Motivating the unmotivated: how can health behavior be changed in those unwilling to change?

Engaging Unmotivated Smokers to Move Toward Quitting: Design of Motivational Interviewing-Based Chatbot Through Iterative Interactions

BACKGROUND

At any given time, most smokers in a population are ambivalent with no motivation to quit. Motivational interviewing (MI) is an evidence-based technique that aims to elicit change in ambivalent smokers. MI practitioners are scarce and expensive, and smokers are difficult to reach. Smokers are potentially reachable through the web, and if an automated chatbot could emulate an MI conversation, it could form the basis of a low-cost and scalable intervention motivating smokers to quit.

OBJECTIVE

The primary goal of this study is to design, train, and test an automated MI-based chatbot capable of eliciting reflection in a conversation with cigarette smokers. This study describes the process of collecting training data to improve the chatbot's ability to generate MI-oriented responses, particularly reflections and summary statements. The secondary goal of this study is to observe the effects on participants through voluntary feedback given after completing a conversation with the chatbot.

METHODS

An interdisciplinary collaboration between an MI expert and experts in computer engineering and natural language processing (NLP) co-designed the conversation and algorithms underlying the chatbot. A sample of 121 adult cigarette smokers in 11 successive groups were recruited from a web-based platform for a single-arm prospective iterative design study. The chatbot was designed to stimulate reflections on the pros and cons of smoking using MI's running head start technique. Participants were also asked to confirm the chatbot's classification of their free-form responses to measure the classification accuracy of the underlying NLP models. Each group provided responses that were used to train the chatbot for the next group.

RESULTS

A total of 6568 responses from 121 participants in 11 successive groups over 14 weeks were received. From these responses, we were able to isolate 21 unique reasons for and against smoking and the relative frequency of each. The gradual collection of responses as inputs and smoking reasons as labels over the 11 iterations improved the F1 score of the classification within the chatbot from 0.63 in the first group to 0.82 in the final group. The mean time spent by each participant interacting with the chatbot was 21.3 (SD 14.0) min (minimum 6.4 and maximum 89.2). We also found that 34.7% (42/121) of participants enjoyed the interaction with the chatbot, and 8.3% (10/121) of participants noted explicit smoking cessation benefits from the conversation in voluntary feedback that did not solicit this explicitly.

CONCLUSIONS

Recruiting ambivalent smokers through the web is a viable method to train a chatbot to increase accuracy in reflection and summary statements, the building blocks of MI. A new set of 21 smoking reasons (both for and against) has been identified. Initial feedback from smokers on the experience shows promise toward using it in an intervention.

The MIPAM trial: a 12-week intervention with motivational interviewing and physical activity monitoring to enhance the daily amount of physical activity in community-dwelling older adults - a study protocol for a randomized controlled trial

BACKGROUND

Physical Activity Monitors (PAMs) have been shown to effectively enhance level of physical activity (PA) in older adults. Motivational interviewing is a person-centred model where participants are guided using self-reflection and counselling, and addresses the behavioural and psychological aspects of why people initiate health behaviour change by prompting increases in motivation and self-efficacy. The addition of motivational interviewing to PA interventions may increase the effectiveness of PAMs for older adults.

METHODS

This motivational interviewing and PA monitoring trial is designed as an investigator-blinded, two arm parallel group, randomized controlled superiority trial with primary endpoint after 12 weeks of intervention. The intervention group will receive a PAM-based intervention and motivational interviewing and the control group will only receive the PAM-based intervention. The primary outcome is PA, objectively measured as the average daily number of steps throughout the intervention period. Secondary outcome measures include self-reported PA health-related quality of life, loneliness, self-efficacy for exercise, outcome expectancy for exercise, and social relations. The outcomes will be analysed with a linear regression model investigating between-group differences, adjusted for baseline scores. Following the intention to treat principle, multiple imputation will be performed to handle missing values.

DISCUSSION

A moderate effect of daily PA measured using PAMs is expected in this superiority RCT investigating the effect of adding motivational interviewing to a PAM intervention. According to the World Health Organization, walking and cycling are key activities in regular PA and should be promoted. To increase the general public health and lower the burden of inactivity in older adults, cost-beneficial solutions should be investigated further. If this RCT shows that motivational interviewing can enhance the effect of PAM-based interventions, it might be included as an add-on intervention when appropriate. No matter what the results of this study will be, the conclusions will be relevant for clinicians as the dependence on technology is increasing, especially in relation to public health promotion.

TRIAL REGISTRATION

NCT03906162 , April 1, 2019.

Resources in vulnerable young adults: self-assessments during preventive consultation with their general practitioner in Denmark

Inequality in health is increasing. People with many problems often lack energy to improve well-being and reduce their problems. This study analyses how psycho-socially challenged younger (20- to 44-year-old) patients described their own resources to reach lifestyle goals or alter life circumstances. Within the context of a randomized controlled trial, Danish participants had two structured preventive person-centred consultations with their general practitioner. Consultations focused on well-being, salutogenesis, resources, barriers and support of autonomy. Using the qualitative method: Systematic Text Condensation, we made thematic cross-analysis of patients' goal-specific resource statements described at the first consultation. Of the 209 patients, 191 (91%) chose one or two goals for a better life next year; nearly all (179) could recall and describe which resources they would use to reach their goal. We categorized resource statements into (i) personal constitution as 'willpower' and 'tenacity'; (ii) network, e.g. family; (iii) personal experience with identical or similar problems. Some patients needed to free up resources by handling psychological problems before being able to focus on lifestyle goals. The study demonstrates that patients with particular psycho-social problems could describe essential resources in a structured, salutogenic, preventive consultation with their general practitioner. Reflecting intrinsic and extrinsic motivation, these resources reflected dimensions of essential health theories like sense of coherence, self-efficacy and self-determination theory. Increased awareness of these resources seems essential for vulnerable patients by improving psychological well-being and optimism, thereby facilitating health-related changes. This may be an important step to reducing inequality in health.

