegetable consumption.

Mummah Sarah A, King Abby C, Gardner Christopher D, Sutton Stephen

The international journal of behavioral nutrition and physical activity [13:90] (2016)

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Mobile technology may serve as a cost-effective and scalable tool for delivering behavioral nutrition interventions. This research sought to iteratively develop a theory-driven mobile app, Vegethon, to increase vegetable consumption. Development of Vegethon followed phases outlined by the IDEAS framework: 1) empathize with users (qualitative interviews, n = 18); 2) specify target behavior; 3) ground in behavioral theory; 4) ideate implementation strategies; 5) prototype potential products; 6) gather user feedback (qualitative interviews, n = 14; questionnaire, n = 41); 7) build minimum viable product; and 8) pilot potential efficacy and usability (pilot RCT, n = 17). Findings from each phase informed subsequent phases. The target population that informed intervention development was 18-50 years of age, had BMIs of 28-40 kg/m(2), and lived in the geographical area surrounding Stanford University. A full description of the final version of Vegethon is included in the paper. Qualitative findings that shaped initial intervention conception were: participants' interests in accountability without judgment; their desire for simple and efficient dietary self-monitoring; and the importance of planning meals in advance. Qualitative findings identified during intervention refinement were the need for a focus on vegetable self-monitoring; inclusion of vegetable challenges; simplification of features; advice and inspiration for eating vegetables; reminder notifications; and peer comparison. Pilot RCT findings suggested the initial efficacy, acceptance, and feasibility of the intervention. The final version of Vegethon enabled easy self-monitoring of vegetable consumption and included a range of features designed to engage the user (e.g., surprise challenges; leaderboard; weekly reports). Vegethon was coded for its inclusion of 18 behavior change techniques (BCTs) (e.g., goal setting; feedback; social comparison; prompts/cues; framing/reframing; identity). Vegethon is a theory-based, user-informed mobile intervention that was systematically developed using the IDEAS framework. Vegethon targets increased vegetable consumption among overweight adults and is currently being evaluated in a randomized controlled efficacy trial. Clinical Trials.gov: NCT01826591.


Design of a Mobile App for Nutrition Education (TreC-LifeStyle) and Formative Evaluation With Families of Overweight Children.

Gabrielli Silvia, Dianti Marco, Maimone Rosa, Betta Marta, Filippi Lorena, Ghezzi Monica, Forti Stefano

JMIR mHealth and uHealth [5:e48] (2017)

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Nutrition and diet apps represent today a popular area of mobile health (mHealth), offering the possibility of delivering behavior change (BC) interventions for healthy eating and weight management in a scalable and cost-effective way. However, if commercial apps for pediatric weight management fail to retain users because of a lack of theoretical background and evidence-based content, mHealth apps that are more evidence-based are found less engaging and popular among consumers. Approaching the apps development process from a multidisciplinary and user-centered design (UCD) perspective is likely to help overcome these limitations, raising the chances for an easier adoption and integration of nutrition education apps within primary care interventions. The aim of this study was to describe the design and development of the TreC-LifeStyle nutrition education app and the results of a formative evaluation with families. The design of the nutrition education intervention was based on a multidisciplinary UCD approach, involving a team of BC experts, working with 2 nutritionists and 3 pediatricians from a primary care center. The app content was derived from evidence-based knowledge founded on the Food Pyramid and Mediterranean Diet guidelines used by pediatricians in primary care. A formative evaluation of the TreC-LifeStyle app involved 6 families of overweight children (aged 7-12 years) self-reporting daily food intake of children for 6 weeks and providing feedback on the user experience with the mHealth intervention. Analysis of the app's usage patterns during the intervention and of participants' feedback informed the refinement of the app design and a tuning of the nutrition education strategies to improve user engagement and compliance with the intervention. Design sessions with the contribution of pediatricians and nutritionists helped define the nutrition education app and intervention, providing an effective human and virtual coaching approach to raise parents' awareness about children's eating behavior and lifestyle. The 6 families participating in the pilot study found the app usable and showed high compliance with the intervention over the 6 weeks, but analysis of their interaction and feedback showed the need for improving some of the app features related to the BC techniques "monitoring of the behavior" and "information provision." The UCD and formative evaluation of TreC-LifeStyle show that nutrition education apps are feasible and acceptable solutions to support health promotion interventions in primary care.


Impact of a male-only weight loss maintenance programme on social-cognitive determinants of physical activity and healthy eating: A randomized controlled trial.

Young Myles D, Plotnikoff Ronald C, Collins Clare E, Callister Robin, Morgan Philip J

British journal of health psychology [20:724-44] (2015)

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To examine the effect of a gender-tailored, Social Cognitive Theory (SCT)-based weight loss maintenance (WLM) intervention on men's physical activity and healthy eating cognitions and behaviours in the 12 months after completing a weight loss programme. A two-phase, assessor-blinded, randomized controlled trial. Ninety-two overweight/obese men (mean [SD] age: 49.2 years [10.1], BMI: 30.7 [3.3] kg/m(2) ) who lost at least 4 kg after completing the 3-month SCT-based SHED-IT Weight Loss Program were randomly allocated to receive (1) the SCT-based SHED-IT WLM Program; or (2) no additional resources (self-help control group). The 6-month gender-tailored SHED-IT WLM Program was completely self-administered and operationalized SCT behaviour change principles to assist men to increase moderate-to-vigorous physical activity (MVPA) and decrease energy-dense, nutrient-poor (discretionary) food consumption after initial weight loss. After randomization (WLM baseline), men were reassessed at 6 months (WLM post-test) and 12 months (6-month WLM follow-up). SCT cognitions (e.g., self-efficacy, goal setting), MVPA, and discretionary food consumption were assessed with validated measures. Following significant improvements in cognitions, MVPA and discretionary food consumption during the weight loss phase, intention-to-treat, linear mixed models revealed no significant group-by-time differences in cognitions or behaviours during the WLM phase. Initial improvements in MVPA and some cognitions (e.g., goal setting, planning, and social support) were largely maintained by both groups at the end of the study. Dietary effects were not as strongly maintained, with the intervention and control groups maintaining 57% and 75% of the Phase I improvements in discretionary food intake, respectively. An additional SCT-based WLM programme did not elicit further improvements over a self-help control in the cognitions or behaviours for MVPA or discretionary food intake of men who had lost weight with a SCT-based weight loss programme. Statement of contribution What is already known on this subject?Weight regain after weight loss (WL) is common. As successful weight loss maintenance (WLM) requires sustained improvements in cognitions and behaviours, health psychology can contribute to intervention development. However, little research has examined the utility of psychological theory in the context of a WLM randomised controlled trial. What does this study add? A theory-based WL program improved men's physical activity and dietary behaviours and cognitions. Men who also received a theory-based WLM program did not show further improvements in physical activity or dietary cognitions and behaviours compared to those that did not.


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.


Field experiment of a very brief worksite intervention to improve nutrition among health care workers.

Armitage CJ

Journal of behavioral medicine [38:599-608] (2015)

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Despite the potential of worksite interventions to boost productivity and save insurance costs, they tend to be costly and tested in nonrandomized trials. The aim of the present study was to test the ability of a very brief worksite intervention based on implementation intentions to improve nutrition among health care workers. Seventy-nine health care workers were randomly allocated to a control condition or to form implementation intentions using standard instructions or with a supporting tool. Fruit intake and metacognitive processing (operationalized as awareness of standards, self-monitoring and self-regulatory effort) were measured at baseline and follow-up. Participants who formed implementation intentions ate significantly more fruit and engaged in significantly more metacognitive processing at follow-up than did participants in the control condition (ds > .70). The findings support the efficacy of implementation intentions for increasing fruit intake in health care workers and preliminary support for the utility of a tool to support implementation intention formation.


Application of Intervention Mapping to develop a community-based health promotion pre-pregnancy intervention for adolescent girls in rural South Africa: Project Ntshembo (Hope).

Draper Catherine E, Micklesfield Lisa K, Kahn Kathleen, Tollman Stephen M, Pettifor John M, Dunger David B, Norris Shane A

BMC public health [14 Suppl 2:S5] (2014)

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South Africa (SA) is undergoing multiple transitions with an increasing burden of non-communicable diseases and high levels of overweight and obesity in adolescent girls and women. Adolescence is key to addressing trans-generational risk and a window of opportunity to intervene and positively impact on individuals' health trajectories into adulthood. Using Intervention Mapping (IM), this paper describes the development of the Ntshembo intervention, which is intended to improve the health and well-being of adolescent girls in order to limit the inter-generational transfer of risk of metabolic disease, in particular diabetes risk. This paper describes the application of the first four steps of IM. Evidence is provided to support the selection of four key behavioural objectives: viz. to eat a healthy, balanced diet, increase physical activity, reduce sedentary behaviour, and promote reproductive health. Appropriate behaviour change techniques are suggested and a theoretical framework outlining components of relevant behaviour change theories is presented. It is proposed that the Ntshembo intervention will be community-based, including specialist adolescent community health workers who will deliver a complex intervention comprising of individual, peer, family and community mobilisation components. The Ntshembo intervention is novel, both in SA and globally, as it is: (1) based on strong evidence, extensive formative work and best practice from evaluated interventions; (2) combines theory with evidence to inform intervention components; (3) includes multiple domains of influence (community through to the individual); (4) focuses on an at-risk target group; and (5) embeds within existing and planned health service priorities in SA.


Maternal Obesity Management Using Mobile Technology: A Feasibility Study to Evaluate a Text Messaging Based Complex Intervention during Pregnancy.

Soltani Hora, Duxbury Alexandra M S, Arden Madelynne A, Dearden Andy, Furness Penny J, Garland Carolyn

Journal of obesity [2015:814830] (2015)

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Maternal obesity and excessive gestational weight gain (GWG) are on the rise with negative impact on pregnancy and birth outcomes. Research into managing GWG using accessible technology is limited. The maternal obesity management using mobile technology (MOMTech) study aimed at evaluating the feasibility of text messaging based complex intervention designed to support obese women (BMI ≥ 30) with healthier lifestyles and limit GWG. Participants received two daily text messages, supported by four appointments with healthy lifestyle midwife, diet and activity goal setting, and self-monitoring diaries. The comparison group were obese mothers who declined to participate but consented for their routinely collected data to be used for comparison. Postnatal interviews and focus groups with participants and the comparison group explored the intervention's acceptability and suggested improvements. Fourteen women completed the study which did not allow statistical analyses. However, participants had lower mean GWG than the comparison group (6.65 kg versus 9.74 kg) and few (28% versus 50%) exceeded the Institute of Medicine's upper limit of 9 kg GWG for obese women. MOMTech was feasible within clinical setting and acceptable intervention to support women to limit GWG. Before further trials, slight modifications are planned to recruitment, text messages, and the logistics of consultation visits.


Nutrition self-efficacy is unidirectionally related to outcome expectations in children.

Larsen Andrew L, McArdle John J, Robertson Trina, Dunton Genevieve F

Appetite [84:166-70] (2015)

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To clarify the underlying relationship between nutrition self-efficacy and outcome expectations because the direction of the relationship (unidirectional vs bidirectional) is debated in the literature. Secondary data analysis of a 10-week, 10-lesson school-based nutrition education intervention among 3rd grade students (N  =  952). Nutrition self-efficacy (7 items) and nutrition outcome expectations (9 items) were measured through student self-report at intervention pre- (time 1) and post- (time 2) assessments. A series of two time point, multi-group cross-lagged bivariate change score models were used to determine the direction of the relationship. A cross lag from nutrition self-efficacy at time 1 predicting changes in nutrition outcome expectations at time 2 significantly improved the fit of the model (Model 3), whereas a cross lag from nutrition outcome expectations at time 1 to changes in nutrition self-efficacy at time 2 only slightly improved the fit of the model (Model 2). Furthermore, adding both cross lags (Model 4) did not improve model fit compared to the model with only the self-efficacy cross lag (Model 3). Lastly, the nutrition outcome expectations cross lag did not significantly predict changes in nutrition self-efficacy in any of the models. Data suggest that there is a unidirectional relationship between nutrition self-efficacy and outcome expectations, in which self-efficacy predicts outcome expectations. Therefore, theory-based nutrition interventions may consider focusing more resources on changing self-efficacy because it may also lead to changes in outcome expectations as well.


Effects of a tailored health promotion program for female blue-collar workers: health works for women.

Campbell Marci Kramish, Tessaro Irene, DeVellis Brenda, Benedict Salli, Kelsey Kristine, Belton Leigh, Sanhueza Antonio

Preventive medicine [34:313-23] (2002)

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This study assessed the effects of the Health Works for Women (HWW) intervention on improving multiple behaviors including nutrition and physical activity among rural female blue-collar employees in North Carolina. Nine small to mid-size workplaces were randomly assigned to either intervention or delayed intervention conditions. After a baseline survey, an intervention consisting of two computer-tailored magazines and a natural helpers program was conducted over 18 months. Delayed worksites received one tailored magazine. Approximately 77 and 76% of baseline respondents completed follow-up surveys at 6 and 18 months, respectively, and 538 women (63%) completed all three surveys. At the 18-month follow-up, the intervention group had increased fruit and vegetable consumption by 0.7 daily servings compared to no change in the delayed group (P < 0.05). Significant differences in fat intake were observed at 6 months (P < 0.05) but not at 18 months. The intervention group also demonstrated improvements in strengthening and flexibility exercise compared to the delayed group. The rates of smoking cessation and cancer screening did not differ between study groups. The HWW project was a successful model for achieving certain health behavior changes among blue-collar women.


