Increasing physical activity in patients with asthma through positive affect and self-affirmation: a randomized trial

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

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

Positive Psychology Interventions in Medical Populations: Critical Issues in Intervention Development, Testing, and Implementation

Positive psychological well-being is prospectively associated with superior health outcomes. Positive psychology interventions have promise as a potentially feasible and effective means of increasing well-being and health in those with medical illness, and several initial studies have shown the potential of such programs in medical populations. At the same time, numerous key issues in the existing positive psychology literature must be addressed to ensure that these interventions are optimally effective. These include (1) assessing the nature and scope of PPWB as part of intervention development and application; (2) identifying and utilizing theoretical models that can clearly outline potential mechanisms by which positive psychology interventions may affect health outcomes; (3) determining consistent, realistic targets for positive psychology interventions; (4) developing consistent approaches to the promotion of positive psychological well-being; (5) emphasizing the inclusion of diverse samples in treatment development and testing; and (6) considering implementation and scalability from the start of intervention development to ensure effective real-world application. Attention to these six domains could greatly facilitate the generation of effective, replicable, and easily adopted positive psychology programs for medical populations with the potential to have an important impact on public health.

An online behavior change intervention to promote physical activity in adults with asthma: study protocol for a multicenter randomized controlled trial

BACKGROUND

Behavior change interventions have been the focus of recent studies, and the COVID-19 pandemic highlighted the importance of online interventions. However, no previous studies have investigated behavior change techniques to improve physical activity in adults with asthma through online intervention.

METHODS

This double-blind clinical trial will investigate the effectiveness of an online behavior change intervention in increasing physical activity and reducing sedentary behavior in adults with asthma, as well as in improving other clinical outcomes in short and medium terms. Patients with clinically stable moderate to severe asthma, who are physically inactive and do not have cardiovascular and/or osteoneuromuscular impairments will be randomized into control or intervention groups (23 in each). Both groups will carry out an online educational program (1 h). Additionally, the intervention group will receive weekly individual online sessions for 12 weeks of motivation-based behavior change intervention to promote an increase in physical activity and reduce sedentary behavior based on both self-determination theory and transtheoretical model. The intervention group will also receive an activity monitor with specific strategies related to it. Both groups will be reassessed immediately after the intervention and 6 months after that. The primary outcomes are physical activity and sedentary behavior, which will be objectively assessed by a triaxial accelerometer (Actigraph wGT3X-BT). Secondary outcomes are Asthma Control Questionnaire, Incremental Step Test, Sit-To-Stand, Timed Up-and-Go, 4-Metre Gait Speed, Asthma Quality of Life Questionnaire, Pittsburgh Sleep Quality Index, Epworth Sleepiness Scale, Actiwatch 2, and the Hospital Anxiety and Depression Scale.

DISCUSSION

The intervention is unprecedented and was carefully developed to joint most characteristics and techniques of both behavioral strategies (transtheoretical model and self-determination theory). Therefore, this intervention has the potential to improve physical activity levels and asthma management and reduce sedentary behavior. As a consequence, this novel intervention will improve global health in this population and support its use in clinical practice. The intervention will be carried out online with direct weekly contact with the therapist. Consequently, it has low implementation costs, might improve patient's attendance, and has the potential to be largely offered elsewhere.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05241223 . Registered on January 22, 2022.

Can positive psychological interventions improve health behaviors? A systematic review of the literature

Positive psychological interventions (PPIs), which aim to cultivate psychological well-being, have the potential to improve health behavior adherence. This systematic review summarized the existing literature on PPI studies with a health behavior outcome to examine study methodology, quality, and efficacy. Of the 27 identified studies, 20 measured physical activity, eight measured medication adherence, seven measured diet, and three measured smoking (eight targeted multiple behaviors). Twenty studies were randomized controlled trials (RCTs; 13 fully powered), and seven had a single-arm design. Study samples were usually adults (n = 21), majority non-Hispanic white (n = 15) and female (n = 14), and with a specific disease (e.g., diabetes, n = 16). Most interventions combined a PPI with health behavior-focused content (n = 17), used a remote delivery method (n = 17), and received a moderate or low study quality rating. Overall, 19/27 studies found a health behavior improvement of at least medium effect size, while six of the 13 studies powered to detect significant effects were statistically significant. Of the behaviors measured, physical activity was most likely to improve (14/20 studies). In summary, PPIs are being increasingly studied as a strategy to enhance health behavior adherence. The existing literature is limited by small sample size, low study quality and inconsistent intervention content and outcome measurement. Future research should establish the most effective components of PPIs that can be tailored to different populations, use objective health behavior measurement, and robustly examine the effects of PPIs on health behaviors in fully powered RCTs.

Patient contracts for chronic medical conditions: Scoping review

OBJECTIVE

To describe how and why patient contracts are used for the management of chronic medical conditions.

DATA SOURCES

A scoping review was conducted in the following databases: MEDLINE, Embase, AMED, PsycInfo, Cochrane Library, CINAHL, and Nursing & Allied Health. Literature from 1997 to 2017 was included.

STUDY SELECTION

Articles were included if they were written in English and described the implementation of a patient contract by a health care provider for the management of a chronic condition. Articles had to present an outcome as a result of using the contract or an intervention that included the contract.

SYNTHESIS

Of the 7528 articles found in the original search, 76 met the inclusion criteria for the final review. Multiple study types were included. Extensive variety in contract elements, target populations, clinical settings, and cointerventions was found. Purposes for initiating contracts included behaviour change and skill development, including goal development and problem solving; altering beliefs and knowledge, including motivation and perceived self-efficacy; improving interpersonal relationships and role clarification; improving quality and process of chronic care; and altering objective and subjective health indices. How contracts were developed, implemented, and assessed was inconsistently described.

CONCLUSION

More research is required to determine whether the use of contracts is accomplishing their intended purposes. Questions remain regarding their rationale, development, and implementation.

The Management of Extrapulmonary Comorbidities and Treatable Traits; Obesity, Physical Inactivity, Anxiety, and Depression, in Adults With Asthma

Asthma is a complex and heterogenous disease characterized by variability in disease expression and severity. Multiple extrapulmonary comorbidities and treatable traits are common in people with asthma, and there is an increasing appreciation of how these may complicate asthma management. This review will discuss the prevalence and impact of extrapulmonary comorbidities/risk factors or "traits," which have been found to co-exist in asthma (obesity, symptoms of depression and/or anxiety and physical inactivity), the impact these traits have on future outcomes (including exacerbation risk and quality of life) and asthma management, and how we should target treatment in asthma when these extrapulmonary traits are present.

Design of a randomized controlled trial of digital health and community health worker support for diabetes management among low-income patients

BACKGROUND

Insulin-dependent diabetes is a challenging disease to manage and involves complex behaviors, such as self-monitoring of blood glucose. This can be especially challenging in the face of socioeconomic barriers and in the wake of the COVID-19 pandemic. Digital health self-monitoring interventions and community health worker support are promising and complementary best practices for improving diabetes-related health behaviors and outcomes. Yet, these strategies have not been tested in combination. This protocol paper describes the rationale and design of a trial that measures the combined effect of digital health and community health worker support on glucose self-monitoring and glycosylated hemoglobin.

METHODS

The study population was uninsured or publicly insured; lived in high-poverty, urban neighborhoods; and had poorly controlled diabetes mellitus with insulin dependence. The study consisted of three arms: usual diabetes care; digital health self-monitoring; or combined digital health and community health worker support. The primary outcome was adherence to blood glucose self-monitoring. The exploratory outcome was change in glycosylated hemoglobin.

