The impact of theory on the effectiveness of worksite physical activity interventions: a meta-analysis and meta-regression

Stress Management Apps With Regard to Emotion-Focused Coping and Behavior Change Techniques: A Content Analysis

BACKGROUND

Chronic stress has been shown to be associated with disease. This link is not only direct but also indirect through harmful health behavior such as smoking or changing eating habits. The recent mHealth trend offers a new and promising approach to support the adoption and maintenance of appropriate stress management techniques. However, only few studies have dealt with the inclusion of evidence-based content within stress management apps for mobile phones.

OBJECTIVE

The aim of this study was to evaluate stress management apps on the basis of a new taxonomy of effective emotion-focused stress management techniques and an established taxonomy of behavior change techniques.

METHODS

Two trained and independent raters evaluated 62 free apps found in Google Play with regard to 26 behavior change and 15 emotion-focused stress management techniques in October 2015.

RESULTS

The apps included an average of 4.3 behavior change techniques (SD 4.2) and 2.8 emotion-focused stress management techniques (SD 2.6). The behavior change technique score and stress management technique score were highly correlated (r=.82, P=.01).

CONCLUSIONS

The broad variation of different stress management strategies found in this sample of apps goes in line with those found in conventional stress management interventions and self-help literature. Moreover, this study provided a first step toward more detailed and standardized taxonomies, which can be used to investigate evidence-based content in stress management interventions and enable greater comparability between different intervention types.

The BASE-Program-A Multidimensional Approach for Health Promotion in Companies

Multidimensional assessments for conducting interventions are needed to achieve positive health effects within companies. BASE is an acronym, consisting of B = "Bedarfsbestimmung" (requirements); A = "Arbeitsplatzorganisation" (organisation of work); S = "Schulung des belastungsverträglichen Alltagshandelns" (coaching preventive behaviour at work); E = "Eigenverantwortung und Selbstwirksamkeit" (self-responsibility and self-efficacy). It is a prevention program designed to avoid and reduce work-related musculoskeletal diseases. It was developed to support prevention strategies within companies. It comprises aspects of health protection, ergonomics, exercise and self-efficacy. A comprehensive assessment will identify strain e.g., musculoskeletal discomforts due to body positions or psychological stress. Moreover, the general health status, preferences and barriers for participating in health promotion programs are evaluated. This analysis leads to practical and goal-oriented recommendations and interventions which suit the needs of companies and employees. These are executed onsite in real workplace situations and involve the introduction of first-hand experience in behavioural change. Therefore, this practical approach enhances the employees' acceptance and self-efficacy for health promotion. This can result in long-term health promoting behaviour. This article presents the outcome and sustainability effects of BASE in three different application fields (logistic, industrial and office workers).

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

Background

Clinical guidelines recommend that assessment and management of patients with stroke commences early including in emergency departments (ED). To inform the development of an implementation intervention targeted in ED, we conducted a systematic review of qualitative and quantitative studies to identify relevant barriers and enablers to six key clinical behaviours in acute stroke care: appropriate triage, thrombolysis administration, monitoring and management of temperature, blood glucose levels, and of swallowing difficulties and transfer of stroke patients in ED.

Methods

Studies of any design, conducted in ED, where barriers or enablers based on primary data were identified for one or more of these six clinical behaviours. Major biomedical databases (CINAHL, OVID SP EMBASE, OVID SP MEDLINE) were searched using comprehensive search strategies. The barriers and enablers were categorised using the theoretical domains framework (TDF). The behaviour change technique (BCT) that best aligned to the strategy each enabler represented was selected for each of the reported enablers using a standard taxonomy.

Results

Five qualitative studies and four surveys out of the 44 studies identified met the selection criteria. The majority of barriers reported corresponded with the TDF domains of “environmental, context and resources” (such as stressful working conditions or lack of resources) and “knowledge” (such as lack of guideline awareness or familiarity). The majority of enablers corresponded with the domains of “knowledge” (such as education for physicians on the calculated risk of haemorrhage following intravenous thrombolysis [tPA]) and “skills” (such as providing opportunity to treat stroke cases of varying complexity). The total number of BCTs assigned was 18. The BCTs most frequently assigned to the reported enablers were “focus on past success” and “information about health consequences.”

Conclusions

Barriers and enablers for the delivery of key evidence-based protocols in an emergency setting have been identified and interpreted within a relevant theoretical framework. This new knowledge has since been used to select specific BCTs to implement evidence-based care in an ED setting. It is recommended that findings from similar future reviews adopt a similar theoretical approach. In particular, the use of existing matrices to assist the selection of relevant BCTs.

Use of Theory in Behavior Change Interventions

OBJECTIVE

Theory use may enhance effectiveness of behavioral interventions, yet critics question whether theory-based interventions have been sufficiently scrutinized. This study applied a framework to evaluate theory use in physical activity interventions for breast cancer survivors. The aims were to (1) evaluate theory application intensity and (2) assess the association between extensiveness of theory use and intervention effectiveness.

METHODS

Studies were previously identified through a systematic search, including only randomized controlled trials published from 2005 to 2013, that addressed physical activity behavior change and studied survivors who were <5 years posttreatment. Eight theory items from Michie and Prestwich's coding framework were selected to calculate theory intensity scores. Studies were classified into three subgroups based on extensiveness of theory use (Level 1 = sparse; Level 2 = moderate; and Level 3 = extensive).

RESULTS

Fourteen randomized controlled trials met search criteria. Most trials used the transtheoretical model ( n = 5) or social cognitive theory ( n = 3). For extensiveness of theory use, 5 studies were classified as Level 1, 4 as Level 2, and 5 as Level 3. Studies in the extensive group (Level 3) had the largest overall effect size ( g = 0.76). Effects were more modest in Level 1 and 2 groups with overall effect sizes of g = 0.28 and g = 0.36, respectively.

CONCLUSIONS

Theory use is often viewed as essential to behavior change, but theory application varies widely. In this study, there was some evidence to suggest that extensiveness of theory use enhanced intervention effectiveness. However, there is more to learn about how theory can improve interventions for breast cancer survivors.