Psychological correlates of physical activity and exercise preferences in metropolitan and nonmetropolitan cancer survivors

OBJECTIVE

Interventions to increase physical activity (PA) in cancer survivors have often adopted a "one-size-fits-all" approach and may benefit from being tailored to psychological constructs associated with behavior. The study objective was to investigate the exercise preferences and psychological constructs related to PA among cancer survivors.

METHODS

Posttreatment colorectal, endometrial, and breast cancer survivors (n = 183) living in metropolitan and nonmetropolitan areas completed survey measures of PA, exercise preferences, attitudes, self-efficacy, perceived behavioral control (PBC), and intention toward PA.

RESULTS

A structural equation model with adequate fit and quality indices revealed that instrumental attitude and self-efficacy were related to PA intention. Intention was related to behavior and mediated the relationship between self-efficacy and behavior. Preferred exercise intensity was related to self-efficacy, PBC, attitudes, and intention, while preferred exercise company was related to self-efficacy and PBC. Participants preferred moderate-intensity PA (71%), specifically self-paced (52%) walking (65%) in an outdoor environment (58%).

CONCLUSIONS

Since instrumental attitude and self-efficacy were associated with PA, incorporating persuasive communications targeting attitudes in PA interventions may promote PA participation. As cancer survivors who prefer low-intensity exercise and exercising with others report lower self-efficacy and PBC, interventions targeting confidence and successful experience in this group may also be warranted.

The Development of an Internet-Based Decision Coaching Guide to Encourage Audiology Care: The Results of a Participatory Design Approach

Purpose The purpose of the research described here is to create a theoretically based, interactive online program to motivate adults with untreated hearing loss to seek audiology care. We describe the results of the participatory design (PD) approach used to increase uptake and adherence to the Internet-based program. Method Using information gathered from field experts (n = 7), a program outline was generated by the study team. In keeping with PD principles, multiple focus groups and panels consisting of persons with hearing loss (n = 26), frequent communication partners (n = 6), audiologists (n = 9), and other area experts (n = 16) revised and expanded both content and design of the program in an iterative fashion. Results The proposed program was modified multiple times based on the input of stakeholders throughout the PD process. In particular, the scope of the program shifted from focusing on self-management strategies to decision coaching regarding the choice to visit an audiologist. Other specific program content and activities were modified based on stakeholder input. Conclusions The program evolved dramatically through the influence and input of multiple stakeholders as a result of the implementation of PD principles.

Self-Efficacy and Social Support are Associated with Disability for Ambulatory Prosthesis Users After Lower-Limb Amputation

BACKGROUND

Interventions targeting psychosocial factors may improve rehabilitation outcomes for prosthesis users after lower-limb amputation (LLA), but there is a need to identify targeted factors for minimizing disability.

OBJECTIVE

To identify psychosocial factors related to disability for prosthesis users after LLA in middle age or later.

DESIGN

Cross-sectional study.

SETTING

General community.

PARTICIPANTS

Participants with LLA (N = 122) were included in this cross-sectional study if their most recent LLA was at least 1 year prior, they were ambulating independently with a prosthesis, and they were between 45 and 88 years old.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Disability, the primary outcome, was measured using the World Health Organization Disability Assessment Schedule 2.0 (WHODAS). Candidate psychosocial variables included self-efficacy, social support, and motivation, measured using the Self-Efficacy of Managing Chronic Disease questionnaire (SEMCD), Multidimensional Scale of Perceived Social Support questionnaire (MSPSS), and modified contemplation ladder (mCL), respectively. The hypothesis was that greater self-efficacy, social support, and motivation would be associated with lower disability when controlling for covariates.

RESULTS

The covariate model, including etiology, age, sex, U.S. military veteran status, LLA characteristics, time since LLA, medical complexity, and perceived functional capacity, explained 66.1% of disability variability (WHODAS 2.0). Backward elimination of candidate psychosocial variables stopped after removal of motivation (P = .10), with self-efficacy (P < .001) and social support (P = .002) variables remaining in the final model. The final model fit was statistically improved (P < .001) and explained an additional 6.1% of disability variability when compared to the covariate model.

CONCLUSIONS

Greater self-efficacy and social support are related to lower disability after LLA. Findings suggest there may be a role for interventions targeting increased physical function, self-efficacy, and social support for ambulatory prosthesis users after LLA in middle age or later, especially when complicated by multiple chronic conditions.

"To be there for my family" and "Keep my independence": Metropolitan and Non-Metropolitan Cancer Survivors' Health Behaviour Motives

PURPOSE

Cancer survivors are at risk of comorbidities and mortality, and those living outside of metropolitan areas are particularly susceptible given poorer socioeconomic, health and support resources. As engagement in health behaviours is affected by participants' autonomous motives, investigation of the motives of cancer survivors in metropolitan and non-metropolitan areas could elucidate the values and reasons for practising health behaviours, allowing programs to be tailored to these motives.

METHODS

Metropolitan (n = 103) and non-metropolitan (n = 80) Australian cancer survivors completed a survey item by describing their motives for physical activity and healthy diet change. Inductive thematic analysis of responses was performed to establish themes across health behaviour motives.

RESULTS

Analyses revealed four themes: to be able to, longevity, psychological health and appearance. Survivors primarily referred to being able to enjoy family, leisure activities, travel and staying independent, with these motives often linked to longevity. Motives were similar across locations; however, those in non-metropolitan locations reported continuation of work and pain relief more frequently. Female survivors more often reported weight loss.

CONCLUSIONS

A predominant motive for health behaviour change in cancer survivors across geographical location was the ability to enjoy family and engage in leisure and work activities. Programs aiming to promote health behaviours in cancer survivors might consider framing interventions accordingly by emphasizing benefits of longevity and maintaining independence.

Impact of Digital Divide on the Adoption of Online Patient Portals for Self-Motivated Patients

OBJECTIVE

Our study aimed to determine the effect of the digital divide in the adoption of online patient portals by motivated patients who wish to improve their health outcomes through the use of the Internet and information technology to assess determinants of low adoption rates of online portals and to explore social media use as a correlation to patient portal use.