CONCLUSION

The design of this trial was grounded in social justice and community engagement. The study protocols were designed in collaboration with frontline community health workers, the study aim was explicit about furthering knowledge useful for advancing health equity, and the population was focused on low-income people. This trial will advance knowledge of whether combining digital health and community health worker interventions can improve glucose self-monitoring and diabetes-related outcomes in a high-risk population.

Recommendations for Physical Activity in Asthma: A Work Group Report of the AAAAI Sports, Exercise, and Fitness Committee

Regular physical activity not only improves general health but also can positively impact asthma outcomes, such as control and quality of life. Despite this, many asthma patients do not engage in regular physical activity because they mistakenly believe that they should restrict exercise participation. Health care providers have an opportunity to influence the physical activity levels of their patients during regular office visits. Nonetheless, health care providers often overlook physical activity counseling as an adjunct to pharmacological therapy in asthma patients, and in particular, overlook physical activity counseling. Some providers who acknowledge the benefits of physical activity report being unaware how to approach a conversation with patients about this topic. To address these issues, members of the Sports, Exercise, and Fitness Committee of the American Academy of Allergy, Asthma, and Immunology (AAAAI) performed a focused literature search to identify and evaluate the effects of physical activity in patients with asthma. The purpose of this report is to summarize the evidence for physical activity's impact on asthma patients' disease control, pulmonary function, and overall well-being. Several subpopulations of patients with asthma, including children, adolescents, and older adults, are considered individually. In addition, this report offers practical recommendations for clinicians, including how to identify and overcome barriers to counseling, and methods to incorporate physical activity counseling into asthma treatment practice.

A systematic review of the characteristics of interventions that promote physical activity in adults with asthma

Physical activity is promoted in the asthma population through pulmonary rehabilitation, but limited funding and facilities are available. This review aimed to examine the effectiveness of interventions that promote physical activity and identify the behaviour change techniques (BCTs) and other intervention components used. Five databases were searched, and 25 studies met the inclusion criteria. Interventions had a significant positive effect on physical activity, sedentary behaviour, quality of life and asthma symptoms. BCTs used across intervention and control groups were similar in studies that showed effects and those that did not. Future interventions should employ techniques that help to maintain behaviour change.

Applying theoretical models of positive emotion to improve pediatric asthma: A positive psychology approach

Positive emotion, encompassing feelings such as joy and happiness, has been shown to predict a multitude of health outcomes. However, the role of positive emotion in pediatric asthma is not understood. No work to date has examined how positive emotion may offer benefits to children and adolescents with asthma. Based on theory and models of positive emotion and health, we hypothesize that positive emotion may improve asthma outcomes through mediators such as health behaviors and health-relevant physiological functioning. Moreover, boosting positive emotion during times of stress may be particularly relevant in mitigating asthma symptoms. In the present commentary, we elaborate on the hypothesized mechanisms behind such associations grounded within positive emotion theoretical frameworks. Additionally, we summarize the methodologically rigorous work of positive emotion interventions in other clinical settings to propose that positive emotion could be a useful tool in the management of pediatric asthma.

Examining self-affirmation as a tactic for recruiting inactive women into exercise interventions

Recruitment of insufficiently active individuals into exercise interventions is difficult due to many different barriers, including motivational barriers and negative body image. The present study provided an initial conceptual test of whether self-affirmation can help increase recruitment of insufficiently active women to an exercise intervention. Emerging adult women were randomly assigned to complete a self-affirmation or control task prior to reading the same message concerning the consequences of inactivity. In addition to completing demographic and body image measures at baseline, U.S. undergraduate participants (N = 254) indicated their interest in registering for an intervention and their intention to exercise after the experimental manipulation. Data did not support hypotheses that (1) self-affirmed women would find the message less threatening and less manipulative, (2) self-affirmed women would have higher intentions to exercise, (3) self-affirmed women would be more likely to register interest for a future exercise intervention, and (4) condition and body dissatisfaction would interact such that the intervention would be particularly beneficial for women with high body dissatisfaction. Results revealed that 70% of participants were unwilling to register for an exercise intervention, which indicates that other novel exercise intervention recruitment techniques need to be tested.

A Systematic Review of the Effect of Physical Activity on Asthma Outcomes

BACKGROUND

Asthma is a chronic respiratory disease that affects millions worldwide. Medication management is the current mainstay of treatment; however, there is evidence to suggest additional benefit with lifestyle changes, particularly with increased physical activity.

OBJECTIVE

To discover and evaluate the effects of physical activity on asthma outcomes.

METHODS

Systematic search of PubMed, Excerpta Medica database, Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, Rehabilitation and Sports Medicine Source, Scopus, and Web of Science identified 11,155 results. Thirty-five articles met our inclusion criteria spanning 20 studies. Data extraction was conducted by 6 independent reviewers, and final results were evaluated by a seventh reviewer and the senior author.

RESULTS

Wide variation among selected studies, including the heterogeneity of interventions and outcome variables, did not support a meta-analysis. Mixed results of the effects of physical activity on asthma outcomes were found. Most studies suggest that physical activity improves asthma control, quality of life, lung function parameters, and inflammatory serologies, whereas 3 found no improvements in any of these outcomes. No studies reported worsening asthma outcomes.

CONCLUSIONS

This review highlights the emerging and promising role of physical activity as a nonpharmacologic treatment for asthma. Additional high-quality randomized controlled trials are needed to overcome the problems of measurement heterogeneity and the dilution of outcome effect size measurement related to physical activity interventions for asthma.

Frequency of persistent obesity 5 years after first time diagnosis of status asthmaticus

BACKGROUND/OBJECTIVES

When a severe asthma exacerbation occurs in an obese pediatric patient, it is unknown if this body type persists in future encounters. Persistent obesity can lead to future asthma exacerbations. The main study objective is to evaluate the persistence of a BMI percentile ≥85th in children 5 years after the first reported diagnosis of status asthmaticus. We hypothesized that a hospital admission for status asthmaticus was associated with persistence of a BMI percentile ≥85th.

METHODS

This was a long-term retrospective observational cohort study utilizing TriNetX ® electronic health record (EHR) data. We included subjects aged 2 to 18 years of age with a diagnosis of status asthmaticus. Study population was divided into two groups based on their admission body mass index percentile: (underweight/healthy weight [<85th percentile] and overweight/obese [≥85th percentile]) and evaluated for the following outcomes: age, race, ethnicity, diagnostic codes, and BMI percentiles (initially and 5 years after diagnosis of status asthmaticus).

RESULTS

A total of 129 subjects (n%) (76 [58.9%] underweight/healthy weight and 53 [41.1%] overweight/obese) were included. Children that were initially overweight/obese with status asthmaticus had significantly increased odds of continuing to be overweight/obese 5 years after diagnosis compared to children who were underweight/healthy weight at baseline (OR = 7.50 [95% confidence interval, 3.20-17.60; p < 0.001]).

CONCLUSIONS

Overweight/obese asthmatic children are at risk of continuing to be obese several years after being diagnosed with status asthmaticus. This study reinforces the notion that when an asthmatic obese child presents with status asthmaticus, a thorough evaluation of nutrition, physical activity, and asthma control should be considered to reduce the risk of persistent obesity and possibly future asthma exacerbations.

