Behavioral Phenotyping in Health Promotion: Embracing or Avoiding Failure

Understanding Health Beliefs and Health Behaviors in Older Adults at Risk for Alzheimer's Disease

Background

There are significant public health benefits to delaying the onset of Alzheimer's disease (AD) in individuals at risk. However, adherence to brain healthy behaviors is low. The Health Belief Model proposes that specific beliefs are mediators of behavior change.

Objective

To characterize health belief measures from the Science of Behavior Change Research Network (SBCRN) in an older adult population and associations between health beliefs, AD risk, and current health behaviors.

Methods

A total of 172 individuals from the Rhode Island AD Prevention Registry participated. SBCRN health belief measures included assessments of future time perspective, self-efficacy, deferment of gratification, and consideration of future consequences. Outcome measures included individual AD risk index score, dementia risk awareness, and lifestyle behaviors including physical, cognitive, and social activity.

Results

Participants who were older had higher scores for AD risk, lower future time perspective, and lower generalized self-efficacy (all at p < 0.001). Higher generalized self-efficacy was related to increased physical activity (p < 0.010). Higher future time perspective (p < 0.001) and generalized self-efficacy (p = 0.48) were associated with lower AD risk score. Subjective cognitive decline (SCD) was associated with lower self-efficacy, ability to delay gratification, and a less expansive future time perspective.

Conclusions

Greater self-efficacy and perceived future time remaining were associated with lower AD risk and greater engagement in physical activity. SCD was associated with health beliefs that may negatively affect engagement in positive brain health behaviors. Assessment of and psychoeducation about these intrapersonal health belief constructs may be important targets for behavioral interventions to reduce AD risk.

The Fully Understanding Eating and Lifestyle Behaviors (FUEL) trial: Protocol for a cohort study harnessing digital health tools to phenotype dietary non-adherence behaviors during lifestyle intervention

Objective

Lifestyle intervention can produce clinically significant weight loss and reduced disease risk/severity for many individuals with overweight/obesity. Dietary lapses, instances of non-adherence to the recommended dietary goal(s) in lifestyle intervention, are associated with less weight loss and higher energy intake. There are distinct "types" of dietary lapse (e.g., eating an off-plan food, eating a larger portion), and behavioral, psychosocial, and contextual mechanisms may differ across dietary lapse types. Some lapse types also appear to impact weight more than others. Elucidating clear lapse types thus has potential for understanding and improving adherence to lifestyle intervention.

Methods

This 18-month observational cohort study will use real-time digital assessment tools within a multi-level factor analysis framework to uncover "lapse phenotypes" and understand their impact on clinical outcomes. Adults with overweight/obesity (n = 150) will participate in a 12-month online lifestyle intervention and 6-month weight loss maintenance period. Participants will complete 14-day lapse phenotyping assessment periods at baseline, 3, 6, 12, and 18 months in which smartphone surveys, wearable devices, and geolocation will assess dietary lapses and relevant phenotyping characteristics. Energy intake (via 24-h dietary recall) and weight will be collected at each assessment period.

Results

This trial is ongoing; data collection began on 31 October 2022 and is scheduled to complete by February 2027.

Conclusion

Results will inform novel precision tools to improve dietary adherence in lifestyle intervention, and support updated theoretical models of adherence behavior. Additionally, these phenotyping methods can likely be leveraged to better understand non-adherence to other health behavior interventions.

Trial Registration

This study was prospectively registered https://clinicaltrials.gov/study/NCT05562427.

Perceptions of Using Instant Messaging Apps for Alcohol Reduction Intervention Among University Student Drinkers: Semistructured Interview Study With Chinese University Students in Hong Kong

BACKGROUND

Mobile instant messaging (IM) apps (eg, WhatsApp and WeChat) have been widely used by the general population and are more interactive than text-based programs (SMS text messaging) to modify unhealthy lifestyles. Little is known about IM app use for health promotion, including alcohol reduction for university students.

OBJECTIVE

This study aims to explore university student drinkers' perceptions of using IM apps for alcohol reduction as they had high alcohol exposure (eg, drinking invitations from peers and alcohol promotion on campus) and the proportion of IM app use in Hong Kong.

METHODS

A qualitative study was conducted with 20 Hong Kong Chinese university students (current drinkers) with Alcohol Use Disorder Identification test scores of ≥8 recruited using purposive sampling. Semistructured individual interviews were conducted from September to October 2019. Interview questions focused on drinking behaviors, quitting history, opinions toward IM app use as an intervention tool, perceived usefulness of IM apps for alcohol reduction, and opinions on the content and design of IM apps for alcohol reduction. Each interview lasted approximately 1 hour. All interviews were audio-taped and transcribed verbatim. Two researchers independently analyzed the transcripts using thematic analysis with an additional investigator to verify the consistency of the coding.

RESULTS

Participants considered IM apps a feasible and acceptable platform for alcohol reduction intervention. They preferred to receive IMs based on personalized problem-solving and drinking consequences with credible sources. Other perceived important components of instant messages included providing psychosocial support in time and setting goals with participants to reduce drinking. They further provided suggestions on the designs of IM interventions, in which they preferred simple and concise messages, chat styles based on participants' preferences (eg, adding personalized emojis and stickers in the chat), and peers as counselors.