METHODS

We utilized data from the Health Information National Trends Survey (HINTS) 2017 and 2018. We performed a cross-sectional study analyzing the outcome variable of patient portal use with several predictor variables, namely, age, marital status, gender, mental health, education, Medicaid, income, number of people in household, trust, social media, chronic disease, and health app use. Basic descriptive statistics and logistic regression were performed using SPSS version 25.

RESULTS

Our study found that low adoption rates go beyond the digital divide. A correlation exists between social media use and patient portal use, and the impact of previously identified factors on patients with self-motivation for health improvement.

CONCLUSION

Self-motivation is an important factor in patient portal use and access. Behavioral and motivational interventions geared towards the adoption of health information technology tools, such as online portals, can assist with improving the public health significance of these tools.

Can we stop the stroke tsunami? Mitigating the barriers, amplifying the facilitators

In this narrative review article, by critically appraising the Global Burden of Disease 1990-2017 data on stroke and currently used primary stroke prevention strategies, we show that the global burden of stroke will continue to rise unless new primary stroke and cardiovascular disease (CVD) prevention strategies are urgently implemented. We provide an overview of the advantages and disadvantagesof population-wide and high CVD risk prevention strategies and mobile technologies available for stroke and CVD prevention on individual and population levels. Our recent NZ pilot RCT demonstrated the feasibility, consumer acceptability, motivational value and a clinically important, albeit statistically non-significant, behaviour change, improvement in diet, and awareness of stroke symptoms. We also identify and discuss causes for failure in the currently used primary stroke and CVD prevention strategies and emphasise the importance of complementary use of population-wide and elevated CVD risk strategies (including polypill interventions with blood pressure and lipid-lowering off-patent medications in middle-aged adults with elevated CVD risk) with motivational population-wide strategy to manage lifestyle and behavioural risk factors regardless of the level of stroke risk. The best mix of population-wide and elevated CVD risk-targeted strategiesfor primary stroke and CVD prevention remains to be determined.

Children's physical activity behavior following a supervised physical activity program in pediatric oncology

BACKGROUND

The theory of planned behavior (TPB) model and its components have been applied to comprehend the adoption of physical activity along with informational and motivational parameters. Thus, the first aim of this exploratory study was to explore the evolution of children's physical activity levels over a supervised physical activity program. The second aim was to describe the evolution of TPB measures, self-reported fitness and self-esteem in the physical domain to better understand children's physical activity behavior over the course of the physical activity program.

METHODS

A total of 16 children (8 boys and 8 girls) with cancer answered psychosocial questionnaires before and after a supervised physical activity program to explore the TPB measures, self-reported fitness, self-esteem in the physical domain and their daily physical activities.

RESULTS

A significant increase of 13.8 min/day [95% CI (16.7; 10.8); p < 0.0001; d = 1.4] of daily MVLPA was observed between the time before (9.3 ± 9.1 min/day) and after (23.1 ± 10.8 min/day) the physical activity program. We found that the physical activity program positively impacted children's TPB measures (mean in attitude, identity, facilitating factors, self-confidence and intention) and MVLPA levels. The TPB model explained 36.2% of the variance in MVLPA by injunctive norms after the physical activity program.

CONCLUSION

This study highlighted the need to provide children with physical activity support as soon as the cancer is diagnosed and showed that children's physical activity behaviors were facilitated by familial support measured by injunctive norms.

A self-management support intervention for patients with atrial fibrillation: a randomized controlled pilot trial

BACKGROUND

Atrial fibrillation (AF) is the most common arrhythmia worldwide. Despite effective treatment, it is characterized by frequent recurrences. Optimal therapeutic management of AF requires active participation and self-management from patients. Two major components of self-management are self-monitoring and sign-and-symptom management. Pulse self-palpation (PSP) is a method of self-monitoring; however, not all AF patients are capable of successfully performing PSP. Due to a lack of interventions on this topic, a nurse-led intervention for patients with AF (PSPAF intervention) was developed to foster self-monitoring and to enhance self-management through PSP. The purpose of this pilot study was to test the acceptability, feasibility, and potential effects of this intervention on the capability of patients' PSP and sign-and-symptom management. Moreover, we aimed at gathering data on the feasibility of applied research methods to aid in the design of future studies.

METHODS

The pilot trial involved 20 adult patients with AF, randomized to an intervention or usual care group. At baseline and during a home visit 3-5 weeks later, we collected data using questionnaires, checklists, field notes, a mobile ECG device, and a diary. Acceptability and feasibility measures were validated through predefined cut-off points. Effect size estimates were expressed as relative risks (RR) and the number needed to treat (NNT).

RESULTS

The PSPAF intervention seemed feasible, but only partly acceptable. There were limitations in terms of potential effectiveness, suitability, addressing participants' willingness to implement its content in daily life, and adherence. Estimations of effect sizes suggest a large effect of the intervention on patients' PSP capability (RR = 6.0; 95% CI = [0.83, 43.3]; NNT = 2.4), but almost no effect on sign-and-symptom management (RR = 1.5; 95% CI = [0.7, 3.1]; NNT = 4.0). The feasibility of applied research methods showed minor limitations on recruitment and participant burden.

CONCLUSIONS

Despite some limitations, the intervention seemed to be applicable and promising. Taking into account the suggestions and amendments we have made, we recommend conducting a full-scale trial to examine the efficacy of the PSPAF intervention.

TRIAL REGISTRATION

This pilot study was registered in the German Clinical Trials Register at September 4, 2017 (Main ID: DRKS00012808).

Guidelines for Physical Activity-A Cross-Sectional Study to Assess Their Application in the General Population. Have We Achieved Our Goal?

National and international healthcare organizations propose guidelines for physical activity worldwide, defining its characteristics. These guidelines' practical applications are difficult to estimate, since they are not fully followed. The aim of the present cross-sectional observational study was to assess awareness about guidelines for physical activity and to evaluate their practical applications in a sample of the Italian population. In total, 310 participants completed an online survey (mean age 29.10 ± 4.44), assessing the habits, beliefs and health effects of physical activity. In total, 39.35% of respondents were inactive. In total, 6.91% of active respondents did not perform a warm-up phase at the beginning of each training session and 77.14% did not check their own heart rate during the training session. Approximately half of respondents reported erroneous beliefs about the type, frequency and volume of physical activity, compared to data proposed by the guidelines. The preventive effect of physical activity was clearly perceived for cardiovascular diseases, diabetes, metabolic syndrome and depression. Several subjects misinterpreted the preventive role of physical activity in colon and breast cancers, and in femur and vertebral fractures. Habits and beliefs about physical activity in the general population are far from the guidelines and recommendations. Therefore, it is necessary to strengthen the conscious practice of physical activity further.