[Asthma 2020 Nursing Consensus Document]

Asthma is a chronic respiratory disease which presents with a risk of exacerbations. Good patient management and continuous monitoring are crucial for good disease control, and pharmacological and non-pharmacological interventions are essential for proper treatment. Nurses specialised in asthma can contribute to the correct management of asthmatic patients. They play a key role in diagnostic tests, administration of medication, and patient follow-up and education. This consensus arose from the need to address an aspect of asthma management that does not appear in the specific recommendations of current guidelines. This document highlights and updates the role of specialized nurses in the care and management of asthma patients, offering conclusions and practical recommendations with the aim of improving their contribution to the treatment of this disease. Proposed recommendations appear as the result of a nominal consensus which was developed during 2019, and validated at the beginning of 2020.

Mediterranean Lifestyle to Promote Physical, Mental, and Environmental Health: The Case of Chile

Chile is currently experiencing a progressive epidemiological transition towards chronic diseases. In this country, >50% of annual deaths are attributed to cardiovascular disease and cancer. Moreover, health surveys have shown high prevalence of obesity, diabetes, hypertension, and elevated cardiovascular disease risk. In addition, mental health issues are also frequent among Chilean adults. On the other hand, the agri-food system contributes to 21-37% of greenhouse gases emissions worldwide. Overall, current health and food chain situation calls out for design and implementation of evidence-based feasible and effective nutritional interventions needed to promote physical and mental health along with addressing food sustainability in Chile. Nowadays, the Mediterranean diet is recognized as one of the healthiest dietary patterns based on observational and interventional studies linked to a wide variety of health outcomes. However, a Mediterranean lifestyle goes well beyond food intake: it includes promotion of psychosocial resources, community life as well as cultural traditions. Indeed, Mediterranean lifestyle is a true modus vivendi that integrally promotes physical, mental, and social well-being. In addition, the Mediterranean diet stands out for its environmental sustainability because it is characterized mainly as a plant-based dietary pattern with low carbon and water footprints. Remarkably, Central Chile has a Mediterranean-like setting with plant and animal food production and availability patterns comparable to those present in countries located around the Mediterranean Sea. Therefore, this article reviews how promotion of Mediterranean lifestyle adherence in Chile offers great potential for management of the ongoing epidemiological transition to chronic diseases as well to promote psychological well-being within a unique food system and dietary sustainability vision for this Latin American country.

A Behavior Change Intervention Aimed at Increasing Physical Activity Improves Clinical Control in Adults With Asthma: A Randomized Controlled Trial

BACKGROUND

Higher levels of physical activity have been associated with better asthma clinical control.

RESEARCH QUESTION

Does a behavior change intervention aimed at increasing physical activity change asthma clinical control, physical activity, sedentary time, health-related quality of life (HRQoL), and anxiety and depression symptoms?

STUDY DESIGN AND METHODS

This single-blind, randomized controlled trial included participants who were allocated to an intervention group (IG) or to a control group (CG). Both groups received usual care and disease-specific education. Participants in the IG also underwent an 8-week behavior change intervention aimed at increasing physical activity. Prior to and following the intervention period, measures were made of asthma clinical control (Asthma Control Questionnaire [ACQ]), physical activity, sedentary time and sleep quality (ActiGraph), HRQoL (Asthma Quality of Life Questionnaire), and anxiety and depression symptoms (Hospital Anxiety and Depression Scale). Data on asthma exacerbations were recorded 12 months prior to and throughout the intervention period.

RESULTS

Fifty-one participants were included (CG, n = 26; IG, n = 25). On completion of the intervention period, compared with the CG, those in the IG exhibited improvements in asthma control (mean difference [95% CI] in ACQ score, -0.8 [-1.1 to -0.4]); in daily step count, 3,605 [1,937 to 8,867] steps/d; in sleep efficiency, 9.2% [-7.1% to 21.9%]; and a reduction in sedentary time, -1.1 [-2.9 to -0.6] h/d). No between-group difference in HRQoL was observed. The percentage of participants who experienced exacerbations during the intervention period was 27% in the IG vs 60% in the CG (P = .04). The change in time spent in moderate-intensity physical activity was inversely associated with change in ACQ (r = -0.60). Compared with the CG, a higher percentage of participants in the IG reported a reduction in anxiety symptoms (43% vs 0%; P < .02).

INTERPRETATION

In adults with moderate to severe asthma, a comprehensive behavior change intervention that increased physical activity also produced improvements in asthma clinical control, sedentary time, sleep quality, and anxiety symptoms.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov; No.: NCT03705702; URL: www.clinicaltrials.gov.

Optimism and Social Support Predict Healthier Adult Behaviors Despite Socially Disadvantaged Childhoods

BACKGROUND

Studies have shown adverse effects of a disadvantaged childhood on adult health-promoting behaviors and related outcomes. Optimism and social support have been linked to greater likelihood of engaging in healthy behavior, but it is unclear whether these positive psychosocial factors may buffer harmful effects of early adversity. This study aims to determine if optimism and social support in adulthood can modify effects of childhood disadvantage on health behavior-related outcomes.

METHODS

Longitudinal data were analyzed from a subset of participants in a US birth cohort established in 1959-1966 (ns of 681-840, per outcome). An index of childhood social disadvantage was derived from adverse socioeconomic and family stability factors reported by mothers at child's birth and age 7 years. Health behavior-related outcomes were self-reported when participants were of mean age 47 years. Multivariable adjusted robust Poisson regressions were performed.

RESULTS

Regardless of level of childhood social disadvantage, we found higher levels of optimism and social support were both associated with higher probabilities of being a non-smoker (relative risk [RR]_optimism = 1.17, 95% confidence interval [CI] = 1.09-1.26; RR_{social support} = 1.24, 95%CI = 1.11-1.39), having a healthy diet (RR_optimism = 1.25, 95%CI = 1.10-1.43; RR_{social support} = 1.27, 95%CI = 1.04-1.56), and a healthy body mass index (RR_optimism = 1.18, 95%CI = 1.00-1.40; RR_{social support} = 1.29, 95%CI = 1.00-1.66). Interactions link higher optimism or social support with lower risk of smoking among those with moderate childhood disadvantage.

CONCLUSIONS

Overall, these findings are consistent with the possibility that positive psychosocial resources contribute to maintaining a healthy lifestyle in mid-adulthood and may buffer effects of childhood social disadvantage.

Physical Activity: A Missing Link in Asthma Care

Asthma is the commonest respiratory disease and one of unceasingly increasing prevalence and burden. As such, asthma has attracted a major share or scientific interest and clinical attention. With the various clinical and pathophysiological aspects of asthma having been extensively investigated, the important association between asthma and physical activity remains underappreciated and insufficiently explored. Asthma impacts adversely on physical activity. Likewise, poor physical activity may lead to worse asthma outcomes. This concise clinical review presents the current recommendations for physical activity, discusses the available evidence on physical activity in asthma, and examines the causes of low physical activity in adult asthmatic patients. It also reviews the effect of daily physical activity and exercise training on the pathology and clinical outcomes of asthma. Finally, it summarizes the evidence on interventions targeting physical activity in asthma.

Psychosocial interventions for cancer survivors: A meta-analysis of effects on positive affect

PURPOSE

Positive affect has demonstrated unique benefits in the context of health-related stress and is emerging as an important target for psychosocial interventions. The primary objective of this meta-analysis was to determine whether psychosocial interventions increase positive affect in cancer survivors.

METHODS

We coded 28 randomized controlled trials of psychosocial interventions assessing 2082 cancer survivors from six electronic databases. We calculated 76 effect sizes for positive affect and conducted synthesis using random effects models with robust variance estimation. Tests for moderation included demographic, clinical, and intervention characteristics.

