From Theory-Inspired to Theory-Based Interventions: A Protocol for Developing and Testing a Methodology for Linking Behaviour Change Techniques to Theoretical Mechanisms of Action

Maintaining long-term physical activity after cancer: a conceptual framework to inform intervention development

PURPOSE

This paper describes a conceptual framework of maintenance of physical activity (PA) and its application to future intervention design.

METHODS

Evidence from systematic literature reviews and in-depth (N = 27) qualitative interviews with individuals with cancer were used to develop a conceptual framework of long-term physical activity behaviour. Determinants of long-term PA were listed and linked with domains of the Theoretical Domains Framework which in turn were linked to associated behaviour change techniques (BCTs) and finally to proposed mechanisms of action (MoA).

RESULTS

The conceptual framework is presented within the context of non-modifiable contextual factors (such as demographic and material resources) and in the presence of learnt and adapted behavioural determinants of skills, competence and autonomous motivation that must be established as part of the initiation of physical activity behaviour. An inventory of 8 determinants of engagement in long-term PA after cancer was developed. Clusters of BCTs are presented along with proposed MoA which can be tested using mediation analysis in future trials.

CONCLUSION

Understanding the processes of PA maintenance after cancer and presentation of implementable and testable intervention components and mechanisms of action to promote continued PA can inform future intervention development.

IMPLICATIONS FOR CANCER SURVIVORS

This resource can act as a starting point for selection of intervention components for those developing future interventions. This will facilitate effective support of individuals affected by cancer to maintain PA for the long term.

A qualitative exploration of participants' perspectives and experiences of novel digital health infrastructure to enhance patient care in remote communities within the Home Health Project

The Home Health Project, set on Clare Island, five kilometres off the Irish Atlantic coast, is a pilot exploration of ways in which various forms of technology can be utilised to improve healthcare for individuals living in isolated communities. The integration of digital health technologies presents enormous potential to revolutionise the accessibility of healthcare systems for those living in remote communities, allowing patient care to function outside of traditional healthcare settings. This study aims to explore the personal experiences and perspectives of participants who are using digital technologies in the delivery of their healthcare as part of the Home Health Project. Individual semi-structured interviews were conducted with nine members of the Clare Island community participating in the Home Health Project. Interviews took place in-person, in June 2023. Interviews were audio-recorded and transcribed verbatim. The data were analysed inductively using reflexive thematic analysis. To identify determinants of engagement with the Home Health Project, the data was then deductively coded to the Theoretical Domains Framework (TDF) and organised into themes. Seven of the possible 14 TDF domains were supported by the interview data as influences on engagement with the Project: Knowledge, Beliefs about capabilities, Optimism, Intentions, Environmental context and resources, Social influences and Emotion. Overall, participants evaluated the Home Health Project as being of high quality which contributed to self-reported increases in health literacy, autonomy, and feeling well supported in having their health concerns addressed. There was some apprehension related to data protection, coupled with a desire for extended training to address aspects of digital illiteracy. Future iterations can capitalise on the findings of this study by refining the technologies to reflect tailored health information, personalised to the individual user.

Protection motivation theory and health behaviour: conceptual review, discussion of limitations, and recommendations for best practice and future research

Protection motivation theory is a pre-eminent health behaviour theory purposed to predict participation in health protection and risk behaviours. It has been widely applied across multiple behaviours, populations and contexts. In this conceptual review, we summarise research applying the theory and identify shortcomings and evidence gaps that limit reported inferences and impede theory and intervention development. Accordingly, we provide recommendations for best practices and suggestions for future research to resolve these limitations. Limitations identified include a dearth of comprehensive theory tests, sparse evidence of theory sufficiency, a lack of studies including additional constructs, overuse of correlational and cross-sectional research designs, a paucity of intervention studies and tests of theory-consistent mechanisms of action, few tests intrapersonal and environmental moderators of theory effects and measurement concerns. We provide recommendations to address these limitations including conducting comprehensive theory tests in support of nomological validity; incorporating past behaviour and other constructs to establish theory sufficiency and extend its scope; adopting cross-lagged panel and factorial experimental research designs to test directional effects, permit better causal inference and test mechanisms of action; testing effects of moderators to identify conditions that may affect theory applicability and developing measurement standards for study constructs and adopting non-self-report behaviour measures.

Understanding the mechanisms of change in social norms around tobacco use: A systematic review and meta-analysis of interventions

BACKGROUND AND AIMS

Tobacco use spreads through social networks influencing social norms around tobacco use. However, the social norms scholarship is extremely diverse and occasionally conflicting, complicating efforts to understand how best to leverage social norms to reduce tobacco use. This study systematically reviewed and meta-analyzed this vast terrain by focusing on social norms measurement and mechanism, and intervention effectiveness and modality aimed at changing social norms around tobacco use and actual tobacco use.

METHODS

We searched Scopus, PubMed, PsycInfo, Clinicaltrials.gov, ProQuest Dissertations, the Cochrane Trial Registry, as well as the websites of the Society for Research on Nicotine and Tobacco, the Open Science Framework, medrXiv and the Truth Initiative for experimental and quasi-experimental evaluation studies of interventions designed to shift tobacco use. We included studies written in English from inception to 30 May 2024. We only included studies which noted social norms or social influence as part of the intervention design or set of measured variables. We excluded studies with only one time point, without an intervention being evaluated and those not published in English. Study screening followed the PRISMA 2020 guidelines, and was conducted by at least two independent reviewers who resolved discrepancies through discussion and consensus. All included studies were analyzed in a narrative synthesis, and those providing sufficient statistics for tobacco and social norms outcomes were included in meta-analyses, which were performed separately for tobacco outcomes and social norms outcomes. Study outcomes were transformed into a standardized mean difference (Hedges' g) and several meta-regressions were fit to explore sources of heterogeneity using a robust variance estimation specification to handle effect size dependency.

RESULTS

A total of 95 studies met inclusion criteria for the narrative synthesis, 200 effect sizes from 86 studies were included in the tobacco outcomes meta-analysis, and 66 effect sizes from 29 studies were included in the social norms outcomes meta-analysis. Nearly 90% of included studies were conducted in high-income settings, with the remainder conducted in middle-income settings. No studies were conducted in Latin America or on the African continent. Social norms change interventions had a statistically significant effect on reducing tobacco use and pro-tobacco social normative perceptions [g = 0.233, 95% confidence interval (CI) = 0.166, 0.301, P < 0.001 and g = 0.292, 95% CI = 0.090, 0.494, P = 0.007, respectively]. Interventions were commonly conducted among schoolchildren in classrooms through multicomponent education sessions, often coupled with regular 'booster' sessions over time. Among adult populations, motivational interviewing and other counselling approaches were used in some cases, and few interventions leveraged digital technologies to change social norms.

CONCLUSIONS

Social norms change interventions appear to be effective for reducing tobacco use and pro-tobacco social normative perceptions. In particular, leveraging role models appears to be the most effective social norms change mechanisms for tobacco control.

The PHEM-B toolbox of methods for incorporating the influences on Behaviour into Public Health Economic Models

BACKGROUND

It is challenging to predict long-term outcomes of interventions without understanding how they work. Health economic models of public health interventions often do not incorporate the many determinants of individual and population behaviours that influence long term effectiveness. The aim of this paper is to draw on psychology, sociology, behavioural economics, complexity science and health economics to: (a) develop a toolbox of methods for incorporating the influences on behaviour into public health economic models (PHEM-B); and (b) set out a research agenda for health economic modellers and behavioural/ social scientists to further advance methods to better inform public health policy decisions.

METHODS

A core multidisciplinary group developed a preliminary toolbox from a published review of the literature and tested this conceptually using a case study of a diabetes prevention simulation. The core group was augmented by a much wider group that covered a broader range of multidisciplinary expertise. We used a consensus method to gain agreement of the PHEM-B toolbox. This included a one-day workshop and subsequent reviews of the toolbox.

RESULTS

The PHEM-B toolbox sets out 12 methods which can be used in different combinations to incorporate influences on behaviours into public health economic models: collaborations between modellers and behavioural scientists, literature reviewing, application of the Behaviour Change Intervention Ontology, systems mapping, agent-based modelling, differential equation modelling, social network analysis, geographical information systems, discrete event simulation, theory-informed statistical and econometric analyses, expert elicitation, and qualitative research/process tracing. For each method, we provide a description with key references, an expert consensus on the circumstances when they could be used, and the resources required.

CONCLUSIONS

This is the first attempt to rigorously and coherently propose methods to incorporate the influences on behaviour into health economic models of public health interventions. It may not always be feasible or necessary to model the influences on behaviour explicitly, but it is essential to develop an understanding of the key influences. Changing behaviour and maintaining that behaviour change could have different influences; thus, there could be benefits in modelling these separately. Future research is needed to develop, collaboratively with behavioural scientists, a suite of more robust health economic models of health-related behaviours, reported transparently, including coding, which would allow model reuse and adaptation.

Compendium of dyadic intervention techniques (DITs) to change health behaviours: a systematic review

BACKGROUND

Dyadic interventions for health behaviour change involving the romantic partner are promising. However, it often remains unclear how exactly the partner is involved in dyadic interventions. We propose a novel compendium of dyadic intervention techniques (DITs) that facilitates systematic description of dyadic interventions in terms of who performs what for whom during intervention delivery and subsequent implementation.

OBJECTIVE

We aimed to systematically characterise dyadic interventions along their degree of partner involvement and to provide a comprehensive list of DITs used in dyadic interventions with romantic partners.