Beyond depression, anxiety and post-traumatic stress disorder symptoms: Qualitative study of negative emotional experiences in hematopoietic stem cell transplant patients

OBJECTIVE

Psychological distress impacts a variety of health outcomes in hematopoietic stem cell transplantation (HSCT). Focused qualitative studies on a wider range of psychological distress in HSCT patients are lacking. However, understanding the subtleties of psychological distress (e.g. fear, guilt, loss of control) in HSCT patients is imperative to optimising the psychological well-being of this vulnerable population. To explore psychological distress after transplantation, we conducted semi-structured interviews with 25 HSCT patients.

METHODS

Interviews were completed in the first 100 days after transplantation. Interview modules explored psychological distress symptoms in the hospital and during the first 100 days after HSCT, along with the perceived impact of these symptoms on their recovery.

RESULTS

Of the negative emotional experiences reported, feeling trapped, fear, guilt, discouragement and powerlessness were frequently expressed. Patients reported that negative emotional states interfered with their motivation to participate in health behaviours important to the transplant recovery.

CONCLUSION

As one of the few qualitative studies broadly characterising the nature of negative emotional experiences after HSCT, these findings add to our understanding of the specific psychological challenges in this growing patient population and can inform development of targeted interventions and overall management of psychological distress during HSCT recovery.

Potential for, and readiness to, dietary-style changes during the retirement status passage: a systematic mixed-studies review

Context

Unfavorable diets contribute to the global burden of disease and particularly affect individuals’ health in old age. To promote healthy aging, it is vital to understand the biographical circumstances under which diets manifest and change.

Objective

This systematic mixed-studies review explored changes in dietary styles of people facing retirement.

Data Sources

Seven electronic databases were searched systematically, along with reference lists.

Data Extraction

Five qualitative and five quantitative studies were identified out of n = 974 records screened. Relevant study characteristics were extracted with a piloted form.

Data Synthesis

A qualitative convergent synthesis design was conducted.

Results

Study results were inconsistent. The majority of studies identified various dietary-style changes after retirement – some in favorable ways (eg, increased vegetable consumption [n = 4]) and some in rather unfavorable ways (eg, increased snacking [n = 2]). Influencing factors were changes in mealtime structures, available time, and financial situations accompanying retirement.

Conclusion

More high-quality, longitudinal research is needed to build a sound basis for interventions by utilizing the retirement transition as a window of opportunity for dietary changes.

Systematic Review Registration

PROSPERO registration no. CRD42018074049.

Nontraditional and Home-Based Self-management Interventions in Cancer Patients With Pain: A Mixed-Method Systematic Review

One or 2 decades ago, oncologists focused on only cancer treatments or acute care related to cancer. Since cancer care is considered as long-term cares, cancer patients require self-management (SM) ability or skill to manage their symptoms and daily cares. This mixed-method review is to evaluate quantitative and qualitative studies, which were conducted using non-traditional SM interventions for cancer pain based. This review also explores the process of SM in the chronic care model (CCM). PubMed, CINAHL, Scopus, and Wiley were used from 2011 to 2018. A total of 16 quantitative and 2 qualitative studies were included for this review. All interventions are divided into 3 types, which are educational and/or counseling programs, complementary and alternative medicine (CAM) therapy, and exercise. Ten of the included 16 studies were statistically significant on pain management: 3 CAM studies (100%), 1 exercise study (100%), and 6 of the 12 educational and/or counseling studies (50%). The CAM and exercise were statistically effective in improving cancer pain in the review. However, uncertainty remains regarding the strength of the evidence, due to the small number of studies included and lack of consistent methodologies. The application (5A) of SM support may help cancer patients to manage their pain.

The psychometric properties of the Italian adaptation of the Health Orientation Scale (HOS)

Background

A novel approach suggested that cognitive and dispositional features may explain in depth the health behaviors adoption and the adherence to prevention programs. The Health Orientation Scale (HOS) has been extensively used to map the adoption of health and unhealthy behaviors according to cognitive and dispositional features. Coherently, the main aim of the current research was to assess the factor structure of the Italian version of the HOS using exploratory and confirmatory factor analysis and testing the construct validity of the scale by assessing differences in health orientations between tobacco cigarette smokers and nonsmokers.

Method

The research protocol was organized in two studies. Study 1 evaluated the dimensionality of the HOS in a sample of Northern Italian healthy people. Three hundred and twenty-one participants were enrolled; they were 229 women (71.3%) and 92 men (28.7%). In Study 2, the factor structure and construct validity of the HOS Italian version was assessed trough confirmatory factor analysis using a tobacco cigarette smokers and nonsmokers population. Two hundred and nineteen participants were enrolled; they were 164 women (75.2%) and 55 men (24.8%).

Results

In Study 1, a seven factors solution was obtained explaining 60% of cumulative variance instead of 10 factors solution of the original version of the HOS. In Study 2, the factor structure of the Italian version of the HOS was confirmed and applied to the smokers and nonsmokers; nonsmokers reported higher values than smokers in Factor 1 (MHPP) [t (208) = − 2.739 p < .007] (CI 95–4.96% to −.809), Factor 2 (HES) [t (209) = − 3.387 p < .001] (CI 95–3.93% to -. 1.03), Factor 3 (HIC) [t(213) = − 2.468 p < .014] (CI 95–2.56% to −.28) and Factor 7 (HEX) [t(217) = − 3.451 p < .001] (CI 95%- 1.45 to .39).

Conclusions

Results of the Italian adaptation of HOS lead to a partial redistribution of items and confirmed 7 subscales to distinguish psycho-cognitive dispositional dimensions involved in health orientation styles.