CONCLUSIONS

Qualitative interviews with Chinese university student drinkers showed high acceptability, engagement, and perceived utility of IM apps for alcohol reduction intervention. IM intervention can be an alternative for alcohol reduction intervention apart from traditional text-based programs. The study has implications for developing the IM intervention for other unhealthy behaviors and highlights important topics that warrant future research, including substance use and physical inactivity.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04025151; https://clinicaltrials.gov/ct2/show/NCT04025151?term=NCT04025151.

Systematic Review of Health Promotion Frameworks Focused on Health in the Postpartum Period

OBJECTIVE

To systematically review the scope and development of frameworks to promote health during the postpartum period.

DATA SOURCES

We searched PubMed, CINAHL, and American Psychological Association PsycInfo during May 2021.

STUDY SELECTION

We included English-language, peer-reviewed articles focused on frameworks for health promotion in the postpartum period. We placed no time limit on publication date. Our search resulted in 2,355 articles after we removed duplicates. After excluding articles based on titles and abstracts, we conducted full-text reviews of 23 articles. Three articles met inclusion criteria and addressed the following frameworks: Integrated Perinatal Health Framework, Perinatal Maternal Health Promotion Model, and Maternal Self-Care Framework.

DATA EXTRACTION

We extracted data into analytic tables that included categories for the scope, such as time frame, and criteria for the level of development of the frameworks, including the origins, concept definitions and theoretical linkages among concepts, and evidence of application in research or practice.

DATA SYNTHESIS

The three frameworks described in the articles included in our review covered various periods, including the reproductive life span, the first year after birth, and the first 6 weeks after birth. Overall, the frameworks were comprehensive. Most key concepts in the frameworks were defined, and some degree of relationships linking concepts was specified. Empirical referents were provided for most but not all concepts in the frameworks. Developers of the three frameworks elaborated on application in practice or health services, but only the developers of the Maternal Self-Care Framework indicated how their framework might be used in research. The Integrated Perinatal Health Framework and Maternal Self-Care Framework were partially derived from existing general theories; the methods used to develop the Perinatal Maternal Health Promotion Model were less clear.

CONCLUSION

The frameworks met most criteria and together provided a comprehensive strategy for health promotion during the postpartum period. Elaboration of the frameworks for application in research is needed.

Effectiveness of a Text-Based Gamification Intervention to Improve Physical Activity Among Postpartum Individuals With Hypertensive Disorders of Pregnancy: A Randomized Clinical Trial

Importance

Hypertensive disorders of pregnancy are associated with increased risk of cardiovascular disease, yet few interventions have targeted this population to decrease long-term risk.

Objective

To determine whether a digital health intervention improves physical activity in postpartum individuals with hypertensive disorders of pregnancy.

Design, Setting, and Participants

This 12-week randomized clinical trial enrolled postpartum individuals who delivered at the University of Pennsylvania and had a hypertensive disorder of pregnancy between October 2019 and June 2020. Analysis was intention to treat.

Interventions

All participants received a wearable activity tracker, established a baseline step count, selected a step goal greater than baseline, and were randomly assigned to control or intervention. Participants in the control arm received daily feedback on goal attainment. Participants in the intervention arm were placed on virtual teams and enrolled in a game with points and levels for daily step goal achievement and informed by principles of behavioral economics.

Main Outcomes and Measures

The primary outcome was change in mean daily step count from baseline to 12-week follow-up. Secondary outcome was proportion of participant-days that step goal was achieved.

Results

A total of 127 participants were randomized (64 in the control group and 63 in the intervention group) and were enrolled a mean of 7.9 weeks post partum. Participants had a mean (SD) age of 32.3 (5.6) years, 70 (55.1%) were Black, and 52 (41.9%) had Medicaid insurance. The mean (SD) baseline step count was similar in the control and intervention arms (6042 [2270] vs 6175 [1920] steps, respectively). After adjustment for baseline steps and calendar month, participants in the intervention arm had a significantly greater increase in mean daily step steps from baseline compared with the control arm (647 steps; 95% CI, 169-1124 steps; P = .009). Compared with the control arm, participants in the intervention arm achieved their steps goals on a greater proportion of participant-days during the intervention period (0.47 vs 0.38; adjusted difference 0.11; 95% CI, 0.04-0.19; P = .003).

Conclusions and Relevance

In this study, a digital health intervention using remote monitoring, gamification, and social incentives among postpartum individuals at elevated cardiovascular risk significantly increased physical activity throughout 12 weeks.

Trial Registration

ClinicalTrials.gov Identifier: NCT03311230.

Mediation role of patient engagement on the association between health literacy and self-care behaviours in individuals with type 2 diabetes

AIM

This study examined the relationship between health literacy and self-care behaviours among individuals with type 2 diabetes and whether the association is mediated by patient engagement.

METHODS

This cross-sectional study was conducted between November 2019 and September 2020. The sample consisted of 218 participants with type 2 diabetes, older than 18 years old, applying to two endocrine outpatient clinics in Turkey. Multiple regression analyses were performed to identify the relationship between health literacy and self-care behaviours. The Sobel test method was used to examine the mediation role of patient engagement.

RESULTS

Sample characteristics included mean age of 53.7 years, 57.3% were female and the mean A1C was 7.8%. The regression equation analyses demonstrated that health literacy (β = 0.219, P < 0.05) and patient engagement (β = 2.844, P < 0.05) significantly predicted diabetes self-care behaviours. Patient engagement served a mediational role in the association of health literacy and self-care behaviours (z value = 2.049, P < 0.02).

CONCLUSION

Given the relationship between health literacy and diabetes self-care behaviours, the patient engagement concept presented a practical insight into the applicability of health-related information. Clinicians are recommended to consider patients' health literacy and engagement levels while planning customized interventions to facilitate diabetes management.