METHODS

We systematically reviewed dyadic health behaviour change interventions with controlled designs. We included 165 studies describing 122 distinct dyadic interventions with romantic partners. Interventions were classified along their degree of partner involvement, 160 DITs were extracted, and their frequencies of use counted.

RESULTS

The majority of interventions (n = 90, 74%) explicitly instructed partners to interact. Half of the DITs were performed jointly by the couple and also targeted the couple. Mostly, couples were instructed to jointly practice communication skills and to jointly perform problem solving for the couple.

DISCUSSION

The present review contributes to the development of a shared and systematic way of describing dyadic interventions to facilitate cumulation of evidence.

Tackling unmanaged oropharyngeal dysphagia in primary care: a behavioural science realist review of interventions

INTRODUCTION

Oropharyngeal dysphagia (OD) is difficulty manipulating a food bolus from the mouth to the throat. Up to 70% of older adults develop OD; however, it is unmanaged in primary care, leading to avoidable hospitalisation.

OBJECTIVE

This behavioural science realist review aimed to develop programme theories to describe how interventions facilitate primary care healthcare professionals (HCPs) to proactively manage OD.

METHODS

We developed initial programme theories (IPTs) inductively using the expertise of stakeholders and deductively using the theoretical domains framework (TDF). Databases were searched to identify evidence regarding contexts, behavioural mechanisms and outcomes related to proactive management of OD and comparative behaviours which offer transferrable learning. IPTs were tested with the evidence to confirm, refine or refute, to produce final programme theories.

RESULTS

36 sources of evidence were included. Five final programme theories were generated explaining how primary care HCPs can be facilitated to proactively manage OD: (1) OD education and training, (2) checklists with OD signs and symptoms, (3) incorporating OD identification into existing workflow, (4) making HCPs aware that older adults and carers expect them to manage OD and (5) raising awareness of the adverse outcomes of OD.

CONCLUSION

The five programme theories provide the behavioural mechanisms by which an intervention may facilitate primary care HCPs to proactively manage OD. Through the programme theories' linkage to the TDF, behaviour change techniques (BCTs) mapped to the relevant TDF domain can be selected for an intervention. Operationalisation of selected BCTs into a coherent intervention package should be undertaken using codesign methodology.

PROSPERO REGISTRATION NUMBER

CRD42022320327.

From alcohol and other drug treatment mediator to mechanism to implementation: A systematic review and the cases of self-efficacy, social support, and craving

Research designed to establish alcohol and other drug (AOD) mechanisms of behavioral change (MOBC) has centered on what variables mediate the relation between AOD treatment and outcomes. The purpose of this paper was to review this research evidence to identify empirically supported mediators of alcohol and other drug use and related outcomes and then to evaluate their potential as being AOD treatment MOBC. The first phase was a systematic review of reviews (2008-2023) to identify the variables with the strongest empirical support as mediators of AOD treatment effects. Eligible reviews focused on AOD treatment modalities, included empirically tested mediators, and targeted adult samples. The second phase was a systematic review of empirical studies (1990-2023) testing the hypothesis that variables identified in phase one were AOD treatment mediators/mechanisms and then evaluating each eligible stage two study according to the Kazdin and Nock (Journal of Child Psychology and Psychiatry, 44, 1116) criteria. Eligible articles included empirical studies with adult samples attending AOD treatment and empirically tested one of the three treatment mechanisms as a mediator of an AOD-related outcome. Databases were searched in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. This systematic review was not preregistered. The first review of 11 eligible review articles identified self-efficacy, social support, and craving as having the strongest empirical support. The second review captured 48 individual studies. An evaluation of each of these studies by the Kazdin and Nock criteria suggested that they likely are MOBC and therefore are ready for implementation. The implementation of self-efficacy, social support, and craving into clinical practice and training is warranted. Six directions for future research to solidify and generalize empirical support for the case that self-efficacy, social support, and craving are MOBC are presented, as are five implications for clinical practice and training.

Bridging the Gap between Intuition and Theory: A Comparison of Different Approaches to Implementation Strategy Development for Improving Lynch Syndrome Detection

INTRODUCTION

Despite growing calls for the explicit application of theory when designing behaviour change interventions, limited empirical evidence exists regarding the effectiveness of these methods compared to non-theoretical approaches. A cluster randomized controlled trial (Hide and Seek Project - HaSP) tested two implementation approaches for improving hereditary cancer referral practices with one key distinction: implementation strategies were designed based explicitly on psychological theory or based on stakeholder intuition. This study presents the detailed methods and resources used to facilitate this comparison, whilst examining the strategies generated through both approaches.

METHODS

Across seven Australian hospitals, clinical stakeholders attended focus groups to co-design site-specific strategies for improving Lynch syndrome referral. Co-design methods differed according to trial arm. Implementation strategy content was examined, with intuitively derived strategies retrospectively coded to determine theoretical alignment.

RESULTS

Fifty-one strategies were proposed across all sites (theory-based arm = 32, intuition-based arm = 19). Overall, nine behaviour change technique (BCT) categories were used on 77 occasions. In the theory-based trial arm, eight BCT categories were identified on 53 occasions; and five BCT categories on 24 occasions in the intuition-based arm. BCT categories were largely similar across both arms. After retrospectively coding intuitively derived strategies, 42% contained mechanistic links, thereby demonstrating theoretical alignment.

CONCLUSION

Methods facilitated robust comparison of theoretical and intuitive approaches to implementation strategy design. Recognizing the known benefits of theory for enhancing scientific learning, applying these methods on a larger scale may provide definitive evidence about the comparative effectiveness of theoretical approaches.

Epidaure Market-Effectiveness and transferability of a school-based intervention to improve healthy and sustainable food choices by schoolchildren: Protocol of a randomized controlled trial and qualitative study

CONTEXT

At least 40% of cancers are linked to environmental or behavioral factors, and dietary behavior appears to be a major lever. Epidaure Market is a prevention initiative developed using a method for co-constructing health promotion initiatives and prevention programs that stratifies evidence from the scientific literature and combines it with experiential knowledge (DEVA, TPB, BCT). It promotes a sustainable diet (i.e., healthy, ecological and ethical nutrition) among 5th and 4th grade students during the crucial period of adolescence, when these behaviors are often far from the recommendations.

METHOD

The protocol implemented was carried out in 72 middle school classes in the Montpellier and Dijon academies. The intervention included teaching sessions and a virtual supermarket game, integrated into the school curriculum and delivered by science teachers. Effectiveness is tested in a cluster randomized controlled trial with 3 evaluation times (pre- and post-intervention and 1 follow-up). The study also includes an implementation assessment, with process analysis and implementation elements, as well as a transferability assessment based on key functions (FIC model and Astaire grid).

EXPECTED OUTCOMES

The study is still underway within the school. The primary expected outcome is a positive influence on the motives underlying food choices to move towards a sustainable diet. Secondary expectations involve changes in variables such as self-efficacy and perceived social norms, as well as an increase in knowledge about healthy eating. We also expect the qualitative approaches to provide information on the deployment process in the new territories.

DISCUSSION

The study aims not only to demonstrate the effectiveness of Epidaure Market, but also to identify the optimal conditions for its nationwide implementation in France's middle schools. Ultimately, the initiative aims to help reduce the incidence of cancer by promoting healthier eating habits among teenagers.

Effectiveness of behavior change in rehabilitation interventions to improve functional recovery after lower limb fracture: a systematic review

Ankle fractures are common injuries that can significantly impact mobility and quality of life. Rehabilitation following ankle fracture treatment is crucial for recovery, yet adherence to regimens remains a challenge. Behaviour Change Techniques (BCTs) have been suggested to improve adherence, but their effectiveness in ankle fracture rehabilitation is not well established. This review aimed to evaluate the effectiveness of BCTs in the rehabilitation of ankle fracture patients. We conducted a comprehensive search across multiple databases, including MEDLINE and EMBASE, focusing on Randomised Controlled Trials (RCTs) that incorporated BCTs into rehabilitation interventions. The effectiveness of BCTs on patient-reported outcomes (PROMs), quality of life, and adverse events was analysed. Nine RCTs met the inclusion criteria, encompassing a range of interventions that employed BCTs, most commonly including goal setting and instruction on how to perform behaviours, specifically physiotherapy exercises. The review found limited evidence supporting their effectiveness in improving PROMs. Only one study showed a significant positive effect, but it was deemed at high risk of bias. The lack of integration of behavioural theory in the design of rehabilitation interventions and the varied nature of the BCTs employed across studies may contribute to these findings. The use of BCTs in ankle fracture rehabilitation is prevalent, but this review highlights a significant gap their role of enhancing patient outcomes. Future research should incorporate a theory-based approach to intervention design, utilising a broader range of BCTs, to fully evaluate their potential in improving rehabilitation adherence and outcomes following ankle fracture .

Improving Delivery and Use of HIV Pre-Exposure Prophylaxis in the US: A Systematic Review of Implementation Strategies and Adjunctive Interventions

Implementation of pre-exposure prophylaxis (PrEP) to prevent HIV transmission is suboptimal in the United States. To date, the literature has focused on identifying determinants of PrEP use, with a lesser focus on developing and testing change methods to improve PrEP implementation. Moreover, the change methods available for improving the uptake and sustained use of PrEP have not been systematically categorized. To summarize the state of the literature, we conducted a systematic review of the implementation strategies used to improve PrEP implementation among delivery systems and providers, as well as the adjunctive interventions used to improve the uptake and persistent adherence to PrEP among patients. Between November 2020 and January 2021, we searched Ovid MEDLINE, PsycINFO, and Web of Science for peer reviewed articles. We identified 44 change methods (18 implementation strategies and 26 adjunctive interventions) across a variety of clinical and community-based service settings. We coded implementation strategies and adjunctive interventions in accordance with established taxonomies and reporting guidelines. Most studies focused on improving patient adherence to PrEP and most conducted pilot trials. Just over one-third of included studies demonstrated a positive effect on outcomes. In order to end the human immunodeficiency virus (HIV) epidemic in the U.S., future, large scale HIV prevention research is needed that develops and evaluates implementation strategies and adjunctive interventions for target populations disproportionately affected by HIV.