Moderators of Theory-Based Interventions to Promote Physical Activity in 77 Randomized Controlled Trials

A meta-analysis of randomized controlled trials (RCTs) has recently showed that theory-based interventions designed to promote physical activity (PA) significantly increased PA behavior. The objective of the present study was to investigate the moderators of the efficacy of these theory-based interventions. Seventy-seven RCTs evaluating theory-based interventions were systematically identified. Sample, intervention, methodology, and theory implementation characteristics were extracted, coded by three duos of independent investigators, and tested as moderators of interventions effect in a multiple–meta-regression model. Three moderators were negatively associated with the efficacy of theory-based interventions on PA behavior: intervention length (≥14 weeks; β = −.22, p = .004), number of experimental patients (β = −.10, p = .002), and global methodological quality score (β = −.08, p = .04). Our findings suggest that the efficacy of theory-based interventions to promote PA could be overestimated consequently due to methodological weaknesses of RCTs and that interventions shorter than 14 weeks could maximize the increase of PA behavior.

Behaviour change techniques: the development and evaluation of a taxonomic method for reporting and describing behaviour change interventions (a suite of five studies involving consensus methods, randomised controlled trials and analysis of qualitative data)

BACKGROUND

Meeting global health challenges requires effective behaviour change interventions (BCIs). This depends on advancing the science of behaviour change which, in turn, depends on accurate intervention reporting. Current reporting often lacks detail, preventing accurate replication and implementation. Recent developments have specified intervention content into behaviour change techniques (BCTs) - the 'active ingredients', for example goal-setting, self-monitoring of behaviour. BCTs are 'the smallest components compatible with retaining the postulated active ingredients, i.e. the proposed mechanisms of change. They can be used alone or in combination with other BCTs' (Michie S, Johnston M. Theories and techniques of behaviour change: developing a cumulative science of behaviour change. Health Psychol Rev 2012;6:1-6). Domain-specific taxonomies of BCTs have been developed, for example healthy eating and physical activity, smoking cessation and alcohol consumption. We need to build on these to develop an internationally shared language for specifying and developing interventions. This technology can be used for synthesising evidence, implementing effective interventions and testing theory. It has enormous potential added value for science and global health.

OBJECTIVE

(1) To develop a method of specifying content of BCIs in terms of component BCTs; (2) to lay a foundation for a comprehensive methodology applicable to different types of complex interventions; (3) to develop resources to support application of the taxonomy; and (4) to achieve multidisciplinary and international acceptance for future development.

DESIGN AND PARTICIPANTS

Four hundred participants (systematic reviewers, researchers, practitioners, policy-makers) from 12 countries engaged in investigating, designing and/or delivering BCIs. Development of the taxonomy involved a Delphi procedure, an iterative process of revisions and consultation with 41 international experts; hierarchical structure of the list was developed using inductive 'bottom-up' and theory-driven 'top-down' open-sort procedures (n = 36); training in use of the taxonomy (1-day workshops and distance group tutorials) (n = 161) was evaluated by changes in intercoder reliability and validity (agreement with expert consensus); evaluating the taxonomy for coding interventions was assessed by reliability (intercoder; test-retest) and validity (n = 40 trained coders); and evaluating the taxonomy for writing descriptions was assessed by reliability (intercoder; test-retest) and by experimentally testing its value (n = 190).

RESULTS

Ninety-three distinct, non-overlapping BCTs with clear labels and definitions formed Behaviour Change Technique Taxonomy version 1 (BCTTv1). BCTs clustered into 16 groupings using a 'bottom-up' open-sort procedure; there was overlap between these and groupings produced by a theory-driven, 'top-down' procedure. Both training methods improved validity (both p < 0.05), doubled the proportion of coders achieving competence and improved confidence in identifying BCTs in workshops (both p < 0.001) but did not improve intercoder reliability. Good intercoder reliability was observed for 80 of the 93 BCTs. Good within-coder agreement was observed after 1 month (p < 0.001). Validity was good for 14 of 15 BCTs in the descriptions. The usefulness of BCTTv1 to report descriptions of observed interventions had mixed results.

CONCLUSIONS

The developed taxonomy (BCTTv1) provides a methodology for identifying content of complex BCIs and a foundation for international cross-disciplinary collaboration for developing more effective interventions to improve health. Further work is needed to examine its usefulness for reporting interventions.

FUNDING

This project was funded by the Medical Research Council Ref: G0901474/1. Funding also came from the Peninsula Collaboration for Leadership in Applied Health Research and Care.

Use of theory in computer-based interventions to reduce alcohol use among adolescents and young adults: a systematic review

BACKGROUND

Alcohol use and binge drinking among adolescents and young adults remain frequent causes of preventable injuries, disease, and death, and there has been growing attention to computer-based modes of intervention delivery to prevent/reduce alcohol use. Research suggests that health interventions grounded in established theory are more effective than those with no theoretical basis. The goal of this study was to conduct a literature review of computer-based interventions (CBIs) designed to address alcohol use among adolescents and young adults (aged 12-21 years) and examine the extent to which CBIs use theories of behavior change in their development and evaluations. This study also provides an update on extant CBIs addressing alcohol use among youth and their effectiveness.

METHODS

Between November and December of 2014, a literature review of CBIs aimed at preventing or reducing alcohol in PsychINFO, PubMed, and Google Scholar was conducted. The use of theory in each CBI was examined using a modified version of the classification system developed by Painter et al. (Ann Behav Med 35:358-362, 2008).

RESULTS

The search yielded 600 unique articles, 500 were excluded because they did not meet the inclusion criteria. The 100 remaining articles were retained for analyses. Many articles were written about a single intervention; thus, the search revealed a total of 42 unique CBIs. In examining the use of theory, 22 CBIs (52 %) explicitly named one or more theoretical frameworks. Primary theories mentioned were social cognitive theory, transtheoretical model, theory of planned behavior and reasoned action, and health belief model. Less than half (48 %), did not use theory, but mentioned either use of a theoretical construct (such as self-efficacy) or an intervention technique (e.g., manipulating social norms). Only a few articles provided detailed information about how the theory was applied to the CBI; the vast majority included little to no information.