Provision of social norm feedback to high prescribers of antibiotics in general practice: a pragmatic national randomised controlled trial.

Hallsworth Michael, Chadborn Tim, Sallis Anna, Sanders Michael, Berry Daniel, Greaves Felix, Clements Lara, Davies Sally C

Lancet (London, England) [387:1743-52] (2016)

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Unnecessary antibiotic prescribing contributes to antimicrobial resistance. In this trial, we aimed to reduce unnecessary prescriptions of antibiotics by general practitioners (GPs) in England. In this randomised, 2 × 2 factorial trial, publicly available databases were used to identify GP practices whose prescribing rate for antibiotics was in the top 20% for their National Health Service (NHS) Local Area Team. Eligible practices were randomly assigned (1:1) into two groups by computer-generated allocation sequence, stratified by NHS Local Area Team. Participants, but not investigators, were blinded to group assignment. On Sept 29, 2014, every GP in the feedback intervention group was sent a letter from England's Chief Medical Officer and a leaflet on antibiotics for use with patients. The letter stated that the practice was prescribing antibiotics at a higher rate than 80% of practices in its NHS Local Area Team. GPs in the control group received no communication. The sample was re-randomised into two groups, and in December, 2014, GP practices were either sent patient-focused information that promoted reduced use of antibiotics or received no communication. The primary outcome measure was the rate of antibiotic items dispensed per 1000 weighted population, controlling for past prescribing. Analysis was by intention to treat. This trial is registered with the ISRCTN registry, number ISRCTN32349954, and has been completed. Between Sept 8 and Sept 26, 2014, we recruited and assigned 1581 GP practices to feedback intervention (n=791) or control (n=790) groups. Letters were sent to 3227 GPs in the intervention group. Between October, 2014, and March, 2015, the rate of antibiotic items dispensed per 1000 population was 126.98 (95% CI 125.68-128.27) in the feedback intervention group and 131.25 (130.33-132.16) in the control group, a difference of 4.27 (3.3%; incidence rate ratio [IRR] 0.967 [95% CI 0.957-0.977]; p<0.0001), representing an estimated 73,406 fewer antibiotic items dispensed. In December, 2014, GP practices were re-assigned to patient-focused intervention (n=777) or control (n=804) groups. The patient-focused intervention did not significantly affect the primary outcome measure between December, 2014, and March, 2015 (antibiotic items dispensed per 1000 population: 135.00 [95% CI 133.77-136.22] in the patient-focused intervention group and 133.98 [133.06-134.90] in the control group; IRR for difference between groups 1.01, 95% CI 1.00-1.02; p=0.105). Social norm feedback from a high-profile messenger can substantially reduce antibiotic prescribing at low cost and at national scale; this outcome makes it a worthwhile addition to antimicrobial stewardship programmes. Public Health England.


Development of a Theory-Based Intervention to Increase Clinical Measurement of Reactive Balance in Adults at Risk of Falls.

Sibley Kathryn M, Brooks Dina, Gardner Paula, Janaudis-Ferreira Tania, McGlynn Mandy, OʼHoski Sachi, McEwen Sara, Salbach Nancy M, Shaffer Jennifer, Shing Paula, Straus Sharon E, Jaglal Susan B

Journal of neurologic physical therapy : JNPT [40:100-6] (2016)

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Effective balance reactions are essential for avoiding falls, but are not regularly measured by physical therapists. Physical therapists report wanting to improve reactive balance assessment, and theory-based approaches are recommended as the foundation for the development of interventions. This article describes how a behavior change theory for health care providers, the theoretical domains framework (TDF), was used to develop an intervention to increase reactive balance measurement among physical therapists who work in rehabilitation settings and treat adults who are at risk of falls. We employed published recommendations for using the TDF-guided intervention development. We identified what health care provider behavior is in need of change, relevant barriers and facilitators, strategies to address them, and how we would measure behavior change. In this case, identifying strategies required selecting both a reactive balance measure and behavior change techniques. Previous research had determined that physical therapists need to increase reactive balance measurement, and identified barriers and facilitators that corresponded to 8 TDF domains. A published review informed the selection of the Balance Evaluation Systems Test (Reactive Postural Responses Section) as addressing the barriers and facilitators, and existing research informed the selection of 9 established behavior change techniques corresponding to each identified TDF domain. The TDF framework were incorporated into a 12-month intervention with interactive group sessions, local champions, and health record modifications. Intervention effect can be evaluated using health record abstraction, questionnaires, and qualitative semistructured interviews. Although future research will evaluate the intervention in a controlled study, the process of theory-based intervention development can be applied to other rehabilitation research contexts, maximizing the impact of this work.Video Abstract is available for more insights from the authors (see Supplemental Digital Content 1, http://links.lww.com/JNPT/A123).


Characterising an implementation intervention in terms of behaviour change techniques and theory: the 'Sepsis Six' clinical care bundle.

Steinmo Siri, Fuller Christopher, Stone Sheldon P, Michie Susan

Implementation science : IS [10:111] (2015)

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Sepsis is a major cause of death from infection, with a mortality rate of 36 %. This can be halved by implementing the 'Sepsis Six' evidence-based care bundle within 1 h of presentation. A UK audit has shown that median implementation rates are 27-47 % and interventions to improve this have demonstrated minimal effects. In order to develop more effective implementation interventions, it is helpful to obtain detailed characterisations of current interventions and to draw on behavioural theory to identify mechanisms of change. The aim of this study was to illustrate this process by using the Behaviour Change Wheel; Behaviour Change Technique (BCT) Taxonomy; Capability, Opportunity, Motivation model of behaviour; and Theoretical Domains Framework to characterise the content and theoretical mechanisms of action of an existing intervention to implement Sepsis Six. Data came from documentary, interview and observational analyses of intervention delivery in several wards of a UK hospital. A broad description of the intervention was created using the Template for Intervention Description and Replication framework. Content was specified in terms of (i) component BCTs using the BCT Taxonomy and (ii) intervention functions using the Behaviour Change Wheel. Mechanisms of action were specified using the Capability, Opportunity, Motivation model and the Theoretical Domains Framework. The intervention consisted of 19 BCTs, with eight identified using all three data sources. The BCTs were delivered via seven functions of the Behaviour Change Wheel, with four ('education', 'enablement', 'training' and 'environmental restructuring') supported by the three data sources. The most frequent mechanisms of action were reflective motivation (especially 'beliefs about consequences' and 'beliefs about capabilities') and psychological capability (especially 'knowledge'). The intervention consisted of a wide range of BCTs targeting a wide range of mechanisms of action. This study demonstrates the utility of the Behaviour Change Wheel, the BCT Taxonomy and the Theoretical Domains Framework, tools recognised for providing guidance for intervention design, for characterising an existing intervention to implement evidence-based care.


Strengthening the role and functions of nursing staff in inpatient stroke rehabilitation: developing a complex intervention using the Behaviour Change Wheel.

Loft Mia Ingerslev, Martinsen Bente, Esbensen Bente Appel, Mathiesen Lone L, Iversen Helle K, Poulsen Ingrid

International journal of qualitative studies on health and well-being [12:1392218] (2017)

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Over the past two decades, attempts have been made to describe the nurse's role and functions in the inpatient stroke rehabilitation; however, the nursing contribution is neither clear nor well-defined. Previous studies have highlighted the need for research aimed at developing interventions in the neuro-nursing area. The objective of this paper was to describe the development of a nursing intervention aimed at optimising the inpatient rehabilitation of stroke patients by strengthening the role and functions of nursing staff. A systematic approach was used, consistent with the framework for developing and evaluating complex interventions by the UK's Medical Research Council (MRC). Based on qualitative methods and using the Behaviour Change Wheel's (BCW) stepwise approach, we sought behaviours related to nursing staffs' roles and functions. We conducted a behavioural analysis to explain why nursing staff were or were not engaged in these behaviours. The nursing staff's Capability, Opportunity and Motivation were analysed with regard to working systematically with a rehabilitative approach and working deliberately and systematically with the patient's goals. We developed the educational intervention Rehabilitation 24/7. Following the MRC and the BCW frameworks is resource-consuming, but offers a way of developing a practical, well-structured intervention that is theory- and evidence based.


Evaluation of a tailored, multi-component intervention for implementation of evidence-based clinical practice guidelines in primary care physical therapy: a non-randomized controlled trial.

Bernhardsson Susanne, Larsson Maria E H, Eggertsen Robert, Olsén Monika Fagevik, Johansson Kajsa, Nilsen Per, Nordeman Lena, van Tulder Maurits, Öberg Birgitta

BMC health services research [14:105] (2014)

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Clinical practice guidelines are important for transmitting research findings into practice and facilitating the application of evidence-based practice (EBP). There is a paucity of knowledge about the impact of guideline implementation strategies in primary care physical therapy. The aim of this study was to evaluate the effect of a guideline implementation intervention in primary care physical therapy in western Sweden. An implementation strategy based on theory and current evidence was developed. A tailored, multi-component implementation intervention, addressing earlier identified determinants, was carried out in three areas comprising 28 physical therapy practices including 277 physical therapists (PTs) (intervention group). In two adjacent areas, 171 PTs at 32 practices received no intervention (control group). The core component of the intervention was an implementation seminar with group discussions. Among other components were a website and email reminders. Data were collected at baseline and follow-up with a web-based questionnaire. Primary outcomes were the self-reported awareness of, knowledge of, access to, and use of guidelines. Secondary outcomes were self-reported attitudes toward EBP and guidelines. Analyses were performed using Pearson's χ2 test and approximative z-test. 168 PTs (60.6%) in the intervention group and 88 PTs (51.5%) in the control group responded to the follow-up questionnaire. 186/277 PTs (67.1%) participated in the implementation seminars, of which 97 (52.2%) responded. The proportions of PTs reporting awareness of (absolute difference in change 20.6%, p = 0.023), knowledge where to find (20.4%, p = 0.007), access to (21.7%, p < 0.001), and frequent use of (9.5%, NS) guidelines increased more in the intervention group than in the control group. The proportion of PTs reporting frequent guideline use after participation in the implementation seminar was 15.2% (p = 0.043) higher than the proportion in the control group. A higher proportion considered EBP helpful in decision making (p = 0.018). There were no other significant differences in secondary outcomes. A tailored, theory- and evidence-informed, multi-component intervention for the implementation of clinical practice guidelines had a modest, positive effect on awareness of, knowledge of, access to, and use of guidelines, among PTs in primary care in western Sweden. In general, attitudes to EBP and guidelines were not affected.


The demonstration of a theory-based approach to the design of localized patient safety interventions.

Taylor Natalie, Lawton Rebecca, Slater Beverley, Foy Robbie

Implementation science : IS [8:123] (2013)

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There is evidence of unsafe care in healthcare systems globally. Interventions to implement recommended practice often have modest and variable effects. Ideally, selecting and adapting interventions according to local contexts should enhance effects. However, the means by which this can happen is seldom systematic, based on theory, or made transparent. This work aimed to demonstrate the applicability, feasibility, and acceptability of a theoretical domains framework implementation (TDFI) approach for co-designing patient safety interventions. We worked with three hospitals to support the implementation of evidence-based guidance to reduce the risk of feeding into misplaced nasogastric feeding tubes. Our stepped process, informed by the TDF and key principles from implementation literature, entailed: involving stakeholders; identifying target behaviors; identifying local factors (barriers and levers) affecting behavior change using a TDF-based questionnaire; working with stakeholders to generate specific local strategies to address key barriers; and supporting stakeholders to implement strategies. Exit interviews and audit data collection were undertaken to assess the feasibility and acceptability of this approach. Following audit and discussion, implementation teams for each Trust identified the process of checking the positioning of nasogastric tubes prior to feeding as the key behavior to target. Questionnaire results indicated differences in key barriers between organizations. Focus groups generated innovative, generalizable, and adaptable strategies for overcoming barriers, such as awareness events, screensavers, equipment modifications, and interactive learning resources. Exit interviews identified themes relating to the benefits, challenges, and sustainability of this approach. Time trend audit data were collected for 301 patients over an 18-month period for one Trust, suggesting clinically significant improved use of pH and documentation of practice following the intervention. The TDF is a feasible and acceptable framework to guide the implementation of patient safety interventions. The stepped TDFI approach engages healthcare professionals and facilitates contextualization in identifying the target behavior, eliciting local barriers, and selecting strategies to address those barriers. This approach may be of use to implementation teams and policy makers, although our promising findings confirm the need for a more rigorous evaluation; a balanced block evaluation is currently underway.


A Technological Innovation to Reduce Prescribing Errors Based on Implementation Intentions: The Acceptability and Feasibility of MyPrescribe.