Autonomy support in an exercise intervention with colorectal cancer patients during chemotherapy: a qualitative perspective

OBJECTIVE

Physical activity (PA) has emerged as an important element of supportive care for cancer patients, but few patients engage with exercise. Considering that autonomy support is associated with healthy lifestyles, it would be useful to know the specific autonomy-supportive techniques that can help to encourage PA in colorectal cancer (CRC) patients. This study aims to qualitatively explore autonomy support perceptions through a self-determination-theory-based exercise program (FIT-CANCER) with CRC patients during chemotherapy treatment.

METHODS AND MEASURES

A total of 27 participants were included, 16 CRC patients, six relatives, and five healthcare professionals. Qualitative data from semi-structured interviews and observational field notes were analyzed with thematic analysis.

RESULTS

Three main themes were identified: Healthcare professionals encouraging enrollment in the exercise program, Relatives supporting attendance to the exercise sessions, Exercise instructor favoring adherence to the exercise program. The different subthemes showed autonomy-supportive techniques from these social agents to promote CRC patients' participation in the exercise program.

CONCLUSION

The present research showed the importance of autonomy support from healthcare professionals, relatives and the exercise instructor to promote the initiation and maintenance of CRC patients' PA behavior and improve their quality of life, health and well-being.

Health behavior interventions among people with lower socio-economic position: a scoping review of behavior change techniques and effectiveness

Background

Behavior change interventions can unintendedly widen existing socio-economic health inequalities. Understanding why interventions are (in)effective among people with lower socio-economic position (SEP) is essential. Therefore, this scoping review aims to describe what is reported about the behavior change techniques (BCTs) applied within interventions and their effectiveness in encouraging physical activity and healthy eating, and reducing smoking and alcohol consumption according to SEP.

Methods

A systematic search was conducted in 12 electronic databases, and 151 studies meeting the eligibility criteria were included and coded for health behavioral outcomes, SEP-operationalization, BCTs (type and number) and effectiveness.

Results

Findings suggest that approaches for measuring, defining and substantiating lower SEP vary. Current studies of behavior change interventions for people of different SEP do not systematically identify BCTs, making systematic evaluation of BCT effectiveness impossible. The effectiveness of interventions is mainly evaluated by overall intervention outcomes and SEP-moderation effects are mostly not assessed.

Conclusion

Using different SEP-operationalizations and not specifying BCTs hampers systematic evidence accumulation regarding effective (combinations of) BCTs for the low SEP population. To learn which BCTs effectively improve health behaviors among people with lower SEP, future intervention developers should justify how SEP is operationalized and must systematically describe and examine BCTs.

Theory-based interventions aimed at promoting physical activity in pregnant women: A systematic review and meta-analysis of randomized controlled trials

OBJECTIVES

The objectives were to assess (i) the quality of theory implementation, (ii) the application of behavior change techniques, and (iii) the effectiveness of theory-based interventions in promoting physical activity in pregnant women and improving maternal and neonatal outcomes.

METHODS

A systematic search was conducted across 8 databases (Cumulative Index to Nursing and Allied Health Literature, the Cochrane Library, EMBASE, MEDLINE, APA PsycINFO, PubMed, SPORTDiscus, and Web of Science) to identify randomized controlled trials published from database inception to 8 July 2023. The Cochrane risk-of-bias 2.0 tool was used to evaluate the quality of the included studies. The theory coding scheme was used to measure the quality of theory implementation, and behavior change techniques were coded according to behavior change taxonomy (version 1). The meta-analysis was performed using RevMan 5.3. The Grading of Recommendations, Assessment, Development, and Evaluation Approach was used to assess the certainty of evidence.

RESULTS

Eleven studies met the study criteria. Nine studies were based on one theory, while two studies were based on a combination of two theories. The quality of theory implementation was generally moderate. A total of 24 unique behavior change techniques were extracted. The most commonly used types of behavior change techniques were 'instruction on how to perform the behavior' (n = 9), 'goal setting' (behavior) (n = 8), 'action planning' (n = 7), and 'information about health consequences' (n = 7). Theory-based interventions significantly improved moderate-to-vigorous physical activity (standardized mean difference (SMD) = 0.17, 95 % confidence interval (CI) [0.04, 0.30], P = 0.01; moderate certainty of evidence), reduced the average gestational weight gain per week (mean difference (MD) = -0.06, 95 % CI [-0.11, -0.01], P = 0.02; moderate certainty of evidence), and decreased the incidence of gestational diabetes mellitus (risk ratio (RR) = 0.64, 95 % CI [0.46, 0.89], P = 0.008; high certainty of evidence). However, the effects of theory-based interventions on total physical activity, total gestational weight gain and the incidence of gestational hypertension and preterm delivery were unclear (P > 0.05).

CONCLUSIONS

(i) Most of the studies exhibited a moderate level of theory implementation quality. (ii) The use of theories varies, but common behavior change techniques were found across studies. (iii) Theory-based interventions can improve physical activity and maternal and neonatal outcomes and appear to be safe. Appropriate health behavior theories and behavior change techniques should be fully utilized in future interventions.

REGISTRATION

PROSPERO: CRD42023440886.

TWEETABLE ABSTRACT

Theory-based interventions can improve physical activity and maternal and neonatal outcomes and appear to be safe. Appropriate health behavior theories and behavior change techniques should be fully utilized in the development of future interventions.

An ontology of mechanisms of action in behaviour change interventions

Background

Behaviour change interventions influence behaviour through causal processes called "mechanisms of action" (MoAs). Reports of such interventions and their evaluations often use inconsistent or ambiguous terminology, creating problems for searching, evidence synthesis and theory development. This inconsistency includes the reporting of MoAs. An ontology can help address these challenges by serving as a classification system that labels and defines MoAs and their relationships. The aim of this study was to develop an ontology of MoAs of behaviour change interventions.

Methods

To develop the MoA Ontology, we (1) defined the ontology's scope; (2) identified, labelled and defined the ontology's entities; (3) refined the ontology by annotating (i.e., coding) MoAs in intervention reports; (4) refined the ontology via stakeholder review of the ontology's comprehensiveness and clarity; (5) tested whether researchers could reliably apply the ontology to annotate MoAs in intervention evaluation reports; (6) refined the relationships between entities; (7) reviewed the alignment of the MoA Ontology with other relevant ontologies, (8) reviewed the ontology's alignment with the Theories and Techniques Tool; and (9) published a machine-readable version of the ontology.

Results

An MoA was defined as "a process that is causally active in the relationship between a behaviour change intervention scenario and its outcome behaviour". We created an initial MoA Ontology with 261 entities through Steps 2-5. Inter-rater reliability for annotating study reports using these entities was α=0.68 ("acceptable") for researchers familiar with the ontology and α=0.47 for researchers unfamiliar with it. As a result of additional revisions (Steps 6-8), 23 further entities were added to the ontology resulting in 284 entities organised in seven hierarchical levels.

Conclusions

The MoA Ontology extensively captures MoAs of behaviour change interventions. The ontology can serve as a controlled vocabulary for MoAs to consistently describe and synthesise evidence about MoAs across diverse sources.

In-classroom physical activity breaks program among school children in Sri Lanka: study protocol for a randomized controlled trial

Background

The problem of sedentary behavior among primary school children is alarming, with numbers gradually increasing worldwide, including Sri Lanka. Physical activity interventions within classroom settings have been acknowledged as a critical strategy to increase students' movement behaviors while enhancing their academic achievement and health. Yet, the busy curriculum and challenging educational demands encourage more sedentary classroom behavior. Hence, this study aims to develop and evaluate an in-classroom physical activity breaks (IcPAB) intervention among fifth graders in Sri Lanka.

Methods

The study will adopt a randomized controlled trial (RCT), comprising an in-classroom physical activity breaks program group and a control group to evaluate the effects of IcPAB on academic achievement, movement behaviors and health outcomes. The intervention design is based on the capability (C), opportunity (O) and motivation (M) behavior (B) (COM-B) model. A least 198 fifth graders will be recruited from two schools in Uva province, Sri Lanka. The recruitment process will start in late 2022. Class teachers of the intervention group will implement 5-min activity breaks at least three times a day after completing a training session. The primary variables include mathematics and reading achievement. The secondary variables include physical activity levels, steps count, sedentary behavior, body mass index, aerobic fitness, and perceived stress. Data collection will be implemented at pre-test and post-test, respectively. Intervention fidelity and the process will also be evaluated.

Discussion

The IcPAB is designed to prevent pure educational time loss by introducing curriculum-integrated short bouts of physical active breaks into the classroom routine. If the IcPAB is effective, it can (1) improve the mathematics and reading achievement of fifth-grade girls and boys, which is a significant factor determining the performance at the Grade Five National Scholarship Examination in Sri Lanka; (2) improve movement behaviors as well as physical and mental health outcomes among primary school students. Sequentially, the IcPAB will enrich school-based physical activity intervention approaches which can in turn bring academic and health benefits to primary school children in Sri Lanka.