CONCLUSIONS

Given the importance of theory in guiding interventions, greater emphasis on the selection and application of theory is needed. The classification system used in this review offers a guiding framework for reporting how theory based principles can be applied to computer based interventions.

Attitudes, social norms and perceived behavioral control factors influencing participation in a cooking skills program in rural Central Appalachia

A focus group session, using the Theory of Planned Behavior to guide questions and discussion, was conducted at midpoint of a 12-month cooking skills program in a rural Appalachian food desert. The purpose of this qualitative study was to determine the attitudes, subjective norms and perceived behavioral control beliefs that influenced participation in these classes. Participants viewed the classes as opportunities for social interaction and to have new experiences. Subjective norms were influenced by family members and traditional cooking. Perceived behavioral control was influenced by the opportunity to try new foods without concern of food waste, acquisition of the knowledge to introduce healthy foods into family meals and enhanced food preparation skills. During the evaluation, a strong sense of participant appreciation of researcher presence was discovered. This unexpected positive component of the program will be promoted using motivational interviewing techniques to enhance adherence to healthy eating behaviors during and after cooking skills programs.

Assessing Connections Between Behavior Change Theories Using Network Analysis

BACKGROUND

A cross-disciplinary scoping review identified 83 of behavior change theories, with many similarities and overlapping constructs. Investigating the derivation of these theories may provide further understanding of their contribution and intended application.

PURPOSE

To develop and apply a method to describe the explicit derivation of theories of behavior change.

METHODS

A network analysis of the explicit "contributing to" relations between the 83 theories was conducted. Identification of relations involved textual analysis of primary theory sources.

FINDINGS

One hundred and twenty-two connections between the theories were identified amounting to 1.8% of the number possible. On average, theories contributed to one or two theories (mean = 1.47 ± 3.69 contributions) and were informed by one or two theories (mean = 1.47 ± 1.61 contributing theories).

DISCUSSION

Most behavior change theories appear to be explicitly informed by few prior theories. If confirmed, this suggests a considerable dislocation between generations of theories which would be expected to undermine scientific progress.

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

BACKGROUND

Dental caries in young children is a major public health problem impacting on the child and their family in terms of pain, infection and substantial financial burden on healthcare funders. In the UK, national guidance on the prevention of dental caries advises parents to supervise their child's brushing with fluoride toothpaste until age 7. However, there is a dearth of evidence-based interventions to encourage this practice in parents. The current study used intervention mapping (IM) to develop a home-based parental-supervised toothbrushing intervention to reduce dental caries in young children.

METHODS

The intervention was developed using the six key stages of the IM protocol: (1) needs assessment, including a systematic review, qualitative interviews, and meetings with a multi-disciplinary intervention development group; (2) identification of outcomes and change objectives following identification of the barriers to parental-supervised toothbrushing (PSB), mapped alongside psychological determinants outlined in the Theoretical Domains Framework (TDF); (3) selection of methods and practical strategies; (4) production of a programme plan; (5) adoption and implementation and (6) Evaluation.

RESULTS

The comprehensive needs assessment highlighted key barriers to PSB, such as knowledge, skills, self-efficacy, routine setting and behaviour regulation and underlined the importance of individual, social and structural influences. Parenting skills (routine setting and the ability to manage the behaviour of a reluctant child) were emphasised as critical to the success of PSB. The multi-disciplinary intervention development group highlighted the need for both universal and targeted programmes, which could be implemented within current provision. Two intervention pathways were developed: a lower cost universal pathway utilising an existing national programme and an intensive targeted programme delivered via existing parenting programmes. A training manual was created to accompany each intervention to ensure knowledge and standardise implementation procedures.

CONCLUSIONS

PSB is a complex behaviour and requires intervention across individual, social and structural levels. IM, although a time-consuming process, allowed us to capture this complexity and allowed us to develop two community-based intervention pathways covering both universal and targeted approaches, which can be integrated into current provision. Further research is needed to evaluate the acceptability and sustainability of these interventions.

Non-pharmacological interventions for attention-deficit/hyperactivity disorder (ADHD) delivered in school settings: systematic reviews of quantitative and qualitative research

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterised by age-inappropriate levels of inattention, impulsivity and hyperactivity. School can be particularly challenging for children with ADHD. Few reviews have considered non-pharmacological interventions in school settings.

OBJECTIVES

To assess the effectiveness of non-pharmacological interventions delivered in school settings for pupils with, or at risk of, ADHD and to explore the factors that may enhance, or limit, their delivery.

DATA SOURCES

Twenty electronic databases (including PsycINFO, MEDLINE, EMBASE, Education Resources Information Centre, The Cochrane Library and Education Research Complete) were searched from 1980 to February-August 2013. Three separate searches were conducted for four systematic reviews; they were supplemented with forward and backwards citation chasing, website searching, author recommendations and hand-searches of key journals.

REVIEW METHODS

The systematic reviews focused on (1) the effectiveness of school-based interventions for children with or at risk of ADHD; (2) quantitative research that explores attitudes towards school-based non-pharmacological interventions for pupils with ADHD; (3) qualitative research investigating the attitudes and experiences of children, teachers, parents and others using ADHD interventions in school settings; and (4) qualitative research exploring the experience of ADHD in school among pupils, their parents and teachers more generally. Methods of synthesis included a random-effects meta-analysis, meta-regression and narrative synthesis for review 1, narrative synthesis for review 2 and meta-ethnography and thematic analysis for reviews 3 and 4.