Motivational Strategies to Prevent Frailty in Older Adults with Diabetes: A Focused Review

The prevalence of diabetes among Americans aged 65 years and older is greater than 25%. Medical expenditures for persons with diabetes are more than twice as high as those for patients without diabetes. Diabetes in older adults often times coexists with frailty, resulting in reduced quality of life and increased health-care use. Many older adults with type 2 diabetes have mobility impairments and experience falls, which contributes to increased frailty. Exercise has a protective effect for frailty and falls, yet less than half of persons with diabetes exercise and approximately one-quarter meet exercise recommendations. In addition to exercise, nutrition may help reduce the risk for falls; however, nutritional interventions have not been tested as a fall-prevention intervention. According to a review, there is insufficient evidence to create nutritional guidelines specific for frail older adults with type 2 diabetes. There is a need to motivate and empower older adults with type 2 diabetes to make lifestyle changes to prevent frailty. The purpose of this review was to identify and integrate what is known and what still needs to be done for this population to be successful in making health behavior changes to reduce frailty. There is some evidence that motivational approaches have worked for older adults with various chronic disease conditions. However, studies applying motivational strategies are lacking for frail older adults with type 2 diabetes. A novel motivational approach was described; it combines aspects of the Health Belief Model and Motivational Interviewing. Intervention studies incorporating this model are needed to determine whether this client-driven strategy can help various racial/ethnic populations make the sustainable health behavior changes of increasing exercise and healthy eating while taking into consideration physiological, psychological, and economic barriers.

Analyzing Awareness on Risk Factors, Barriers and Prevention of Cervical Cancer among Pairs of Nepali High School Students and Their Mothers

Providing information on increased cancer risks associated with certain behaviors might encourage adolescents to initiate protective behaviors. This study firstly determined the knowledge of risk factors and prevention of cervical cancer. Secondly, it checked an association between mothers' screening practice and student's knowledge. A descriptive, cross sectional study was conducted among 253 pairs of high school students and their mothers. Knowledge on cervical cancer was significantly lower among students and mothers. While cancer screening tests, maintenance of hygiene were considered as major preventive measures for cervical cancer, human papilloma vaccine was the least considered preventive measure. Students who were female, attended discussions on cancer and had a healthy diet had better awareness of cancer. Mothers of female students had better knowledge about cervical cancer than mothers of male students. Less perceived susceptibility and lack of knowledge were major obstacles among mothers, limiting cervical cancer screening to 15%. Although association between knowledge of students and screening practice of mothers was not clear, it was observed that cancer communication increased awareness of cervical cancer in both groups. Our findings showed a strong need for school-based cancer education program to address the issues of human papillomavirus vaccinations, cervical cancer risk and screening.

Tailoring Persuasive Electronic Health Strategies for Older Adults on the Basis of Personal Motivation: Web-Based Survey Study

Background

Persuasive design, in which the aim is to change attitudes and behaviors by means of technology, is an important aspect of electronic health (eHealth) design. However, selecting the right persuasive feature for an individual is a delicate task and is likely to depend on individual characteristics. Personalization of the persuasive strategy in an eHealth intervention therefore seems to be a promising approach.

Objective

This study aimed to develop a method that allows us to model motivation in older adults with respect to leading a healthy life and a strategy for personalizing the persuasive strategy of an eHealth intervention, based on this user model.

Methods

We deployed a Web-based survey among older adults (aged >60 years) in the Netherlands. In the first part, we administered an adapted version of the revised Sports Motivation Scale (SMS-II) as input for the user models. Then, we provided each participant with a selection of 5 randomly chosen mock-ups (out of a total of 11), each depicting a different persuasive strategy. After showing each strategy, we asked participants how much they appreciated it. The survey was concluded by addressing demographics.

Results

A total of 212 older adults completed the Web-based survey, with a mean age of 68.35 years (SD 5.27 years). Of 212 adults, 45.3% were males (96/212) and 54.7% were female (116/212). Factor analysis did not allow us to replicate the 5-factor structure for motivation, as targeted by the SMS-II. Instead, a 3-factor structure emerged with a total explained variance of 62.79%. These 3 factors are intrinsic motivation, acting to derive satisfaction from the behavior itself (5 items; Cronbach alpha=.90); external regulation, acting because of externally controlled rewards or punishments (4 items; Cronbach alpha=.83); and a-motivation, a situation where there is a lack of intention to act (2 items; r=0.50; P<.001). Persuasive strategies were appreciated differently, depending on the type of personal motivation. In some cases, demographics played a role.

Conclusions

The personal type of motivation of older adults (intrinsic, externally regulated, and/or a-motivation), combined with their educational level or living situation, affects an individual’s like or dislike for a persuasive eHealth feature. We provide a practical approach for profiling older adults as well as an overview of which persuasive features should or should not be provided to each profile. Future research should take into account the coexistence of multiple types of motivation within an individual and the presence of a-motivation.

Gamification to Motivate the Unmotivated Smoker: The "Take a Break" Digital Health Intervention

Objective: Digital health technologies most often reach only those more motivated to engage, particularly when preventive health is targeted. To test whether gamification could be used to engage low-motivation smokers, we conceptualized "Take a Break"-a 3-week technology-assisted challenge for smokers to compete in setting and achieving brief abstinence goals. Materials and Methods: In the feasibility study of the multi-technology Take a Break challenge, low-motivation smokers were given (1) daily motivational messages, (2) brief "challenge quizzes" related to smoking behaviors, (3) a telehealth call to personalize their abstinence goal for the challenge, (4) "coping minigames" to help manage cravings while attempting to achieve their brief abstinence goals, and (5) a leaderboard "webApp," providing comparative feedback on smokers' participation, and allowing for competition. Heterogeneity of engagement was tracked. Results: All 41 smokers initially reported that they were not actively quitting. Over half were employed less than full time (51%), completed less than a 4-year college education (76%), and experienced financial stress (54%). No smokers opted out of the motivational messages, and mean proportion of response to the challenge quizzes was 0.88 (SD = 0.19). Half of the smokers reported using the "coping minigames." Almost all set abstinence goals (78%), with over half lasting 1-2 days (51%); median = 1 day (IQR 1-7). Leaderboard points ranged widely. Conclusions: Rates of smoking in the developed world have declined, and those who remain smokers are complex and have lower motivation to quit. Using a game-inspired challenge, we achieved high levels of engagement from low-motivation smokers.