RESULTS

Interventions had a modest effect on positive affect (g = 0.35, 95% CI [0.16, 0.54]) with substantial heterogeneity of effects across studies ([Formula: see text]; I² = 78%). Three significant moderators were identified: in-person interventions outperformed remote interventions (P = .046), effects were larger when evaluated against standard of care or wait list control conditions versus attentional, educational, or component controls (P = .009), and trials with survivors of early-stage cancer diagnoses yielded larger effects than those with advanced-stage diagnoses (P = .046). We did not detect differential benefits of psychosocial interventions across samples varying in sex, age, on-treatment versus off-treatment status, or cancer type. Although no conclusive evidence suggested outcome reporting biases (P = .370), effects were smaller in studies with lower risk of bias.

CONCLUSIONS

In-person interventions with survivors of early-stage cancers hold promise for enhancing positive affect, but more methodological rigor is needed.

IMPLICATIONS FOR CANCER SURVIVORS

Positive affect strategies can be an explicit target in evidence-based medicine and have a role in patient-centered survivorship care, providing tools to uniquely mobilize human strengths.

Is it better to cultivate positive affect or optimism? Predicting improvements in medical adherence following a positive psychology intervention in patients with acute coronary syndrome

OBJECTIVE

Adherence to health behaviors following an acute coronary syndrome (ACS) is strongly associated with superior prognosis. Both optimism and positive affect may play important roles in such adherence. However, the relationship between changes in these constructs in the context of positive psychology interventions (PPIs) and adherence to health behaviors is not fully understood. Accordingly, we aimed to examine these relationships among a cohort of post-ACS patients receiving a PPI.

METHOD

Post-ACS participants who received a PPI during a factorial trial (N = 128) completed self-report measures of positive affect and optimism, along with the Medical Outcomes Study Specific Adherence Scale items for diet, physical activity, and medication adherence, over 16 weeks. The baseline and longitudinal effects of positive affect and optimism-representing changes in those constructs-on adherence were analyzed using mixed effects regression models.

RESULTS

Positive affect, but not optimism, was longitudinally associated with greater overall adherence to health behaviors (positive affect: β = 0.057, p = .006; optimism: β = 0.032, p = .36), with the effect driven by physical activity adherence (positive affect: β = 0.040, p = .004; optimism: β = 0.005, p = .83).

CONCLUSION

Changes in positive affect may be more strongly associated with post-ACS adherence than optimism; this could have important implications for the development of PPIs to promote adherence.

The effectiveness of nudges in improving the self-management of patients with chronic diseases: A systematic literature review

In this systematic literature review, we identify evidence on the effectiveness of nudges in improving the self-management of adults with chronic diseases and derive policy recommendations. We included empirical studies of any design published up to April 12^th, 2018. We synthesized the results of the studies narratively by comparing statistical significance and direction of different nudge types' effects on primary study outcomes. Lastly, we categorized the nudges according to their degree of manipulation and transparency. We identified 26 studies, where 13 were of high or moderate quality. The most commonly tested nudges were reminders, planning prompts, small financial incentives, and feedback. Overall, 8 of 9 studies with a high or moderate quality ranking, focused on self-management outcomes, i.e., physical activity, attendance, self-monitoring, and medication adherence, found that nudges had significant positive effects. However, only 1 of 4 studies of high or moderate quality, analyzing disease control outcomes (e.g., glycemic control), found that nudges had a significant positive effect for one intervention arm. In summary, this review demonstrates that nudges can improve chronic disease self-management, but there is hardly any evidence to date that these interventions lead to improved disease control. Reminders, feedback, and planning prompts appear to improve chronic disease self-management most consistently and are among the least controversial types of nudges. Accordingly, they can generally be recommended to policymakers.

Effects of a behaviour change intervention aimed at increasing physical activity on clinical control of adults with asthma: study protocol for a randomised controlled trial

Background

In adults with asthma, physical activity has been associated with several asthma outcomes. However, it is unclear whether changes in physical activity, measured via an accelerometer, have an effect on asthma control. The objective of the present study is, in adults with moderate-to-severe asthma, to investigate the effects of a behaviour change intervention, which aims to increase participation in physical activity, on asthma clinical control.

Methods

This is a single-blind (outcome assessor), two-arm, randomised controlled trial (RCT). Fifty-five participants with moderate-to-severe asthma, receiving optimized pharmacological treatment, will be randomly assigned (computer-generated) into either a Control Group (CG) or an Intervention Group (IG). Both groups will receive usual care (pharmacological treatment) and similar educational programmes. In addition to these, participants in the IG will undergo the behaviour change intervention based on feedback, which aims to increase participation in physical activity. This intervention will be delivered over eight sessions as weekly one-on-one, face-to-face 40-min consultations. Both before and following the completion of the intervention period, data will be collected on asthma clinical control, levels of physical activity, health-related quality of life, asthma exacerbation and levels of anxiety and depression symptoms. Anthropometric measurements will also be collected. Information on comorbidities, lung function and the use of asthma medications will be extracted from the participant’s medical records.

Discussion

If successful, this study will demonstrate that, in adults with asthma, a behavioural change intervention which aims to increase participation in physical activity also affects asthma control.

Trial registration

Clinical Trials.gov PRS (Protocol registration and Results System): NCT-03705702 (04/10/2018).

Randomized controlled trial of a facilitated online positive emotion regulation intervention for dementia caregivers

OBJECTIVE

To test the effects of Life Enhancing Activities for Family Caregivers (LEAF), a 6-week positive emotion regulation intervention, on outcomes of positive emotion, depression, anxiety, and physical health as measured by the Patient-Reported Outcomes Measurement Information System® (PROMIS®).

METHOD

A randomized controlled trial (N = 170) comparing LEAF (N = 86) to an emotion reporting/waitlist condition (N = 84) in dementia caregivers. LEAF was individually delivered online by trained facilitators. Participants in the control condition completed daily online emotion reports and then crossed over into the intervention condition after 6 weeks. The study was registered with Clinicaltrials.gov (NCT01825681) and funded by R01NR014435.

RESULTS

Analyses of difference in change from baseline to 6 weeks demonstrated significantly greater decreases in PROMIS® depression (d = -.25; p = .02) and Quality of Life in Neurological Disorders (NeuroQOL) anxiety (d = -.33; p < .01), as well as improvements in PROMIS® physical health (d = .24; p = .02) in the intervention condition compared to the emotion reporting/waitlist control. The intervention also showed greater improvements in positive emotion (d = .58; p < .01) and positive aspects of caregiving (d = .36; p < .01). Increases in positive emotion significantly mediated the effect of LEAF on depression over time.

CONCLUSIONS

This randomized controlled trial of the online-facilitated positive emotion regulation intervention in dementia caregivers demonstrated small to medium effect sizes on caregiver well-being and shows promise for remotely delivered programs to improve psychological well-being in caregivers of people with dementia and other chronic illnesses. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Positive Affect and Health: What Do We Know and Where Next Should We Go?

Positive affect (PA) is associated with better health across a wide range of physical health outcomes. This review reflects on why the study of PA is an essential component of our understanding of physical health and expands on pathways that connect these two variables. To encourage forward movement in this burgeoning research area, measurement and design issues in the study of PA and health are discussed, as are the connections between PA and a range of different health outcomes. Plausible biological, social, and behavioral pathways that allow for positive feelings to get under the skin and influence physical wellness are detailed and framed in the context of several theoretical models. Finally, new directions for the field and important methodological and interpretative considerations that are essential to moving this important research area forward are explored.