RESULTS

For review 1, 54 controlled trials met the inclusion criteria. For the 36 meta-analysed randomised controlled trials, beneficial effects (p < 0.05) were observed for several symptom and scholastic outcomes. Mean weighted effect sizes ranged from very small (d + < 0.20) to large (d + ≥ 0.80), but substantial heterogeneity in effect size estimates across studies was reported. Moderator analyses were not able to clarify which intervention features were linked with effectiveness. For review 2, 28 included studies revealed that educators' attitudes towards interventions ranged in positivity. Most interventions were rated positively or neutrally across different studies. The only intervention that consistently recorded positive attitudes from educators was daily report cards. For review 3, 33 studies met the inclusion criteria. Key findings included tensions regarding the preferred format of interventions, particularly how structured interventions were and the extent to which they are tailored to the child with ADHD. There were mixed views about the impact of interventions, although it was clear that interventions both influence and are influenced by the relationships held by children with ADHD and participants' attitudes towards school and ADHD. For review 4, 34 studies met the inclusion criteria. Key findings included the importance of causal attributions that teachers, parents and pupils made about ADHD symptoms, the decisions teachers made about treatment, the self-perceptions pupils developed about themselves, the role of the classroom environment and stigma in aggravating ADHD symptoms, and the significant barrier to treatment posed by the common presence of conflict in relationships between pupils-teachers, parents-teachers and pupils-peers in relation to ADHD. An overarching synthesis of the four reviews highlighted the importance of the context affecting interventions. It suggested that ADHD psychoeducation and relationship-building skills are potential implications for interventions.

LIMITATIONS

The breadth of both interventions and outcomes in the reviewed studies presented a challenge for categorisation, analysis and interpretation in reviews 1-3. Across reviews, relatively few studies were conducted in the UK, limiting the applicability of findings to UK education. In reviews 1 and 2, the poor methodological quality of some included studies was identified as a barrier to establishing effectiveness or comparing attitudes. In review 3 the descriptive analysis used by the majority of studies constrained theorising during synthesis. Studies in review 4 lacked detail regarding important issues like gender, pupil maturity and school level.

CONCLUSION

Findings suggest some beneficial effects of non-pharmacological interventions for ADHD used in school settings, but substantial heterogeneity in effect sizes was seen across studies. The qualitative reviews demonstrate the importance of the context in which interventions are used. Future work should consider more rigorous evaluation of interventions, as well as focus on what works, for whom and in which contexts. Gaps in current research present opportunities for the development and testing of standardised tools to describe interventions, agreement on gold-standard outcome measures assessing ADHD behaviour and testing a range of potential moderators alongside intervention trials.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42011001716.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Providing NHS staff with height-adjustable workstations and behaviour change strategies to reduce workplace sitting time: protocol for the Stand More AT (SMArT) Work cluster randomised controlled trial

BACKGROUND

High levels of sedentary behaviour (i.e., sitting) are a risk factor for poor health. With high levels of sitting widespread in desk-based office workers, office workplaces are an appropriate setting for interventions aimed at reducing sedentary behaviour. This paper describes the development processes and proposed intervention procedures of Stand More AT (SMArT) Work, a multi-component randomised control (RCT) trial which aims to reduce occupational sitting time in desk-based office workers within the National Health Service (NHS).

METHODS/DESIGN

SMArT Work consists of 2 phases: 1) intervention development: The development of the SMArT Work intervention takes a community-based participatory research approach using the Behaviour Change Wheel. Focus groups will collect detailed information to gain a better understanding of the most appropriate strategies, to sit alongside the provision of height-adjustable workstations, at the environmental, organisational and individual level that support less occupational sitting. 2) intervention delivery and evaluation: The 12 month cluster RCT aims to reduce workplace sitting in the University Hospitals of Leicester NHS Trust. Desk-based office workers (n = 238) will be randomised to control or intervention clusters, with the intervention group receiving height-adjustable workstations and supporting techniques based on the feedback received from the development phase. Data will be collected at four time points; baseline, 3, 6 and 12 months. The primary outcome is a reduction in sitting time, measured by the activPAL(TM) micro at 12 months. Secondary outcomes include objectively measured physical activity and a variety of work-related health and psycho-social measures. A process evaluation will also take place.

DISCUSSION

This study will be the first long-term, evidence-based, multi-component cluster RCT aimed at reducing occupational sitting within the NHS. This study will help form a better understanding and knowledge base of facilitators and barriers to creating a healthier work environment and contribute to health and wellbeing policy.

TRIAL REGISTRATION

ISRCTN10967042 . Registered 2 February 2015.

Which behavior change techniques are associated with changes in physical activity, diet and body mass index in people with recently diagnosed diabetes?

Background

Meta-analyses have identified promising behavior change techniques (BCTs) in changing obesity-related behaviors from intervention descriptions. However, it is unclear whether these BCTs are used by intervention participants and are related to outcomes.

Purpose

The purpose of this study is to investigate BCT use by participants of an intervention targeting physical activity and diet and whether BCT use was related to behavior change and weight loss.

Methods

Intervention participants (N = 239; 40–69 years) with recently diagnosed type 2 diabetes in the ADDITION-Plus trial received a theory-based intervention which taught them a range of BCTs. BCT usage was reported at 1 year.

Results

Thirty-six percent of the participants reported using all 16 intervention BCTs. Use of a higher number of BCTs and specific BCTs (e.g., goal setting) were associated with a reduction in body mass index (BMI).

Conclusions

BCT use was associated with weight loss. Future research should identify strategies to promote BCT use in daily life. (Trial Registration: ISRCTN99175498.)

Electronic supplementary material

The online version of this article (doi:10.1007/s12160-014-9624-9) contains supplementary material, which is available to authorized users.

The features of interventions associated with long-term effectiveness of physical activity interventions in adults aged 55-70 years: a systematic review and meta-analysis

Content, delivery and effects of physical activity (PA) interventions are heterogeneous. There is a need to identify intervention features (content and delivery) related to long-term effectiveness. Behaviour change techniques (BCTs) and modes of intervention delivery were coded in 19 randomised controlled trials included in a systematic review of PA interventions for adults aged 55-70 years, published between 2000 and 2010, with PA outcomes ≥ 12 months after randomisation; protocol registration: PROSPERO CRD42011001459. Meta-analysis, moderator analyses and meta-regression were conducted. Meta-analysis revealed that interventions were effective in promoting PA compared with no/minimal intervention comparators [d = 0.29, 95% CI = 0.19-0.40, I(2) = 79.8%, Q-value = 89.16 (df = 18, p < 0.01)]. Intervention features often concurred and goal setting was the most commonly used BCT. Subgroup analyses suggested that interventions using the BCT feedback may be more effective, whilst interventions using printed materials or the BCTs information on where and when to perform the behaviour and information on consequences of behaviour to the individual may be less effective. Meta-regression revealed that neither the number of BCTs nor self-regulatory BCTs significantly related to effect size. Feedback appears to be a potentially effective candidate BCT for future interventions promoting long-term PA. Considering concurrence of intervention features alongside moderator analyses is important.