Trial registration

The first version of the trial was registered with the ISRCTN registry (Ref: ISRCTN52180050) on 20/07/2022.

Barriers to COVID-19 Vaccination in a Troop of Fleet Antiterrorism Security Team Marines: Observational Study

BACKGROUND

In 2019, the World Health Organization declared the reluctance to vaccinate despite the availability of vaccination services as one of the top 10 threats to global health. In early 2021, self-reported reluctance to vaccinate among military personnel might have been considered a significant threat to national security. Having a choice architecture that made COVID-19 vaccination optional rather than required for military personnel could have inadvertently undermined military readiness if vaccination uptake did not reach an acceptable threshold.

OBJECTIVE

The purpose of this observational study was to examine Marines' self-reported reasons for planning to decline the COVID-19 vaccine to understand their barriers to vaccination.

METHODS

As the vaccination became available to 1 company of Fleet Antiterrorism Security Team (FAST) Marines in early 2021, company command required those planning to decline vaccination to write an essay with up to 5 reasons for their choice. These essays provided the data for this study. Qualitative descriptive analysis with elements from grounded theory was used to thematically categorize FAST Marines' written reasons for planning to decline the COVID-19 vaccine into a codebook describing 8 key behavioral determinants. Interrater agreement among 2 qualitatively trained researchers was very good (κ=0.81).

RESULTS

A troop of 47 Marines provided 235 reasons why they planned to decline the COVID-19 vaccine. The most frequent reasons were difficulty understanding health information (105/235, 45%), low estimates of risk (33/235, 14%), and fear of physical discomfort (29/235, 12%). Resulting interventions directly targeted Marines' self-reported reasons by reducing barriers (eg, normalized getting the vaccine), increasing vaccine benefits (eg, improved access to base gyms and recreational facilities), and increasing nonvaccine friction (eg, required in writing 5 reasons for declining the vaccine).

CONCLUSIONS

Understanding the barriers military personnel experience toward COVID-19 vaccination remains critical as vaccine acquisition and availability continue to protect military personnel. Insights from subpopulations like FAST Marines can enhance our ability to identify barriers and appropriate intervention techniques to influence COVID-19 vaccination behaviors.

The IMPROVE trial: study protocol for a pragmatic cluster randomised controlled trial to assess the effectiveness of using lay health workers to improve uptake and completion of pulmonary rehabilitation in patients with chronic obstructive pulmonary disease

BACKGROUND

Pulmonary rehabilitation (PR) is a programme of exercise and education and the most effective treatment for the symptoms and disability associated with chronic obstructive pulmonary disease. However, the benefits of PR are limited by poor uptake and completion. This trial will determine whether using trained volunteer lay health workers, called "PR buddies," improves uptake and completion of PR and is cost-effective. This trial protocol outlines the methods for evaluating effectiveness, cost-effectiveness, and acceptability.

METHODS

The IMPROVE trial is a pragmatic, open, cluster randomised controlled trial planned in 38 PR services across England and Wales. PR services will be randomised to either intervention arm-offering support from PR buddies to patients with chronic obstructive pulmonary disease-or to usual care as the control arm. PR staff in trial sites randomised to the intervention arm will receive training in recruiting and training PR buddies. They will deliver training to volunteers, recruited from among people who have recently completed PR in their service. The 3-day PR-buddy training programme covers communication skills, confidentiality, boundaries of the PR-buddy role and behaviour change techniques to help patients overcome obstacles to attending PR. An internal pilot will test the implementation of the trial in eight sites (four intervention sites and four in control arm). The primary outcome of the trial is the uptake and completion of PR. A process evaluation will investigate the acceptability of the intervention to patients, PR staff and the volunteer PR buddies, and intervention fidelity. We will also conduct a cost-effectiveness analysis.

DISCUSSION

Improving outcomes for chronic obstructive pulmonary disease and access to PR are priorities for the UK National Health Service (NHS) in its long-term plan. The trial hypothesis is that volunteer PR buddies, who are recruited and trained by local PR teams, are an effective and cost-effective way to improve the uptake and completion rates of PR. The trial is pragmatic, since it will test whether the intervention can be incorporated into NHS PR services. Information obtained in this trial may be used to influence policy on the use of PR buddies in PR and other similar services in the NHS.

TRIAL REGISTRATION

ISRCTN12658458. Registered on 23/01/2023.

Increasing venous thromboembolism risk assessment through a whole hospital-based intervention: a pre-post service evaluation to demonstrate quality improvement

Venous thromboembolism (VTE) is a primary cause of morbidity and mortality in hospitalized patients. VTE risk assessment is a crucial part of the VTE prevention guideline. However, VTE risk assessment was not consistently undertaken for admitted patients. The aim of this study was to identify whether a quality improvement project implemented to change documentation of VTE risk assessment for hospitalized patients impacted patient safety by decreasing the rate of VTE incidences. The study was set in a 600+ bed acute hospital that provides medical and surgical services for adult patients during the period October 2018-September 2020. The hospital adopted the American College of Chest Physicians (ACCP) 9th edition VTE prevention guidelines and followed the Modified Caprini risk assessment tool. Following the FOCUS-Plan-Do-Check-Act (FOCUS PDCA) improvement methodology, the improvement team implemented multicomponent interventions over a 3-month period, including conducting educational sessions, sharing VTE documentation compliance results, giving reminders during rounds, assigning a VTE liaison physician within each clinical specialty, and updating and communicating the hospital adopted VTE guidelines. A total of 17 612 patients were included, respectively, 8971 in pre-intervention and 8641 post-intervention period. Documentation of VTE risk assessment upon admission increased significantly in the post quality improvement intervention period (60% vs. 42%, relative increase of 30%, χ2 = 1.43, P < 0.001). The run chart trend analysis demonstrated significant improvement shift and improvement trend after quality improvement project implementation, and it was sustained for 15 months. There was no impact on patient safety with a slight not statistically significant decrease in the VTE incidences rate post intervention period (0.4% vs. 0.5%, relative decrease of 1%, χ2 = 0.82, P < 0.397). The quality improvement project intervention significantly increased the percentage of patients assessed for VTE risk in a hospital setting.

Evaluating barriers and facilitators to healthcare providers' use of an emergency department electronic referral portal for high-risk children with asthma using the Theoretical Domains Framework

OBJECTIVE

Urban children with asthma are at risk for frequent emergency department (ED) visits and suboptimal asthma management. ED visits provide an opportunity for referrals to community-based asthma management services. Electronic medical record-based referral portals have been shown to improve quality of care but use of these portals by healthcare providers (HCPs) is variable. The purpose of the study was to investigate facilitators, barriers, and recommendations to improve the use of an electronic referral portal to connect children presenting with asthma exacerbations in an urban pediatric ED to community-based education and case management services.

METHODS

The study was grounded in the Theoretical Domains Framework, an implementation provided the theoretical basis of the study. All ED HCPs were invited to complete qualitative interviews; twenty-three HCPs participated. Interviews were coded using directed content analysis.

RESULTS

Facilitators to portal use included its relative ease of use and HCP beliefs regarding the importance of such referrals for preventive asthma care. Barriers included insufficient time to make referrals, lack of information regarding the community agency and challenges communicating the value of the referral to patients and/or their caregivers.

CONCLUSIONS

Successfully engaging HCPs working in ED settings to use electronic portals to refer children with asthma to community agencies for health services may involve helping providers increase their comfort and knowledge of the external provider agency, ensuring organizational leaders support the need for preventive asthma care and provision of feedback to HCPs on the success of such referrals in meeting the needs of those families served.

Core components of project-based intervention after acquired brain injury: Delivering meaningful groups online

BACKGROUND

Rehabilitation for cognitive-communication impairments following brain injury can be complex given the heterogenous nature of impairments post injury. Project-based intervention has the potential to improve communication skills and create a meaningful real-life context where individuals collaborate to develop a concrete product, which benefits others. While evidence for this intervention is emerging, the COVID-19 pandemic prompted increased use of telehealth interventions to serve people with brain injury. This paper aims to describe a framework for the delivery of project-based intervention via telehealth within community rehabilitation settings; and present several case studies of telehealth groups completed in the United Kingdom and the United States during the COVID-19 pandemic.

METHODS

A working group was formed to map the components of project-based intervention onto the rehabilitation treatment specification system (RTSS). This system is a conceptual framework that helps to explain the link between treatment theory and ingredients, allowing a clinician to clearly understand how and why a treatment works. First, a literature search was completed to identify eligible studies on project-based intervention after brain injury. Second, those studies were thematically mapped onto the RTSS to identify important intervention components. Third, the presence of these components was assessed for community brain injury groups delivered via telehealth in the United Kingdom and United States. These groups were further described using a taxonomy of social activities that help to describe the degree of meaningful social engagement.

RESULTS

The literature was described with a thematic RTSS summary. Treatment aims focus on skills training and self-efficacy, advocacy and self-empowerment, emotional well-being and quality of life, and collaboration and community belonging. Treatment ingredients involve a range of cognitive and behavioural supports to deliver meaningful activities and contexts to complete a project. Mechanisms of action involve learning by doing and cognitive and affective information processing. All four telehealth groups conducted in the United Kingdom and United States involved at least three treatment aims, >7 targets, and >8 treatment ingredients. All groups reported positive experiences from activities that involve working collaboratively to help others and contribute to society.