Keyworth Chris, Hart Jo, Thoong Hong, Ferguson Jane, Tully Mary

JMIR human factors [4:e17] (2017)

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Although prescribing of medication in hospitals is rarely an error-free process, prescribers receive little feedback on their mistakes and ways to change future practices. Audit and feedback interventions may be an effective approach to modifying the clinical practice of health professionals, but these may pose logistical challenges when used in hospitals. Moreover, such interventions are often labor intensive. Consequently, there is a need to develop effective and innovative interventions to overcome these challenges and to improve the delivery of feedback on prescribing. Implementation intentions, which have been shown to be effective in changing behavior, link critical situations with an appropriate response; however, these have rarely been used in the context of improving prescribing practices. Semistructured qualitative interviews were conducted to evaluate the acceptability and feasibility of providing feedback on prescribing errors via MyPrescribe, a mobile-compatible website informed by implementation intentions. Data relating to 200 prescribing errors made by 52 junior doctors were collected by 11 hospital pharmacists. These errors were populated into MyPrescribe, where prescribers were able to construct their own personalized action plans. Qualitative interviews with a subsample of 15 junior doctors were used to explore issues regarding feasibility and acceptability of MyPrescribe and their experiences of using implementation intentions to construct prescribing action plans. Framework analysis was used to identify prominent themes, with findings mapped to the behavioral components of the COM-B model (capability, opportunity, motivation, and behavior) to inform the development of future interventions. MyPrescribe was perceived to be effective in providing opportunities for critical reflection on prescribing errors and to complement existing training (such as junior doctors' e-portfolio). The participants were able to provide examples of how they would use "If-Then" plans for patient management. Technology, as opposed to other methods of learning (eg, traditional "paper based" learning), was seen as a positive advancement for continued learning. MyPrescribe was perceived as an acceptable and feasible learning tool for changing prescribing practices, with participants suggesting that it would make an important addition to medical prescribers' training in reflective practice. MyPrescribe is a novel theory-based technological innovation that provides the platform for doctors to create personalized implementation intentions. Applying the COM-B model allows for a more detailed understanding of the perceived mechanisms behind prescribing practices and the ways in which interventions aimed at changing professional practice can be implemented.


Bridging the gap between pragmatic intervention design and theory: using behavioural science tools to modify an existing quality improvement programme to implement "Sepsis Six".

Steinmo Siri H, Michie Susan, Fuller Christopher, Stanley Sarah, Stapleton Caitriona, Stone Sheldon P

Implementation science : IS [11:14] (2016)

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Sepsis has a mortality rate of 40 %, which can be halved if the evidence-based "Sepsis Six" care bundle is implemented within 1 h. UK audit shows low implementation rates. Interventions to improve this have had minimal effects. Quality improvement programmes could be further developed by using theoretical frameworks (Theoretical Domains Framework (TDF)) to modify existing interventions by identifying influences on clinical behaviour and selecting appropriate content. The aim of this study was to illustrate using this process to modify an intervention designed using plan-do-study-act (P-D-S-A) cycles that had achieved partial success in improving Sepsis Six implementation in one hospital. Factors influencing implementation were investigated using the TDF to analyse interviews with 34 health professionals. The nursing team who developed and facilitated the intervention used the data to select modifications using the Behaviour Change Technique (BCT) Taxonomy (v1) and the APEASE criteria: affordability, practicability, effectiveness, acceptability, safety and equity. Five themes were identified as influencing implementation and guided intervention modification. These were:(1) "knowing what to do and why" (TDF domains knowledge, social/professional role and identity); (2) "risks and benefits" (beliefs about consequences), e.g. fear of harming patients through fluid overload acting as a barrier to implementation versus belief in the bundle's effectiveness acting as a lever to implementation; (3) "working together" (social influences, social/professional role and identity), e.g. team collaboration acting as a lever versus doctor/nurse conflict acting as a barrier; (4) "empowerment and support" (beliefs about capabilities, social/professional role and identity, behavioural regulation, social influences), e.g. involving staff in intervention development acting as a lever versus lack of confidence to challenge colleagues' decisions not to implement acting as a barrier; (5) "staffing levels" (environmental context and resources), e.g. shortages of doctors at night preventing implementation. The modified intervention included six new BCTs and consisted of two additional components (Sepsis Six training for the Hospital at Night Co-ordinator; a partnership agreement endorsing engagement of all clinical staff and permitting collegial challenge) and modifications to two existing components (staff education sessions; documents and materials). This work demonstrates the feasibility of the TDF and BCT Taxonomy (v1) for developing an existing quality improvement intervention. The tools are compatible with the pragmatic P-D-S-A cycle approach generally used in quality improvement work.


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.


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.


Effective Feedback to Improve Primary Care Prescribing Safety (EFIPPS) a pragmatic three-arm cluster randomised trial: designing the intervention (ClinicalTrials.gov registration NCT01602705).

Barnett Karen N, Bennie Marion, Treweek Shaun, Robertson Christopher, Petrie Dennis J, Ritchie Lewis D, Guthrie Bruce

Implementation science : IS [9:133] (2014)

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High-risk prescribing in primary care is common and causes considerable harm. Feedback interventions have small/moderate effects on clinical practice, but few trials explicitly compare different forms of feedback. There is growing recognition that intervention development should be theory-informed, and that comprehensive reporting of intervention design is required by potential users of trial findings. The paper describes intervention development for the Effective Feedback to Improve Primary Care Prescribing Safety (EFIPPS) study, a pragmatic three-arm cluster randomised trial in 262 Scottish general practices. The NHS chose to implement a feedback intervention to utilise a new resource, new Prescribing Information System (newPIS). The development phase required selection of high-risk prescribing outcome measures and design of intervention components: (1) educational material (the usual care comparison), (2) feedback of practice rates of high-risk prescribing received by both intervention arms and (3) a theory-informed behaviour change component to be received by one intervention arm. Outcome measures, educational material and feedback design, were developed with a National Health Service Advisory Group. The behaviour change component was informed by the Theory of Planned Behaviour and the Health Action Process Approach. A focus group elicitation study and an email Delphi study with general practitioners (GPs) identified key attitudes and barriers of responding to the prescribing feedback. Behaviour change techniques were mapped to the psychological constructs, and the content was informed by the results of the elicitation and Delphi study. Six high-risk prescribing measures were selected in a consensus process based on importance and feasibility. Educational material and feedback design were based on current NHS Scotland practice and Advisory Group recommendations. The behaviour change component was resource constrained in development, mirroring what is feasible in an NHS context. Four behaviour change interventions were developed and embedded in five quarterly rounds of feedback targeting attitudes, subjective norms, perceived behavioural control and action planning (2×). The paper describes a process which is feasible to use in the resource-constrained environment of NHS-led intervention development and documents the intervention to make its design and implementation explicit to potential users of the trial findings. ClinicalTrials.gov: NCT01602705.


Paper-based and web-based intervention modeling experiments identified the same predictors of general practitioners' antibiotic-prescribing behavior.

Treweek Shaun, Bonetti Debbie, Maclennan Graeme, Barnett Karen, Eccles Martin P, Jones Claire, Pitts Nigel B, Ricketts Ian W, Sullivan Frank, Weal Mark, Francis Jill J

Journal of clinical epidemiology [67:296-304] (2014)

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To evaluate the robustness of the intervention modeling experiment (IME) methodology as a way of developing and testing behavioral change interventions before a full-scale trial by replicating an earlier paper-based IME. Web-based questionnaire and clinical scenario study. General practitioners across Scotland were invited to complete the questionnaire and scenarios, which were then used to identify predictors of antibiotic-prescribing behavior. These predictors were compared with the predictors identified in an earlier paper-based IME and used to develop a new intervention. Two hundred seventy general practitioners completed the questionnaires and scenarios. The constructs that predicted simulated behavior and intention were attitude, perceived behavioral control, risk perception/anticipated consequences, and self-efficacy, which match the targets identified in the earlier paper-based IME. The choice of persuasive communication as an intervention in the earlier IME was also confirmed. Additionally, a new intervention, an action plan, was developed. A web-based IME replicated the findings of an earlier paper-based IME, which provides confidence in the IME methodology. The interventions will now be evaluated in the next stage of the IME, a web-based randomized controlled trial.


Development of a behaviour change intervention: a case study on the practical application of theory.

Porcheret Mark, Main Chris, Croft Peter, McKinley Robert, Hassell Andrew, Dziedzic Krysia

Implementation science : IS [9:42] (2014)

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Use of theory in implementation of complex interventions is widely recommended. A complex trial intervention, to enhance self-management support for people with osteoarthritis (OA) in primary care, needed to be implemented in the Managing Osteoarthritis in Consultations (MOSAICS) trial. One component of the trial intervention was delivery by general practitioners (GPs) of an enhanced consultation for patients with OA. The aim of our case study is to describe the systematic selection and use of theory to develop a behaviour change intervention to implement GP delivery of the enhanced consultation. The development of the behaviour change intervention was guided by four theoretical models/frameworks: i) an implementation of change model to guide overall approach, ii) the Theoretical Domains Framework (TDF) to identify relevant determinants of change, iii) a model for the selection of behaviour change techniques to address identified determinants of behaviour change, and iv) the principles of adult learning. Methods and measures to evaluate impact of the behaviour change intervention were identified. The behaviour change intervention presented the GPs with a well-defined proposal for change; addressed seven of the TDF domains (e.g., knowledge, skills, motivation and goals); incorporated ten behaviour change techniques (e.g., information provision, skills rehearsal, persuasive communication); and was delivered in workshops that valued the expertise and professional values of GPs. The workshops used a mixture of interactive and didactic sessions, were facilitated by opinion leaders, and utilised 'context-bound communication skills training.' Methods and measures selected to evaluate the behaviour change intervention included: appraisal of satisfaction with workshops, GP report of intention to practise and an assessment of video-recorded consultations of GPs with patients with OA. A stepped approach to the development of a behaviour change intervention, with the utilisation of theoretical frameworks to identify determinants of change matched with behaviour change techniques, has enabled a systematic and theory-driven development of an intervention designed to enhance consultations by GPs for patients with OA. The success of the behaviour change intervention in practice will be evaluated in the context of the MOSAICS trial as a whole, and will inform understanding of practice level and patient outcomes in the trial.


Developing a targeted, theory-informed implementation intervention using two theoretical frameworks to address health professional and organisational factors: a case study to improve the management of mild traumatic brain injury in the emergency department.

Tavender Emma J, Bosch Marije, Gruen Russell L, Green Sally E, Michie Susan, Brennan Sue E, Francis Jill J, Ponsford Jennie L, Knott Jonathan C, Meares Sue, Smyth Tracy, O'Connor Denise A

Implementation science : IS [10:74] (2015)

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Despite the availability of evidence-based guidelines for the management of mild traumatic brain injury in the emergency department (ED), variations in practice exist. Interventions designed to implement recommended behaviours can reduce this variation. Using theory to inform intervention development is advocated; however, there is no consensus on how to select or apply theory. Integrative theoretical frameworks, based on syntheses of theories and theoretical constructs relevant to implementation, have the potential to assist in the intervention development process. This paper describes the process of applying two theoretical frameworks to investigate the factors influencing recommended behaviours and the choice of behaviour change techniques and modes of delivery for an implementation intervention. A stepped approach was followed: (i) identification of locally applicable and actionable evidence-based recommendations as targets for change, (ii) selection and use of two theoretical frameworks for identifying barriers to and enablers of change (Theoretical Domains Framework and Model of Diffusion of Innovations in Service Organisations) and (iii) identification and operationalisation of intervention components (behaviour change techniques and modes of delivery) to address the barriers and enhance the enablers, informed by theory, evidence and feasibility/acceptability considerations. We illustrate this process in relation to one recommendation, prospective assessment of post-traumatic amnesia (PTA) by ED staff using a validated tool. Four recommendations for managing mild traumatic brain injury were targeted with the intervention. The intervention targeting the PTA recommendation consisted of 14 behaviour change techniques and addressed 6 theoretical domains and 5 organisational domains. The mode of delivery was informed by six Cochrane reviews. It was delivered via five intervention components : (i) local stakeholder meetings, (ii) identification of local opinion leader teams, (iii) a train-the-trainer workshop for appointed local opinion leaders, (iv) local training workshops for delivery by trained local opinion leaders and (v) provision of tools and materials to prompt recommended behaviours. Two theoretical frameworks were used in a complementary manner to inform intervention development in managing mild traumatic brain injury in the ED. The effectiveness and cost-effectiveness of the developed intervention is being evaluated in a cluster randomised trial, part of the Neurotrauma Evidence Translation (NET) program.


Use of the theoretical domains framework to develop an intervention to improve physical therapist management of the risk of falls after discharge.

Thomas S, Mackintosh S

Physical therapy [94:1660-75] (2014)

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Older adults have an increased risk of falls after discharge from the hospital. Guidelines to manage this risk of falls are well documented but are not commonly implemented. The aim of this case report is to describe the novel approach of using the Theoretical Domains Framework (TDF) to develop an intervention to change the clinical behavior of physical therapists. This project had 4 phases: identifying the evidence-practice gap, identifying barriers and enablers that needed to be addressed, identifying behavior change techniques to overcome the barriers, and determining outcome measures for evaluating behavior change. The evidence-practice gap was represented by the outcome that few patients who had undergone surgery for hip fracture were recognized as having a risk of falls or had a documented referral to a community agency for follow-up regarding the prevention of falls. Project aims aligned with best practice guidelines were established; 12 of the 14 TDF domains were considered to be relevant to behaviors in the project, and 6 behavior change strategies were implemented. Primary outcome measures included the proportion of patients who had documentation of the risk of falls and were referred for a comprehensive assessment of the risk of falls after discharge from the hospital. A systematic approach involving the TDF was useful for designing a multifaceted intervention to improve physical therapist management of the risk of falls after discharge of patients from an acute care setting in South Australia, Australia. This framework enabled the identification of targeted intervention strategies that were likely to influence health care professional behavior. Early case note audit results indicated that positive changes were being made to reduce the evidence-practice gap.


Improving correctional healthcare providers' ability to care for transgender patients: Development and evaluation of a theory-driven cultural and clinical competence intervention.