Formative research to develop a school-based, community-linked physical activity role model programme for girls: CHoosing Active Role Models to INspire Girls (CHARMING)

BACKGROUND

Physical inactivity is a persistent challenge among girls. School-based physical activity (PA) interventions have shown mixed effects on girl's activity levels, with multi-component approaches involving both school and community links appearing more effective for sustainable change. The purpose of the current research was to gather views from preadolescent girls, parents, teachers and stakeholders in order to co-produce a multi-component school-based, community linked PA intervention programme.

METHODS

Focus groups were conducted in two primary schools with 34 girls aged 9-11 years and 11 parents (10 female, 1 male). In-depth interviews were conducted with four female teachers (including two head teachers). Focus groups and interviews focused on programme design (structure, content and delivery) and potential factors affecting intervention uptake and continued PA participation. A series of stakeholder engagement events occurred throughout the study period. All data were transcribed verbatim and thematically analysed in NVivo 11.

RESULTS

Girls reported that fun taster sessions delivered by role models would encourage them to participate in a school-based role model programme, with tailored taster sessions each week to enhance continued PA participation. Parents and teachers identified a number of barriers to uptake and continued PA participation, and active involvement of stakeholders facilitated the development of intervention strategies. Strategies included; single-sex after-school sessions, use of female role models, low-cost activity options and mapping community provision. Analyses revealed the importance of tailoring the programme to align with local needs, demands and provision.

CONCLUSIONS

Data show numerous barriers to intervention uptake and continued PA participation when designing a school-based, community-linked intervention. Adopting a co-production approach, this formative work highlights a number of potential strategies for overcoming these barriers. Findings from the research directed the development and implementation of the CHARMING role model intervention and informed the creation of an intervention logic model.

Guidelines-Driven Educational Intervention Promotes Healthy Lifestyle Among Adolescents and Adults: A Serbian National Longitudinal Study

Background and objectives: The effectiveness of short-term focused educational programs to change health behaviors across large populations seems to be poorly described so far. The main aim of the present study was to evaluate an age-specific 45-min educational program, designed in accordance with the current U.S. Department of Health and Human Services and U.S. Department of Agriculture dietary guidelines and physical activity (PA) guidelines, among adolescents and adults. Materials and Methods: We evaluated the health-promoting lifestyle habits by the Health-Promoting Lifestyle Profile (HPLP-II) at baseline and following 6–8 weeks post-education in a nationally representative sample of Serbian adolescents and adults (n = 3822). Results: The percentage of adolescents eating 3–5 servings of vegetables per day increased at follow-up (20.1% versus 23.1%, p = 0.001), with significantly more adolescents regularly reading food labels (from 12.2% at baseline to 14.2% at follow-up; p = 0.02). Taken together, mean HPLP-II scores in adolescents significantly improved for both diet (0.05 points; p < 0.0001) and PA (0.09 points; p < 0.0001), and for PA in adults (0.08 points; p < 0.0001). Hierarchical multiple regression analysis revealed that our model as a whole (including time of testing as a predictor variable, and age and gender as control variables) explained 3.0% of the variance in mean HPLP-II scores for diet (p = 0.942) and 3.0% for PA (p = 0.285) in adolescents, and 1.1% of the variance in HPLP-II scores for diet (p = 0.781) and 1.9% for PA (p = 0.075) in adults, respectively. Conclusions: It appears that a brief focused education can positively tackle unhealthy lifestyles in promoting good health in general population. Different modes of interactive communication used here appeared to strengthen participants’ capacities for lifestyle changes.

Virtual Reality-Based Exercise with Exergames as Medicine in Different Contexts: A Short Review

There is enough evidence that, nowadays, the sedentary lifestyle is one of the major health problems worldwide, linked to many chronic diseases, including mental comorbidities, systemic hypertension, metabolic dysregulation, and cancer. Although health societies recommend engagement to physical activities, there is an overwhelming number of people remaining sedentary, even knowing the health benefits of regular exercises. One of the main factors that justifies this scenario is the lack of motivation, which is a barrier to people intended to start new habits for health. Considering this previous information, new alternatives for exercises may help people engage in a healthier lifestyle. Technology has contributed to this with devices that allow movements based on virtual reality approaches, including the exergames. These are games available even in commercial devices, as video-games, that allow people to work with different physical components. Furthermore, exergames add cognitive gain through its dual-task characteristic. Moreover, due to the combination of these benefits, they are feasible to acquire, and easy to use. Exergames are not only a potential strategy to reduce sedentary lifestyle but also a good method to improve health gains and rehabilitation in different populations and pathological conditions: older adults, stroke survivors, and Parkinson's disease. In this review, we aim to demonstrate some conditions that literature supports the intervention with exergames due to its physical and cognitive benefits. Furthermore, at the end of this review, we also explore the neurobiological mechanisms behind virtual-reality based exercises.

Factors affecting rehabilitation and use of upper limb after stroke: views from healthcare professionals and stroke survivors

BACKGROUND

Training of the upper limb (UL) is limited in stroke rehabilitation, and about 50% of stroke survivors do not regain useful function in their upper limb.

OBJECTIVES

This study explored what factors affect rehabilitation and use of upper limb after stroke from a stroke survivor and healthcare professional perspective to better understand low engagement in UL rehabilitation in the chronic stages of stroke.

METHOD

Eight chronic stroke survivors and 21 healthcare professionals took part in semi-structured interviews or in one of three focus groups, respectively.

RESULTS

Thematic analysis revealed three main themes: Availability of resources, Healthcare professional-patient relationship, and Psychosocial factors. Availability of resources and Healthcare professional-patient relationship indicated that due to resource pressures and a lack of communication and education, positive upper limb rehabilitation behaviors (e.g. engaging and integrating the upper limb in daily activity) were not always established in the early stages post-stroke. Psychosocial factors illustrated the cognitive and psychological barriers to sustained engagement with upper limb rehabilitation.