CONCLUSIONS

Project-based intervention delivered via telehealth has the potential for supporting people with acquired brain injury to improve their communication skills and engage in meaningful, collaborative activity. Application of the RTSS helps clinicians to understand the aims and therapeutic ingredients (or clinician activities) through which a person with brain injury may achieve specific treatment targets during the rehabilitation process.

WHAT THIS PAPER ADDS

What is already known on the subject Project-based interventions have the potential to improve cognitive, self-regulatory, behavioural and social communication skills, renegotiate identity and reaffirm sense of self, providing a positive impact on quality of life for persons with acquired brain injuries. Projects serve as a context for meaningful engagement for individuals in the chronic phase of traumatic brain injury recovery, without fulfilling work, family or social responsibilities. However, most published research has involved in-person projects and few projects have been delivered via telehealth. What this paper adds to existing knowledge While past published works have shared core principles of intervention, a variety of projects, durations, dosages and methods have been employed. The current paper provides a framework to support more consistent implementation. By mapping previous project-based interventions to the RTSS, clinicians will have a better understanding of the aims, targets, ingredients and theoretical underpinnings of project-based interventions. In the wake of the COVID-19 pandemic, the shift to telehealth moved interventions to a virtual context. The four case projects in this paper demonstrate that it is possible to conduct project-based interventions via telehealth and provides a clear description to guide clinicians in their delivery. What are the potential or actual clinical implications of this work? This work begins to build the foundation for more rigorous, empirical examination of project-based interventions. By mapping project-based interventions to the RTSS, core aims, targets and ingredients are established that can be objectively examined. This investigation also provides a road map for clinicians who wish to implement this complex intervention.

Behaviour change and rehabilitation adherence in adults with tendinopathy: a scoping review

PURPOSE

This scoping review aimed to identify behaviour change strategies influencing rehabilitation adherence in adults with tendinopathy, a common musculoskeletal condition requiring prolonged rehabilitation with poor adherence and variable outcomes.

METHODS

Following the Joanna Briggs Institute (JBI) methodology, seven databases were searched until April 2023. Records included reviews, intervention, and qualitative studies published in English. Behaviour change strategies were deductively coded and mapped to the capability, opportunity, and motivation model of behaviour (COM-B).

RESULTS

Eighty-six articles were retained. The primary behaviour change strategies in tendinopathy rehabilitation reports addressed Psychological Capability; from knowledge through education, instruction, and self-monitoring using exercise diaries. Also, Social Opportunity involves demonstration and monitoring of rehabilitation behaviour, and Physical Opportunity focuses on time-efficient programs with access to equipment and health professionals. Few reports addressed Automatic Motivation (positive reinforcement and habit formation). Barriers identified in the reports were Reflective Motivation (negative beliefs and fears), Physical Opportunity (time-constraints), and Physical Capability (pain and comorbidities).

CONCLUSIONS

Further research should explore the impact of education on beliefs, fears, and pain-management, as well as the effectiveness of teaching habit formation for improved time-management. Implementing these behaviour change strategies may enhance tendinopathy rehabilitation adherence, improving clinical trial efficacy, guiding clinical practice, and impacting patient outcomes.

Deep rest: An integrative model of how contemplative practices combat stress and enhance the body's restorative capacity

Engaging in contemplative practice like meditation, yoga, and prayer, is beneficial for psychological and physical well-being. Recent research has identified several underlying psychological and biological pathways that explain these benefits. However, there is not yet consensus on the underlying overlapping physiological mechanisms of contemplative practice benefits. In this article, we integrate divergent scientific literatures on contemplative practice interventions, stress science, and mitochondrial biology, presenting a unified biopsychosocial model of how contemplative practices reduce stress and promote physical health. We argue that engaging in contemplative practice facilitates a restorative state termed "deep rest," largely through safety signaling, during which energetic resources are directed toward cellular optimization and away from energy-demanding stress states. Our model thus presents a framework for how contemplative practices enhance positive psychological and physiological functioning by optimizing cellular energy consumption. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Comprehensive framework for developing mHealth-based behavior change interventions

Background

Understanding human behaviors has been the subject of several studies. Their main goal was to inform behavior change interventions aimed at promoting positive behaviors and improving negative ones. However, as a non-expert in behavioral science, it is extremely difficult for researchers from other disciplines to design and develop evidence-based behavior change interventions. Moreover, all existing frameworks stop at the conceptual stage and do not provide instructions for developing digital-based behavior change interventions.

Objective

We present an end-to-end framework for the design and development of mHealth-based behavior change interventions by drawing on the synergy of theory, practices, and evidence from previous research.

Methods

We reconcile the frameworks most used in the literature for the design of behavior change interventions. Therefore, the authors examined the steps of each framework, and the mapping between these steps was carried out through several iterations to obtain five common steps.

Results

The proposed framework includes five steps: (1) Definition of the scope of the intervention. (2) Understanding and explanation of behavior. (3) Definition of the intervention content and strategies. (4) Implementation of the intervention. (5) Evaluation of the intervention. Each step is explained in detail, while providing researchers with examples and the necessary materials that will boost the success of their interventions.

Conclusion

This work provides a framework that will guide researchers in the design and implementation of mHealth-based behavior change interventions. It differs from its predecessors in that it goes beyond the conceptual level of intervention design by providing details about the technical implementation of mHealth solutions. Also, explanations and examples for different steps are provided to help researchers and practitioners and design, implement, and evaluate their mHealth-based behavior change interventions.

Assessing the effectiveness of a sexual and reproductive health and rights training programme in changing healthcare practitioners' attitudes and practices in low-income countries

INTRODUCTION

In low-income countries the utilisation of sexual and reproductive health and rights (SRHR) services is influenced by healthcare practitioners' knowledge, attitudes and practices. Despite awareness of the potential problems due to ingrained biases and prejudices, few approaches have been effective in changing practitioners' knowledge, attitudes and practices concerning SRHR in low-income countries.

OBJECTIVES

1) To assess whether participating in an SRHR international training programme (ITP) changed healthcare practitioners' SRHR knowledge, SRHR attitudes and SRHR practices and 2) examine associations between trainees' characteristics, their SRHR work environment and transfer of training.

METHODS

A pre- and post-intervention study, involving 107 trainees from ten low-income countries, was conducted between 2017 and 2018. Paired samples t-test and independent samples t-test were used to assess differences between trainees' pre- and post-training scores in self-rated SRHR knowledge, attitudes, knowledge seeking behaviour and practices. Linear regression models were used to examine association between trainees' baseline characteristics and post-training attitudes and practices.

RESULTS

Trainees' self-rated scores for SRHR knowledge, attitudes and practices showed statistically significant improvement. Baseline high SRHR knowledge was positively associated with improvements in attitudes but not practices. High increases in scores on knowledge seeking behaviour were associated with higher practice scores. No statistically significant associations were found between scores that measured changes in SRHR knowledge, attitudes and practices.

CONCLUSION

The findings indicate that the ITP was effective in improving trainees' self-rated scores for SRHR knowledge, attitudes and behaviours (practices). The strongest association was found between improvement in SRHR knowledge seeking behaviour and the improvement in SRHR practices. This suggests that behaviour intention may have a central role in promoting fair open-minded SRHR practices among healthcare practitioners in low-income countries.

Trust as a dyadic mechanism of action: a call to explore patient-provider relationships in the twenty-first century

Background: There is general agreement that trust between patients and providers influences patient knowledge, behaviors, and adherence to provider-recommendations--with subsequent impacts on patient health-related outcomes and provider practices. There is less academic agreement on the processes by which trust is formulated and changed over time and how trust with ongoing healthcare providers can influence health-related outcomes over time.Methods: This opinion draws on social constructionism and symbolic interactionism to posit the possibility that trust can emanate through the communication process, during which a patient and provider transmit and attend to words, images, and paralanguage to convey their states of being and to induce responses, usually acknowledgement, suasion, or physical behaviors, from one another.Results: Theoretical bases for this construct are provided as are qualitative, quantitative, and mixed measurement approaches for multiple healthcare settings.Conclusions: A mechanistic approach to understand how trust is established through patient-provider communication and how trust informs patient health-related outcomes can contribute over time to improve communication in healthcare encounters.

Barriers and facilitators to older adults' acceptance of camera-based active and assisted living technologies: a scoping review protocol

Objective

To identify and synthesize evidence on the barriers and facilitators to older adults' acceptance of camera-based active and assisted living (AAL) technologies in the home.

Introduction

Camera-based AAL technologies have been heralded as an important solution to population ageing. By leveraging state-of-the-art computer vision techniques, camera-based AAL technologies can secure greater levels of safety, health, and independence for older adults whilst benefiting their desires to age-in-place. However, these technologies face widespread rejection and are at present scarcely used. A critical first step toward enhancing older adults' acceptance and uptake of camera-based AAL technologies is to understand the barriers and facilitators to their acceptance of said technology.

Inclusion criteria

This review will consider primary studies reporting data on the barriers and facilitators to the acceptance of camera-based AAL technologies among community-dwelling older adults aged 60 and above. No date or language restrictions will be applied.

Methods

Following JBI scoping review methodology, key electronic databases ( e.g., MEDLINE, CINAHL, Embase, Web of Science, ACM Digital Library, IEEE Xplore) and the grey literature ( e.g., Google Scholar) will be searched to locate both unpublished and published articles of relevance. Retrieved citations will undergo independent screening against pre-defined eligibility criteria. Data will be independently extracted and mapped to the Theoretical Domains Framework with guidance from a pre-piloted coding manual. Results will be presented in tabular form accompanied by a narrative summary of barriers and facilitators.