White Hughto, Jaclyn M, Clark Kirsty A, Altice Frederick L, Reisner Sari L, Kershaw Trace S, Pachankis John E

Social science & medicine (1982) [195:159-169] (2017)

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Correctional healthcare providers' limited cultural and clinical competence to care for transgender patients represents a barrier to care for incarcerated transgender individuals. The present study aimed to adapt, deliver, and evaluate a transgender cultural and clinical competence intervention for correctional healthcare providers. In the summer of 2016, a theoretically-informed, group-based intervention to improve transgender cultural and clinical competence was delivered to 34 correctional healthcare providers in New England. A confidential survey assessed providers' cultural and clinical competence to care for transgender patients, self-efficacy to provide hormone therapy, subjective norms related to transgender care, and willingness to provide gender-affirming care to transgender patients before and after (immediately and 3-months) the intervention. Linear mixed effects regression models were fit to assess change in study outcomes over time. Qualitative exit interviews assessed feasibility and acceptability of the intervention. Providers' willingness to provide gender-affirming care improved immediately post-intervention (β = 0.38; SE = 0.41, p < 0.001) and from baseline to 3-months post-intervention (β = 0.36; SE = 0.09; p < 0.001; omnibus test of fixed effects χ = 23.21; p < 0.001). On average, transgender cultural competence (χ = 22.49; p < 0.001), medical gender affirmation knowledge (χ = 11.24; p = 0.01), self-efficacy to initiate hormones for transgender women, and subjective norms related to transgender care (χ = 14.69; p = 0.001) all significantly increased over time. Providers found the intervention to be highly acceptable and recommended that the training be scaled-up to other correctional healthcare providers and expanded to custody staff. The intervention increased correctional healthcare providers' cultural and clinical competence, self-efficacy, subjective norms, and willingness to provide gender-affirming care to transgender patients. Continued efforts should be made to train correctional healthcare providers in culturally and clinically competent gender-affirming care in order to improve the health of incarcerated transgender people. Future efficacy testing of this intervention is warranted.


General practitioner views on the determinants of test ordering: a theory-based qualitative approach to the development of an intervention to improve immunoglobulin requests in primary care.

Cadogan S L, McHugh S M, Bradley C P, Browne J P, Cahill M R

Implementation science : IS [11:102] (2016)

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Research suggests that variation in laboratory requesting patterns may indicate unnecessary test use. Requesting patterns for serum immunoglobulins vary significantly between general practitioners (GPs). This study aims to explore GP's views on testing to identify the determinants of behaviour and recommend feasible intervention strategies for improving immunoglobulin test use in primary care. Qualitative semi-structured interviews were conducted with GPs requesting laboratory tests at Cork University Hospital or University Hospital Kerry in the South of Ireland. GPs were identified using a Health Service Executive laboratory list of GPs in the Cork-Kerry region. A random sample of GPs (stratified by GP requesting patterns) was generated from this list. GPs were purposively sampled based on the criteria of location (urban/rural); length of time qualified; and practice size (single-handed/group). Interviews were carried out between December 2014 and February 2015. Interviews were transcribed verbatim using NVivo 10 software and analysed using the framework analysis method. Emerging themes were mapped to the theoretical domains framework (TDF), which outlines 12 domains that can enable or inhibit behaviour change. The behaviour change wheel and behaviour change technique (BCT) taxonomy were then used to identify potential intervention strategies. Sixteen GPs were interviewed (ten males and six females). Findings suggest that intervention strategies should specifically target the key barriers to effective test ordering, while considering the context of primary care practice. Seven domains from the TDF were perceived to influence immunoglobulin test ordering behaviours and were identified as 'mechanisms for change' (knowledge, environmental context and resources, social/professional role and identity, beliefs about capabilities, beliefs about consequences, memory, attention and decision-making processes and behavioural regulation). Using these TDF domains, seven BCTs emerged as feasible 'intervention content' for targeting GPs' ordering behaviour. These included instructions on how to effectively request the test (how to perform behaviour), information on GPs' use of the test (feedback on behaviour), information about patient consequences resulting from not doing the test (information about health consequences), laboratory/consultant-based advice/education (credible source), altering the test ordering form (restructuring the physical environment), providing guidelines (prompts/cues) and adding interpretive comments to the results (adding objects to the environment). These BCTs aligned to four intervention functions: education, persuasion, environmental restructuring and enablement. This study has effectively applied behaviour change theory to identify feasible strategies for improving immunoglobulin test use in primary care using the TDF, 'behaviour change wheel' and BCT taxonomy. The identified BCTs will form the basis of a theory-based intervention to improve the use of immunoglobulin tests among GPs. Future research will involve the development and evaluation of this intervention.


Specifying content and mechanisms of change in interventions to change professionals' practice: an illustration from the Good Goals study in occupational therapy.

Kolehmainen N, Francis JJ

Implementation science : IS [7:100] (2012)

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It is widely agreed that interventions to change professionals' practice need to be clearly specified. This involves (1) selecting and defining the intervention techniques, (2) operationalising the techniques and deciding their delivery, and (3) formulating hypotheses about the mechanisms through which the techniques are thought to result in change. Descriptions of methods to achieve these objectives are limited. This paper reports methods and illustrates outputs from a study to meet these objectives, specifically from the Good Goals study to improve occupational therapists' caseload management practice. (1) Behaviour change techniques were identified and selected from an existing matrix that maps techniques to determinants. An existing coding manual was used to define the techniques. (2) A team of occupational therapists generated context-relevant, acceptable modes of delivery for the techniques; these data were compared and contrasted with previously collected data, literature on caseload management, and the aims of the intervention. (3) Hypotheses about the mechanisms of change were formulated by drawing on the matrix and on theories of behaviour change. (1) Eight behaviour change techniques were selected: goal specified; self-monitoring; contract; graded tasks; increasing skills (problem solving, decision making, goal setting); coping skills; rehearsal of relevant skills; social processes of encouragement, support, and pressure; demonstration by others; and feedback. (2) A range of modes of delivery were generated (e.g., graded tasks' consisting of series of clinical cases and situations that become increasingly difficult). Conditions for acceptable delivery were identified (e.g., 'self-monitoring' was acceptable only if delivered at team level). The modes of delivery were specified as face-to-face training, task sheets, group tasks, DVDs, and team-based weekly meetings. (3) The eight techniques were hypothesized to target caseload management practice through eleven mediating variables. Three domains were hypothesized to be most likely to change: beliefs about capabilities, motivation and goals, and behavioural regulation. The project provides an exemplar of a systematic and reportable development of a quality-improvement intervention, with its methods likely to be applicable to other projects. A subsequent study of the intervention has provided early indication that use of systematic methods to specify interventions may help to maximize acceptability and effectiveness.


Evaluating multisite multiprofessional simulation training for a hyperacute stroke service using the Behaviour Change Wheel.

Ross A J, Reedy G B, Roots A, Jaye P, Birns J

BMC medical education [15:143] (2015)

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Stroke is a clinical priority requiring early specialist assessment and treatment. A London (UK) stroke strategy was introduced in 2010, with Hyper Acute Stroke Units (HASUs) providing specialist and high dependency care. To support increased numbers of specialist staff, innovative multisite multiprofessional simulation training under a standard protocol-based curriculum took place across London. This paper reports on an independent evaluation of the HASU training programme. The main aim was to evaluate mechanisms for behaviour change within the training design and delivery, and impact upon learners including potential transferability to the clinical environment. The evaluation utilised the Behaviour Change Wheel framework. Procedures included: mapping training via the framework; examination of course material; direct and video-recorded observations of courses; pre-post course survey sheet; and follow up in-depth interviews with candidates and faculty. Patient management skills and trainee confidence were reportedly increased post-course (post-course median 6 [IQ range 5-6.33]; pre-course median 5 [IQ range 4.67-5.83]; z = 6.42, P


An Audit and Feedback Intervention for Reducing Antibiotic Prescribing in General Dental Practice: The RAPiD Cluster Randomised Controlled Trial.

Elouafkaoui Paula, Young Linda, Newlands Rumana, Duncan Eilidh M, Elders Andrew, Clarkson Jan E, Ramsay Craig R

PLoS medicine [13:e1002115] (2016)

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Dentists prescribe approximately 10% of antibiotics dispensed in UK community pharmacies. Despite clear clinical guidance, dentists often prescribe antibiotics inappropriately. This cluster-randomised controlled trial used routinely collected National Health Service (NHS) dental prescribing and treatment claim data to compare the impact of individualised audit and feedback (A&F) interventions on dentists' antibiotic prescribing rates. All 795 antibiotic prescribing NHS general dental practices in Scotland were included. Practices were randomised to the control (practices = 163; dentists = 567) or A&F intervention group (practices = 632; dentists = 1,999). A&F intervention practices were allocated to one of two A&F groups: (1) individualised graphical A&F comprising a line graph plotting an individual dentist's monthly antibiotic prescribing rate (practices = 316; dentists = 1,001); or (2) individualised graphical A&F plus a written behaviour change message synthesising and reiterating national guidance recommendations for dental antibiotic prescribing (practices = 316; dentists = 998). Intervention practices were also simultaneously randomised to receive A&F: (i) with or without a health board comparator comprising the addition of a line to the graphical A&F plotting the monthly antibiotic prescribing rate of all dentists in the health board; and (ii) delivered at 0 and 6 mo or at 0, 6, and 9 mo, giving a total of eight intervention groups. The primary outcome, measured by the trial statistician who was blinded to allocation, was the total number of antibiotic items dispensed per 100 NHS treatment claims over the 12 mo post-delivery of the baseline A&F. Primary outcome data was available for 152 control practices (dentists = 438) and 609 intervention practices (dentists = 1,550). At baseline, the number of antibiotic items prescribed per 100 NHS treatment claims was 8.3 in the control group and 8.5 in the intervention group. At follow-up, antibiotic prescribing had decreased by 0.4 antibiotic items per 100 NHS treatment claims in control practices and by 1.0 in intervention practices. This represents a significant reduction (-5.7%; 95% CI -10.2% to -1.1%; p = 0.01) in dentists' prescribing rate in the intervention group relative to the control group. Intervention subgroup analyses found a 6.1% reduction in the antibiotic prescribing rate of dentists who had received the written behaviour change message relative to dentists who had not (95% CI -10.4% to -1.9%; p = 0.01). There was no significant between-group difference in the prescribing rate of dentists who received a health board comparator relative to those who did not (-4.3%; 95% CI -8.6% to 0.1%; p = 0.06), nor between dentists who received A&F at 0 and 6 mo relative to those who received A&F at 0, 6, and 9 mo (0.02%; 95% CI -4.2% to 4.2%; p = 0.99). The key limitations relate to the use of routinely collected datasets which did not allow evaluation of any effects on inappropriate prescribing. A&F derived from routinely collected datasets led to a significant reduction in the antibiotic prescribing rate of dentists. Current Controlled Trials ISRCTN49204710.


The Fear Reduction Exercised Early (FREE) approach to low back pain: study protocol for a randomised controlled trial.

Darlow Ben, Stanley James, Dean Sarah, Abbott J Haxby, Garrett Sue, Mathieson Fiona, Dowell Anthony

Trials [18:484] (2017)

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Low back pain (LBP) is a major health issue associated with considerable health loss and societal costs. General practitioners (GPs) play an important role in the management of LBP; however, GP care has not been shown to be the most cost-effective approach unless exercise and behavioural counselling are added to usual care. The Fear Reduction Exercised Early (FREE) approach to LBP has been developed to assist GPs to manage LBP by empowering exploration and management of psychosocial barriers to recovery and provision of evidence-based care and information. The aim of the Low Back Pain in General Practice (LBPinGP) trial is to explore whether patients with LBP who receive care from GPs trained in the FREE approach have better outcomes than those who receive usual care. This is a cluster randomised controlled superiority trial comparing the FREE approach with usual care for LBP management with investigator-blinded assessment of outcomes. GPs will be recruited and then cluster randomised (in practice groups) to the intervention or control arm. Intervention arm GPs will receive training in the FREE approach, and control arm GPs will continue to practice as usual. Patients presenting to their GP with a primary complaint of LBP will be allocated on the basis of allocation of the GP they consult. We aim to recruit 60 GPs and 275 patients (assuming patients are recruited from 75% of GPs and an average of 5 patients per GP complete the study, accounting for 20% patient participant dropout). Patient participants and the trial statistician will be blind to group allocation throughout the study. Analyses will be undertaken on an intention-to-treat basis. The primary outcome will be back-related functional impairment 6 months post-initial LBP consultation (interim data at 2 weeks, 6 weeks and 3 months), measured with the Roland-Morris Disability Questionnaire. Secondary patient outcomes include pain, satisfaction, quality of life, days off from work and costs of care. Secondary GP outcomes include beliefs about pain and impairment, GP confidence, and actual and reported clinical behaviour. Health economic and process evaluations will be conducted. In the LBPinGP trial, we will investigate providing an intervention during the first interaction a person with back pain has with their GP. Because the FREE approach is used within a normal GP consultation, if effective, it may be a cost-effective means of improving LBP care. Australian New Zealand Clinical Trials Registry, ACTRN12616000888460 . Registered on 6 July 2016.


Applying the Theoretical Domains Framework to identify barriers and targeted interventions to enhance nurses' use of electronic medication management systems in two Australian hospitals.

