Adaptive Intervention Designs to Promote Behavioral Change in Adults: What Is the Evidence?

Innovation in the Delivery of Behavioral Health Services

Several factors motivate the need for innovation to improve the delivery of behavioral health services, including increased rates of mental health and substance use disorders, limited access to services, inconsistent use of evidence-based practices, and persistent racial and ethnic disparities. This narrative review identifies promising innovations that address these challenges, assesses empirical evidence for the effectiveness of these innovations and the extent to which they have been adopted and implemented, and suggests next steps for research. We review five categories of innovations: organizational models, including a range of novel locations for providing services and new ways of organizing services within and across sites; information and communication technologies; workforce; treatment technologies; and policy and regulatory changes. We conclude by discussing the need to strengthen and accelerate the contributions of implementation science to close the gap between the launch of innovative behavioral health services and their widespread use.

Understanding Heterogeneity in Individual Responses to Digital Lifestyle Intervention Through Self-Monitoring Adherence Trajectories in Adults With Overweight or Obesity: Secondary Analysis of a 6-Month Randomized Controlled Trial

BACKGROUND

Achieving clinically significant weight loss through lifestyle interventions for obesity management is challenging for most individuals. Improving intervention effectiveness involves early identification of intervention nonresponders and providing them with timely, tailored interventions. Early and frequent self-monitoring (SM) adherence predicts later weight loss success, making it a potential indicator for identifying nonresponders in the initial phase.

OBJECTIVE

This study aims to identify clinically meaningful participant subgroups based on longitudinal adherence to SM of diet, activity, and weight over 6 months as well as psychological predictors of participant subgroups from a self-determination theory (SDT) perspective.

METHODS

This was a secondary data analysis of a 6-month digital lifestyle intervention for adults with overweight or obesity. The participants were instructed to perform daily SM on 3 targets: diet, activity, and weight. Data from 50 participants (mean age: 53.0, SD 12.6 y) were analyzed. Group-based multitrajectory modeling was performed to identify subgroups with distinct trajectories of SM adherence across the 3 SM targets. Differences between subgroups were examined for changes in clinical outcomes (ie, body weight, hemoglobin A1c) and SDT constructs (ie, eating-related autonomous motivation and perceived competence for diet) over 6 months using linear mixed models.

RESULTS

Two distinct SM trajectory subgroups emerged: the Lower SM group (21/50, 42%), characterized by all-around low and rapidly declining SM, and the Higher SM group (29/50, 58%), characterized by moderate and declining diet and weight SM with high activity SM. Since week 2, participants in the Lower SM group exhibited significantly lower levels of diet (P=.003), activity (P=.002), and weight SM (P=.02) compared with the Higher SM group. In terms of clinical outcomes, the Higher SM group achieved a significant reduction in body weight (estimate: -6.06, SD 0.87 kg; P<.001) and hemoglobin A1c (estimate: -0.38, SD 0.11%; P=.02), whereas the Lower SM group exhibited no improvements. For SDT constructs, both groups maintained high levels of autonomous motivation for over 6 months. However, the Lower SM group experienced a significant decline in perceived competence (P=.005) compared with the Higher SM group, which maintained a high level of perceived competence throughout the intervention (P=.09).

CONCLUSIONS

The presence of the Lower SM group highlights the value of using longitudinal SM adherence trajectories as an intervention response indicator. Future adaptive trials should identify nonresponders within the initial 2 weeks based on their SM adherence and integrate intervention strategies to enhance perceived competence in diet to benefit nonresponders.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05071287; https://clinicaltrials.gov/study/NCT05071287.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1016/j.cct.2022.106845.

Physicians' and Patients' Expectations From Digital Agents for Consultations: Interview Study Among Physicians and Patients

BACKGROUND

Physicians are currently overwhelmed by administrative tasks and spend very little time in consultations with patients, which hampers health literacy, shared decision-making, and treatment adherence.

OBJECTIVE

This study aims to examine whether digital agents constructed using fast-evolving generative artificial intelligence, such as ChatGPT, have the potential to improve consultations, adherence to treatment, and health literacy. We interviewed patients and physicians to obtain their opinions about 3 digital agents-a silent digital expert, a communicative digital expert, and a digital companion (DC).