A Systematic Review of the Mediators of Resistance Training Behavior

BACKGROUND

Resistance training (RT) has been identified as an important lifestyle activity for health. While systematic reviews have examined behavior change techniques (BCTs) used in interventions and potential correlates of RT behavior, the connection between BCTs and changes in putative mediators and RT participation have yet to be linked. The purpose of this review was to examine RT intervention effects, as coded by BCT clusters, on behavior change via capability, opportunity, and motivation as putative mediators of that change.

METHOD

Literature searches were concluded in January of 2023, using three databases. Eligible studies included a comparison group, assessed RT as an outcome, included BCTs, assessed potential mediators, and were in English. The initial search yielded 1050 hits, which was reduced to 5 to independent RT interventions. Screening of previous reviews yielded three additional papers for a total of 8 papers. Each paper was assessed for the associations between intervention effects (as BCT clusters) on mechanisms of action (a path), effects of mechanisms of action on behavior (b path), and indirect (ab path) and direct (c path) effects of BCT clusters.

RESULTS

There was support that interventions had significant effects on capability and opportunity with inconclusive effects on motivation (a path). Both capabilities and motivation had associations with RT behavior (b path). The examined studies showed that changes in capabilities have the strongest support as a mediator with some support for motivation as a mediator (ab path). Studies that used more BCT clusters seemed to have a more positive effect on behavior, yet there were no trends to suggest any one crucial BCT cluster (c path).

CONCLUSION

Current evidence suggests that capabilities and motivation are important to target in RT interventions. Future interventions would be well suited to utilize behavior change techniques that address these mediators.

Development of a physical activity counseling intervention for people with chronic respiratory disease based on the health action process approach

BACKGROUND

Physical activity (PA) counseling holds promise for increasing PA levels in people with chronic respiratory disease, though little long-term change has been shown to date. Here, we describe the development of a Health Action Process Approach-based PA counseling intervention that aims to promote PA and exercise in people with chronic respiratory disease who are enrolled in pulmonary rehabilitation.

METHODS

To collaborate in defining and refining the intervention, we convened a varied team of authors that included a panel of five stakeholder partners: three patients, one clinician, and one health behavior change researcher. We completed three steps in the intervention development process: (1) initial intervention creation, (2) iterative intervention refinement, and (3) assessment of intervention acceptability. In step 1, we created an initial draft of the PA counseling intervention based on the HAPA theoretical framework, previous evidence in people with chronic respiratory disease, and clinical experience. In step 2, we used qualitative methods of focus groups and interviews to further develop and refine the intervention. Fifteen meetings occurred with the five-member stakeholder partner panel (six focus groups with the three patient partners, four interviews with the clinician partner, and five interviews with the researcher partner) over 5 months to systematically elicit input and incorporate it into the intervention. In step 3, we measured the intervention acceptability using five-point Likert scale ratings.

RESULTS

Intervention materials included the eligibility screen, participant workbook, and leader guide. We identified key themes in the input from the stakeholder partners and incorporated this input into the intervention content and methods. Ratings of the intervention by the stakeholder partners (n=5) were high with mean ratings ranging 4.0-5.0 on a five-point scale.

CONCLUSIONS

This development process successfully engaged an intervention development team with diverse perspectives and resulted in a PA counseling intervention for people with chronic respiratory disease. The intervention's strong theoretical underpinning, person-centeredness, and the contributions from varied perspectives during intervention development position it well for future evaluations of feasibility, efficacy, and effectiveness.

Encouraging pro-environmental behavior: Do testimonials by experts work?

Using non-pecuniary interventions to motivate pro-environmental behavior appeals to program administrators seeking cost-effective ways to increase adoption of environmental practices. However, all good-intended interventions should not be expected to be effective and reporting when interventions fail is as important as documenting their successes. We used a framed field experiment with 308 adults from the Mid-Atlantic in the United States to test the effectiveness of an expert testimonial in encouraging adoption of native plants in residential settings. Though studies have found testimonials to be effective in other contexts, we find that the video testimonial had no effect on residents' willingness to pay for native plants. Our analysis also shows that consumers who are younger, have higher incomes, and use other environmentally friendly practices on their lawns are more likely than other consumers to purchase native plants.

Key Considerations When Addressing Physical Inactivity and Sedentary Behaviour in People with Asthma

People with asthma tend to be less physically active and more sedentary than people without asthma. This narrative review aimed to present key considerations when addressing physical inactivity and sedentary behaviour in people with asthma by identifying barriers and facilitators, determinants and correlates, and intervention approaches. Using a search strategy, electronic databases were searched for relevant studies. Data extracted from studies were qualitatively synthesised. A total of 26 studies were included in the review. Six studies reported asthma symptoms as a barrier to physical activity, while four studies reported having a supportive network as a physical activity facilitator. Across studies, physical activity correlates/determinants were pulmonary function, exercise capacity, body mass index, dyspnoea, psychological health, and asthma control. Interventions that effectively improved physical activity in the short term were a step-based prescription programme, a weight loss programme incorporating aerobic and resistance training, and a weight loss lifestyle intervention, while a high-intensity interval training pulmonary rehabilitation program was effective in the long term. The collective findings suggest that a personalised physical activity programme incorporating different strategies is needed. There was minimal evidence to provide recommendations to optimise sedentary behaviour in asthma, and more research is needed on the topic.

Designing an evidence-based working method for medical work disability prognosis evaluation-an intervention mapping approach

Purpose

Performing evidence-based work disability prognosis evaluation (WDPE) of clients on sick leave is a difficult task for physicians. The aim was to develop a working method to support physicians in performing evidence-based WDPE and to improve WDPE quality.

Materials and methods

Intervention Mapping (IM) supplemented with elements of the Behavior Change Wheel (BCW) guided project planning for developing the working method. This approach allowed combination with other frameworks and, e.g., behavior change theories. WDPE quality challenges were analyzed on various ecological levels, e.g., the individual (i.e., the physician), interpersonal (i.e., the client) and organizational level, culminating into a multilevel logic model of the problem. Determinants that contributed to this problem, e.g., lack of physicians' knowledge on performing evidence-based WDPE, were identified. Performance objectives were formulated that could contribute to a desired change in WDPE quality. From the performance objectives and determinants (e.g., knowledge), change objectives were derived. In order to achieve these change objectives, suitable intervention functions (e.g., education) and policy categories (e.g., service provision) were identified, allowing the formulation of intervention components. Behavior change techniques (e.g., feedback on outcomes of a behavior) were selected to serve the intervention functions to deliver the desired change. This led to the conceptualization of an intervention plan.

Results

The intervention "Prognosable" is presented. It consists of a stepwise working method (SWM) for evidence-based WDPE. The SWM offers an overview of important aspects (e.g., medical condition, clients' confidence in return-to-work) to consider in individual clients' WDPE. The SWM helps physicians to identify crucial functional limitations, find and appraise evidence-based information, weigh all relevant prognostic aspects and it supports physicians to conclude with an evidence-based WDPE, tailored to the individual client. The intervention "Prognosable" was designed, which also includes an educational program and a supportive software tool to enable implementation of the SWM.

Conclusion

IM combined with BCW elements guided the development of a SWM for evidence-based WDPE. The SWM will be delivered through an educational program for physicians supported by a digital tool. The SWM, educational program and digital tool are ready to be implemented and evaluated in practice as the intervention "Prognosable."

Development of "Baby, Me, & NRT": A Behavioral Intervention to Improve the Effectiveness of Nicotine Replacement Therapy in Pregnancy

BACKGROUND

The effectiveness of Nicotine Replacement Therapy (NRT) for smoking cessation in pregnancy is limited by inconsistent and incorrect use. This paper describes the development process for "Baby, Me, & NRT", a novel pregnancy-specific intervention aimed at enhancing adherence to NRT.

METHODS

An integrated approach to intervention development was used, combining evidence, theory, stakeholders' feedback, and tailoring principles. The process involved six iterative steps: (1) synthesizing relevant published evidence and guidance, (2) collecting primary qualitative data on barriers and facilitators to NRT adherence along with potential intervention design features, (3) identifying relevant behavioral theories and mapping the evidence against these, (4) prioritizing behavioral determinants identified in steps 1 and 2, generating intervention objectives, and identifying behavior change techniques which target the prioritized determinants, (5) consulting with stakeholders on intervention components, key content and tailoring features, and (6) producing a prototype intervention along with implementation guidance.

RESULTS

The prototype intervention comprises of a multi-component, 1-month cessation programme, which includes six enhanced behavioral support sessions delivered by a trained advisor, tailored text messages, a website, and an illustrated booklet. It promotes the uptake of high-dose and combination NRT, emphasizes the importance of adherence, addresses motivation to use NRT, proactively helps problem solve NRT use issues, and provides guidance on preventing and managing smoking lapses.

CONCLUSION

The development process generated an evidence- and theory-guided intervention, designed with stakeholder input, aimed at improving NRT effectiveness for smoking cessation in pregnancy. The prototype intervention has since been optimized and is being evaluated in a randomized controlled trial.