Weight-loss intervention using implementation intentions and mental imagery: a randomised control trial study protocol

BACKGROUND

Overweight and obesity are major health problems worldwide. This protocol describes the HEALTHI (Healthy Eating and Active LifesTyle Health Intervention) Program, a 12-week randomised-controlled weight-loss intervention that adopts two theory-based intervention techniques, mental imagery and implementation intentions, a behaviour-change technique based on planning that have been shown to be effective in promoting health-behaviour change in previous research. The effectiveness of goal-reminder text messages to augment intervention effects will also be tested. The trial will determine the effects of a brief, low cost, theory-based weight-loss intervention to improve dietary intake and physical activity behaviour and facilitate weight-loss in overweight and obese individuals.

METHODS/DESIGN

Overweight or obese participants will be randomly allocated to one of three conditions: (1) a psycho-education plus an implementation intentions and mental imagery condition; (2) a psycho-education plus an implementation intentions and mental imagery condition with text messages; or (3) a psycho-education control condition. The intervention will be delivered via video presentation to increase the intervention's applicability in multiple contexts and keep costs low. We hypothesise that the intervention conditions will lead to statistically-significant changes in the primary and secondary outcome variables measured at 6 and 12 weeks post-intervention relative to the psycho-education control condition after controlling for baseline values. The primary outcome variable will be body weight and secondary outcome variables will be biomedical (body mass, body fat percentage, muscle mass, waist-hip circumference ratio, systolic and diastolic blood pressure, low-density lipoprotein, high-density lipoprotein, total cholesterol, triglycerides, blood glucose and insulin levels), psychological (quality of life, motivation, risk perception, outcome expectancy, intention, action self-efficacy, maintenance self-efficacy, goal setting and planning), and behavioural (self-reported diet intake, and physical activity involvement) measures. We also expect the intervention condition augmented with text messages to lead to statistically significant differences in the primary and secondary outcome variables at the follow up periods after controlling for baseline values.

DISCUSSION

The planned trial will test the effectiveness of the theory-based HEALTHI program intervention to reduce weight and salient psychological, biomedical, and behavioural outcomes in overweight and obese adults. The study has been designed to maximise applicability to real world settings and could be integrated into existing weight management practices.

TRIAL REGISTRATION

ACTRN: ACTRN12613001274763. Registration date 19/11/2013.

Context effects and behaviour change techniques in randomised trials: a systematic review using the example of trials to increase adherence to physical activity in musculoskeletal pain

OBJECTIVE

To describe and explore the effects of contextual and behaviour change technique (BCT) content of control and target interventions in clinical trials.

DESIGN

Review and meta-analysis of 42 trials from a Cochrane review of physical activity in chronic musculoskeletal pain.

MAIN OUTCOME MEASURES

Two researchers coded descriptions of target and control interventions for (a) 93 BCTs and (b) whether target and control interventions shared each of five contextual features (practitioners' characteristics, patient-practitioner relationship, intervention credibility, superficial treatment characteristics e.g. delivery modality, and environment). Quality of study reporting was assessed. Effect sizes for adherence to physical activity and class attendance were computed (Cohen's d) and analysed separately.

RESULTS

For physical activity outcomes, after controlling for reporting quality, larger effect sizes were associated with target and control interventions using different modalities (β = -.34, p = .030), target and control interventions involving equivalent patient-practitioner relationship (β = .40, p = .002), and target interventions having more unique BCTs (i.e. more BCTs not also in the control) (β = .008, p = .030). There were no significant effect moderators for class attendance outcomes.

CONCLUSION

Contents of control conditions can influence effect sizes and should be considered carefully in trial design and systematic reviews.

Evidence-based programs registry: blueprints for Healthy Youth Development

There is a growing demand for evidence-based programs to promote healthy youth development, but this growth has been accompanied by confusion related to varying definitions of evidence-based and mixed messages regarding which programs can claim this designation. The registries that identify evidence-based programs, while intended to help users sift through the findings and claims regarding programs, has oftentimes led to more confusion with their differing standards and program ratings. The advantages of using evidence-based programs and the importance of adopting a high standard of evidence, especially when taking programs to scale,are described. One evidence-based registry is highlighted--Blueprints for Healthy Youth Development hosted at the University of Colorado Boulder. Unlike any previous initiative of its kind, Blueprints established unmatched standards for identifying evidence-based programs and has acted in a way similar to the FDA--evaluating evidence, data and research to determine which programs meet their high standard of proven efficacy.

Poor quality of external validity reporting limits generalizability of overweight and/or obesity lifestyle prevention interventions in young adults: a systematic review

Young adulthood is a high-risk life stage for weight gain. Evidence is needed to translate behavioural approaches into community practice to prevent weight gain in young adults. This systematic review assessed the effectiveness and reporting of external validity components in prevention interventions. The search was limited to randomized controlled trial (RCT) lifestyle interventions for the prevention of weight gain in young adults (18-35 years). Mean body weight and/or body mass index (BMI) change were the primary outcomes. External validity, quality assessment and risk of bias tools were applied to all studies. Twenty-one RCTs were identified through 14 major electronic databases. Over half of the studies were effective in the short term for significantly reducing body weight and/or BMI; however, few showed long-term maintenance. All studies lacked full reporting on external validity components. Description of the intervention components and participant attrition rates were reported by most studies. However, few studies reported the representativeness of participants, effectiveness of recruitment methods, process evaluation detail or costs. It is unclear from the information reported how to implement the interventions into community practice. Integrated reporting of intervention effectiveness and enhanced reporting of external validity components are needed for the translation and potential upscale of prevention strategies.

Effects of workplace-based dietary and/or physical activity interventions for weight management targeting healthcare professionals: a systematic review of randomised controlled trials

BACKGROUND

The prevalence of overweight and obesity is high amongst healthcare professionals and there is growing interest in delivering weight loss interventions in the workplace. We conducted a systematic review to (i) examine the effectiveness of workplace-based diet and/or physical activity interventions aimed at healthcare professionals and to (ii) identify and describe key components of effective interventions. Seven electronic databases were systematically searched.