METHODS

We conducted in-depth interviews with 25 patients and 22 physicians from a purposeful sample, with the patients having a wide age range and coming from different educational backgrounds and the physicians having different medical specialties. Transcripts of the interviews were deductively coded using MAXQDA (VERBI Software GmbH) and then summarized according to code and interview before being clustered for interpretation.

RESULTS

Statements from patients and physicians were categorized according to three consultation phases: (1) silent and communicative digital experts that are part of the consultation, (2) digital experts that hand over to a DC, and (3) DCs that support patients in the period between consultations. Overall, patients and physicians were open to these forms of digital support but had reservations about all 3 agents.

CONCLUSIONS

Ultimately, we derived 9 requirements for designing digital agents to support consultations, treatment adherence, and health literacy based on the literature and our qualitative findings.

Exploring Patient Needs and Designing Concepts for Digitally Supported Health Solutions in Managing Type 2 Diabetes: Cocreation Study

BACKGROUND

Self-management of the progressive disease type 2 diabetes mellitus (T2DM) becomes part of the daily life of patients starting from the time of diagnosis. However, despite the availability of technical innovations, the uptake of digital solutions remains low. One reason that has been reported is that digital solutions often focus purely on clinical factors that may not align with the patient's perspective.

OBJECTIVE

The aim of this study was to develop digital solutions that address the needs of patients with T2DM, designed from the user's perspective. The goal was to address the patients' expressed real-world needs by having the users themselves choose the scope and format of the solutions.

METHODS

Using participatory methods, we conducted 3 cocreation workshops in collaboration with the Danish Diabetes Association, with 20 persons with T2DM and 11 stakeholders across workshops: user experience designers, researchers, and diabetes experts including a diabetes nurse. The overall structure of the 3 workshops was aligned with the 4 phases of the double diamond: initially discovering and mapping out key experienced issues, followed by a workshop on thematic mapping and definition of key concepts, and succeeded by an exploration and development of 2 prototypes. Subsequently, high-fidelity interactive prototypes were refined as part of the delivery phase, in which 7 formative usability tests were conducted.

RESULTS

The workshops mapped experiential topics over time from prediagnosis to the current state, resulting in a detailed exploration and understanding of 6 themes related to and based on the experiences of patients with T2DM: diabetes care, diabetes knowledge, glucose monitoring, diet, physical activity, and social aspects of diabetes. Two prototypes were developed by the participants to address some of their expressed needs over time related to the 6 themes: an activity-based continuous glucose monitoring app and a web-based guide to diabetes. Both prototypes emphasize periods of structured self-measurements of blood glucose to support evolving needs for self-exploration through distinct phases of learning, active use, and supporting use. Periods of low or intermittent use may thus not reflect a failure of design in a traditional sense but rather be a sign of evolving needs over time.

CONCLUSIONS

Our results indicate that the needs of patients with T2DM differ between individuals and change over time. As a result, the suggested digitally supported empowering health prototypes can be personalized to support self-exploration, individual preference in long-term management, and changing needs over time. Despite individuals experiencing different journeys with diabetes, users perceive the self-measurement of blood glucose as a universally useful tool to empower everyday decision-making.

Optimizing adaptive stepped-care interventions to change adults' health behaviors: A systematic review

Chronic diseases are ubiquitous and costly in American populations. Interventions targeting health behavior change to manage chronic diseases are needed, but previous efforts have fallen short of producing meaningful change on average. Adaptive stepped-care interventions, that tailor treatment based on the needs of the individual over time, are a promising new area in health behavior change. We therefore conducted a systematic review of tests of adaptive stepped-care interventions targeting health behavior changes for adults with chronic diseases. We identified 9 completed studies and 13 research protocols testing adaptive stepped-care interventions for health behavior change. The most common health behaviors targeted were substance use, weight management, and smoking cessation. All identified studies test intermediary tailoring for treatment non-responders via sequential multiple assignment randomized trials (SMARTs) or singly randomized trials (SRTs); none test baseline tailoring. From completed studies, there were few differences between embedded adaptive interventions and minimal differences between those classified as treatment responders and non-responders. In conclusion, updates to this work will be needed as protocols identified here publish results. Future research could explore baseline tailoring variables, apply methods to additional health behaviors and target populations, test tapering interventions for treatment responders, and consider adults' context when adapting interventions.