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.

Oncologist phenotypes and associations with response to a machine learning-based intervention to increase advance care planning: Secondary analysis of a randomized clinical trial

BACKGROUND

While health systems have implemented multifaceted interventions to improve physician and patient communication in serious illnesses such as cancer, clinicians vary in their response to these initiatives. In this secondary analysis of a randomized trial, we identified phenotypes of oncology clinicians based on practice pattern and demographic data, then evaluated associations between such phenotypes and response to a machine learning (ML)-based intervention to prompt earlier advance care planning (ACP) for patients with cancer.

METHODS AND FINDINGS

Between June and November 2019, we conducted a pragmatic randomized controlled trial testing the impact of text message prompts to 78 oncology clinicians at 9 oncology practices to perform ACP conversations among patients with cancer at high risk of 180-day mortality, identified using a ML prognostic algorithm. All practices began in the pre-intervention group, which received weekly emails about ACP performance only; practices were sequentially randomized to receive the intervention at 4-week intervals in a stepped-wedge design. We used latent profile analysis (LPA) to identify oncologist phenotypes based on 11 baseline demographic and practice pattern variables identified using EHR and internal administrative sources. Difference-in-differences analyses assessed associations between oncologist phenotype and the outcome of change in ACP conversation rate, before and during the intervention period. Primary analyses were adjusted for patients' sex, age, race, insurance status, marital status, and Charlson comorbidity index. The sample consisted of 2695 patients with a mean age of 64.9 years, of whom 72% were White, 20% were Black, and 52% were male. 78 oncology clinicians (42 oncologists, 36 advanced practice providers) were included. Three oncologist phenotypes were identified: Class 1 (n = 9) composed primarily of high-volume generalist oncologists, Class 2 (n = 5) comprised primarily of low-volume specialist oncologists; and 3) Class 3 (n = 28), composed primarily of high-volume specialist oncologists. Compared with class 1 and class 3, class 2 had lower mean clinic days per week (1.6 vs 2.5 [class 3] vs 4.4 [class 1]) a higher percentage of new patients per week (35% vs 21% vs 18%), higher baseline ACP rates (3.9% vs 1.6% vs 0.8%), and lower baseline rates of chemotherapy within 14 days of death (1.4% vs 6.5% vs 7.1%). Overall, ACP rates were 3.6% in the pre-intervention wedges and 15.2% in intervention wedges (11.6 percentage-point difference). Compared to class 3, oncologists in class 1 (adjusted percentage-point difference-in-differences 3.6, 95% CI 1.0 to 6.1, p = 0.006) and class 2 (adjusted percentage-point difference-in-differences 12.3, 95% confidence interval [CI] 4.3 to 20.3, p = 0.003) had greater response to the intervention.

CONCLUSIONS

Patient volume and time availability may be associated with oncologists' response to interventions to increase ACP. Future interventions to prompt ACP should prioritize making time available for such conversations between oncologists and their patients.

Supervised Exercise Therapy is Effective for Patients With Intermittent Claudication Regardless of Psychological Constructs

OBJECTIVE

According to current guidelines, supervised exercise therapy (SET) is the treatment of choice for intermittent claudication (IC). Little is known about the potential consequences of psychological factors on the effectiveness of treatment. The aim of this study was to determine possible associations between a set of psychological constructs and treatment outcomes, and to investigate whether self efficacy increased after SET.

METHODS

This was a substudy of the ELECT Registry, a multicentre Dutch prospective cohort study in patients with IC receiving primary SET. A complete set of validated questionnaires scoring extraversion, neuroticism, conscientiousness, anxiety, depression, self control, optimism, and self efficacy was obtained in 237 patients (median age 69 years, 40% female). Anxiety and depression were dichotomised using established cutoff scores, whereas other scores were analysed as continuous measures. Multiple linear regression analyses determined possible associations between these independent variables and maximum and functional walking distances (MWD and FWD, respectively), Six Minute Walk Test (6MWT), and VascuQol-6 (dependent variables). Self efficacy during 12 months of SET was analysed using a linear mixed model.

RESULTS

Neuroticism and anxiety were associated with lower overall VascuQol-6 scores (estimate -1.35 points [standard error (SE) 0.57; p = .018] and -1.98 points [SE 0.87, p = .023], respectively). Optimism and self efficacy demonstrated higher overall 6MWT (5.92 m [SE 2.34; p = .012] and 1.35 m [SE 0.42; p = .001], respectively). Self control was associated with lower overall log MWD (-0.02 [SE 0.01; p = .038] and log FWD (-0.02 [SE 0.01; p = .080), whereas self efficacy had a higher overall log MWD (0.01 [SE 0.003; p = .009]) and log FWD (0.01 [SE 0.003; p = .011]). Depressive patients with IC demonstrated a greater improvement in 6MWT during follow up (17.56 m [SE 8.67; p = .044]), but this small effect was not confirmed in sensitivity analysis. Self efficacy did not increase during follow up (0.12% [SE 0.49; p = .080]).

CONCLUSIONS

The beneficial effects of SET occur regardless of the psychological constructs, supporting current guidelines recommending a SET first strategy in each patient with IC.