Identification of the Most Suitable Mobile Apps to Support Dietary Approaches to Stop Hypertension (DASH) Diet Self-Management: Systematic Search of App Stores and Content Analysis

Smartphone apps might provide an opportunity to support the Dietary Approaches to Stop Hypertension (DASH) diet, a healthy diet designed to help lower blood pressure. This study evaluated DASH diet self-management apps based on their quality, likely effectiveness, and data privacy/security to identify the most suitable app(s). A systematic search and content analysis were conducted of all DASH diet apps available in Google Play and the Apple App Store in the UK in November 2022. Apps were included if they provided DASH diet tracking. A previous systematic literature review found some commercial apps not found in the app store search, and these were also included in this review. Three reviewers used the App Quality Evaluation Tool (AQEL) to assess each app's quality across seven domains: knowledge acquisition, skill development, behaviour change, purpose, functionality, and appropriateness for adults with hypertension. Domains with a score of 8 or higher were considered high-quality. Two reviewers assessed the apps' data privacy and security and then coded Behaviour change techniques (BCTs) linked to the Theoretical Domain Framework (TDF) underpinning the likely effectiveness of the apps. Seven DASH diet apps were assessed, showing the limited availability of apps supporting DASH diet self-management. The AQEL assessment showed that three apps scored higher than eight in most of the AQEL domains. Nineteen BCTs were used across the apps, linked to nine TDF action mechanisms that may support DASH diet self-management behaviours. Four apps met standards for privacy and security. All seven apps with self-monitoring functionality had sufficient theoretical basis to demonstrate likely effectiveness. However, most had significant quality and data security shortcomings. Only two apps, NOOM and DASH To TEN, were found to have both adequate quality and security and were thus deemed suitable to support DASH diet self-management.

Decision support training for advanced cancer family caregivers: Study protocol for the CASCADE factorial trial

BACKGROUND

Patients with advanced cancer face numerous decisions when diagnosed and often receive decision support from family caregivers. The CASCADE (CAre Supporters Coached to be Adept DEcision partners) factorial trial intervention aims to train caregivers in skills to provide effective decision support to patients and identify most effective intervention components.

METHODS

This is a 2-site, single-blind, 24 factorial trial to test components of the CASCADE decision support training intervention for family caregivers of patients with newly-diagnosed advanced cancer delivered by specially-trained, telehealth, palliative care lay coaches over 24 weeks. Family caregivers (target N = 352) are randomly assigned to one of 16 combinations of four components with two levels each: 1) psychoeducation on effective decision partnering principles (1 vs. 3 sessions); 2) decision support communication training (1 session vs. none); 3) Ottawa Decision Guide training (1 session vs. none) and 4) monthly follow-up (1 call vs. calls for 24 weeks). The primary outcome is patient-reported decisional conflict at 24 weeks. Secondary outcomes include patient distress, healthcare utilization, caregiver distress, and quality of life. Mediators and moderators (e.g., sociodemographics, decision self-efficacy, social support) will be explored between intervention components and outcomes. Results will be used to build two versions of CASCADE: one with only effective components (d ≥ 0.30) and another optimized for scalability and cost.

DISCUSSION

This protocol describes the first factorial trial, informed by the multiphase optimization strategy, of a palliative care decision-support intervention for advanced cancer family caregivers and will address the field's need to identify effective components that support serious illness decision-making.

TRIAL REGISTRATION

NCT04803604.

How to enable healthier and more sustainable food practices in collective meal contexts: A scoping review

Collective meal contexts such as restaurants, cafeterias and canteens can help accelerate transitions to healthier and more sustainable diets. However, evidence from intervention studies on these contexts lacks integration. This scoping review aimed to map determinants of dietary change in collective meal contexts across multiple settings, interventions, target groups, and target behaviors. The review provided two main outcomes: (i) identifying intervention components to promote dietary change in collective meal contexts, based on the existing body of evidence; and (ii) classifying and integrating these intervention components into an overarching framework of behavior change (i.e., COM-B system). The review encompassed twenty-eight databases via two indexing services and extracted information from 232 primary sources (27,458 records selected for title and abstract screening, 574 articles selected for full-text screening). We identified a total of 653 intervention activities, which were classified into intervention components and grouped under three broad themes, namely contextual and environmental changes, social influence, and knowledge and behavioral regulation. Multi-component interventions tended to report overall positive outcomes. The review proposes several directions for future research, including: (i) moving toward more theory-based interventions in collective meal contexts; (ii) providing more detailed information about intervention settings, implementation, target groups, activities, and materials; and (iii) improving the use of open science practices in the field. Furthermore, the review offers a free, original, open-access list and synthesis of 277 intervention studies in collective meal contexts, which can help intervention planners and evaluators optimize their efforts to promote healthier and more sustainable food practices in these contexts.

Assessing the feasibility, fidelity and acceptability of a behaviour change intervention to improve tractor safety on farms: protocol for the BeSafe tractor safety feasibility study

BACKGROUND

In Ireland, the agriculture sector reports the highest number of fatalities even though farmers constitute only 6% of the working population. Tractor-related behaviours are implicated in 55% of all vehicle work-related fatalities and 25% of reported injuries, and many of these occur in farmyards. There is limited research on the feasibility and acceptability of behaviour change interventions to improve tractor safety. Target behaviours that promote safe operation in farmyards, determining and addressing blind spots of tractors, were identified, and an intervention was developed following the Behaviour Change Wheel Approach. The objective of the study is to examine the feasibility, fidelity and acceptability of a behaviour change intervention to enhance the safe operation of tractors in farmyards with a particular focus on tractor blind spots.

METHOD

A single group feasibility study will be undertaken. Approximately 16 farmers from four major farm types will be recruited for the study between August and September 2022. The intervention involves an in-person demo session, facilitated discussion and personalised safety training procedure with safety goals. The study will collect data from participants at three time points: baseline (3-10 days prior to the intervention), during the intervention and at the follow-up session (7-30 days post-intervention). Quantitative data will be collected through a pre-intervention interview and feedback surveys. A pre- and post-intervention qualitative interview will also be conducted with the participants and will be supplemented with qualitative data from recruitment logs, observational memos and logs and feedback from recruiters. Evaluation of the feasibility, acceptability and fidelity of the intervention will be guided by a pre-determined feasibility checklist, fidelity framework and theoretical framework of acceptability, respectively. Interviews will be analysed using the content analysis.

DISCUSSION

The current study can determine the feasibility and fidelity of delivering a systematic, theoretically driven, tailored behaviour change intervention. It will also assess whether the intervention, its ingredients and delivery are acceptable to the farming population. This study will also inform the development of a future larger trial to test the effectiveness of the intervention.

TRIAL REGISTRATION

ISRCTN Identifier: ISRCTN22219089. Date applied 29 July 2022.

Theoretical components of smoking cessation interventions for persons with physical disabilities: A scoping review

Rationale Persons with physical disabilities report higher cigarette smoking rates and a lower likelihood of accessing health services (e.g., smoking cessation services). Explicit and systematic application of behaviour change theory may be a promising approach to addressing these inequities and developing impactful smoking cessation interventions for persons with physical disabilities.

OBJECTIVE

This scoping review aimed to explore how behaviour change theory and intervention components have been used to design smoking cessation interventions for persons with physical disabilities.

METHODS

Electronic databases (Medline, Embase, PsycINFO, CINAHL, Web of Science) were systematically searched. Smoking cessation interventions for persons with physical disabilities were identified. Behaviour change theory and intervention components, including behaviour change techniques, intervention functions, mode of delivery, intervention source, and setting, were extracted from the included articles.

RESULTS

Among the eleven included articles, there were nine unique smoking cessation interventions for persons with physical disabilities. Three interventions mentioned theory, but none of these articles explicitly applied or tested the theory. Intervention components were consistently combined to deliver pharmacotherapy and behavioural counselling-based interventions.

CONCLUSION

The results of this review highlight the scarcity of theory-based smoking cessation interventions for persons with physical disabilities. While the interventions were not theory-based, they were evidence-based and aligned with recommendations for smoking cessation treatment (i.e., behavioural counselling plus pharmacotherapy). Future research should take a theory-based approach to intervention development to enhance the likelihood that smoking cessation interventions for persons with physical disabilities are effective, replicable, and equitable.

Design and methods of a translational, community-based, lifestyle weight management pilot intervention trial in breast cancer survivors with overweight or obesity

Background

Breast cancer survivors (BCS) with overweight or obesity are at heightened risk of cancer recurrence, cardiometabolic disease, and compromised quality of life. Given the prevalence of significant weight gain during and following breast cancer treatment, there is growing recognition of the need to develop efficacious, widely-accessible, weight management programs for BCS. Unfortunately, access to evidence-based weight management resources for BCS remains limited and little is known of the optimal theoretical basis, program components, and mode of delivery for community-based interventions. The primary aim of the Healthy New Albany Breast Cancer (HNABC) pilot trial was to determine the safety, feasibility, and preliminary efficacy of delivering a translational, evidence-based, and theory-driven lifestyle weight management intervention to BCS with overweight or obesity in the community setting.

Methods

HNABC was a single-arm, pilot trial evaluating a 24-week, multi-component intervention leveraging exercise, dietary modification, and group-mediated cognitive behavioral (GMCB) counseling components designed to facilitate lifestyle behavior change and promote sustained independent adherence. Assessments of various objectively-determined and patient-reported outcomes and theory-derived determinants of behavioral adoption and maintenance were obtained at baseline, 3- and 6-month follow-up. Measures of trial feasibility were calculated prospectively throughout the study.

Conclusion

Findings from the HNABC pilot trial will provide evidence demonstrating the feasibility and preliminary efficacy of a multi-component, community-based, GMCB lifestyle weight management intervention for BCS. Results will inform the design of a future, large-scale, randomized controlled efficacy trial. If successful, this approach could offer a widely accessible, community-based intervention model for weight management programs in BCS.