Rationale for participation in university worksite wellness programs

Objective: To understand the wellness needs of university employees to design more effective and inclusive worksite wellness programs (WWP) for health promotion. Methods: Cross-sectional assessment of university employees' wellness needs (online survey, n = 639). Results: Employees were most interested in physical activity (PA), nutrition, and lifestyle WWP. Principal barriers to participation were time, scheduling, location, motivation, and confidentiality concerns. Significant correlations exist between having a diagnosed health condition and the likelihood of participating in related programs. 67.1% of past participation was predicted by (1) health status today versus last year, (2) use of university recreational facilities, (3) gender, (4) general health status, (5) PA in the past month, (6) faculty/staff, and (7) age. Conclusions: Our findings contribute to building a road map of how-to better design university WWP based on understanding participation predictors, barriers/facilitators, and the influence of health status/conditions on topics of interest/participation. Tailoring WWP to meet employees' needs may increase reach, engagement and promote a health culture.

Norms, prices, and commitment: A comprehensive overview of field experiments in the energy domain and treatment effect moderators

This paper provides a comprehensive overview of field experiments utilizing social norms, commitment and price-based interventions to promote energy conservation, load shifting, and energy efficiency behaviors. Treatment effects reported in the extant literature, as well as the factors that may strengthen or dampen these effects are reviewed. We find that social norm and incentive-based interventions mostly achieve small reductions in energy consumption, and that the effects of commitment-based interventions are essentially zero for the most part. Incentive effects on energy efficiency investments are mostly non-existent, safe for a few exceptions. One gap that we identify is the almost complete absence of field experiments leveraging social norms or commitment to promote energy efficiency investments. We discuss a broad range of (mostly under-researched) plausible moderators of the interventions' effects. Crucially, a more careful attention to moderators in future research can highlight instances in which interventions can be effective, notwithstanding their modest or non-existent average treatment effects. Our review offers a starting point in this regard.

User-centered development of a digitally-delivered dietary intervention for adults with type 2 diabetes: The T2Diet study

BACKGROUND

Web-based interventions can help address challenges of accessibility and availability of dietary support for people with type 2 diabetes (T2D). However, concerns regarding adherence and engagement in web-based interventions have been noted. Implementing a user-centered approach to intervention development has been shown to encourage better participant engagement. The overarching aim of this paper was to describe the user-centered approach used in the T2Diet Study to develop a new web-based dietary intervention for adults with T2D, exploring strategies for enhancing adherence and engagement.

METHODS

Intervention development was based on a flexible iterative user-centered approach to enable new product development. Twenty-one adults with T2D were engaged in six guided discussion groups across four iterative development phases, alongside reference to evidence and theory throughout the process. The phases of user inquiry progressed from broad discussion on areas to support dietary needs; to design feedback on aspects of site layout; through to further feedback on aesthetics and functionality; then into a two-week field test followed by final user inquiry and participation in user experience polls. A hybrid approach of thematic data analysis was used, incorporating both a data-driven inductive approach and a deductive approach based on a priori identification of themes.

RESULTS

Group discussion across the four phases highlighted factors the participants considered may motivate them to adhere and engage, which predominantly included relevance of resources, clear and simple positive communication, and flexibility for personal tailoring. Participant feedback provided an actionable list of intervention developments and input to inform intervention structure and theoretical framework. The two-week field test highlighted factors participants valued in terms of the user experience, most notably usability and accessibility. Additionally, the field test indicated a positive user experience, with no significant usability issues identified.

CONCLUSION

This paper provided the first detailed report of a user-centered approach to iterative development in the context of a web-based T2D dietary intervention. The insights will be useful to inform future digitally-delivered dietary interventions for adults with T2D or to inform a similar user-centered approach for other chronic health conditions.