Mobile Health and Telehealth Interventions to Increase Physical Activity in Adolescents with Obesity: a Promising Approach to Engaging a Hard-to-Reach Population

PURPOSE OF REVIEW

Adolescence represents a critical time to set habits for long-term health, yet adequate rates of physical activity are uncommon in this age group. Mobile technology use, however, is ubiquitous. We review advantages and challenges posed by mobile health (mHealth) and telehealth-based physical activity interventions aimed at adolescents.

RECENT FINDINGS

Mobile Health (mHealth) and telehealth interventions to increase physical activity in adolescents include use of wearable activity trackers, text messages or apps, and video visits with exercise specialists. Definitions and goals for physical activity differ across interventions, and methods of activity measurement also vary. User engagement is often poor, if tracked at all. No identified studies included use of behavioral economics-informed engagement strategies. Intervention designers must plan for ways to maximize engagement and to reliably measure the intended outcome. Although mHealth and telehealth interventions have advantages such as scalability and acceptability, potential pitfalls must be addressed before widespread implementation.

Self-regulatory behaviour change techniques in interventions to promote healthy eating, physical activity, or weight loss: a meta-review

Poor quality diet, physical inactivity, and obesity are prevalent, covariant risk factors for chronic disease, suggesting that behaviour change techniques (BCTs) that effectively change one risk factor might also improve the others. To examine that question, registered meta-review CRD42019128444 synthesised evidence from 30 meta-analyses published between 2007 and 2017 aggregating data from 409,185 participants to evaluate whether inclusion of 14 self-regulatory BCTs in health promotion interventions was associated with greater improvements in outcomes. Study populations and review quality varied, with minimal overlap among summarised studies. AMSTAR-2 ratings averaged 37.31% (SD = 16.21%; range 8.33-75%). All BCTs were examined in at least one meta-analysis; goal setting and self-monitoring were evaluated in 18 and 20 reviews, respectively. No BCT was consistently related to improved outcomes. Although results might indicate that BCTs fail to benefit diet and activity self-regulation, we suggest that a Type 3 error occurred, whereby the meta-analytic research design implemented to analyse effects of multi-component intervention trials designed for a different purpose was mismatched to the question of how BCTs affect health outcomes. An understanding of independent and interactive effects of individual BCTs on different health outcomes and populations is needed urgently to ground a cumulative science of behaviour change.

Weight-Related Information Avoidance Prospectively Predicts Poorer Self-Monitoring and Engagement in a Behavioral Weight Loss Intervention

BACKGROUND

Self-monitoring is a key component of behavioral weight loss (BWL) interventions. Past research suggests that individuals may avoid self-monitoring in certain contexts (e.g., skipping self-weighing after higher-than-usual calorie intake). However, no studies have attempted to quantify individuals' inclination to avoid information about their weight control ("weight-related information avoidance"; WIA) or prospectively examined its implications for treatment engagement and outcomes in BWL programs.

PURPOSE

Characterize WIA using a validated questionnaire among adults enrolled in BWL treatment and examine whether WIA prospectively predicts self-monitoring adherence, session attendance, treatment discontinuation, or weight loss.

METHODS

Participants (N = 87; MBMI = 34.9 kg/m2, 83% female) completed a measure of WIA prior to starting a 12 week, group-based BWL intervention. Participants were given digital self-monitoring tools and instructed to self-monitor their food intake daily, physical activity daily, and body weight weekly (Weeks 1-10) and then daily (Weeks 11-12). Session attendance and treatment discontinuation were recorded. Weight was measured in-clinic pretreatment and posttreatment.

RESULTS

While mean WIA was low (M = 2.23, standard deviation [SD] = 0.95; potential scale range: 1-7), greater WIA predicted poorer attendance (r = -.23; p = .03) and poorer self-monitoring of physical activity (r = -.28; p = .009) and body weight (r = -.32; p = .003). WIA did not predict food monitoring (p = .08), treatment discontinuation (p = .09), or 12 week weight loss (p = .91).

CONCLUSIONS

Greater WIA, as assessed via a brief questionnaire, may place individuals at risk for poorer self-monitoring and treatment engagement during BWL. Further research on the implications of WIA in the context of weight management is warranted, including evaluation of correlates, moderators, and mechanisms of action of WIA.

CLINICAL TRIAL REGISTRATION

NCT03337139.

Incorporating emotions into clinical decision-making solutions

Health and emotions are inexorably connected. Yet there is still little emphasis on emotions in many clinical decision-making tools and interventions. Instead, existing solutions have tended to target cognition - how people comprehend and act on information about health and disease. While clear thinking contributes to better choices, a potential consequence of heavily targeting cognition is an under-emphasis on emotions - a tendency to work on improving how people think about health care choices without addressing how they feel about them. Several solutions can help clinicians and behavioral scientists address these dynamics: critically evaluating current decision-making conceptual frameworks and strategies, searching for areas where emotions may play a role and where they may have been overlooked; and filling any identified gaps by drawing on insights from affective science. Clinical decision-making solutions should address how individuals feel, not just how they think.