Development and evaluation of a school-based physical literacy intervention for children in Germany: protocol of the PLACE study

Introduction

Fueled by the COVID-19 pandemic, the physical activity behavior of children has reached a concerning level nowadays. By empowering individuals to be physically active throughout the life course, the concept of physical literacy has recently gained increasing attention and adopts a holistic-integrative perspective on PA promotion. Although the field has successively attempted to translate the conceptual ideas of physical literacy into interventions, the theoretical base is heterogeneous and is often lacking within interventions. Furthermore, several countries, including Germany, have not equally adopted the concept yet. Therefore, the goal of the present study protocol is to describe the development and evaluation approach of a PL intervention ("PLACE") for children in grades three and four within the German all-day schooling system.

Methods

The physical literacy intervention cultivates explicit theory-content links and comprises 12 heterogeneous sessions (each 60-90 min in length). The study contains three different phases with two initial pilot studies and a subsequent main study. The two pilot studies take a mixed-methods character by drawing on quantitative pre-post-designs as well as interviews with children (in groups). In the main study, we will longitudinally compare the course of PL values (five outcome domains: physical, affective, cognitive, social, behavioral) between two study arms: school classes of children are either assigned to an intervention condition (regular physical education and health care plus PL intervention) or to a control condition (regular physical education and health care only).

Discussion

The findings of this study will provide evidence on how to structure a multicomponent intervention in Germany based on the PL concept. In summary, the results will report on the effectiveness of the intervention and, therefore, decide whether to scale-up the intervention.

Activation Versus Change as a Principle Underlying Intervention Strategies to Promote Health Behaviors

BACKGROUND AND PURPOSE

Interventions are effective in promoting health behavior change to the extent that (a) intervention strategies modify targets (i.e., mechanisms of action), and (b) modifying targets leads to changes in behavior. To complement taxonomies that characterize the variety of strategies used in behavioral interventions, we outline a new principle that specifies how strategies modify targets and thereby promote behavior change. We distinguish two dimensions of targets-value (positive vs. negative) and accessibility (activation level)-and show that intervention strategies operate either by altering the value of what people think, feel, or want (target change) or by heightening the accessibility of behavior-related thoughts, feelings, and goals (target activation).

METHODS AND RESULTS

We review strategies designed to promote target activation and find that nudges, cue-reminders, goal priming, the question-behavior effect, and if-then planning are each effective in generating health behavior change, and that their effectiveness accrues from heightened accessibility of relevant targets. We also identify several other strategies that may operate, at least in part, via target activation (e.g., self-monitoring, message framing, anticipated regret inductions, and habits).

CONCLUSIONS

The Activation Vs. Change Principle (AVCP) offers a theoretically grounded and parsimonious means of distinguishing among intervention strategies. By focusing on how strategies modify targets, the AVCP can aid interventionists in deciding which intervention strategies to deploy and how to combine different strategies in behavioral trials. We outline a research agenda that could serve to further enhance the design and delivery of interventions to promote target activation.

Expanding the analysis of mechanisms of action in behavioral interventions: cognitive change versus cognitive activation

OBJECTIVE

To understand the mechanisms of action underlying behavioral interventions, researchers typically examine whether the treatment changes cognitions and whether changes in cognition predict behavior (cognitive change). This current research explores an alternative mechanism whereby the intervention increases the impact of pre-existing cognitions on behavior (cognitive activation). We tested whether cognitive change or cognitive activation explains the impact of cigarette pack messages on smoking restraint.

DESIGN

The research comprised a validation experiment (N = 135) and a 4-week RCT (N = 719) with smokers.

MAIN OUTCOME MEASURES

At both baseline and follow-up of the RCT, smokers self-reported threat appraisals, coping appraisals, and smoking restraint.

RESULTS

Intervention messages heightened the accessibility of threat appraisals compared to control messages (validation experiment). In the RCT, smoking restraint increased among intervention participants but not controls. Trial arm showed no corresponding change in threat or coping appraisals. However, trial arm interacted with baseline health cognitions such that synergies between threat appraisal components, and between threat appraisals and coping appraisals, predicted smoking restraint for intervention participants but not for controls.

CONCLUSION

Our findings support a cognitive activation process whereby health messages on cigarette packs increase the impact of pre-existing threat appraisals on smoking restraint.

Preliminary Support for the Use of Motivational Interviewing to Improve Parent/Adult Caregiver Behavior for Obesity and Cancer Prevention

Motivational interviewing (MI) is a promising behavioral intervention for improving parent and adult caregiver (PAC) health behavior for obesity and cancer prevention. This study explored the preliminary effects of MI from a registered dietitian (RDMI) within an obesity prevention intervention to promote PAC behavior change and positive proxy effects on children and the home environment. N = 36 PAC/child dyads from low-resource communities were enrolled in a randomized trial testing a 10-week obesity prevention intervention. Intervention dyads were offered RDMI sessions. Data were collected at baseline and post-intervention (PAC diet quality (Healthy Eating Index (HEI)), child skin carotenoids, home environment, and PAC ambivalence regarding improving diet). Results show that for every RDMI dose, PAC HEI scores increased (0.571 points, p = 0.530), child skin carotenoid scores improved (1.315%, p = 0.592), and the home food environment improved (3.559%, p = 0.026). There was a significant positive relationship between RDMI dose and change in ambivalence (ρ = 0.533, p = 0.007). Higher baseline ambivalence was associated with greater dose (ρ = -0.287, p = 0.173). Thus, RDMI for PACs may improve diets among PACs who are otherwise ambivalent, with potential effects on the diets of their children and the home food environment. Such intervention strategies have the potential for greater effect, strengthening behavioral interventions targeting obesity and cancer.

Active Ingredients of Interventions Improving Smoking Cessation Support by Dutch Primary Care Providers: A Systematic Review

The objective was to assess active ingredients, change mechanisms, and fidelity in interventions aiming to increase the quality of smoking cessation care in the Dutch primary healthcare setting. We conducted a systematic review searching five scientific databases on August 2nd, 2019, updated on October 28th, 2021. We included effect data of behavioural interventions aiming at improving the provision of smoking cessation support by Dutch primary care providers to their patients. We excluded studies published before 2000 and those without a behavioural support intervention for primary care providers targeting smoking cessation in their patients. We found 1939 articles and included 15 distinct interventions in the review. We provided an overview of study characteristics, intervention effects, fidelity, active ingredients and change mechanisms using the Behaviour Change Techniques (BCT) Taxonomy and Mechanisms of Action (MoAs) protocols. Interventions seemed more effective when including a face-to-face component, using active learning strategies and providing a tool to help follow the guidelines in practice (e.g., physical cards with information). BCTs, MoAs, and fidelity were overall poorly reported on. To support the application of smoking cessation practices in Dutch primary care, we recommend implementation of face-to-face training programs incorporating active skill training elements combined with practical tools.

Future Directions in Youth and Family Treatment Engagement: Finishing the Bridge Between Science and Service

The field has spent more than 50 years investing in the quality of youth mental healthcare, with intervention science yielding roughly 1,300 efficacious treatments. In the latter half of this period, concurrent efforts in implementation science have developed effective methods for supporting front-line service organizations and therapists to begin to bridge the science to service gap. However, many youths and families still do not benefit fully from these strategic investments due to low treatment engagement: nearly half of youths in need of services pursue them, and among those who do, roughly another half terminate prematurely. The negative impact of low engagement is substantial, and is disproportionally and inequitably so for many. We contend that to build a robust and "finished" bridge connecting science and service, the field must go beyond its two historical foci of designing interventions and preparing therapists to deliver them, to include an intentional focus on the youths and families who participate in these interventions and who work with those therapists. In this paper, we highlight the significance of treatment engagement in youth mental healthcare and discuss the current state of the literature related to four priorities: conceptualization, theory, measurement, and interventions. Next, we offer an example from our own program of research as one illustration for advancing these priorities. Finally, we propose recommendations to act on these priorities.

The development of a family-based wearable intervention using behaviour change and co-design approaches: move and connect

BACKGROUND

Previous research has explored the effectiveness of wearable activity trackers (wearables) for increasing child physical activity (PA) levels, but there have been mixed results. The use of theoretical frameworks and co-design techniques are recognised ways of increasing an intervention's acceptability and effectiveness.

AIMS

This study aims to use co-design workshops and an evidence-based theoretical framework (the Behaviour Change Wheel) to develop a family-based PA intervention using wearables.

METHODS

Three stages of intervention development outlined by the Behaviour Change Wheel were used. Co-design workshops with seven families (11 parents and 12 children) and seven PA experts were conducted where stakeholders discussed how to overcome previously identified barriers to families being active and using wearables. This resulted in the intervention's components being developed, with each component's mechanisms of action (e.g. intervention functions and behaviour change techniques) being retrospectively identified.

RESULTS

The 'Move & Connect' intervention was developed, which targets family PA and wearable use. The intervention takes a flexible approach and includes eight components, including wearable devices (Fitbit Alta HR), support resources, an introductory workshop, collective challenges, goal setting and reviewing, engagement prompts, social support and health-related resources (e.g. educational videos). The intervention incorporates six intervention functions targeting PA and wearable use: education, training, modelling, persuasion, incentivisation and environmental restructuring and 24 behaviour change techniques, including goal setting, social comparison, feedback on behaviour and graded task.

CONCLUSIONS

This is the first known study to use an evidence-based framework and co-design to develop a family-based wearable intervention. The identification of the intervention's mechanisms of action will prove useful when implementing and evaluating the 'Move & Connect' intervention and allow researchers to replicate its components.