Reconceptualizing Self-Affirmation With the Trigger and Channel Framework: Lessons From the Health Domain

Self-affirmation—a theory-based technique to affirm the adaptive adequacy of the self—can promote positive behavior change and adaptive outcomes, although effects are variable. We extend a novel framework (Trigger and Channel), proposing three conditions that facilitate self-affirmation-induced behavior change: (a) presence of psychological threat, (b) presence of resources to foster change, and (c) timeliness of the self-affirmation with respect to threat and resources. Using health behavior as a focus, we present meta-analytic evidence demonstrating that when these conditions are met, self-affirmation acts as a psychological trigger into a positive channel of resources that facilitate behavior change. The presence of a timely threat and the availability of timely resources independently predicted larger self-affirmation effects on behavior change, and the two interacted synergistically to predict still larger effects. The results illustrate the conditionality of self-affirmation effects and offer guidelines for when, where, and for whom self-affirmation will be most effective.

Affective stimuli in behavioural interventions soliciting for health check-up services and the service users' socioeconomic statuses: a study at Japanese pachinko parlours

Editor’s note

The study reported in this article examines a health intervention that uses gendered stereotypes of the nursing profession and suggestive uniforms that play on women’s sexuality to encourage people to engage in health checkups. The intervention was not under the control of the authors and the study was approved by an institutional research ethics board. The Journal of Epidemiology & Community Health condemns the use of sexism, gender and professional stereotypes and other forms of discriminatory or exploitative behaviour for any purpose, including health promotion programs. In light of concerns raised about this paper (see eLetters with this paper), we are conducting an audit of our review process and will put in place measures to ensure that the material we publish condemns sexism, racism and other forms of discrimination and embodies principles of inclusion and non-discrimination.

Advancing the Science of Behavioral Self-Management of Chronic Disease: The Arc of a Research Trajectory

This article describes advances in the behavioral self-management of chronic disease from the perspective of a 25-year trajectory of National Institute of Health-funded research in arthritis and cardiopulmonary diseases that has sought to develop a transdisciplinary understanding of how applied behavioral science can be used to improve health behaviors, functional status, and health outcomes. The article traces the arc of a novel research program-conducted in collaboration with physician-scientists at Columbia, Weill Cornell Medical College, and New York University School of Medicine-that runs through social cognitive theory, behavioral economics, and the emerging science of positive psychology in an effort to develop promising new approaches to fostering the adoption and maintenance of health-related behavioral change. The article concludes with what has been learned and what the implications of the work are for advancing behavioral self-management and patient education to improve patient outcomes and achieve the compression of morbidity.

Testing a Positive Psychological Intervention for Osteoarthritis

OBJECTIVE

Osteoarthritis is a leading cause of disability for which there is no cure. Psychosocial-oriented treatments are underexplored. We developed and tested an intervention to build positive psychological skills (e.g., gratitude) to reduce osteoarthritis symptom severity, including pain and functioning, and to improve psychosocial well-being in patients with knee or hip osteoarthritis.

DESIGN

Two-arm randomized design with six-month follow-up.

SETTING

An academic Veterans Affairs Medical Center.

SUBJECTS

Patients aged 50 years or older with knee or hip osteoarthritis and pain ratings of 4 or higher.

METHODS

Patients (N = 42) were randomized to a six-week program containing positive skill-building activities or neutral control activities tailored to the patient population. Adherence was assessed by telephone each week. We assessed osteoarthritis symptom severity (WOMAC Osteoarthritis Index) and measures of well-being (positive affect, negative affect, and life satisfaction) at baseline and by telephone one, three, and six months after the program ended. We used linear mixed models to examine changes over time.

RESULTS

The majority (64%) of patients completed more than 80% of their weekly activities. Patients in the positive (vs neutral) program reported significantly more improvement over time in osteoarthritis symptom severity (P = 0.02, Cohen's d = 0.86), negative affect (P = 0.03, Cohen's d = 0.50), and life satisfaction (P = 0.02, Cohen's d = 0.36).

CONCLUSIONS

The study successfully engaged patients with knee or hip osteoarthritis in a six-week intervention to build positive psychological skills. Improving osteoarthritis symptom severity and measures of psychosocial well-being, the intervention shows promise as a tool for chronic pain management.

Positive psychological well-being and health in patients with heart disease: a brief review

Poor psychological health (e.g., depression and anxiety) is prospectively associated with adverse cardiac outcomes. In contrast, there is increasing evidence that positive psychological constructs like happiness, optimism and gratitude are independently and prospectively linked to better health behaviors and superior cardiac prognosis in people with and without heart disease. However, a critical question is whether such positive states and traits are modifiable. Recent studies of systematic positive psychology interventions designed to promote well-being have shown promise in patients with heart disease, and more data are needed to learn whether these interventions are effective and whether they can be broadly applied to impact public health.

Effects of an unsupervised pedometer-based physical activity program on daily steps of adults with moderate to severe asthma: a randomized controlled trial

Supervised exercise has shown benefits for subjects with asthma, but little is known about the effectiveness of unsupervised physical activity on this population. We investigated the effects of a 12-week unsupervised pedometer-based physical activity program on daily steps and on clinical and psychological parameters of adults with asthma. Clinically stable adults with moderate to severe asthma were encouraged to take daily 30-minute walks and were randomized to pedometer and control groups. The pedometer group received pedometers and individualized daily step targets. Changes in daily steps (average of steps taken during six consecutive days), six-minute walk test (6MWT), health-related quality of life, asthma control and anxiety and depression levels were assessed 12 weeks after intervention and 24-28 weeks after randomization. Thirty-seven participants were recruited and 30 completed the intervention. At 12 weeks, the groups differed significantly in daily steps (adjusted average difference, 2488 steps; 95% confidence interval [CI], 803 to 4172; p = 0.005) and in the 6MWT (adjusted average difference, 21.9 m; 95% CI, 6.6 to 37.3; p = 0.006). These differences were not significant 24-28 weeks after randomization. The program was effective in increasing daily steps of adults with moderate to severe asthma 12 weeks after intervention.

Randomized controlled trial of a positive affect intervention for people newly diagnosed with HIV

OBJECTIVE

We conducted a randomized controlled trial to determine whether IRISS (Intervention for those Recently Informed of their Seropositive Status), a positive affect skills intervention, improved positive emotion, psychological health, physical health, and health behaviors in people newly diagnosed with HIV.

METHOD

One-hundred and fifty-nine participants who had received an HIV diagnosis in the past 3 months were randomized to a 5-session, in-person, individually delivered positive affect skills intervention or an attention-matched control condition.

RESULTS

For the primary outcome of past-day positive affect, the group difference in change from baseline over time did not reach statistical significance (p = .12, d = .30). Planned secondary analyses within assessment point showed that the intervention led to higher levels of past-day positive affect at 5, 10, and 15 months postdiagnosis compared with an attention control. For antidepressant use, the between group difference in change from baseline was statistically significant (p = .006, d = -.78 baseline to 15 months) and the difference in change over time for intrusive and avoidant thoughts related to HIV was also statistically significant (p = .048, d = .29). Contrary to findings for most health behavior interventions in which effects wane over the follow up period, effect sizes in IRISS seemed to increase over time for most outcomes.

CONCLUSIONS

This comparatively brief positive affect skills intervention achieved modest improvements in psychological health, and may have the potential to support adjustment to a new HIV diagnosis. (PsycINFO Database Record

Healthy Physical Activity Levels Below Recommended Thresholds Two Years After Lumbar Spine Surgery

STUDY DESIGN

Prospective analysis.

OBJECTIVE

To quantify physical activity after lumbar surgery and identify spine-related variables associated with not meeting recommended activity thresholds.