CONCLUSION

The findings indicate that stroke survivors and healthcare professionals have very similar understandings of barriers to UL activity, and positive upper limb rehabilitation behaviors are not always established early in recovery post-stroke. Increased resources and healthcare professional-patient relationships seem key factors to establishing positive perceptions of UL rehabilitation. Addressing psychosocial issues and resource limitations may help sustain engagement with UL rehabilitation.

Public Participation, Trust and Data Sharing: Gardens as Hubs for Citizen Science and Environmental Health Literacy Efforts

Gardenroots: A Citizen Science Project (2015) is the product of a needs assessment, revealing environmental quality concerns of gardeners living near hazardous waste or resource extraction activities. Participants were trained, collected garden samples for analysis, and later received their data visualized (individual and aggregated) via community events or mail. This article describes participant motivations, changes in knowledge and efficacy, and whether these depend on the mode of data sharing and visualization. Motivations were internal, and self-efficacy increased, while knowledge and satisfaction were higher in event attendees due to increased researcher contact. This reveals importance of data-sharing events, data visualizations, and participatory research processes.

An Exploratory Model of Psychosocial Factors and Healthy Habits in University Students of Physical Education Depending on Gender

(1) Background: Several researches have shown the relationship between healthy habits and physical and mental health. Thus, it is essential to study how some psychosocial factors can promote positive behaviours in university students, specifically in those who will be teachers of Physical Education. (2) Methods: This descriptive and cross-sectional research was conducted on 775 university students of Physical Education from Spain. This study aims to develop an explanatory model for the relationships between motivational climate, healthy habits (Mediterranean Diet (MD), Physical Activity (PA) and substance consumption) and some indicators of physical health (oxygen consumption (VO2MAX)) and mental health (self-concept) according to gender, using structural equations analysis. (3) Results: The motivational climate was positively associated with PA, showing a stronger relationship for ego-oriented climate in women. The adherence to MD showed a positive association with PA and self-concept, while it is negative for the consumption of tobacco in men. Likewise, PA was directly related to VO2MAX with a higher regression weight for women. The ego-oriented motivational climate was negatively related to tobacco consumption in women. (4) Conclusions: Task-oriented goals are related to more positive and healthy behaviours such as PA, although it was no association was found with MD. Therefore, we can conclude the importance of promoting task-oriented goals in educational contexts linked to Physical Education in order to avoid negative behaviours.

Wearable Activity Technology And Action-Planning (WATAAP) to promote physical activity in cancer survivors: Randomised controlled trial protocol

Background/Objective: Colorectal and gynecologic cancer survivors are at cardiovascular risk due to comorbidities and sedentary behaviour, warranting a feasible intervention to increase physical activity. The Health Action Process Approach (HAPA) is a promising theoretical framework for health behaviour change, and wearable physical activity trackers offer a novel means of self-monitoring physical activity for cancer survivors. Method: Sixty-eight survivors of colorectal and gynecologic cancer will be randomised into 12-week intervention and control groups. Intervention group participants will receive: a Fitbit Alta™ to monitor physical activity, HAPA-based group sessions, booklet, and support phone-call. Participants in the control group will only receive the HAPA-based booklet. Physical activity (using accelerometers), blood pressure, BMI, and HAPA constructs will be assessed at baseline, 12-weeks (post-intervention) and 24-weeks (follow-up). Data analysis will use the Group x Time interaction from a General Linear Mixed Model analysis. Conclusions: Physical activity interventions that are acceptable and have robust theoretical underpinnings show promise for improving the health of cancer survivors.

Short report: moderations in exercise motivation - gender and age moderates the relations of motivation quality and exercise behavior

Aims

Self-determined motivation has been found to be an important predictor of exercise behavior. Findings on gender and age differences are however mixed and previous research has called for studies to examine gender and age as potential moderating factors as they might influence how motivation quality affects exercise behavior.

Methods

Embedded in a controlled trial of a digital intervention aiming to promote exercise motivation, this study examined specific (longitudinal) pathways related to motivation quality, psychological need satisfaction and exercise behavior within the self-determination theory (SDT) process model in a sample of 318 adult employees. The participants completed web-based versions of Basic Psychological Needs in Exercise Scale, Behavioural Regulations in Exercise Questionnaire-2, and Leisure Time Exercise Questionnaire three times during a six weeks period.

Results

Moderation analyses revealed significant gender and age differences in the associations of motivation quality, basic psychological needs and exercise behavior over time. Several paths in the SDT-process model, linking psychological needs and motivation quality to exercise behavior, were moderated by gender and age. The stipulated mechanisms between exercise, motivation and psychological need satisfaction in the SDT-process model revealed to be stronger for women than for men, and stronger for older adults than for younger and middle-aged adults. The effect of amotivation on exercise was also significantly moderated by age in the full sample, by positively predicting light exercise for younger adults.

Conclusions

Future recommendations are related to the examination of potential differences in opportunities of autonomy support in the social context based on factors such as gender and age, and also to further examine these factors as potential moderators instead of statistically controlling them as default.

Do factors related to participation in physical activity change following restrictive bariatric surgery? A qualitative study

AIMS

To explore participants' ability to participate in physical activity (PA), and barriers and facilitators to PA, at 12 months following restrictive bariatric surgery, and how these differed from participants' pre-surgery perceptions. Motivators for PA post-surgery were also explored.

METHODS

Qualitative one-on-one in-depth interviews were conducted pre- and 12 months post-surgery. Data were analysed using inductive thematic analysis.

RESULTS

Fourteen adults (12 females), with a mean (range) age of 41.4 years (25.0-56.0), body mass index (BMI) of 31.7kg/m² (22.3-48.2), and excess weight loss of 66% (2-127) completed both interviews. Lack of participation in PA during the first 3-6 months post-surgery was a common theme. Although participants reported increased ability to participate in PA, attributing this to a reduction in obesity-related physical barriers to PA, many participants reported that some pre-surgery obesity-related barriers to PA remained at 12 months post-surgery. For most participants, pre-surgery non-obesity related barriers to PA also remained at 12 months post-surgery. Facilitators to PA were consistent pre- and post-surgery. Weight loss and improvement in physical appearance were the most common motivators for PA post-surgery.