Debono Deborah, Taylor Natalie, Lipworth Wendy, Greenfield David, Travaglia Joanne, Black Deborah, Braithwaite Jeffrey

Implementation science : IS [12:42] (2017)

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Medication errors harm hospitalised patients and increase health care costs. Electronic Medication Management Systems (EMMS) have been shown to reduce medication errors. However, nurses do not always use EMMS as intended, largely because implementation of such patient safety strategies requires clinicians to change their existing practices, routines and behaviour. This study uses the Theoretical Domains Framework (TDF) to identify barriers and targeted interventions to enhance nurses' appropriate use of EMMS in two Australian hospitals. This qualitative study draws on in-depth interviews with 19 acute care nurses who used EMMS. A convenience sampling approach was used. Nurses working on the study units (N = 6) in two hospitals were invited to participate if available during the data collection period. Interviews inductively explored nurses' experiences of using EMMS (step 1). Data were analysed using the TDF to identify theory-derived barriers to nurses' appropriate use of EMMS (step 2). Relevant behaviour change techniques (BCTs) were identified to overcome key barriers to using EMMS (step 3) followed by the identification of potential literature-informed targeted intervention strategies to operationalise the identified BCTs (step 4). Barriers to nurses' use of EMMS in acute care were represented by nine domains of the TDF. Two closely linked domains emerged as major barriers to EMMS use: Environmental Context and Resources (availability and properties of computers on wheels (COWs); technology characteristics; specific contexts; competing demands and time pressure) and Social/Professional Role and Identity (conflict between using EMMS appropriately and executing behaviours critical to nurses' professional role and identity). The study identified three potential BCTs to address the Environmental Context and Resources domain barrier: adding objects to the environment; restructuring the physical environment; and prompts and cues. Seven BCTs to address Social/Professional Role and Identity were identified: social process of encouragement; pressure or support; information about others' approval; incompatible beliefs; identification of self as role model; framing/reframing; social comparison; and demonstration of behaviour. It proposes several targeted interventions to deliver these BCTs. The TDF provides a useful approach to identify barriers to nurses' prescribed use of EMMS, and can inform the design of targeted theory-based interventions to improve EMMS implementation.


Developing theory-informed behaviour change interventions to implement evidence into practice: a systematic approach using the Theoretical Domains Framework.

French Simon D, Green Sally E, O'Connor Denise A, McKenzie Joanne E, Francis Jill J, Michie Susan, Buchbinder Rachelle, Schattner Peter, Spike Neil, Grimshaw Jeremy M

Implementation science : IS [7:38] (2012)

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There is little systematic operational guidance about how best to develop complex interventions to reduce the gap between practice and evidence. This article is one in a Series of articles documenting the development and use of the Theoretical Domains Framework (TDF) to advance the science of implementation research. The intervention was developed considering three main components: theory, evidence, and practical issues. We used a four-step approach, consisting of guiding questions, to direct the choice of the most appropriate components of an implementation intervention: Who needs to do what, differently? Using a theoretical framework, which barriers and enablers need to be addressed? Which intervention components (behaviour change techniques and mode(s) of delivery) could overcome the modifiable barriers and enhance the enablers? And how can behaviour change be measured and understood? A complex implementation intervention was designed that aimed to improve acute low back pain management in primary care. We used the TDF to identify the barriers and enablers to the uptake of evidence into practice and to guide the choice of intervention components. These components were then combined into a cohesive intervention. The intervention was delivered via two facilitated interactive small group workshops. We also produced a DVD to distribute to all participants in the intervention group. We chose outcome measures in order to assess the mediating mechanisms of behaviour change. We have illustrated a four-step systematic method for developing an intervention designed to change clinical practice based on a theoretical framework. The method of development provides a systematic framework that could be used by others developing complex implementation interventions. While this framework should be iteratively adjusted and refined to suit other contexts and settings, we believe that the four-step process should be maintained as the primary framework to guide researchers through a comprehensive intervention development process.


Implementation of a nurse-led behaviour change intervention to support medication taking in type 2 diabetes: beyond hypothesised active ingredients (SAMS Consultation Study).

Hardeman Wendy, Lamming Laura, Kellar Ian, De Simoni Anna, Graffy Jonathan, Boase Sue, Sutton Stephen, Farmer Andrew, Kinmonth Ann Louise

Implementation science : IS [9:70] (2014)

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Implementation of trial interventions is rarely assessed, despite its effects on findings. We assessed the implementation of a nurse-led intervention to facilitate medication adherence in type 2 diabetes (SAMS) in a trial against standard care in general practice. The intervention increased adherence, but not through the hypothesised psychological mechanism. This study aimed to develop a reliable coding frame for tape-recorded consultations, assessing both a priori hypothesised and potential active ingredients observed during implementation, and to describe the delivery and receipt of intervention and standard care components to understand how the intervention might have worked. 211 patients were randomised to intervention or comparison groups and 194/211 consultations were tape-recorded. Practice nurses delivered standard care to all patients and motivational and action planning (implementation intention) techniques to intervention patients only. The coding frame was developed and piloted iteratively on selected tape recordings until a priori reliability thresholds were achieved. All tape-recorded consultations were coded and a random subsample double-coded. Nurse communication, nurse-patient relationship and patient responses were identified as potential active ingredients over and above the a priori hypothesised techniques. The coding frame proved reliable. Intervention and standard care were clearly differentiated. Nurse protocol adherence was good (M (SD) = 3.95 (0.91)) and competence of intervention delivery moderate (M (SD) = 3.15 (1.01)). Nurses frequently reinforced positive beliefs about taking medication (e.g., 65% for advantages) but rarely prompted problem solving of negative beliefs (e.g., 21% for barriers). Patients' action plans were virtually identical to current routines. Nurses showed significantly less patient-centred communication with the intervention than comparison group. It is feasible to reliably assess the implementation of behaviour change interventions in clinical practice. The main study results could not be explained by poor delivery of motivational and action planning components, definition of new action plans, improved problem solving or patient-centred communication. Possible mechanisms of increased medication adherence include spending more time discussing it and mental rehearsal of successful performance of current routines, combined with action planning. Delivery of a new behaviour change intervention may lead to less patient-centred communication and possible reduction in overall trial effects. ISRCTN30522359.


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.


The design of a theory-based intervention to improve medication adherence in chronic pain patients.

Timmerman Leon, Stronks Dirk L, Huygen Frank J P M

Current medical research and opinion (2017)

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Non-adherence to pain medication is common in chronic pain patients and may result in unfavorable treatment outcomes. Interventions to improve adherence behavior often fail to significantly change medication use. In this report, we describe the application of a theoretical psychological model of behavior change in order to design an intervention to improve medication adherence in chronic pain patients. This study applies the Behavior Change Wheel framework and the Behavior Change Techniques Taxonomy to design a theory-based intervention to improve pain medication use. Available literature was used to extract determinants of adherence in chronic pain patients. Selected target behaviors to improve medication adherence are: share agreement on follow up policy, monitor medication adherence, provide patient education routinely, discuss attitudes and concerns towards pain medication, develop medication taking habits and use medication reminders. The intervention consists of three components in which relevant behavior change techniques are applied: (1) changes in the electronic patient data management systems to enable medical staff to apply target behaviors; (2) bi-annual education of medical staff to commit the team to the proposed intervention and provide feedback; (3) routine and mandatory education of chronic pain patients following prescription of pain medication. To improve medication adherence in chronic pain patients, most interventions should be focused on providers of pain therapy. Prescribing chronic pain medication should be seen as part of a larger treatment regimen including adequate follow-up, adherence monitoring and patient education during the course of treatment.


A randomized controlled multimodal behavioral intervention trial for improving antiepileptic drug adherence.

Pakpour Amir H, Gholami Maryam, Esmaeili Ravanbakhsh, Naghibi Seyed Abolhasan, Updegraff John A, Molloy Gerard J, Dombrowski Stephan U

Epilepsy & behavior : E&B [52:133-42] (2015)

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Medication nonadherence is one of the most important reasons for treatment failure in patients with epilepsy. The present study investigated the effectiveness of a multicomponent intervention to improve adherence to antiepileptic drug (AED) medication in patients with epilepsy. In a prospective, randomized multicenter trial, three sessions of face-to-face motivational interviewing (MI) in combination with complementary behavior change techniques were compared with standard care. Motivational interviewing prompted change talk and self-motivated statements from the patients, planning their own medication intake regimen and also identifying and overcoming barriers that may prevent adherence. Participants were provided with calendars to self-monitor their medication taking behavior. A family member and the health-care team were invited to attend the last session of MI in order to improve the collaboration and communication between patients, their caregiver or family member, and their health-care provider. At baseline and 6-month follow-up, psychosocial variables and medical adherence were assessed. In total, 275 participants were included in the study. Compared with the active control group, patients in the intervention group reported significantly higher medication adherence, as well as stronger intention and perceptions of control for taking medication regularly. The intervention group also reported higher levels of action planning, coping planning, self-monitoring, and lower medication concerns. This study shows that MI can be effective in clinical practice to improve medication adherence in patients with epilepsy. It also provides evidence that combining volitional interventions, including action planning, coping planning, and self-monitoring with motivational interviewing can promote the effectiveness of the medical treatments for epilepsy by improving adherence.


Intensified pharmaceutical care is improving immunosuppressive medication adherence in kidney transplant recipients during the first post-transplant year: a quasi-experimental study.

Joost Robert, Dörje Frank, Schwitulla Judith, Eckardt Kai-Uwe, Hugo Christian

Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association [29:1597-607] (2014)

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Medication adherence is critical for transplant patients because the consequences of non-adherence can result in allograft loss and may be life threatening. A prospective study with 74 renal transplant recipients using a sequential control group design was performed to investigate the impact of a pharmaceutical intensified care programme led by a clinical pharmacist on daily drug adherence during the first year after renal transplantation. Thirty-nine patients of the control group received the already established standardized drug and transplant training, while 35 patients of the intensified care group (ICG) received additional inpatient and outpatient pharmaceutical care and counselling by a dedicated clinical pharmacist. Applied interventions were clustered and classified using the behaviour change technique taxonomy according to Michie. Adherence to immunosuppressive drug therapy was monitored up to 1 year using a medication event monitoring system, pill count (PC), drug holiday (DH) occurrence, Morisky questionnaire and self-report. Sixty-seven patients (35 of the standard care and 32 of the ICG) were analysed. Implementation of DA was significantly (P = 0.014) improved in patients of the ICG (91%) compared with SCG (75%) during the first year after transplantion. Daily adherence measures were already improved within 30-40 days after start of intensified patient care and continued throughout the study period. Intensified care patients also showed significantly better results for taking adherence (P = 0.006), PC (P = 0.008) and DHs (P = 0.001). The additional, intensified pharmaceutical care improved patients' medication adherence remarkably, suggesting that the applied additional care programme has the potential to improve outcomes after organ transplantation.


A crossover trial evaluating an educational-behavioural joint protection programme for people with rheumatoid arthritis.

Hammond A, Lincoln N, Sutcliffe L

Patient education and counseling [37:19-32] (1999)

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Joint protection (JP) is a self-management technique widely taught to people with rheumatoid arthritis (RA). JP education aims to enable people with RA to reduce pain, inflammation, joint stress and reduce risks of deformity through using assistive devices and alternative movement patterns of affected joints to perform everyday activities. Previous studies evaluating JP education methods common in the UK have identified JP adherence is poor. A group education programme was developed using the Health Belief Model and Self-efficacy Theory. Strategies used to maximise JP adherence included goal-setting, contracting, modelling, homework programmes, motor learning theory, recall enhancing methods and mental practice. A crossover trial (n = 35) was conducted. Adherence with JP was measured using an objective observational test (the Joint Protection Behaviour Assessment). Significant improvements in use of JP were recorded at 12 and 24 weeks post-education (P < 0.01). No significant changes in measures of pain, functional disability, grip strength, self-efficacy or helplessness occurred post-education, although this may have been due to the small sample size recruited. In conclusion, JP adherence can be facilitated through the use of educational-behavioural strategies, suggesting this approach should be more widely adopted in clinical practice.


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.


Improving adherence to multiple medications in older people in primary care: Selecting intervention components to address patient-reported barriers and facilitators.

Patton Deborah E, Cadogan Cathal A, Ryan Cristín, Francis Jill J, Gormley Gerard J, Passmore Peter, Kerse Ngaire, Hughes Carmel M

Health expectations : an international journal of public participation in health care and health policy (2017)

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Medication adherence is vital to ensuring optimal patient outcomes, particularly amongst multimorbid older people prescribed multiple medications. Interventions targeting adherence often lack a theoretical underpinning and this may impact on effectiveness. The theoretical domains framework (TDF) of behaviour can aid intervention development by systematically identifying key determinants of medication adherence. This study aimed to (i) identify determinants (barriers, facilitators) of adherence to multiple medications from older people's perspectives; (ii) identify key domains to target for behaviour change; and (iii) map key domains to intervention components [behaviour change techniques (BCTs)] that could be delivered in an intervention by community pharmacists. Focus groups were conducted with older people (>65 years) receiving ≥4 medications. Questions explored the 12 domains of the TDF (eg "Knowledge," "Emotion"). Data were analysed using the framework method and content analysis. Identification of key domains and mapping to intervention components (BCTs) followed established methods. Seven focus groups were convened (50 participants). A wide range of determinants were identified as barriers (eg forgetfulness, prioritization of medications) and facilitators (eg social support, personalized routines) of adherence to multiple medications. Eight domains were identified as key targets for behaviour change (eg "Social influences," "Memory, attention and decision processes," "Motivation and goals") and mapped to 11 intervention components (BCTs) to include in an intervention [eg "Social support or encouragement (general)," "Self-monitoring of the behaviour," "Goal-setting (behaviour)"]. This study used a theoretical underpinning to identify potential intervention components (BCTs). Future work will incorporate the selected BCTs into an intervention that will undergo feasibility testing in community pharmacies.