RESULTS

Thirteen randomised controlled trials met the inclusion criteria, of which seven had data available for meta-analysis. Where meta-analysis was possible, studies were grouped according to length of follow-up (<12 months and ≥12 months) and behavioural target (diet only, physical activity only or diet and physical activity), with outcome data pooled using a weighted random effects model. Nine studies reported statistically significant (between-group) differences. Four studies reported being informed by a behaviour change theory. Meta-analysis of all trials reporting weight data demonstrated healthcare professionals allocated to dietary and physical activity interventions lost significantly more body weight (-3.95 Kg, [95% CI -4.96 to- 2.95 Kg]) than controls up to 12 months follow up.

CONCLUSIONS

Workplace diet and/or physical activity interventions targeting healthcare professionals are limited in number and are heterogeneous. To improve the evidence base, we recommend additional evaluations of theory-based interventions and adequate reporting of intervention content.

Changing handwashing behaviour in southern Ethiopia: a longitudinal study on infrastructural and commitment interventions

Improved hand hygiene efficiently prevents the major killers of children under the age of five years in Ethiopia and globally, namely diarrhoeal and respiratory diseases. Effective handwashing interventions are thus in great demand. Evidence- and theory-based interventions, especially when matched to the target population's needs, are expected to perform better than common practice. To test this hypothesis, we selected two interventions drawing on a baseline questionnaire-study that applied the RANAS (Risk, Attitudes, Norms, Abilities, Self-regulation) approach and focused on the primary caregivers of households in four rural, water-scarce kebeles (smallest administrative units of Ethiopia) in southern Ethiopia (N = 462). The two interventions were tested in combination with a standard education intervention in a quasi-experiment, as follows: kebele 1, education intervention, namely an f-diagram exercise, (n = 23); kebele 2, education intervention and public-commitment (n = 122); kebele 3, education intervention and tippy-tap-promotion (i.e. handwashing-station-promotion; n = 150); kebele 4, education intervention, public-commitment and tippy-tap-promotion (n = 113). In kebeles 3 and 4, nearly 100% of the households followed the promotion and invested material and time to construct for themselves a tippy-tap. Three months after intervention termination, the tippy-taps were in use with water and soap being present in up to 83% of the households (kebele 4). Pre-post data analysis on self-reported handwashing revealed that the population-tailored interventions, and especially the tippy-tap-promotion, performed better than the standard education intervention. Tendencies in observed behaviour and a recently developed implicit self-measure pointed to similar results. Changing people's hand hygiene is known to be a challenging task, especially in a water-scarce environment. The present project suggests not only to apply theory and evidence to improve handwashing interventions' effectiveness, but also emphasizes the relevance of tailoring interventions to the target population.

Intervention fidelity and effectiveness of a UK worksite physical activity intervention funded by the BUPA Foundation, UK

The main aim of this study was to test whether the effectiveness of a worksite physical activity intervention delivered in five work organizations varied as a function of intervention fidelity. We conducted a fidelity analysis as part of a large matched-pair cluster randomized controlled trial of a worksite physical activity intervention (AME for Activity). Participants (N = 1260) were employees from five organizations in the UK. The primary trial outcome was physical activity at 9 months post intervention. Adherence, exposure, quality of delivery and participant responsiveness/engagement were measured to assess fidelity. Qualitative data about the context in which the intervention was delivered were collected via focus groups, interviews and field notes. Multi-level modelling was used to provide a comparison of the effect of the intervention on increases in physical activity for worksites where intervention fidelity was good, compared with those where intervention fidelity was poor or moderate. Intervention fidelity was poor in two organizations, moderate in two organizations and good in one organization (local council). Re-analysis of the trial data comparing employees in the local council (N = 443) with employees in all other worksites (N = 611) revealed a significant effect of the intervention on physical activity levels among council employees only. These findings suggest that the measurement of fidelity and the testing of the effects of intervention fidelity on outcomes, as part of the evaluation of complex interventions, are essential to understand the context and conditions in which interventions are most effective.

'On Your Feet to Earn Your Seat', a habit-based intervention to reduce sedentary behaviour in older adults: study protocol for a randomized controlled trial

Background

Many older adults are both highly sedentary (that is, spend considerable amounts of time sitting) and physically inactive (that is, do little physical activity). This protocol describes an exploratory trial of a theory-based behaviour change intervention in the form of a booklet outlining simple activities (‘tips’) designed both to reduce sedentary behaviour and to increase physical activity in older adults. The intervention is based on the ‘habit formation’ model, which proposes that consistent repetition leads to behaviour becoming automatic, sustaining activity gains over time.

Methods

The intervention is being developed iteratively, in line with Medical Research Council complex intervention guidelines. Selection of activity tips was informed by semi-structured interviews and focus groups with older adults, and input from a multidisciplinary expert panel. An ongoing preliminary field test of acceptability among 25 older adults will inform further refinement. An exploratory randomized controlled trial will be conducted within a primary care setting, comparing the tips booklet with a control fact sheet. Retired, inactive and sedentary adults (n = 120) aged 60 to 74 years, with no physical impairments precluding light physical activity, will be recruited from general practices in north London, UK. The primary outcomes are recruitment and attrition rates. Secondary outcomes are changes in behaviour, habit, health and wellbeing over 12 weeks.

Discussion

Data will be used to inform study procedures for a future, larger-scale definitive randomized controlled trial.

Trial registration

Current Controlled Trials ISRCTN47901994.

Electronic supplementary material

The online version of this article (doi:10.1186/1745-6215-15-368) contains supplementary material, which is available to authorized users.