Smartphone-Delivered Ecological Momentary Interventions Based on Ecological Momentary Assessments to Promote Health Behaviors: Systematic Review and Adapted Checklist for Reporting Ecological Momentary Assessment and Intervention Studies

Background

Healthy behaviors are crucial for maintaining a person’s health and well-being. The effects of health behavior interventions are mediated by individual and contextual factors that vary over time. Recently emerging smartphone-based ecological momentary interventions (EMIs) can use real-time user reports (ecological momentary assessments [EMAs]) to trigger appropriate support when needed in daily life.

Objective

This systematic review aims to assess the characteristics of smartphone-delivered EMIs using self-reported EMAs in relation to their effects on health behaviors, user engagement, and user perspectives.

Methods

We searched MEDLINE, Embase, PsycINFO, and CINAHL in June 2019 and updated the search in March 2020. We included experimental studies that incorporated EMIs based on EMAs delivered through smartphone apps to promote health behaviors in any health domain. Studies were independently screened. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed. We performed a narrative synthesis of intervention effects, user perspectives and engagement, and intervention design and characteristics. Quality appraisal was conducted for all included studies.

Results

We included 19 papers describing 17 unique studies and comprising 652 participants. Most studies were quasi-experimental (13/17, 76%), had small sample sizes, and great heterogeneity in intervention designs and measurements. EMIs were most popular in the mental health domain (8/17, 47%), followed by substance abuse (3/17, 18%), diet, weight loss, physical activity (4/17, 24%), and smoking (2/17, 12%). Of the 17 studies, the 4 (24%) included randomized controlled trials reported nonstatistically significant effects on health behaviors, and 4 (24%) quasi-experimental studies reported statistically significant pre-post improvements in self-reported primary outcomes, namely depressive (P<.001) and psychotic symptoms (P=.03), drinking frequency (P<.001), and eating patterns (P=.01). EMA was commonly used to capture subjective experiences as well as behaviors, whereas sensors were rarely used. Generally, users perceived EMIs to be helpful. Common suggestions for improvement included enhancing personalization, multimedia and interactive capabilities (eg, voice recording), and lowering the EMA reporting burden. EMI and EMA components were rarely reported and were not described in a standardized manner across studies, hampering progress in this field. A reporting checklist was developed to facilitate the interpretation and comparison of findings and enhance the transparency and replicability of future studies using EMAs and EMIs.

Conclusions

The use of smartphone-delivered EMIs using self-reported EMAs to promote behavior change is an emerging area of research, with few studies evaluating efficacy. Such interventions could present an opportunity to enhance health but need further assessment in larger participant cohorts and well-designed evaluations following reporting checklists. Future research should explore combining self-reported EMAs of subjective experiences with objective data passively collected via sensors to promote personalization while minimizing user burden, as well as explore different EMA data collection methods (eg, chatbots).

Trial Registration

PROSPERO CRD42019138739; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=138739

Sequential multiple assignment randomized trial studies should report all key components: a systematic review

OBJECTIVE

Sequential Multiple Assignment Randomised Trial (SMART) designs allow multiple randomisations of participants; this allows assessment of stage-specific questions (individual randomisations) and adaptive interventions (i.e. treatment strategies). We assessed the quality of reporting of the information required to design SMART studies.

STUDY DESIGN AND SETTING

We systematically searched four databases (PubMed, Ovid, Web of Science and Scopus) for all trial reports, protocols, reviews, and methodological papers which mentioned SMART designs up to June 15, 2020.

RESULTS

Of the 157 selected records, 12 (7.64%) were trial reports, 24 (15.29%) were study protocols, 91 (58%) were methodological papers, and 30 (19.1%) were review papers. All these trials were powered using stage-specific aims. Only four (33.33%) of these trials reported parameters required for sample size calculations. A small number of the trials (16.67 %) were interested in determining the best embedded adaptive interventions. Most of the trials did not report information about multiple testing adjustment. Furthermore, most of records reported designs that were mainly focused on stage-specific aims.

CONCLUSIONS

Some features of SMART designs are seldomly reported and/or used. Furthermore, studies using this design tend to not adequately report information about all the design parameters, limiting their transparency and interpretability.