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 adherence in stroke survivors: mediators and moderators of treatment effects.

O'Carroll Ronan E, Chambers Julie A, Dennis Martin, Sudlow Cathie, Johnston Marie

Health psychology : official journal of the Division of Health Psychology, American Psychological Association [33:1241-50] (2014)

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The purpose of the current study was to test theory-based predictions of mediators and moderators of treatment effects of a pilot randomized controlled trial, which aimed to increase adherence to preventive medication in stroke survivors via addressing both automatic (i.e., habitual responses) and reflective (i.e., beliefs and value systems) aspects of medication-taking behavior. Sixty-two stroke survivors were randomly allocated to either an intervention or control group. Intervention participants received a brief 2-session intervention aimed at increasing adherence via (a) helping patients establish better medication-taking routines using implementation intentions plans (automatic), and (b) eliciting and modifying any mistaken patient beliefs regarding medication and/or stroke (reflective). The control group received similar levels of non-medication-related contact. Primary outcome was adherence to antihypertensive medicine measured objectively over 3 months using an electronic pill bottle. Secondary outcome measures included self-reported adherence (including forgetting) and beliefs about medication. Intervention participants had 10% greater adherence on doses taken on schedule (intervention, 97%; control, 87%; 95% CI [0.2, 16.2], p = .048), as well as significantly greater increases in self-reported adherence and reductions in concerns about medication. Treatment effects were mediated by reductions in both forgetting and concerns about medication, and moderated by the presence of preexisting medication-taking routines. Addressing both automatic and reflective aspects of behavior via helping stroke survivors develop planned regular routines for medication-taking, and addressing any concerns or misconceptions about their medication, can improve adherence and thus potentially patient outcomes.


Beyond good intentions: The role of proactive coping in achieving sustained behavioural change in the context of diabetes management.

Thoolen Bart Johan, de Ridder Denise, Bensing Jozien, Gorter Kees, Rutten Guy

Psychology & health [24:237-54] (2009)

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This study examines the effectiveness of a brief self-management intervention to support patients recently diagnosed with type-2 diabetes to achieve sustained improvements in their self-care behaviours. Based on proactive coping, the intervention emphasizes the crucial role of anticipation and planning in maintaining self-care behaviours. In a randomised controlled trial among recent screen-detected patients, participants who received the intervention were compared with usual-care controls, examining changes in proximal outcomes (intentions, self-efficacy and proactive coping), self-care behaviour (diet, physical activity and medication) and weight over time (0, 3 and 12 months). Subsequently, the contribution of proactive coping in predicting maintenance of behavioural change was analysed using stepwise hierarchical regression analyses, controlling for baseline self-care behaviour, patient characteristics, and intentions and self-efficacy as measured after the course. The intervention was effective in improving proximal outcomes and behaviour with regard to diet and physical activity, resulting in significant weight loss at 12 months. Furthermore, proactive coping was a better predictor of long-term self-management than either intentions or self-efficacy. Proactive coping thus offers new insights into behavioural maintenance theory and can be used to develop effective self-management interventions.


My Interventional Drug-Eluting Stent Educational App (MyIDEA): Patient-Centered Design Methodology.

Boyd Andrew Dallas, Moores Kaitlin, Shah Vicki, Sadhu Eugene, Shroff Adhir, Groo Vicki, Dickens Carolyn, Field Jerry, Baumann Matthew, Welland Betty, Gutowski Gerry, Flores Jose D, Zhao Zhongsheng, Bahroos Neil, Hynes Denise M, Wilkie Diana J

JMIR mHealth and uHealth [3:e74] (2015)

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Patient adherence to medication regimens is critical in most chronic disease treatment plans. This study uses a patient-centered tablet app, "My Interventional Drug-Eluting Stent Educational App (MyIDEA)." This is an educational program designed to improve patient medication adherence. Our goal is to describe the design, methodology, limitations, and results of the MyIDEA tablet app. We created a mobile technology-based patient education app to improve dual antiplatelet therapy adherence in patients who underwent a percutaneous coronary intervention and received a drug-eluting stent. Patient advisers were involved in the development process of MyIDEA from the initial wireframe to the final launch of the product. The program was restructured and redesigned based on the patient advisers' suggestions as well as those from multidisciplinary team members. To accommodate those with low health literacy, we modified the language and employed attractive color schemes to improve ease of use. We assumed that the target patient population may have little to no experience with electronic tablets, and therefore, we designed the interface to be as intuitive as possible. The MyIDEA app has been successfully deployed to a low-health-literate elderly patient population in the hospital setting. A total of 6 patients have interacted with MyIDEA for an average of 17.6 minutes/session. Including patient advisers in the early phases of a mobile patient education development process is critical. A number of changes in text order, language, and color schemes occurred to improve ease of use. The MyIDEA program has been successfully deployed to a low-health-literate elderly patient population. Leveraging patient advisers throughout the development process helps to ensure implementation success. Our goal is to describe the design, methodology, limitations, and results of the MyIDEA tablet app. We created a mobile technology-based patient education app to improve dual antiplatelet therapy adherence in patients who underwent a percutaneous coronary intervention and received a drug-eluting stent.


Development of an intervention to improve appropriate polypharmacy in older people in primary care using a theory-based method.

Cadogan Cathal A, Ryan Cristín, Francis Jill J, Gormley Gerard J, Passmore Peter, Kerse Ngaire, Hughes Carmel M

BMC health services research [16:661] (2016)

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It is advocated that interventions to improve clinical practice should be developed using a systematic approach and intervention development methods should be reported. However, previous interventions aimed at ensuring that older people receive appropriate polypharmacy have lacked details on their development. This study formed part of a multiphase research project which aimed to develop an intervention to improve appropriate polypharmacy in older people in primary care. The target behaviours for the intervention were prescribing and dispensing of appropriate polypharmacy to older patients by general practitioners (GPs) and community pharmacists. Intervention development followed a systematic approach, including previous mapping of behaviour change techniques (BCTs) to key domains from the Theoretical Domains Framework that were perceived by GPs and pharmacists to influence the target behaviours. Draft interventions were developed to operationalise selected BCTs through team discussion. Selection of an intervention for feasibility testing was guided by a subset of the APEASE (Affordability, Practicability, Effectiveness/cost-effectiveness, Acceptability, Side-effects/safety, Equity) criteria. Three draft interventions comprising selected BCTs were developed, targeting patients, pharmacists and GPs, respectively. Following assessment of each intervention using a subset of the APEASE criteria (affordability, practicability, acceptability), the GP-targeted intervention was selected for feasibility testing. This intervention will involve a demonstration of the behaviour and will be delivered as an online video. The video demonstrating how GPs can prescribe appropriate polypharmacy during a typical consultation with an older patient will also demonstrate salience of consequences (feedback emphasising the positive outcomes of performing the behaviour). Action plans and prompts/cues will be used as complementary intervention components. The intervention is designed to facilitate the prescribing of appropriate polypharmacy in routine practice. A GP-targeted intervention to improve appropriate polypharmacy in older people has been developed using a systematic approach. Intervention content has been specified using an established taxonomy of BCTs and selected to maximise feasibility. The results of a future feasibility study will help to determine if the theory-based intervention requires further refinement before progressing to a larger scale randomised evaluation.


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.


Evaluating a community-based walking intervention for hypertensive older people in Taiwan: a randomized controlled trial.

Lee LL, Arthur A, Avis M

Preventive medicine [44:160-6] (2007)

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To study the effect of a community-based walking intervention on blood pressure among older people. The study design was a randomized controlled trial conducted in a rural area of Taiwan between October 2002 and June 2003. A total of 202 participants aged 60 years and over with mild to moderate hypertension was recruited. Participants randomized to the intervention group (n=102) received a six-month community-based walking intervention based on self-efficacy theory. A public health nurse provided both face-to-face and telephone support designed to assist participants to increase their walking. Control group participants (n=100) received usual primary health care. Primary outcome was change in systolic blood pressure and secondary outcomes were exercise self-efficacy, self-reported walking and diastolic blood pressure. At six-month follow-up the mean change in systolic blood pressure was a decrease of 15.4 mmHg and 8.4 mmHg in the intervention and control group, respectively. The difference in mean change between the two groups was -7.0 mmHg (95% CI, -11.5 to -2.5 mmHg, p=0.002). Improvement in exercise self-efficacy scores was greater among intervention group participants (mean difference 1.23, 95% CI, 0.5 to 2.0, p=0.001). Intervention group participants were more likely to report walking more (p<0.0005) but no differences were observed in diastolic blood pressure (p=0.19). Among hypertensive older people, a six-month community-based walking intervention was effective in increasing their exercise self-efficacy and reducing systolic blood pressure.


Vitalum study design: RCT evaluating the efficacy of tailored print communication and telephone motivational interviewing on multiple health behaviors.

van Keulen Hilde M, Mesters Ilse, Brug Johannes, Ausems Marlein, Campbell Marci, Resnicow Ken, Zwietering Paul J, van Breukelen Gerard, van Mechelen Willem, Severens Johan L, de Vries Hein

BMC public health [8:216] (2008)

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A large proportion of adults fail to meet public health guidelines for physical activity as well as fruit, vegetable and fat intake. Interventions are needed to improve these health behaviors. Both computer tailoring and motivational interviewing have shown themselves to be promising techniques for health behavior change. The Vitalum project aims to compare the efficacy of these techniques in improving the health behaviors of adults aged 45-70. This paper describes the design of the Vitalum study. Dutch general medical practices (N = 23) were recruited via a registration network or by personal invitation. The participants were then enrolled through these general practices using an invitational letter. They (n = 2,881) received a written baseline questionnaire to assess health behaviors, and potential psychosocial and socio-demographic behavioral determinants. A power analysis indicated that 1,600 participants who were failing to meet the guidelines for physical activity and either fruit or vegetable consumption were needed. Eligible participants were stratified based on hypertension status and randomized into one of four intervention groups: tailored print communication, telephone motivational interviewing, combined, and control. The first two groups either received four letters or took part in four interviews, whereas the combined group received two letters and took part in two interviews in turns at 5, 13, 30 and 43 weeks after returning the baseline questionnaire. Each letter and interview focused on physical activity or nutrition behavior. The participants also took part in a telephone survey 25 weeks after baseline to gather new information for tailoring. There were two follow-up questionnaires, at 47 and 73 weeks after baseline, to measure short- and long-term effects. The control group received a tailored letter after the last posttest. The process, efficacy and cost-effectiveness of the interventions will be examined by means of multilevel mixed regression, cost-effectiveness analyses and process evaluation. The Vitalum study simultaneously evaluates the efficacy of tailored print communication and telephone motivational interviewing, and their combined use for multiple behaviors and people with different motivational stages and education levels. The results can be used by policymakers to contribute to evidence-based prevention of chronic diseases. Dutch Trial Register NTR1068.


Remotely Delivered Exercise-Based Cardiac Rehabilitation: Design and Content Development of a Novel mHealth Platform.

Rawstorn Jonathan C, Gant Nicholas, Meads Andrew, Warren Ian, Maddison Ralph

JMIR mHealth and uHealth [4:e57] (2016)

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Participation in traditional center-based cardiac rehabilitation exercise programs (exCR) is limited by accessibility barriers. Mobile health (mHealth) technologies can overcome these barriers while preserving critical attributes of center-based exCR monitoring and coaching, but these opportunities have not yet been capitalized on. We aimed to design and develop an evidence- and theory-based mHealth platform for remote delivery of exCR to any geographical location. An iterative process was used to design and develop an evidence- and theory-based mHealth platform (REMOTE-CR) that provides real-time remote exercise monitoring and coaching, behavior change education, and social support. The REMOTE-CR platform comprises a commercially available smartphone and wearable sensor, custom smartphone and Web-based applications (apps), and a custom middleware. The platform allows exCR specialists to monitor patients' exercise and provide individualized coaching in real-time, from almost any location, and provide behavior change education and social support. Intervention content incorporates Social Cognitive Theory, Self-determination Theory, and a taxonomy of behavior change techniques. Exercise components are based on guidelines for clinical exercise prescription. The REMOTE-CR platform extends the capabilities of previous telehealth exCR platforms and narrows the gap between existing center- and home-based exCR services. REMOTE-CR can complement center-based exCR by providing an alternative option for patients whose needs are not being met. Remotely monitored exCR may be more cost-effective than establishing additional center-based programs. The effectiveness and acceptability of REMOTE-CR are now being evaluated in a noninferiority randomized controlled trial.


Psychosocial mediators of a theory-based resistance training maintenance intervention for prediabetic adults.

Williams David M, Dunsiger Shira, Davy Brenda M, Kelleher Sarah A, Marinik Elaina L, Winett Richard A

Psychology & health [31:1108-24] (2016)

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Examine psychosocial mediators of the effects of high vs. low-dose resistance training (RT) maintenance interventions among older (ages 50-69), overweight and pre-diabetic adults. Participants (N = 123) completed a three-month supervised RT initiation phase and were subsequently randomised (time 1) to high or low-dose six-month unsupervised RT maintenance interventions (time 2), followed by a six-month no-contact phase (time 3). Online measures of putative mediators and RT behaviour. RT intervention condition (high vs. low dose) had significant effects on change from time 1 to time 2 in behavioural expectation, self-regulation and perceived satisfaction (f(2) = .04-.08), but not outcome expectancies, RT strategies or behavioural intentions (f(2) ≤ .02). Change in each of the putative mediators, except for outcome expectancies (f(2) ≤ .02), had significant effects on RT behaviour at times 2 (f(2) = .12-.27) and 3 (f(2) = .23-.40). In a multiple mediation model, behavioural expectation (f(2) = .11) and self-regulation (f(2) = .06) mediated the effects of RT intervention condition on time 2 RT behaviour, whereas perceived satisfaction did not (f(2) = .01). Self-regulation was a significant mediator of intervention effects on time 3 RT behaviour (f(2) = .11), but behavioural expectation and perceived satisfaction were not (f(2) = .04). Findings suggest that behavioural expectation and self-regulation are appropriate targets for RT maintenance interventions among at-risk older adults.