Theories of behaviour and behaviour change across the social and behavioural sciences: a scoping review

Interventions to change health-related behaviours typically have modest effects and may be more effective if grounded in appropriate theory. Most theories applied to public health interventions tend to emphasise individual capabilities and motivation, with limited reference to context and social factors. Intervention effectiveness may be increased by drawing on a wider range of theories incorporating social, cultural and economic factors that influence behaviour. The primary aim of this paper is to identify theories of behaviour and behaviour change of potential relevance to public health interventions across four scientific disciplines: psychology, sociology, anthropology and economics. We report in detail the methodology of our scoping review used to identify these theories including which involved a systematic search of electronic databases, consultation with a multidisciplinary advisory group, web searching, searching of reference lists and hand searching of key behavioural science journals. Of secondary interest we developed a list of agreed criteria for judging the quality of the theories. We identified 82 theories and 9 criteria for assessing theory quality. The potential relevance of this wide-ranging number of theories to public health interventions and the ease and usefulness of evaluating the theories in terms of the quality criteria are however yet to be determined.

From lists of behaviour change techniques (BCTs) to structured hierarchies: comparison of two methods of developing a hierarchy of BCTs

OBJECTIVES

Behaviour change technique (BCT) Taxonomy v1 is a hierarchically grouped, consensus-based taxonomy of 93 BCTs for reporting intervention content. To enhance the use and understanding of BCTs, the aims of the present study were to (1) quantitatively examine the 'bottom-up' hierarchical structure of Taxonomy v1, (2) identify whether BCTs can be reliably mapped to theoretical domains using a 'top-down' theoretically driven approach, and (3) identify any overlap between the 'bottom-up' and 'top-down' groupings.

METHODS AND DESIGN

The 'bottom-up' structure was examined for higher-order groupings using a dendrogram derived from hierarchical cluster analysis. For the theory-based 'top-down' structure, 18 experts sorted BCTs into 14 theoretical domains. Discriminant Content Validity was used to identify groupings, and chi-square tests and Pearson's residuals were used to examine the overlap between groupings.

RESULTS

Behaviour change techniques relating to 'Reward and Punishment' and 'Cues and Cue Responses' were perceived as markedly different to other BCTs. Fifty-nine of the BCTs were reliably allocated to 12 of the 14 theoretical domains; 47 were significant and 12 were of borderline significance. Thirty-four of 208 'bottom-up' × 'top-down' pairings showed greater overlap than expected by chance. However, only six combinations achieved satisfactory evidence of similarity.

CONCLUSIONS

The moderate overlap between the groupings indicates some tendency to implicitly conceptualize BCTs in terms of the same theoretical domains. Understanding the nature of the overlap will aid the conceptualization of BCTs in terms of theory and application. Further research into different methods of developing a hierarchical taxonomic structure of BCTs for international, interdisciplinary work is now required. Statement of contribution What is already known on this subject? Behaviour change interventions are effective in improving health care and health outcomes. The 'active' components of these interventions are behaviour change techniques and over 93 have been identified. Taxonomies of behaviour change techniques require structure to enable potential applications. What does this study add? This study identifies groups of BCTs to aid the recall of BCTs for intervention coding and design. It compares two methods of grouping--'bottom-up' and theory-based 'top-down'--and finds a moderate overlap. Building on identified BCT groups, it examines relationships between theoretical domains and BCTs.

Development of a behaviour change communication tool for medical students: the 'Tent Pegs' booklet

OBJECTIVE

To describe the development and validation of a behaviour change communication tool for medical students.

METHODS

Behaviour change techniques (BCTs) were identified within the literature and used to inform a communication tool to support medical students in discussing health-related behaviour change with patients. BCTs were organized into an accessible format for medical students (the 'Tent Pegs' booklet) and validated using discriminant content validity methods with 11 expert judges.

RESULTS

One-sample t-tests showed that judges reliably mapped BCTs onto six of the seven Tent Pegs domains (confidence rating means ranged from 4.0 to 5.1 out of 10, all p≤0.002). Only BCTs within the 'empowering people to change' domain were not significantly different from the value zero (mean confidence rating=1.2, p>0.05); these BCTs were most frequently allocated to the 'addressing thoughts and emotions' domain instead.

CONCLUSION

BCTs within the Tent Pegs booklet are reliably allocated to corresponding behaviour change domains with the exception of those within the 'empowering people to change' domain.

PRACTICE IMPLICATIONS

The existing evidence-base on BCTs can be used to directly inform development of a communication tool to support medical students facilitate health behaviour change with patients.

Using intervention mapping to develop a culturally appropriate intervention to prevent childhood obesity: the HAPPY (Healthy and Active Parenting Programme for Early Years) study

Introduction

Interventions that make extensive use of theory tend to have larger effects on behaviour. The Intervention Mapping (IM) framework incorporates theory into intervention design, implementation and evaluation, and was applied to the development of a community-based childhood obesity prevention intervention for a multi-ethnic population.

Methods

IM was applied as follows: 1) Needs assessment of the community and culture; consideration of evidence-base, policy and practice; 2) Identification of desired outcomes and change objectives following identification of barriers to behaviour change mapped alongside psychological determinants (e.g. knowledge, self-efficacy, intention); 3) Selection of theory-based methods and practical applications to address barriers to behaviour change (e.g., strategies for responsive feeding); 4) Design of the intervention by developing evidence-based interactive activities and resources (e.g., visual aids to show babies stomach size). The activities were integrated into an existing parenting programme; 5) Adoption and implementation: parenting practitioners were trained by healthcare professionals to deliver the programme within Children Centres.

Results

HAPPY (Healthy and Active Parenting Programme for Early Years) is aimed at overweight and obese pregnant women (BMI > 25); consists of 12 × 2.5 hr. sessions (6 ante-natal from 24 weeks; 6 postnatal up to 9 months); it addresses mother’s diet and physical activity, breast or bottle feeding, infant diet and parental feeding practices, and infant physical activity.

Conclusion

We have demonstrated that IM is a feasible and helpful method for providing an evidence based and theoretical structure to a complex health behaviour change intervention. The next stage will be to assess the impact of the intervention on behaviour change and clinical factors associated with childhood obesity. The HAPPY programme is currently being tested as part of a randomised controlled feasibility trial.