Prognosticating Outcomes and Nudging Decisions with Electronic Records in the Intensive Care Unit Trial Protocol

Expert recommendations to discuss prognosis and offer palliative options for critically ill patients at high risk of death are variably heeded by intensive care unit (ICU) clinicians. How to best promote such communication to avoid potentially unwanted aggressive care is unknown. The PONDER-ICU (Prognosticating Outcomes and Nudging Decisions with Electronic Records in the ICU) study is a 33-month pragmatic, stepped-wedge cluster randomized trial testing the effectiveness of two electronic health record (EHR) interventions designed to increase ICU clinicians' engagement of critically ill patients at high risk of death and their caregivers in discussions about all treatment options, including care focused on comfort. We hypothesize that the quality of care and patient-centered outcomes can be improved by requiring ICU clinicians to document a functional prognostic estimate (intervention A) and/or to provide justification if they have not offered patients the option of comfort-focused care (intervention B). The trial enrolls all adult patients admitted to 17 ICUs in 10 hospitals in North Carolina with a preexisting life-limiting illness and acute respiratory failure requiring continuous mechanical ventilation for at least 48 hours. Eligibility is determined using a validated algorithm in the EHR. The sequence in which hospitals transition from usual care (control), to intervention A or B and then to combined interventions A + B, is randomly assigned. The primary outcome is hospital length of stay. Secondary outcomes include other clinical outcomes, palliative care process measures, and nurse-assessed quality of dying and death.Clinical trial registered with clinicaltrials.gov (NCT03139838).

Identifying behavioral types of dietary lapse from a mobile weight loss program: Preliminary investigation from a secondary data analysis

Success in behavioral weight loss (BWL) programs depends on adherence to the recommended diet to reduce caloric intake. Dietary lapses (i.e., deviations from the BWL diet) occur frequently and can adversely affect weight loss outcomes. Research indicates that lapse behavior is heterogenous; there are many eating behaviors that could constitute a dietary lapse, but they are rarely studied as distinct contributors to weight outcomes. This secondary analysis aims to evaluate six behavioral lapse types during a 10-week mobile BWL program (eating a large portion, eating when not intended, eating an off-plan food, planned lapse, being unaware of caloric content, and endorsing multiple types of lapse). Associations between weekly behavioral lapse type frequency and weekly weight loss were investigated, and predictive contextual characteristics (psychological, behavioral, and environmental triggers for lapse) and individual difference (e.g., age, gender) factors were examined across lapse types. Participants (N = 121) with overweight/obesity (M_BMI = 34.51; 84.3% female; 69.4% White) used a mobile BWL program for 10 weeks, self-weighed weekly using Bluetooth scales, completed daily ecological momentary assessment of lapse behavior and contextual characteristics, and completed a baseline demographics questionnaire. Linear mixed models revealed significant negative associations between unplanned lapses and percent weight loss. Unplanned lapses from eating a large portion, eating when not intended, and having multiple "types" were significantly negatively associated with weekly percent weight loss. A lasso regression showed that behavioral lapse types share many similar stable factors, with other factors being unique to specific lapse types. Results add to the prior literature on lapses and weight loss in BWL and provide preliminary evidence that behavioral lapse types could aid in understanding adherence behavior and developing precision medicine tools to improve dietary adherence.

Pediatrician Delivered Smoking Cessation Messages for Parents: A Latent Class Approach to Behavioral Phenotyping

OBJECTIVE

Message framing can be leveraged to motivate adult smokers to quit, but its value for parents in pediatric settings is unknown. Understanding parents' preferences for smoking cessation messages may help clinicians tailor interventions to increase quitting.

METHODS

We conducted a discrete choice experiment in which parent smokers of pediatric patients rated the relative importance of 26 messages designed to increase smoking cessation treatment. Messages varied on who the message featured (child, parent, and family), whether the message was gain- or loss-framed (emphasizing benefits of engaging or costs of failing to engage in treatment), and the specific outcome included (eg, general health, cancer, respiratory illnesses, and financial impact). Participants included 180 parent smokers at 4 pediatric primary care sites. We used latent class analysis of message ratings to identify groups of parents with similar preferences. Multinomial logistic regression described child and parent characteristics associated with group membership.

RESULTS

We identified 3 groups of parents with similar preferences for messages: Group 1 prioritized the impact of smoking on the child (n = 92, 51%), Group 2 favored gain-framed messages (n = 63, 35%), and Group 3 preferred messages emphasizing the financial impact of smoking (n = 25, 14%). Parents in Group 2 were more likely to have limited health literacy and have a child over age 6 and with asthma, compared to Group 1.

CONCLUSIONS

We identified 3 groups of parent smokers with different message preferences. This work may inform testing of tailored smoking cessation messages to different parent groups, a form of behavioral phenotyping supporting motivational precision medicine.

Patient Interaction Phenotypes With an Automated Remote Hypertension Monitoring Program and Their Association With Blood Pressure Control: Observational Study

Background

Automated texting platforms have emerged as a tool to facilitate communication between patients and health care providers with variable effects on achieving target blood pressure (BP). Understanding differences in the way patients interact with these communication platforms can inform their use and design for hypertension management.

Objective

Our primary aim was to explore the unique phenotypes of patient interactions with an automated text messaging platform for BP monitoring. Our secondary aim was to estimate associations between interaction phenotypes and BP control.

Methods

This study was a secondary analysis of data from a randomized controlled trial for adults with poorly controlled hypertension. A total of 201 patients with established primary care were assigned to the automated texting platform; messages exchanged throughout the 4-month program were analyzed. We used the k-means clustering algorithm to characterize two different interaction phenotypes: program conformity and engagement style. First, we identified unique clusters signifying differences in program conformity based on the frequency over time of error alerts, which were generated to patients when they deviated from the requested text message format (eg, ###/## for BP). Second, we explored overall engagement styles, defined by error alerts and responsiveness to text prompts, unprompted messages, and word count averages. Finally, we applied the chi-square test to identify associations between each interaction phenotype and achieving the target BP.