SUMMARY OF BACKGROUND DATA

National guidelines recommend ≥150 minutes/week of moderate-intensity activity; however, only 52% of the general population meets this threshold. For patients not participating in exercise/sports, ≥1400 kcal/week of energy expenditure, including from walking, is another threshold. Potential spine-related variables associated with not meeting these thresholds after lumbar surgery have not been described.

METHODS

Clinical data were collected pre- and intraoperatively for 422 patients. Patients were contacted 2.2 years postoperatively to measure several patient-reported outcomes, including physical activity with the Paffenbarger Physical Activity and Exercise Index. The Paffenbarger Physical Activity and Exercise Index encompasses blocks walked, stairs climbed, and exercise/sports. Minutes/week of activity and total kcal/week were calculated and compared to recommended thresholds. Spine-related variables associated with not meeting thresholds were assessed in multivariable analyses.

RESULTS

Mean age was 57 years, 55% were men, 80% had degenerative diagnoses, and 63% had multilevel surgery. Only 35% met ≥1400 kcal/week; in multivariable analysis, not meeting this threshold was associated with revision surgery (OR 0.53, CI 0.30-0.95), surgery at ≥3 levels (OR 0.51, CI 0.31-0.84), and more postoperative back pain (OR 0.38, CI 0.24-0.59) (P <0.05 for all variables). Only 26% met ≥150 minutes/week; in multivariable analysis, not meeting this threshold was associated with degenerative diagnoses (OR 0.53, CI 0.31-0.92), subsequent spine surgery (OR 0.17, CI 0.05-0.58), and more postoperative back pain (OR 0.41, CI 0.25-0.67) (P <0.05 for all variables). All multivariable associations persisted after controlling for demographic characteristics.

CONCLUSION

Physical activity is below population norms after lumbar surgery and is associated with spine-related variables. Patients with stable spine conditions should be encouraged to engage in prudent physical activity to decrease their risk of long-term adverse health outcomes due to inactivity.

LEVEL OF EVIDENCE

3.

A Positive Psychology Intervention for Patients with an Acute Coronary Syndrome: Treatment Development and Proof-of-Concept Trial

Positive psychological constructs are associated with superior outcomes in cardiac patients, but there has been minimal study of positive psychology (PP) interventions in this population. Our objective was to describe the intervention development and pilot testing of an 8-week phone-based PP intervention for patients following an acute coronary syndrome (ACS). Initial intervention development and single-arm proof-of-concept trial, plus comparison of the PP intervention to a subsequently-recruited treatment as usual (TAU) cohort. PP development utilized existing literature, expert input, and qualitative interview data in ACS patients. In the proof-of-concept trial, the primary outcomes were feasibility and acceptability, measured by rates of exercise completion and participant ratings of exercise ease/utility. Secondary outcomes were pre-post changes in psychological outcomes and TAU comparisons, measured using effect sizes (Cohen's d). The PP intervention and treatment manual were successfully created. In the proof-of-concept trial, 17/23 PP participants (74 %) completed at least 5 of 8 exercises. Participants rated the ease (M = 7.4/10; SD = 2.1) and utility (M = 8.1/10, SD = 1.6) of PP exercises highly. There were moderate pre-post improvements (ds = .46-.69) in positive affect, anxiety, and depression, but minimal effects on dispositional optimism (d = .08). Compared to TAU participants (n = 22), PP participants demonstrated greater improvements in positive affect, anxiety, and depression (ds = . 47-.71), but not optimism. A PP intervention was feasible, well-accepted, and associated with improvements in most psychological measures among cardiac patients. These results provide support for a larger trial focusing on behavioral outcomes.

Positive affect and its association with viral control among women with HIV infection

OBJECTIVE

We assessed the relationship between positive affect and viral suppression among women with HIV infection.

METHOD

Three waves of 6-month data were analyzed from 995 women on HIV antiretroviral therapy participating in the Women's Interagency HIV Study (10/11-3/13). The predictor variable was self-reported positive affect over 2 waves of data collection, and the outcome was suppressed viral load, defined as plasma HIV-1 RNA <200 copies/mL, measured at a third wave.

RESULTS

Women with higher positive affect (36%) were more likely to have viral suppression at a subsequent wave (OR 1.92, 95% CI [1.34, 2.74]). Adjusting for covariates and their interactions, including negative affect, Wave 1 viral suppression, adherence, study site, recruitment cohort, substance use, heavy drinking, relationship status, interpersonal difficulties, and demographics, a statistically significant interaction was detected between negative affect, positive affect and viral suppression, t(965) = -2.7, p = .008. The association of positive affect and viral suppression differed at negative affect quartile values. For those reporting no negative affect, the AOR for positive affect and viral suppression was 2.41 (95% CI [1.35, 4.31]); at a negative affect score of 2, the AOR was 1.44 (95% CI [0.87, 2.36]); and at a score of 5.5, the AOR was 0.58 (95% CI [0.24, 1.42]).

CONCLUSION

Our central finding related to the interaction effect, that positive affect is associated with viral control under conditions of lower negative affect, is consistent with previous theory and research with other health outcomes, and can help guide efforts to further delineate mechanisms linking affect and health. (PsycINFO Database Record

Cognitive behavioural therapy (CBT) for adults and adolescents with asthma

BACKGROUND

People with asthma have a higher prevalence of anxiety and depression than the general population. This is associated with poorer asthma control, medication adherence, and health outcomes. Cognitive behavioural therapy (CBT) may be a way to improve the quality of life of people with asthma by addressing associated psychological issues, which may lead to a lower risk of exacerbations and better asthma control.

OBJECTIVES

To assess the efficacy of CBT for asthma compared with usual care.

SEARCH METHODS

We searched the Cochrane Airways Group Specialised Register, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP). We also searched reference lists of all primary studies and review articles and contacted authors for unpublished data. The most recent searches were conducted in August 2016.

SELECTION CRITERIA

We included parallel randomised controlled trials (RCTs) comparing any cognitive behavioural intervention to usual care or no intervention. We included studies of adults or adolescents with asthma, with or without comorbid anxiety or depression. We included studies reported as full text, those published as abstract only, and unpublished data.

DATA COLLECTION AND ANALYSIS

Two or more review authors independently screened the search results, extracted data, and assessed included studies for risk of bias. We analysed dichotomous data as odds ratios (ORs) and continuous data as mean differences (MDs) or standardised mean differences (SMD) where scales varied across studies, all using a random-effects model. The primary outcomes were asthma-related quality of life and exacerbations requiring at least a course of oral steroids. We rated all outcomes using GRADE and presented our confidence in the results in a 'Summary of findings' table.