Everything should be as simple as possible, but no simpler: towards a protocol for accumulating evidence regarding the active content of health behaviour change interventions

There is a need to consolidate the evidence base underlying our toolbox of methods of behaviour change. Recent efforts to this effect have conducted meta-regressions on evaluations of behaviour change interventions, deriving each method's effectiveness from its association to intervention effect size. However, there are a range of issues that raise concern about whether this approach is actually furthering or instead obstructing the advancement of health psychology theories and the quality of health behaviour change interventions. Using examples from theory, the literature and data from previous meta-analyses, these concerns and their implications are explained and illustrated. An iterative protocol for evidence base accumulation is proposed that integrates evidence derived from both experimental and applied behaviour change research, and combines theory development in experimental settings with theory testing in applied real-life settings. As evidence gathered in this manner accumulates, a cumulative science of behaviour change can develop.

Evaluation of a theory-informed implementation intervention for the management of acute low back pain in general medical practice: the IMPLEMENT cluster randomised trial

INTRODUCTION

This cluster randomised trial evaluated an intervention to decrease x-ray referrals and increase giving advice to stay active for people with acute low back pain (LBP) in general practice.

METHODS

General practices were randomised to either access to a guideline for acute LBP (control) or facilitated interactive workshops (intervention). We measured behavioural predictors (e.g. knowledge, attitudes and intentions) and fear avoidance beliefs. We were unable to recruit sufficient patients to measure our original primary outcomes so we introduced other outcomes measured at the general practitioner (GP) level: behavioural simulation (clinical decision about vignettes) and rates of x-ray and CT-scan (medical administrative data). All those not involved in the delivery of the intervention were blinded to allocation.

RESULTS

47 practices (53 GPs) were randomised to the control and 45 practices (59 GPs) to the intervention. The number of GPs available for analysis at 12 months varied by outcome due to missing confounder information; a minimum of 38 GPs were available from the intervention group, and a minimum of 40 GPs from the control group. For the behavioural constructs, although effect estimates were small, the intervention group GPs had greater intention of practising consistent with the guideline for the clinical behaviour of x-ray referral. For behavioural simulation, intervention group GPs were more likely to adhere to guideline recommendations about x-ray (OR 1.76, 95%CI 1.01, 3.05) and more likely to give advice to stay active (OR 4.49, 95%CI 1.90 to 10.60). Imaging referral was not statistically significantly different between groups and the potential importance of effects was unclear; rate ratio 0.87 (95%CI 0.68, 1.10) for x-ray or CT-scan.

CONCLUSIONS

The intervention led to small changes in GP intention to practice in a manner that is consistent with an evidence-based guideline, but it did not result in statistically significant changes in actual behaviour.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN012606000098538.

Development and initial validation of the determinants of physical activity questionnaire

BACKGROUND

Physical activity interventions are more likely to be effective if they target causal determinants of behaviour change. Targeting requires accurate identification of specific theoretical determinants of physical activity. Two studies were undertaken to develop and validate the Determinants of Physical Activity Questionnaire.

METHODS

In Study 1, 832 male and female university staff and students were recruited from 49 universities across the UK and completed the 66-item measure, which is based on the Theoretical Domains Framework. Confirmatory factor analysis was undertaken on a calibration sample to generate the model, which resulted in a loss of 31 items. A validation sample was used to cross-validate the model. 20 new items were added and Study 2 tested the revised model in a sample of 466 male and female university students together with a physical activity measure.

RESULTS

The final model consisted of 11 factors and 34 items, and CFA produced a reasonable fit χ2 (472) = 852.3, p < .001, CFI = .933, SRMR = .105, RMSEA = .042 (CI = .037-.046), as well as generally acceptable levels of discriminant validity, internal consistency, and test-retest reliability. Eight subscales significantly differentiated between high and low exercisers, indicating that those who exercise less report more barriers for physical activity.

CONCLUSIONS

A theoretically underpinned measure of determinants of physical activity has been developed with reasonable reliability and validity. Further work is required to test the measure amongst a more representative sample. This study provides an innovative approach to identifying potential barriers to physical activity. This approach illustrates a method for moving from diagnosing implementation difficulties to designing and evaluating interventions.

Threatening communication: a critical re-analysis and a revised meta-analytic test of fear appeal theory

Despite decades of research, consensus regarding the dynamics of fear appeals remains elusive. A meta-analysis was conducted that was designed to resolve this controversy. Publications that were included in previous meta-analyses were re-analysed, and a number of additional publications were located. The inclusion criteria were full factorial orthogonal manipulations of threat and efficacy, and measurement of behaviour as an outcome. Fixed and random effects models were used to compute mean effect size estimates. Meta-analysis of the six studies that satisfied the inclusion criteria clearly showed a significant interaction between threat and efficacy, such that threat only had an effect under high efficacy (d = 0.31), and efficacy only had an effect under high threat (d = 0.71). Inconsistency in results regarding the effectiveness of threatening communication can likely be attributed to flawed methodology. Proper tests of fear appeal theory yielded the theoretically hypothesised interaction effect. Threatening communication should exclusively be used when pilot studies indicate that an intervention successfully enhances efficacy.

Social cognitive theories used to explain physical activity behavior in adolescents: a systematic review and meta-analysis

PURPOSE

To systematically review and examine the explanatory power of key social-cognitive theories used to explain physical activity (PA) intention and behavior, among adolescents.

METHODS

A systematic review and meta-analysis of the literature was performed using the electronic databases Medline, Cumulative Index to Nursing and Allied Health Literature, SPORTdiscus, EBSCO and Education Resources Information Center, Proquest Education Journals Collection, Science Direct, Web of Science and Scopus for social-cognitive theories (i.e., Health Promotion Model, Theory of Planned Behavior, Theory of Reasoned Action, Protection Motivation Theory, Social Cognitive Theory/Self-Efficacy Theory, Health Belief Model, Self-Determination Theory, Transtheoretical Model) used to explain PA intention and behavior. Related keywords in titles, abstracts, or indexing fields were searched.

RESULTS

Twenty-three studies satisfied the inclusion criteria and were retained for data extraction and analysis; 16 were cross-sectional studies and seven were longitudinal studies. Most studies employed self-report measures. In general, the models explained greater proportions of variance for intention compared to behavior. The meta-analyses revealed 33% and 48% of the variance respectively for PA and intention were explained by social cognitive models.

CONCLUSIONS

Few studies have tested the predictive capacity of social cognitive theories to explain objectively measured PA. The majority of PA variance remains unexplained and more theoretical research is needed.