Results

We observed 3 categories of program conformity based on their frequency of error alerts: those who immediately and consistently submitted texts without system errors (perfect users, 51/201), those who did so after an initial learning period (adaptive users, 66/201), and those who consistently submitted messages generating errors to the platform (nonadaptive users, 38/201). Next, we observed 3 categories of engagement style: the enthusiast, who tended to submit unprompted messages with high word counts (17/155); the student, who inconsistently engaged (35/155); and the minimalist, who engaged only when prompted (103/155). Of all 6 phenotypes, we observed a statistically significant association between patients demonstrating the minimalist communication style (high adherence, few unprompted messages, limited information sharing) and achieving target BP (P<.001).

Conclusions

We identified unique interaction phenotypes among patients engaging with an automated text message platform for remote BP monitoring. Only the minimalist communication style was associated with achieving target BP. Identifying and understanding interaction phenotypes may be useful for tailoring future automated texting interactions and designing future interventions to achieve better BP control.

A systematic review of recruitment strategies and behaviour change techniques in group-based diabetes prevention programmes focusing on uptake and retention

BACKGROUND

Many countries worldwide have developed diabetes prevention programmes (DPPs) that involve lifestyle modification. Research has shown that uptake and retention of DPPs are important and by exploring recruitment strategies and behaviour change techniques (BCTs) used, factors that are most effective in promoting uptake and retention can be identified.

OBJECTIVES

This review aims to identify recruitment strategies of group-based DPPs that are associated with high uptake and common BCTs associated with high retention.

METHODS

Papers were identified with a systematic literature search. Programmes that were predominantly group-based and involved lifestyle modification and in which uptake and/or retention could be determined, were included. Intervention details were extracted, recruitment strategies and BCTs identified, and response, uptake and retention rates were calculated.

RESULTS

A range of recruitment strategies were used making it difficult to discern associations with uptake rates. For BCTs, all programmes used a credible source, 81% used instruction on how to perform a behaviour and 71% used goal setting (behaviour). BCTs more commonly found in high retention programmes included problem-solving, demonstrating the behaviour, using behavioural practice and reducing negative emotions.

CONCLUSIONS

Recommendations include that DPPs incorporate BCTs like problem-solving and demonstrating the behaviour to maximise retention.

A Personalized eHealth Intervention for Lifestyle Changes in Patients With Cardiovascular Disease: Randomized Controlled Trial

Background

Behavior change methods involving new ambulatory technologies may improve lifestyle and cardiovascular disease outcomes.

Objective

This study aimed to provide proof-of-concept analyses of an intervention aiming to increase (1) behavioral flexibility, (2) lifestyle change, and (3) quality of life. The feasibility and patient acceptance of the intervention were also evaluated.

Methods

Patients with cardiovascular disease (N=149; mean age 63.57, SD 8.30 years; 50/149, 33.5% women) were recruited in the Do Cardiac Health Advanced New Generation Ecosystem (Do CHANGE) trial and randomized to the Do CHANGE intervention or care as usual (CAU). The intervention involved a 3-month behavioral program in combination with ecological momentary assessment and intervention technologies.

Results

The intervention was perceived to be feasible and useful. A significant increase in lifestyle scores over time was found for both groups (F_2,146.6=9.99; P<.001), which was similar for CAU and the intervention group (F_1,149.9=0.09; P=.77). Quality of life improved more in the intervention group (mean 1.11, SD 0.11) than CAU (mean −1.47, SD 0.11) immediately following the intervention (3 months), but this benefit was not sustained at the 6-month follow-up (interaction: P=.02). No significant treatment effects were observed for behavioral flexibility (F_1,149.0=0.48; P=.07).

Conclusions

The Do CHANGE 1 intervention was perceived as useful and easy to use. However, no long-term treatment effects were found on the outcome measures. More research is warranted to examine which components of behavioral interventions are effective in producing long-term behavior change.

Trial Registration

ClinicalTrials.gov NCT02946281; https://www.clinicaltrials.gov/ct2/show/NCT02946281

Phenotyping physician practice patterns and associations with response to a nudge in the electronic health record for influenza vaccination: A quasi-experimental study

BACKGROUND

Health systems routinely implement changes to the design of electronic health records (EHRs). Physician behavior may vary in response and methods to identify this variation could help to inform future interventions. The objective of this study was to phenotype primary care physician practice patterns and evaluate associations with response to an EHR nudge for influenza vaccination.

METHODS AND FINDINGS

During the 2016-2017 influenza season, 3 primary care practices at Penn Medicine implemented an active choice intervention in the EHR that prompted medical assistants to template influenza vaccination orders for physicians to review during the visit. We used latent class analysis to identify physician phenotypes based on 9 demographic, training, and practice pattern variables, which were obtained from the EHR and publicly available sources. A quasi-experimental approach was used to evaluate response to the intervention relative to control practices over time in each of the physician phenotype groups. For each physician latent class, a generalized linear model with logit link was fit to the binary outcome of influenza vaccination at the patient visit level. The sample comprised 45,410 patients with a mean (SD) age of 58.7 (16.3) years, 67.1% were white, and 22.1% were black. The sample comprised 56 physicians with mean (SD) of 24.6 (10.2) years of experience and 53.6% were male. The model segmented physicians into groups that had higher (n = 41) and lower (n = 15) clinical workloads. Physicians in the higher clinical workload group had a mean (SD) of 818.8 (429.1) patient encounters, 11.6 (4.7) patient appointments per day, and 4.0 (1.1) days per week in clinic. Physicians in the lower clinical workload group had a mean (SD) of 343.7 (129.0) patient encounters, 8.0 (2.8) patient appointments per day, and 3.1 (1.2) days per week in clinic. Among the higher clinical workload group, the EHR nudge was associated with a significant increase in influenza vaccination (adjusted difference-in-difference in percentage points, 7.9; 95% CI, 0.4-9.0; P = .01). Among the lower clinical workload group, the EHR nudge was not associated with a significant difference in influenza vaccination rates (adjusted difference-in-difference in percentage points, -1.0; 95% CI, -5.3-5.8; P = .90).