A Pragmatic Approach to Translating Low- and Very Low-Carbohydrate Diets Into Clinical Practice for Patients With Obesity and Type 2 Diabetes

Across all eating patterns, individuals demonstrate marked differences in treatment response; some individuals gain weight and others lose weight with the same approach. Policy makers and research institutions now call for the development and use of personalized nutrition counseling strategies rather than one-size-fits-all dietary recommendations. However, challenges persist in translating some evidence-based eating patterns into the clinical practice due to the persistent notion that certain dietary approaches-regardless of individuals' preferences and health outcomes-are less healthy than others. For example, low- and very low-carbohydrate ketogenic diets (VLCKDs)-commonly defined as 10-26% and <10% total daily energy from carbohydrate, respectively-are recognized as viable lifestyle change options to support weight loss, glycemic control, and reduced medication use. Yet, critics contend that such eating patterns are less healthy and encourage general avoidance rather than patient-centered use. As with all medical treatments, the potential benefits and risks must be considered in the context of patient-centered, outcome-driven care; this is the cornerstone of evidence-based medicine. Thus, the critical challenge is to identify and safely support patients who may prefer and benefit from dietary carbohydrate restriction. In this Perspective, we propose a pragmatic, 4-stepped, outcome-driven approach to help health professionals use carbohydrate-restricted diets as one potential tool for supporting individual patients' weight loss and metabolic health.

Cluster-randomized trial comparing organizationally tailored versus standard approach for integrating an evidence-based cancer control intervention into African American churches

The field of implementation science has devoted increasing attention to optimizing the fit of evidence-based interventions to the organizational settings in which they are delivered. Institutionalization of health promotion into routine organizational operations is one way to achieve this. However, less is known about how to maximize fit and achieve institutionalization, particularly in settings outside of the healthcare system. This paper reports on findings from a parallel cluster-randomized trial that compared an organizationally tailored with a standard (core components only) approach for institutionalizing ("integrating") an evidence-based cancer control intervention into African American churches. Churches randomized to the organizationally tailored condition identified three or more implementation strategies from a menu of 20, with an implementation time frame for each. The primary study outcome was assessed through the Faith-Based Organization Health Integration Inventory, a measure of institutionalization of health promotion activities in church settings, completed by pastors at baseline and 12-month follow-up. Seventeen churches were randomized and 14 were analyzed as 3 did not implement the study protocol. Though the percent increase in total integration score was greater in the tailored condition (N = 9; 18%) than in the standard condition (N = 5; 12%), linear mixed-effect models did not detect a statistically significant group × time interaction. Despite the challenges of integrating health promotion activities outside of healthcare organizations, the current approach shows promise for fostering sustainable health promotion in community settings and merits further study.

Wearable Devices: Current Status and Opportunities in Pain Assessment and Management

INTRODUCTION

We investigated the possibilities and opportunities for using wearable devices that measure physical activity and physiometric signals in conjunction with ecological momentary assessment (EMA) data to improve the assessment and treatment of pain.

METHODS

We considered studies with cross-sectional and longitudinal designs as well as interventional or observational studies correlating pain scores with measures derived from wearable devices. A search was also performed on studies that investigated physical activity and physiometric signals among patients with pain.

RESULTS

Few studies have assessed the possibility of incorporating wearable devices as objective tools for contextualizing pain and physical function in free-living environments. Of the studies that have been conducted, most focus solely on physical activity and functional outcomes as measured by a wearable accelerometer. Several studies report promising correlations between pain scores and signals derived from wearable devices, objectively measured physical activity, and physical function. In addition, there is a known association between physiologic signals that can be measured by wearable devices and pain, though studies using wearable devices to measure these signals and associate them with pain in free-living environments are limited.

CONCLUSION

There exists a great opportunity to study the complex interplay between physiometric signals, physical function, and pain in a real-time fashion in free-living environments. The literature supports the hypothesis that wearable devices can be used to develop reproducible biosignals that correlate with pain. The combination of wearable devices and EMA will likely lead to the development of clinically meaningful endpoints that will transform how we understand and treat pain patients.