CONCLUSIONS

At 12 months following surgery, many participants reported residual obesity and non-obesity related barriers to PA. These barriers may explain the small, if any, pre- to post-surgery change in PA levels reported by earlier research. Facilitators to PA did not change and post-surgery motivators for PA were mostly esteem-related. These data are relevant to shape interventions aimed at optimising PA in this population.

Changing the Way We Pay for Health Care: Is Value the New Plastic?

DISCLOSURES

Navarro is a clinical professor in the College of Pharmacy at the University of Florida, Gainesville, and is an assistant editor with the Journal of Managed Care and Specialty Pharmacy. Navarro reports consulting fees from Analysis Group, Amgen, Novartis, and Allergan.

Physiological health parameters among college students to promote chronic disease prevention and health promotion

This study aimed to provide physiologic health risk parameters by gender and age among college students enrolled in a U.S. Midwestern University to promote chronic disease prevention and ameliorate health. A total of 2615 college students between 18 and 25 years old were recruited annually using a series of cross-sectional designs during the spring semester over an 8-year period. Physiologic parameters measured included body mass index (BMI), percentage body fat (%BF), blood serum cholesterol (BSC), and systolic (SBP) and diastolic (DBP) blood pressure. These measures were compared to data from NHANES to identify differences in physiologic parameters among 18–25 year olds in the general versus college-enrolled population. A quantitative instrument assessed health behaviors related to physical activity, diet, and licit drug use. Results suggest that average physiologic parameters from 18 to 25 year olds enrolled in college were significantly different from parameters of 18–25 year olds in the general population. Generally, men reported higher percentiles for BMI, SBP, and DBP than women, but lower %BF and BSC percentiles than women at each age. SBP and DBP significantly increased with age and alcohol use. Students in the lowest (5th) and highest percentiles (95th and 75th), for most age groups, demonstrated DBP, BMI, and %BF levels potentially problematic for health and future development of chronic disease based on percentiles generated for their peer group. Newly identified physiologic parameters may be useful to practitioners serving college students 18–25 years old from similar institutions in determining whether behavior change or treatment interventions are appropriate.

Let's Walk Outdoors! Self-Paced Walking Outdoors Improves Future Intention to Exercise in Women With Obesity

In order to examine whether environmental settings influence psychological and physiological responses of women with obesity during self-paced walking, 38 women performed two exercise sessions (treadmill and outdoors) for 30 min, where oxygen uptake, heart rate, ratings of perceived exertion, affect, attentional focus, enjoyment, and future intentions to walk were analyzed. Physiological responses were similar during both sessions. However, during outdoor exercise, participants displayed higher externally focused attention, positive affect, and lower ratings of perceived exertion, followed by greater enjoyment and future intention to participate in outdoor walking. The more externally focused attention predicted greater future intentions to participate in walking. Therefore, women with obesity self-selected an appropriate exercise intensity to improve fitness and health in both environmental settings. Also, self-paced outdoor walking presented improved psychological responses. Health care professionals should consider promoting outdoor forms of exercise to maximize psychological benefits and promote long-term adherence to a physically active lifestyle.

Behavior Change with Fitness Technology in Sedentary Adults: A Review of the Evidence for Increasing Physical Activity

Physical activity is closely linked with health and well-being; however, many Americans do not engage in regular exercise. Older adults and those with low socioeconomic status are especially at risk for poor health, largely due to their sedentary lifestyles. Fitness technology, including trackers and smartphone applications (apps), has become increasingly popular for measuring and encouraging physical activity in recent years. However, many questions remain regarding the effectiveness of this technology for promoting behavior change. Behavior change techniques such as goal setting, feedback, rewards, and social factors are often included in fitness technology. However, it is not clear which components are most effective and which are actually being used by consumers. We discuss additional strategies not typically included in fitness technology devices or apps that are promising for engaging inactive, vulnerable populations. These include action planning, restructuring negative attitudes, enhancing environmental conditions, and identifying other barriers to regular physical activity. We consider which strategies are most conducive to motivating behavior change among sedentary adults. Overall, fitness technology has the potential to significantly impact public health, research, and policies. We suggest ways in which app developers and behavior change experts can collaborate to develop successful apps. Advances are still needed to help inactive individuals determine how, when, where, and with whom they can increase their physical activity.

A qualitative study exploring health perceptions and factors influencing participation in health behaviors in colorectal cancer survivors

PURPOSE

The purpose of the study was to explore colorectal cancer survivors' health perceptions following cessation of active treatment for cancer and to explore the factors influencing participation in health-promoting behaviors that may help reduce cardiovascular disease risk.

METHODS

Face-to-face interviews were conducted with participants that had completed active treatment for cancer within the previous 2 years. Participants were colorectal cancer survivors (N = 24, men = 11, women = 13, M age = 69.38 years, SD = 4.19) recruited from a private hospital in Perth, Australia on the basis that they had existing morbidities that put them at increased risk of cardiovascular disease. Interview transcripts were analyzed using thematic analysis.

RESULTS

Five main themes emerged: back to normal; the pleasures in life: 'is it worth it?'; beliefs about health behavior; skepticism of eating guidelines; and lack of motivation. The majority of participants felt they were in good health and had made a full recovery. Participants questioned whether it was worth changing their lifestyle given their life stage and referred to the desire to enjoy life. Lay health beliefs, skepticism of eating guidelines, and a lack of motivation were barriers to change.

CONCLUSIONS

Interventions should target lay beliefs and skepticism in relation to health behaviors in order to reinforce the importance and value of participating in health-related behavior.

IMPLICATIONS FOR CANCER SURVIVORS

Findings may inform the development of effective, patient-centered interventions that target lay health beliefs and build motivation for health behavior change. Copyright © 2016 John Wiley & Sons, Ltd.