CONCLUSIONS

A model-based approach categorized physician practice patterns into higher and lower clinical workload groups. The higher clinical workload group was associated with a significant response to an EHR nudge for influenza vaccination.

Reach Out Emergency Department: Partnering With an Economically Disadvantaged Community in the Development of a Text-Messaging Intervention to Address High Blood Pressure

Background. Hypertension affects nearly 30% of the U.S. adult population. Due to the ubiquitous nature of mobile phone usage, text messaging offers a promising platform for interventions to assist in the management of chronic diseases including hypertension, including among populations that are historically underserved. We present the intervention development of Reach Out, a health behavior theory-based, mobile health intervention to reduce blood pressure among hypertensive patients evaluated in a safety net emergency department primarily caring for African Americans. Aims. To describe the process of designing and refining text messages currently being implemented in the Reach Out randomized controlled trial. Method. We used a five-step framework to develop the text messages used in Reach Out. These steps included literature review and community formative research, conception of a community-centered behavioral theoretical framework, draft of evidence-based text messages, community review, and revision based on community feedback and finalization. Results. The Reach Out development process drew from pertinent evidence that, combined with community feedback, guided the development of a community-centered health behavior theory framework that led to development of text messages. A total of 333 generic and segmented messages were created. Messages address dietary choices, physical activity, hypertension medication adherence, and blood pressure monitoring. Discussion. Our five-step framework is intended to inform future text-messaging-based health promotion efforts to address health issues in vulnerable populations. Conclusion. Text message-based health promotion programs should be developed in partnership with the local community to ensure acceptability and relevance.

Precision Medicine in Lifestyle Medicine: The Way of the Future?

Precision medicine has captured the imagination of the medical community with visions of therapies precisely targeted to the specific individual's genetic, biological, social, and environmental profile. However, in practice it has become synonymous with genomic medicine. As such its successes have been limited, with poor predictive or clinical value for the majority of people. It adds little to lifestyle medicine, other than in establishing why a healthy lifestyle is effective in combatting chronic disease. The challenge of lifestyle medicine remains getting people to actually adopt, sustain, and naturalize a healthy lifestyle, and this will require an approach that treats the patient as a person with individual needs and providing them with suitable types of support. The future of lifestyle medicine is holistic and person-centered rather than technological.

Depressive symptom severity as a predictor of attendance in the HOME behavioral weight loss trial

OBJECTIVE

We examined whether total depressive symptoms and symptom clusters predicted behavioral weight loss attendance among economically disadvantaged adults in a randomized controlled trial.

METHODS

150 adults with obesity were randomized to 12 months of in-person, video conference, or enhanced usual care weight loss groups. We categorized percent session attendance in the intervention arms into three levels: no attendance, poorer attendance, and better attendance.

RESULTS

Higher baseline Patient Health Questionnaire-8 (PHQ-8) score was associated with a greater odds of being in the poorer versus better attendance group (OR = 1.94, 95% CI: 1.02-3.69, p = .04). A similar relationship between PHQ-8 score and odds of being in the no attendance versus better attendance group was observed but was not statistically significant (OR = 1.63, 95% CI: 0.94-2.81, p = .08). Both cognitive/affective and somatic clusters contributed to the depressive symptoms-attendance relationships.

CONCLUSION

Greater depressive symptoms at the start of a behavioral weight loss program may predict poorer subsequent session attendance. Screening for and addressing depression may improve intervention uptake. ClinicalTrials.gov Identifier: NCT02057952.

Communication practices for delivering health behaviour change conversations in primary care: a systematic review and thematic synthesis

BACKGROUND

Clinical guidelines exhort clinicians to encourage patients to improve their health behaviours. However, most offer little support on how to have these conversations in practice. Clinicians fear that health behaviour change talk will create interactional difficulties and discomfort for both clinician and patient. This review aims to identify how healthcare professionals can best communicate with patients about health behaviour change (HBC).

METHODS

We included studies which used conversation analysis or discourse analysis to study recorded interactions between healthcare professionals and patients. We followed an aggregative thematic synthesis approach. This involved line-by-line coding of the results and discussion sections of included studies, and the inductive development and hierarchical grouping of descriptive themes. Top-level themes were organised to reflect their conversational positioning.

RESULTS

Of the 17,562 studies identified through systematic searching, ten papers were included. Analysis resulted in 10 top-level descriptive themes grouped into three domains: initiating; carrying out; and closing health behaviour change talk. Of three methods of initiation, two facilitated further discussion, and one was associated with outright resistance. Of two methods of conducting behaviour change talk, one was associated with only minimal patient responses. One way of closing was identified, and patients did not seem to respond to this positively. Results demonstrated a series of specific conversational practices which clinicians use when talking about HBC, and how patients respond to these. Our results largely complemented clinical guidelines, providing further detail on how they can best be delivered in practice. However, one recommended practice - linking a patient's health concerns and their health behaviours - was shown to receive variable responses and to often generate resistance displays.