Reducing cardiovascular risk factors in postmenopausal women through a lifestyle change intervention.

Carels Robert A, Darby Lynn A, Cacciapaglia Holly M, Douglass Olivia M

Journal of women's health (2002) [13:412-26] (2004)

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The impact of a 6-month lifestyle change intervention on cardiovascular risk factors in obese, sedentary, postmenopausal women was examined. A secondary aim of this investigation was to determine whether the addition of self-control skills training to an empirically supported lifestyle change intervention would result in greater cardiovascular risk reduction. Forty-four women were randomly assigned to receive either a lifestyle change or a lifestyle change with self-control skills intervention. Pretreatment and posttreatment weight loss, body composition, physical activity, cardiorespiratory fitness, diet, blood pressure (BP), blood lipids, and psychosocial functioning were assessed. Also, at 1-year posttreatment, weight loss, body composition, self-reported physical activity, and psychosocial functioning were assessed. The women significantly increased their physical activity (+39.6%) and cardiorespiratory fitness (+13.5%) and reduced their body weight (-6.5%), fat mass (-7.4%), body fat (-2.4%), BP (SBP -6.2%, DBP -9.2%), total cholesterol (-7.4%), triglycerides (-16.5%), and low-density lipoprotein (LDL) cholesterol (9.1%) and improved their diet (p < 0.05). At the 1-year follow-up, women had regained approximately 63% of their posttreatment weight loss (p < 0.05), but had maintained their previous increases in physical activity. Additionally, there were no significant changes in fat free mass, body fat, anxiety, or depression between the end of treatment and 1-year posttreatment. The addition of self-control skills training did not significantly improve cardiovascular risk reduction. Lifestyle change interventions may be an effective means for reducing cardiovascular risk in obese, sedentary, postmenopausal women. However, greater attention should be devoted to the maintenance of these positive lifestyle changes.


Promoting exercise behavior in older adults: using a cognitive behavioral intervention.

Schneider Joanne Kraenzle, Mercer Gina Touch, Herning Margaret, Smith Catherine A, Prysak Megan Davis

Journal of gerontological nursing [30:45-53] (2004)

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Health benefits associated with exercise are only obtained when exercise is maintained. The purpose of this pilot study was to examine the effects of a cognitive behavioral therapy (CBT) intervention on exercise behavior and physical outcomes in older adults. All participants were taught progressive flexibility, strength, and endurance exercises. The control group received no additional treatment. The experimental group was taught to recognize negative thoughts related to exercise and to counter these thoughts with more positive ones. Subsequent exercise behavior and physical outcomes were measured in all participants. Cognitive behavioral therapy was moderately to largely effective in improving the majority of physical outcomes assessed. In addition, CBT was moderately effective in improving several components of self-reported exercise behavior and mildly effective in improving exercise behavior overall. Results suggest that nurses can train older adults to identify and modify thoughts that interfere with or reduce their exercise behavior and thus improve physical functioning.


Active for Life After Cancer: a randomized trial examining a lifestyle physical activity program for prostate cancer patients.

Carmack Taylor, Cindy L, Demoor Carl, Smith Murray A, Dunn Andrea L, Basen-Engquist Karen, Nielsen Ingrid, Pettaway Curtis, Sellin Rena, Massey Pamela, Gritz Ellen R

Psycho-oncology [15:847-62] (2006)

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Active for Life After Cancer is a randomized trial evaluating the efficacy of a 6-month group-based lifestyle physical activity program (Lifestyle) for prostate cancer patients to improve quality of life (QOL) including physical and emotional functioning compared to a group-based Educational Support Program and a Standard Care Program (no group). A total of 134 prostate cancer patients receiving continuous androgen-ablation were randomly assigned to one of the three study conditions. Results indicated no significant improvements in QOL at 6 or 12 months. Both group-based programs were positively received and yielded good attendance and retention. Lifestyle participants demonstrated significant improvements in most theoretical mediators proposed by the Transtheoretical Model and Social Cognitive Theory to affect physical activity. Despite these improvements, no significant changes were found for most physical activity measures. Results suggest a lifestyle program focusing on cognitive-behavioral skills training alone is insufficient for promoting routine physical activity in these patients.


Moms in motion: a group-mediated cognitive-behavioral physical activity intervention.

Cramp Anita G, Brawley Lawrence R

The international journal of behavioral nutrition and physical activity [3:23] (2006)

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When examining the prevalence of physical inactivity by gender and age, women over the age of 25 are at an increased risk for sedentary behavior. Childbearing and motherhood have been explored as one possible explanation for this increased risk. Post natal exercise studies to date demonstrate promising physical and psychological outcomes, however few physical activity interventions have been theory-driven and tailored to post natal exercise initiates. The purpose of this study was to compare the effects of a group-mediated cognitive behavioral intervention based upon social-cognitive theory and group dynamics (GMCB) to a standard care postnatal exercise program (SE). A randomized, two-arm intervention design was used. Fifty-seven post natal women were randomized to one of two conditions: (1) a standard exercise treatment (SE) and (2) a standard exercise treatment plus group-mediated cognitive behavioral intervention (GMCB). Participants in both conditions participated in a four-week intensive phase where participants received standard exercise training. In addition, GMCB participants received self-regulatory behavioral skills training via six group-mediated counseling sessions. Following the intensive phase, participants engaged in a four-week home-based phase of self-structured exercise. Measures of physical activity, barrier efficacy, and proximal outcome expectations were administered and data were analyzed using ANCOVA procedures. ANCOVA of change scores for frequency, minutes, and volume of physical activity revealed significant treatment effects over the intensive and home-based phases (p's < 0.01). In addition, ANCOVA of change in mean barrier efficacy and proximal outcome expectations at the conclusion of the intensive phase demonstrated that GMCB participants increased their initial level of barrier efficacy and outcome expectations while SE participants decreased (p < 0.05). While both exercise programs resulted in improvements to exercise participation, the GMCB intervention produced greater improvement in overall physical activity, barrier efficacy and proximal outcome expectations.


What do targeting positive views on ageing add to a physical activity intervention in older adults? Results from a randomised controlled trial.

Wolff Julia K, Warner Lisa M, Ziegelmann Jochen P, Wurm Susanne

Psychology & health [29:915-32] (2014)

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Physical activity is a key factor for healthy ageing, yet many older people lead a sedentary lifestyle. Traditional physical activity interventions do not consider the specific needs and views of older adults. As views on ageing are known to be related to health behaviours, the current study evaluates the effectiveness of prompting positive views on ageing within a physical activity intervention. Randomised controlled trial with three groups aged 65+: Intervention for physical activity with 'views-on-ageing'-component (n = 101; IGVoA), and without 'views-on-ageing'-component (n = 30; IG), and active control intervention for volunteering (n = 103; CG). Attitudes towards older adults and physical activity were assessed five weeks before intervention, two weeks, six weeks and 8.5 months after the intervention. Compared to the IG and CG, positive attitudes towards older adults increased in the IGVoA after the intervention. For IGVoA, the indirect intervention effect on change in activity via change in attitudes towards older adults was reliable. A 'views-on-ageing'-component within a physical activity intervention affects change in physical activity via change in views on ageing. Views on ageing are a promising intervention technique to be incorporated into future physical activity interventions for older adults.


A web-based program improves physical activity outcomes in a primary care angina population: randomized controlled trial.

Devi R, Powell J, Singh S

Journal of medical Internet research [16:e186] (2014)

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Angina affects more than 50 million people worldwide. Secondary prevention interventions such as cardiac rehabilitation are not widely available for this population. An Internet-based version could offer a feasible alternative. Our aim was to examine the effectiveness of a Web-based cardiac rehabilitation program for those with angina. We conducted a randomized controlled trial, recruiting those diagnosed with angina from general practitioners (GPs) in primary care to an intervention or control group. Intervention group participants were offered a 6-week Web-based rehabilitation program ("ActivateYourHeart"). The program was introduced during a face-to-face appointment and then delivered via the Internet (no further face-to-face contact). The program contained information about the secondary prevention of coronary heart disease (CHD) and set each user goals around physical activity, diet, managing emotions, and smoking. Performance against goals was reviewed throughout the program and goals were then reset/modified. Participants completed an online exercise diary and communicated with rehabilitation specialists through an email link/synchronized chat room. Participants in the control group continued with GP treatment as usual, which consisted of being placed on a CHD register and attending an annual review. Outcomes were measured at 6-week and 6-month follow-ups during face-to-face assessments. The primary outcome measure was change in daily steps at 6 weeks, measured using an accelerometer. Secondary outcome measures were energy expenditure (EE), duration of sedentary activity (DSA), duration of moderate activity (DMA), weight, diastolic/systolic blood pressure, and body fat percentage. Self-assessed questionnaire outcomes included fat/fiber intake, anxiety/depression, self-efficacy, and quality of life (QOL). A total of 94 participants were recruited and randomized to the intervention (n=48) or the usual care (n=46) group; 84 and 73 participants completed the 6-week and 6-month follow-ups, respectively. The mean number of log-ins to the program was 18.68 (SD 13.13, range 1-51), an average of 3 log-ins per week per participant. Change in daily steps walked at the 6-week follow-up was +497 (SD 2171) in the intervention group and -861 (SD 2534) in the control group (95% CI 263-2451, P=.02). Significant intervention effects were observed at the 6-week follow-up in EE (+43.94 kcal, 95% CI 43.93-309.98, P=.01), DSA (-7.79 minutes, 95% CI -55.01 to -7.01, P=.01), DMA (+6.31 minutes, 95% CI 6.01-51.20, P=.01), weight (-0.56 kg, 95% CI -1.78 to -0.15, P=.02), self-efficacy (95% CI 0.30-4.79, P=.03), emotional QOL score (95% CI 0.01-0.54, P=.04), and angina frequency (95% CI 8.57-35.05, P=.002). Significant benefits in angina frequency (95% CI 1.89-29.41, P=.02) and social QOL score (95% CI 0.05-0.54, P=.02) were also observed at the 6-month follow-up. An Internet-based secondary prevention intervention could be offered to those with angina. A larger pragmatic trial is required to provide definitive evidence of effectiveness and cost-effectiveness.


Using a combined protection motivation theory and health action process approach intervention to promote exercise during pregnancy.

Gaston A, Prapavessis H

Journal of behavioral medicine [37:173-84] (2014)

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Despite the benefits of exercise during pregnancy, many expectant mothers are inactive. This study examined whether augmenting a protection motivation theory (PMT) intervention with a Health Action Process Approach can enhance exercise behavior change among pregnant women. Sixty inactive pregnant women were randomly assigned to one of three treatment groups: PMT-only, PMT + action-planning, and PMT + action-and-coping-planning. Week-long objective (accelerometer) and subjective (self-report) exercise measures were collected at baseline, and at 1- and 4-weeks post-intervention. Repeated-measures ANOVAs demonstrated that while all participants reported increased exercise from baseline to 1-week post-intervention, participants in both planning groups were significantly more active (p < .001) than those in the PMT-only group by 4-weeks post-intervention (η (2) = .13 and .15 for accelerometer and self-report data, respectively). In conclusion, augmenting a PMT intervention with action or action-and-coping-planning can enhance exercise behavior change in pregnant women.


The Southampton Initiative for Health: a complex intervention to improve the diets and increase the physical activity levels of women from disadvantaged communities.

Barker Mary, Baird Janis, Lawrence Wendy, Jarman Megan, Black Christina, Barnard Katharine, Cradock Sue, Davies Jenny, Margetts Barrie, Inskip Hazel, Cooper Cyrus

Journal of health psychology [16:178-91] (2011)

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The Southampton Initiative for Health is a training intervention with Sure Start Children's Centre staff designed to improve the diets and physical activity levels of women of childbearing age. Training aims to help staff to support women in making changes to their lifestyles by improving three skills: reflection on current practice; asking 'open discovery' questions; and goal-setting. The impact of the training on staff practice is being assessed. A before and after non-randomized controlled trial is being used to evaluate the effectiveness and cost-effectiveness of the intervention in improving women's diets and increasing their physical activity levels.


A web-based intervention for health professionals and patients to decrease cardiovascular risk attributable to physical inactivity: development process.