Digital chemsex support and care: The potential of just-in-time adaptive interventions

Chemsex among gay, bisexual and other men who have sex with men (GBMSM) has received increasing attention as a public health concern in recent years. Chemsex can affect a variety of aspects of the lives of GBMSM and contribute to physical, social and emotional health burden. Starting from a continuum perspective of chemsex, rather than a binary view of problematic vs. non-problematic use, we argue that men engaging in chemsex at different points in their chemsex journey may benefit from tailored and personalized support to cope with the various and evolving challenges and concerns that may be related to their chemsex behavior. To date, interactive digital communication technologies are not much used to provide support and care for GBMSM engaging in chemsex, neither for community-based support and care nor by health services. This suggests potential for missed opportunities, as GBMSM are generally avid users of these technologies for social connections and hookups, including in relation to chemsex. Recent research has provided emerging evidence of the potential effects of so-called just in time adaptive interventions (JITAI) to provide effective support and care for a variety of health issues. JITAI hold much promise for the provision of appropriate, tailored support and care for GBMSM at different points in the chemsex journey. Co-designing JITAI with potential users and other stakeholders (co-design) is key to success. At the Institute for Tropical Medicine, in Antwerp (Belgium), we initiated the Chemified project to develop an innovative digital chemsex support and care tool for GBMSM. This project illustrates how current understanding of chemsex as a journey can be integrated with a JITAI approach and make use of co-design principles to advance the available support and care for GBMSM engaging in chemsex.

The ability to benefit from an intervention to encourage use of treadmill workstations: Experiences of office workers with overweight or obesity

One way to increase physical activity in offices is to install treadmill workstations, where office workers can walk on a treadmill while performing their normal tasks. However, the experiences of people using these treadmill workstations over a long period of time is not known. In this 13-month study, we explored the experiences of office workers with treadmill workstations available in their offices. After completing a larger randomized controlled trial with 80 office workers ages 40 to 67 years with overweight or obesity, we interviewed 20 participants from the intervention group, using a semi-structured interview guide. Data were analyzed using a grounded theory approach with constant comparison of emerging codes, subcategories, and categories, followed by connecting the categories to create a core category. The core category is described as the “Ability to benefit.” Although all participants had a rather high motivational level and pre-existing knowledge about the health benefits of increasing physical activity at work, they had different capacities for benefiting from the intervention. The categories are described as ideal types: the Convinced, the Competitive, the Responsible, and the Vacillating. These ideal types do not represent any single participant but suggest generalized abstractions of experiences and strategies emerging from the coding of the interviews. One participant could easily have more than one ideal type. Because of differences in ideal type strategies and paths used throughout the course of the study, participants had different abilities to benefit from the intervention. Knowledge regarding the ideal types may be applied to facilitate the use of the treadmill workstations. Because different ideal types might require different prompts for behavior change, tailored intervention strategies directed towards specific ideal types could be necessary.

Meta-analysis of randomised controlled trials testing behavioural interventions to promote household action on climate change

No consensus exists regarding which are the most effective mechanisms to promote household action on climate change. We present a meta-analysis of randomised controlled trials comprising 3,092,678 observations, which estimates the effects of behavioural interventions holding other factors constant. Here we show that behavioural interventions promote climate change mitigation to a very small degree while the intervention lasts (d = −0.093 95% CI −0.160, −0.055), with no evidence of sustained positive effects once the intervention ends. With the exception of recycling, most household mitigation behaviours show a low behavioural plasticity. The intervention with the highest average effect size is choice architecture (nudges) but this strategy has been tested in a limited number of behaviours. Our results do not imply behavioural interventions are less effective than alternative strategies such as financial incentives or regulations, nor exclude the possibility that behavioural interventions could have stronger effects when used in combination with alternative strategies.

It is not clear which are the most effective mechanisms to achieve sustainable lifestyle behaviour. Here the authors study the impact of behavioural interventions excluding economic incentives by performing a large-scale meta-analysis and find that these interventions promote sustainable behaviours to a small degree in the short-term with no evidence of sustained positive effects once the intervention is completed.