CONCLUSIONS

Health behaviour change talk is smoothly initiated, conducted, and terminated by clinicians and this rarely causes interactional difficulty. However, initiating conversations by linking a person's current health concern with their health behaviour can lead to resistance to advice, while other strategies such as capitalising on patient initiated discussions, or collaborating through question-answer sequences, may be well received.

Transforming Mental Health Delivery Through Behavioral Economics and Implementation Science: Protocol for Three Exploratory Projects

BACKGROUND

Efficacious psychiatric treatments are not consistently deployed in community practice, and clinical outcomes are attenuated compared with those achieved in clinical trials. A major focus for mental health services research is to develop effective and cost-effective strategies that increase the use of evidence-based assessment, prevention, and treatment approaches in community settings.

OBJECTIVE

The goal of this program of research is to apply insights from behavioral economics and participatory design to advance the science and practice of implementing evidence-based practice (EBP) for individuals with psychiatric disorders across the life span.

METHODS

Project 1 (Assisting Depressed Adults in Primary care Treatment [ADAPT]) is patient-focused and leverages decision-making heuristics to compare ways to incentivize adherence to antidepressant medications in the first 6 weeks of treatment among adults newly diagnosed with depression. Project 2 (App for Strengthening Services In Specialized Therapeutic Support [ASSISTS]) is provider-focused and utilizes normative pressure and social status to increase data collection among community mental health workers treating children with autism. Project 3 (Motivating Outpatient Therapists to Implement: Valuing a Team Effort [MOTIVATE]) explores how participatory design can be used to design organizational-level implementation strategies to increase clinician use of EBPs. The projects are supported by a Methods Core that provides expertise in implementation science, behavioral economics, participatory design, measurement, and associated statistical approaches.

RESULTS

Enrollment for project ADAPT started in 2018; results are expected in 2020. Enrollment for project ASSISTS will begin in 2019; results are expected in 2021. Enrollment for project MOTIVATE started in 2018; results are expected in 2019. Data collection had begun for ADAPT and MOTIVATE when this protocol was submitted.

CONCLUSIONS

This research will advance the science of implementation through efforts to improve implementation strategy design, measurement, and statistical methods. First, we will test and refine approaches to collaboratively design implementation strategies with stakeholders (eg, discrete choice experiments and innovation tournaments). Second, we will refine the measurement of mechanisms related to heuristics used in decision making. Third, we will develop new ways to test mechanisms in multilevel implementation trials. This trifecta, coupled with findings from our 3 exploratory projects, will lead to improvements in our knowledge of what causes successful implementation, what variables moderate and mediate the effects of those causal factors, and how best to leverage this knowledge to increase the quality of care for people with psychiatric disorders.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03441399; https://www.clinicaltrials.gov/ct2/show/NCT03441399 (Archived by WebCite at http://www.webcitation.org/74dRbonBD).

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/12121.

Exploring Community Smokers' Perspectives for Developing a Chat-Based Smoking Cessation Intervention Delivered Through Mobile Instant Messaging: Qualitative Study

Background

Advances in mobile communication technologies provide a promising avenue for the delivery of tobacco dependence treatment. Although mobile instant messaging (IM) apps (eg, WhatsApp, Facebook messenger, and WeChat) are an inexpensive and widely used communication tool, evidence on its use for promoting health behavior, including smoking cessation, is scarce.

Objective

This study aims to explore the perception of using mobile IM as a modality to deliver a proposed chat intervention for smoking cessation in community smokers in Hong Kong, where the proportion of smartphone use is among the highest in the world.

Methods

We conducted 5 focus group, semistructured qualitative interviews on a purposive sample of 15 male and 6 female current cigarette smokers (age 23-68 years) recruited from the community in Hong Kong. All interviews were audiotaped and transcribed. Two investigators independently analyzed the transcripts using thematic analyses.

Results

Participants considered mobile IM as a feasible and acceptable platform for the delivery of a supportive smoking cessation intervention. The ability to provide more personalized and adaptive behavioral support was regarded as the most valued utility of the IM–based intervention. Other perceived utilities included improved perceived psychosocial support and identification of motivator to quit. In addition, participants provided suggestions on the content and design of the intervention, which may improve the acceptability and usability of the IM–based intervention. These include avoiding health warning information, positive messaging, using former smokers as counselors, and adjusting the language style (spoken vs written) according to the recipients’ preference.

Conclusions

This qualitative study provides the first evidence that mobile IM may be an alternative mobile health platform for the delivery of a smoking cessation intervention. Furthermore, the findings inform the development of a chat-based, IM smoking cessation program being evaluated in a community trial.

Hierarchical Condition Categories for Pulmonary Diseases: Population Health Management and Policy Opportunities

Hierarchical condition categories (HCCs) are groups of diagnostic codes that are used to adjust federal payments to insurers and health systems based on differences in expected spending. Risk models built on HCCs improve on previous adjustment strategies that used demographic characteristics but did not include clinical diagnoses. Thus, accurate coding by clinicians of inpatient and outpatient encounters ensures capitated payments and reimbursements that are commensurate with predicted expenditures. Pulmonary diseases and various forms of critical illness play a significant role in this risk adjustment process both through their associated HCC codes and through interactions with other risk categories representing cardiac and psychiatric diseases. Ongoing uncertainty in federal health policy ensures a changing role for HCCs and risk-adjusted reimbursements across a variety of payment models and federal programs.