Sassen Barbara, Kok Gerjo, Mesters Ilse, Crutzen Rik, Cremers Anita, Vanhees Luc

JMIR research protocols [1:e21] (2012)

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Patients with cardiovascular risk factors can reduce their risk of cardiovascular disease by increasing their physical activity and their physical fitness. According to the guidelines for cardiovascular risk management, health professionals should encourage their patients to engage in physical activity. In this paper, we provide insight regarding the systematic development of a Web-based intervention for both health professionals and patients with cardiovascular risk factors using the development method Intervention Mapping. The different steps of Intervention Mapping are described to open up the "black box" of Web-based intervention development and to support future Web-based intervention development. The development of the Professional and Patient Intention and Behavior Intervention (PIB2 intervention) was initiated with a needs assessment for both health professionals (ie, physiotherapy and nursing) and their patients. We formulated performance and change objectives and, subsequently, theory- and evidence-based intervention methods and strategies were selected that were thought to affect the intention and behavior of health professionals and patients. The rationale of the intervention was based on different behavioral change methods that allowed us to describe the scope and sequence of the intervention and produced the Web-based intervention components. The Web-based intervention consisted of 5 modules, including individualized messages and self-completion forms, and charts and tables. The systematic and planned development of the PIB2 intervention resulted in an Internet-delivered behavior change intervention. The intervention was not developed as a substitute for face-to-face contact between professionals and patients, but as an application to complement and optimize health services. The focus of the Web-based intervention was to extend professional behavior of health care professionals, as well as to improve the risk-reduction behavior of patients with cardiovascular risk factors. The Intervention Mapping protocol provided a systematic method for developing the intervention and each intervention design choice was carefully thought-out and justified. Although it was not a rapid or an easy method for developing an intervention, the protocol guided and directed the development process. The application of evidence-based behavior change methods used in our intervention offers insight regarding how an intervention may change intention and health behavior. The Web-based intervention appeared feasible and was implemented. Further research will test the effectiveness of the PIB2 intervention. Dutch Trial Register, Trial ID: ECP-92.


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.


Testing the Senior Exercise Self-efficacy Project (SESEP) for use with urban dwelling minority older adults.

Resnick Barbara, Luisi Daria, Vogel Amanda

Public health nursing (Boston, Mass.) [25:221-34] ()

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To test the feasibility and effectiveness of the Senior Exercise Self-efficacy Project (SESEP). A feasibility study using a randomized control trial. The total sample included 166 persons, with a mean age of 73 years (SD=8.2 years), the majority of whom were female (81%), African American (72%), unmarried (86%), had at least a high school education (64%), and were retired (77%). There were 100 participants in the intervention group and 66 in the comparison group. The SESEP was a combined physical activity and efficacy-enhancing intervention for community-dwelling minority older adults. The primary outcomes included self-efficacy, outcome expectations, exercise, and overall physical activity, and the secondary outcomes were mental and physical health-related quality of life, depressive symptoms, pain, fear of falling, mobility, and chair rise time. Data were collected at baseline and following the 12-week intervention. There were statistically significant improvements in outcome expectations (p=.02), time spent in exercise (p=.04), and depressive symptoms (p=.02). Overall, there was a 77% rate of participation in classes. Although there was good participation in the SESEP among minority older adults, the primary outcomes were only minimally supported and there was even less support for the secondary outcomes.


A pilot study evaluating a peer led and professional led physical activity intervention with blue-collar employees.

Elbel Russ, Aldana Steve, Bloswick Don, Lyon Joseph L

Work (Reading, Mass.) [21:199-210] (2003)

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To measure the effect of a physical activity intervention, based on social cognitive theory, delivered by a peer and a professional leader. Quasi-experimental. Three locations at a large Mid-Western railroad. One hundred and forty-eight skilled labor employees participated: one hundred and twenty completed the study. Self-reported energy expenditure, self-efficacy and stages of change. ANOVA and categorical analysis using rates and proportions were used for evaluation. The peer group had a non-significant short-term increase in energy expenditure of 3%, which returned to baseline post intervention. The professional and control groups showed a non-significant decrease in energy expenditure of 5% and 9%, respectively. The peer (p < 0.002) and professional groups (p < 0.004) showed significant increases in average stages scores. The peer group maintained increases over time (p < 0.001). The peer and professional led groups showed a 54% and 24% increase in the number of employees reporting regular physical activity over time, respectively. The peer group also showed positive trends in self-efficacy. The peer intervention enhanced self-efficacy and self-reported physical activity. A job layoff at the professional led site confounded comparisons between locations. Employees reported high energy expenditure and high BMI values, suggesting that a weight management intervention may be more appropriate and appealing in this population.


A Smartphone App to Promote an Active Lifestyle in Lower-Educated Working Young Adults: Development, Usability, Acceptability, and Feasibility Study.

Simons Dorien, De Bourdeaudhuij Ilse, Clarys Peter, De Cocker Katrien, Vandelanotte Corneel, Deforche Benedicte

JMIR mHealth and uHealth [6:e44] (2018)

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Physical activity (PA) levels are problematic in lower-educated working young adults (18-26 years). To promote PA, smartphone apps have great potential, but there is no evidence for their effectiveness in this population. To increase the likelihood that a newly developed app will be effective, formative research and user testing are required. The aim of this study was to describe the development, usability, acceptability, and feasibility of a new theory- and evidence-based smartphone app to promote an active lifestyle in lower-educated working young adults. The new app was developed by applying 4 steps. First, determinants important to promote an active lifestyle in this population were selected. Second, evidence-based behavior change techniques were selected to convert the determinants into practical applications. Third, a new smartphone app was developed. Fourth, volunteers (n=11, both lower and higher educated) tested the app on usability, and lower-educated working young adults (n=16) tested its acceptability and feasibility via (think aloud) interviews, a questionnaire, and Google Analytics. The app was accordingly adapted for the final version. A new Android app, Active Coach, was developed that focused on knowledge, attitude, social support, and self-efficacy (based on outcomes from step 1), and that applied self-regulation techniques (based on outcomes from step 2). The app consists of a 9-week program with personal goals, practical tips, and scientific facts to encourage an active lifestyle. To ensure all-day and automatic self-monitoring of the activity behavior, the Active Coach app works in combination with a wearable activity tracker, the Fitbit Charge. Issues detected by the usability test (eg, text errors, wrong messages) were all fixed. The acceptability and feasibility test showed that participants found the app clear, understandable, and motivating, although some aspects needed to be more personal. By applying a stepwise, user-centered approach that regularly consulted the target group, the new app is adapted to their specific needs and preferences. The Active Coach app was overall positively evaluated by the lower-educated working young adults at the end of the development process.


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.


How effective is community physical activity promotion in areas of deprivation for inactive adults with cardiovascular disease risk and/or mental health concerns? Study protocol for a pragmatic observational evaluation of the 'Active Herts' physical activity programme.

Howlett Neil, Jones Andy, Bain Lucy, Chater Angel

BMJ open [7:e017783] (2017)

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There is a high prevalence of inactive adults in the UK, and many suffer from conditions such as cardiovascular disease (CVD) or poor mental health. These coexist more frequently in areas of higher socioeconomic deprivation. There is a need to test the effectiveness, acceptability and sustainability of physical activity programmes. Active Herts uses novel evidence-based behaviour change techniques to target physical inactivity. Active Herts is a community physical activity programme for inactive adults aged 16+ with one or more risk factors for CVD and/or a mild to moderate mental health condition. This evaluation will follow a mixed-methods longitudinal (baseline, and 3-month, 6-month and 12-month follow-ups) design. Pragmatic considerations mean delivery of the programme differs by locality. In two areas programme users will receive a behaviour change technique booklet, regular consultations, a booster phone call, motivational text messages and signposting to 12 weeks of exercise classes. In another two areas programme users will also receive 12 weeks of free tailored exercise classes, with optional exercise 'buddies' available. An outcome evaluation will assess changes in physical activity as the primary outcome, and sporting participation, sitting, well-being, psychological capability and reflective motivation as secondary outcomes. A process evaluation will explore the views of stakeholders, delivery staff and programme leads. Economic evaluation will examine the programme costs against the benefits gained in terms of reduced risk of morbidity. This study was been approved by the Faculty of Medicine and Health Sciences Research Ethics Committee at the University of East Anglia. Informed written consent will be obtained from programme users in the evaluation. Results will be published in peer-reviewed journals, presented at conferences, and shared through the study website and local community outlets. ClinicalTrials.gov ID number: NCT03153098.


Sedentary behavior, physical activity, and psychological health of Korean older adults with hypertension: effect of an empowerment intervention.

Chang Ae Kyung, Fritschi Cynthia, Kim Mi Ja

Research in gerontological nursing [6:81-8] (2013)

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The aim of this study was to determine the effect of an 8-week empowerment intervention on sedentary behavior, physical activity, and psychological health in Korean older adults with hypertension. Using a quasi-experimental design, older adults participated in either an experimental group (n = 27) or control group (n = 21). The experimental group received an empowerment intervention including lifestyle modification education, group discussion, and exercise training for 8 weeks, and the control group received standard hypertension education. After 8 weeks, participants in the experimental group had significantly decreased sedentary behavior, increased physical activity, increased self-efficacy for physical activity, and increased perceived health (p < 0.05). However, no significant group difference was found for depression. Findings from this study suggest that empowerment interventions may be more effective than standard education in decreasing sedentary behavior and increasing physical activity, self-efficacy for physical activity, and perceived health in Korean older adults with hypertension.


Sensing interstitial glucose to nudge active lifestyles (SIGNAL): feasibility of combining novel self-monitoring technologies for persuasive behaviour change.

Whelan Maxine E, Kingsnorth Andrew P, Orme Mark W, Sherar Lauren B, Esliger Dale W

BMJ open [7:e018282] (2017)

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Increasing physical activity (PA) reduces the risk of developing diabetes, highlighting the role of preventive medicine approaches. Changing lifestyle behaviours is difficult and is often predicated on the assumption that individuals are willing to change their lifestyles today to reduce the risk of developing disease years or even decades later. The self-monitoring technologies tested in this study will present PA feedback in real time, parallel with acute physiological data. Presenting the immediate health benefits of being more physically active may help enact change by observing the immediate consequences of that behaviour. The present study aims to assess user engagement with the self-monitoring technologies in individuals at moderate-to-high risk of developing type 2 diabetes. 45 individuals with a moderate-to-high risk, aged ≥40 years old and using a compatible smartphone, will be invited to take part in a 7-week protocol. Following 1 week of baseline measurements, participants will be randomised into one of three groups: group 1- glucose feedback followed by biobehavioural feedback (glucose plus PA); group 2-PA feedback followed by biobehavioural feedback; group 3-biobehavioural feedback. A PA monitor and a flash glucose monitor will be deployed during the intervention. Participants will wear both devices throughout the intervention but blinded to feedback depending on group allocation. The primary outcome is the level of participant engagement and will be assessed by device use and smartphone usage. Feasibility will be assessed by the practicality of the technology and screening for diabetes risk. Semistructured interviews will be conducted to explore participant experiences using the technologies. ISRCTN17545949. Registered on 15/05/2017.


Targeting motivation and self-regulation to increase physical activity among patients with rheumatoid arthritis: a randomised controlled trial.

Knittle Keegan, De Gucht Veronique, Hurkmans Emalie, Peeters Andre, Ronday Karel, Maes Stan, Vlieland Thea Vliet

Clinical rheumatology [34:231-8] (2015)

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The purpose of this study is to evaluate the effects of targeting both the motivation and action phases of behaviour change in a 5-week intervention to increase physical activity (PA) among patients with rheumatoid arthritis (RA) not meeting current PA recommendations. In a randomised controlled trial, a control group—which received a group-based patient education session led by a physical therapist—was compared to a treatment group which received the education session plus a motivational interview from a physical therapist and two self-regulation coaching sessions from a rheumatology nurse. Outcomes included leisure-time PA, days per week with at least 30 min of moderate-intensity PA, self-efficacy and autonomous motivation (cognitions which predict PA initiation and maintenance), disease activity, functional status, depressive symptoms and fatigue. Effects were assessed using mixed models repeated measures. Of the 78 patients randomised, 76 and 67 completed the post-treatment and follow-up assessments, respectively. Significant treatment effects were found for leisure-time PA (p = 0.022), active days/week (p = 0.016), self-efficacy (p = 0.008) and autonomous motivation (p = 0.001). At post-treatment and 6-months follow-up, significantly more treated patients than controls met current PA recommendations. No significant effects were found for disease activity, functional status, depressive symptoms or fatigue. Combining motivation- and action-focused intervention approaches improved PA-related cognitions and led to improved uptake and maintenance of leisure-time PA. However, further research is necessary to identify ways of helping patients with RA transition to—and maintain—more intensive forms of PA which are more likely to improve disease activity and functional status.


Healthy habits: efficacy of simple advice on weight control based on a habit-formation model.

Lally P, Chipperfield A, Wardle J

International journal of obesity (2005) [32:700-7] (2008)

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To evaluate the efficacy of a simple weight loss intervention, based on principles of habit formation. An exploratory trial in which overweight and obese adults were randomized either to a habit-based intervention condition (with two subgroups given weekly vs monthly weighing; n=33, n=36) or to a waiting-list control condition (n=35) over 8 weeks. Intervention participants were followed up for 8 months. A total of 104 adults (35 men, 69 women) with an average BMI of 30.9 kg m(-2). Intervention participants were given a leaflet containing advice on habit formation and simple recommendations for eating and activity behaviours promoting negative energy balance, together with a self-monitoring checklist. Weight change over 8 weeks in the intervention condition compared with the control condition and weight loss maintenance over 32 weeks in the intervention condition. At 8 weeks, people in the intervention condition had lost significantly more weight (mean=2.0 kg) than those in the control condition (0.4 kg), with no difference between weekly and monthly weighing subgroups. At 32 weeks, those who remained in the study had lost an average of 3.8 kg, with 54% losing 5% or more of their body weight. An intention-to-treat analysis (based on last-observation-carried-forward) reduced this to 2.6 kg, with 26% achieving a 5% weight loss. This easily disseminable, low-cost, simple intervention produced clinically significant weight loss. In limited resource settings it has potential as a tool for obesity management.