MAIN RESULTS

We included nine RCTs involving 407 adults with asthma in this review; no studies included adolescents under 18. Study size ranged from 10 to 94 (median 40), and mean age ranged from 39 to 53. Study populations generally had persistent asthma, but severity and diagnostic measures varied. Three studies recruited participants with psychological symptomatology, although with different criteria. Interventions ranged from 4 to 15 sessions, and primary measurements were taken at a mean of 3 months (range 1.2 to 12 months).Participants given CBT had improved scores on the Asthma Quality of Life Questionnaire (AQLQ) (MD 0.55, 95% confidence interval (CI) 0.17 to 0.93; participants = 214; studies = 6; I2 = 53%) and on measures of asthma control (SMD -0.98, 95% CI -1.76 to -0.20; participants = 95; studies = 3; I2 = 68%) compared to people getting usual care. The AQLQ effect appeared to be sustained up to a year after treatment, but due to its low quality this evidence must be interpreted with caution. As asthma exacerbations requiring at least a course of oral steroids were not consistently reported, we could not perform a meta-analysis.Anxiety scores were difficult to pool but showed a benefit of CBT compared with usual care (SMD -0.38, 95% CI -0.73 to -0.03), although this depended on the analysis used. The confidence intervals for the effect on depression scales included no difference between CBT and usual care when measured as change from baseline (SMD -0.33, 95% CI -0.70 to 0.05) or endpoint scores (SMD -0.41, 95% CI -0.87 to 0.05); the same was true for medication adherence (MD -1.40, 95% CI -2.94 to 0.14; participants = 23; studies = 1; I2 = 0%).Subgroup analyses conducted on the AQLQ outcome did not suggest a clear difference between individual and group CBT, baseline psychological status, or CBT model. The small number of studies and the variation between their designs, populations, and other intervention characteristics limited the conclusions that could be drawn about these possibly moderating factors.The inability to blind participants and investigators to group allocation introduced significant potential bias, and overall we had low confidence in the evidence.

AUTHORS' CONCLUSIONS

For adults with persistent asthma, CBT may improve quality of life, asthma control, and anxiety levels compared with usual care. Risks of bias, imprecision of effects, and inconsistency between results reduced our confidence in the results to low, and evidence was lacking regarding the effect of CBT on asthma exacerbations, unscheduled contacts, depression, and medication adherence. There was much variation between studies in how CBT was delivered and what constituted usual care, meaning the most optimal method of CBT delivery, format, and target population requires further investigation. There is currently no evidence for the use of CBT in adolescents with asthma.

How older citizens engage in their health promotion: a qualitative research-driven taxonomy of experiences and meanings

OBJECTIVES

In this qualitative study, we provide an in-depth exploration of older people's experiences and subjective meanings concerning their engagement in health promotion as well as the emotional and pragmatic difficulties they face during their engagement.

METHODS

The study was designed according to the ethnoscience method, which implies a participatory process that values patients' linguistic expressions to deeply understand the phenomena under the investigation and to give it a meaning. Using this method, thanks to repeated rounds of interviews and the Q-sorting task, participants created a dictionary, with the assistance of the researcher, to describe the phenomenon of interest. They agreed on a shared taxonomy of meanings and experiences related to the phenomenon. 25 North Italian older citizens participated in this study.

RESULTS

Participants described a shared taxonomy of health engagement experiences by depicting 3 main positions (ie, locked position; awakening position; climbing position), which represented different experiential domains grouped by participants into 4 main semantic areas (eg, physical care, soul care, daily lifestyle, contact with ageing). Each position is characterised by specific emotions, personal representations of meaning and healthy behaviours that may sustain or hinder older citizens' engagement in health promotion.

CONCLUSIONS

The results of the present study suggest the importance of deeply understanding older peoples' experiences and their subjective meanings of health promotion. In particular, the results showed how their engagement in health promotion is framed in a complex system of psychological meanings, which may sustain or hinder their ability to adopt healthy behaviours. A deeper understanding of older citizens' lived experiences, their doubts and their difficulties in engaging in health promotion may offer some important cues for orienting interventions in this area.

Positive Psychology and Physical Health: Research and Applications

Positive psychology is the scientific study of a healthy and flourishing life. The goal of positive psychology is to complement and extend the traditional problem-focused psychology that has proliferated in recent decades. Positive psychology is concerned with positive psychological states (eg, happiness), positive psychological traits (eg, talents, interests, strengths of character), positive relationships, and positive institutions. We describe evidences of how topics of positive psychology apply to physical health. Research has shown that psychological health assets (eg, positive emotions, life satisfaction, optimism, life purpose, social support) are prospectively associated with good health measured in a variety of ways. Not yet known is whether positive psychology interventions improve physical health. Future directions for the application of positive psychology to health are discussed. We conclude that the application of positive psychology to health is promising, although much work remains to be done.

Positive Psychological Interventions for Patients with Type 2 Diabetes: Rationale, Theoretical Model, and Intervention Development

Most patients with type 2 diabetes (T2D) have suboptimal adherence to recommended diet, physical activity, and/or medication. Current approaches to improve health behaviors in T2D have been variably effective, and successful interventions are often complex and intensive. It is therefore vital to develop interventions that are simple, well-accepted, and applicable to a wide range of patients who suffer from T2D. One approach may be to boost positive psychological states, such as positive affect or optimism, as these constructs have been prospectively and independently linked to improvements in health behaviors. Positive psychology (PP) interventions, which utilize systematic exercises to increase optimism, well-being, and positive affect, consistently increase positive states and are easily delivered to patients with chronic illnesses. However, to our knowledge, PP interventions have not been formally tested in T2D. In this paper, we review a theoretical model for the use of PP interventions to target health behaviors in T2D, describe the structure and content of a PP intervention for T2D patients, and describe baseline data from a single-arm proof-of-concept (N = 15) intervention study in T2D patients with or without depression. We also discuss how PP interventions could be combined with motivational interviewing (MI) interventions to provide a blended psychological-behavioral approach.

The psychology of change: self-affirmation and social psychological intervention

People have a basic need to maintain the integrity of the self, a global sense of personal adequacy. Events that threaten self-integrity arouse stress and self-protective defenses that can hamper performance and growth. However, an intervention known as self-affirmation can curb these negative outcomes. Self-affirmation interventions typically have people write about core personal values. The interventions bring about a more expansive view of the self and its resources, weakening the implications of a threat for personal integrity. Timely affirmations have been shown to improve education, health, and relationship outcomes, with benefits that sometimes persist for months and years. Like other interventions and experiences, self-affirmations can have lasting benefits when they touch off a cycle of adaptive potential, a positive feedback loop between the self-system and the social system that propagates adaptive outcomes over time. The present review highlights both connections with other disciplines and lessons for a social psychological understanding of intervention and change.

The impact of positive affect on health cognitions and behaviours: a meta-analysis of the experimental evidence

Several reviews suggest that positive affect is associated with improved longevity, fewer physical symptoms, and biological indicators of good health. It is possible that positive affect could influence these outcomes by promoting healthful cognitions and behaviours. The present review identified conceptual pathways from positive affect to health cognitions and behaviour, and used random effects meta-analysis to quantify the impact of positive affect inductions (versus neutral affect conditions) on these outcomes. Literature searches located 54 independent tests that could be included in the review. Across all studies, the findings revealed no reliable effects on intentions (d+ = -.12, 95% CI = -.32 to .08, k = 15) or behaviour (d+ = .15, 95% CI = -.03 to .33, k = 23). There were four reliable effects involving specific cognitions and behaviours, but little clear evidence for generalised benefits or adverse effects of positive emotions on health-related cognitions or actions. Conclusions must be cautious given the paucity of tests available for analysis. The review offers suggestions about research designs that might profitably be deployed in future studies, and calls for additional tests of the impact of discrete positive emotions on health cognitions and behaviour.

An online positive affect skills intervention reduces depression in adults with type 2 diabetes

Positive affect predicts improved glycemic control and longevity in adults with type 2 diabetes. We tested DAHLIA, a self-paced online intervention for type 2 diabetes that teaches positive affect skills such as savoring, gratitude, and acts of kindness. Participants (n=49) were randomized to the 5-week DAHLIA course or an emotion-reporting waitlist control. DAHLIA was understood and accepted by participants and showed good retention (78%). At post-intervention, DAHLIA participants showed a significantly greater decrease in depression than controls (-4.3 vs. +0.6 points on the CES-D, p =.05). Secondary analyses found that this effect was considerably stronger in intervention recipients recruited online than those recruited in person. Intervention recipients recruited online also showed significantly increased positive affect, reduced negative affect, and reduced perceived stress. There were no effects on measures of diabetes-specific efficacy or sense of burden, or preliminary measures of health behaviors. This successful feasibility and efficacy trial provides support for a larger trial focusing more specifically on health behavior.

Mediators and moderators of behavior change in patients with chronic cardiopulmonary disease: the impact of positive affect and self-affirmation

Among patients with chronic cardiopulmonary disease, increasing healthy behaviors improves outcomes, but such behavior changes are difficult for patients to make and sustain over time. This study aims to demonstrate how positive affect and self-affirmation improve health behaviors compared with a patient education control group. The patient education (PE control) patients completed a behavioral contract, promising to increase their physical activity or their medication adherence and received an educational guide. In addition to the contract and guide, the positive affect/self-affirmation intervention (PA intervention) patients also learned to use positive affect and self-affirmation to facilitate behavior change. Follow-up was identical. In 756 patients, enrolled in three randomized trials, the PA intervention resulted in increased positive affect and more success in behavior change than the PE control (p < .01). Behavior-specific self-efficacy also predicted success (p < .01). Induction of positive affect played a critical role in buffering against the adverse behavioral consequences of stress. Patients who experienced either negative psychosocial changes (p < .05) or interval negative life events (p < .05) fared better with the PA intervention than without it. The PA intervention increased self-efficacy and promoted success in behavior change by buffering stress.

Life satisfaction and frequency of doctor visits

OBJECTIVE

Identifying positive psychological factors that reduce health care use may lead to innovative efforts that help build a more sustainable and high-quality health care system. Prospective studies indicate that life satisfaction is associated with good health behaviors, enhanced health, and longer life, but little information about the association between life satisfaction and health care use is available. We tested whether higher life satisfaction was prospectively associated with fewer doctor visits. We also examined potential interactions between life satisfaction and health behaviors.

METHODS

Participants were 6379 adults from the Health and Retirement Study, a prospective and nationally representative panel study of American adults older than 50 years. Participants were tracked for 4 years. We analyzed the data using a generalized linear model with a gamma distribution and log link.

RESULTS

Higher life satisfaction was associated with fewer doctor visits. On a 6-point life satisfaction scale, each unit increase in life satisfaction was associated with an 11% decrease in doctor visits--after adjusting for sociodemographic factors (relative risk = 0.89, 95% confidence interval = 0.86-0.93). The most satisfied respondents (n = 1121; 17.58%) made 44% fewer doctor visits than did the least satisfied (n = 182; 2.85%). The association between higher life satisfaction and reduced doctor visits remained even after adjusting for baseline health and a wide range of sociodemographic, psychosocial, and health-related covariates (relative risk = 0.96, 95% confidence interval = 0.93-0.99).

CONCLUSIONS

Higher life satisfaction is associated with fewer doctor visits, which may have important implications for reducing health care costs.

Positive psychological characteristics in diabetes: a review

Positive psychological characteristics, such as optimism, self-efficacy, and resilience, have been increasingly associated with improved outcomes in medically ill individuals. However, there has been minimal systematic review of these characteristics and their associations with outcomes in people with diabetes. We aim to review these associations, their potential mediating mechanisms, and the evidence supporting interventions targeting these qualities. In people with diabetes, positive psychological characteristics are significantly associated with improved glycemic control, fewer complications, and reduced rates of mortality. Potential mechanisms mediating these associations include behavioral factors (e.g., improved treatment adherence), reduced inflammation, and improved neuroendocrine and autonomic functioning. Most psychosocial treatments in this population have focused on improving self-efficacy and resilience; such interventions may improve quality of life, well-being, and diabetes self-care. While untested in diabetes, interventions to boost other positive characteristics have been effective in other medically ill patients and may warrant further study in this cohort.

Self-affirmation and motivational interviewing: integrating perspectives to reduce resistance and increase efficacy of alcohol interventions

To promote efforts at reducing problematic alcohol use and improving health outcomes, the present review proposes an integration of a social psychological approach - self-affirmation theory - with a clinical psychology intervention - motivational interviewing. Motivational interviewing (MI) is a popular empirically-designed treatment approach that has shown moderate success at reducing drinking and improving health, especially with resistant drinkers. Experiments informed by self-affirmation theory have found that people exhibit reduced defensiveness to threatening health messages and increased intentions to reduce alcohol consumption when affirmed. This review focuses on the mechanisms by which self-affirmation reduces resistance and how these mechanisms are complementary to the MI approach. Further, the review outlines suggestions for conducting and integrating self-affirmation into a MI intervention and provides recommendations for future empirical research.

A brief self-affirmation study to improve the experience of minority patients

BACKGROUND

There is evidence that Black patients may experience stereotype threat--apprehension about being negatively stereotyped--in healthcare settings, which might adversely affect their behavior in clinical encounters. Recent studies conducted outside of healthcare have shown that a brief self-affirmation intervention, in which individuals are asked to focus on and affirm their valued characteristics and sources of personal pride, can reduce the negative effects of stereotype threat on academic performance and on interpersonal communication.

METHODS

This randomised controlled trial examined whether a self-affirmation (SA) intervention would decrease the negative effects of stereotype threat (negative mood, lower state self-esteem, greater perceptions of racial discrimination) and increase communication self-efficacy among Black primary care patients. Self-affirmation was induced by having patients complete a 32-item values affirmation questionnaire.

RESULTS

Patients in the SA condition had lower levels of performance self-esteem and social self-esteem than patients in the control. There were no differences between the SA and the control groups on negative mood, communication self-efficacy, and perceptions of discrimination.

CONCLUSIONS

Our SA intervention lowered state self-esteem among Black patients. Future research is needed to determine the type of SA task that is most effective for this population.

Translating basic behavioral and social science research to clinical application: the EVOLVE mixed methods approach

OBJECTIVE

To describe a mixed-methods approach to develop and test a basic behavioral science-informed intervention to motivate behavior change in 3 high-risk clinical populations. Our theoretically derived intervention comprised a combination of positive affect and self-affirmation (PA/SA), which we applied to 3 clinical chronic disease populations.

METHOD

We employed a sequential mixed methods model (EVOLVE) to design and test the PA/SA intervention in order to increase physical activity in people with coronary artery disease (post-percutaneous coronary intervention [PCI]) or asthma (ASM) and to improve medication adherence in African Americans with hypertension (HTN). In an initial qualitative phase, we explored participant values and beliefs. We next pilot tested and refined the intervention and then conducted 3 randomized controlled trials with parallel study design. Participants were randomized to combined PA/SA versus an informational control and were followed bimonthly for 12 months, assessing for health behaviors and interval medical events.

RESULTS

Over 4.5 years, we enrolled 1,056 participants. Changes were sequentially made to the intervention during the qualitative and pilot phases. The 3 randomized controlled trials enrolled 242 participants who had undergone PCI, 258 with ASM, and 256 with HTN (n = 756). Overall, 45.1% of PA/SA participants versus 33.6% of informational control participants achieved successful behavior change (p = .001). In multivariate analysis, PA/SA intervention remained a significant predictor of achieving behavior change (p < .002, odds ratio = 1.66), 95% CI [1.22, 2.27], controlling for baseline negative affect, comorbidity, gender, race/ethnicity, medical events, smoking, and age.

CONCLUSIONS

The EVOLVE method is a means by which basic behavioral science research can be translated into efficacious interventions for chronic disease populations.