Multiple health behavior changes and co-variation in a telephone counseling trial

Comparison of Motivational Short Interventions to Improve Smokers' Health Behavior (The COSMOS Study): A Pragmatic Cluster-Randomized Two-Arm Trial in General Practice

INTRODUCTION

Helping smokers to quit is an important task of general practitioners (GPs). However, achieving tobacco abstinence is difficult, and smokers who fail may still want to improve their health in other ways. Therefore, Swiss GPs developed a multithematic coaching concept that encourages health behavior changes beyond smoking cessation alone.

AIMS AND METHODS

To compare the effectiveness of such coaching with state-of-the-art smoking cessation counseling, we conducted a pragmatic cluster-randomized two-arm trial with 56 GPs in German-speaking Switzerland and 149 of their cigarette smoking patients. GPs were instructed in either multithematic health coaching or smoking cessation counseling. After 12 months, we compared their patients' improvements in cigarette consumption, body weight, physical inactivity, alcohol consumption, stress, unhealthy diet, and a health behavior of their own choice, using hierarchical logistic regression models and Fisher's exact and t tests.

RESULTS

Over 95% of all participants achieved clinically relevant improvements in at least one health behavior, with no difference between study arms (health coaching vs. smoking cessation counseling: aOR = 1.21, 95% CI = [0.03-50.76]; and aOR = 1.78, 95% CI = [0.51-6.25] after non-responder imputation). Rates of clinically relevant improvements in the individual health behaviors did not differ between study arms either (they were most frequent in physical activity, achieved by 3 out of 4 patients), nor did the extent of the improvements.

CONCLUSIONS

Multithematic health coaching and state-of-the art smoking cessation counseling were found to be comparable interventions, both in terms of smoking cessation success and, quite unexpectedly, their effects on other health behaviors.

IMPLICATIONS

The findings of our study suggest that in general practice, multithematic health coaching is an effective smoking cessation intervention, and conversely, monothematic smoking cessation counseling also achieves the beneficial effects of a multithematic health behavior intervention. This opens up the possibility for GPs to support their smoking patients in improving their health behavior in additional and more flexible ways.

Coaction Between Physical Activity and Fruit and Vegetable Intake in Racially Diverse, Obese Adults

PURPOSE

There is minimal understanding of the potential for coaction, defined as action on one behavior increasing the likelihood of taking action on another behavior, between physical activity (PA) and fruit and vegetable (FV) intake. The purpose of this study was to assess the bidirectional coaction between FV intake and PA, as well as self-efficacy for these behaviors, in a racially diverse sample of obese adults.

DESIGN

This is a secondary analysis using data collected from the Path to Health study, a randomized controlled trial. ClinicalTrials.gov Identifier: NCT03674229.

SAMPLE

Obese adults who completed baseline and 6-month follow-up assessments.

MEASURES

For this study, data on FV intake, leisure time PA, and 7-day accelerometer data were analyzed at baseline and 6-month follow-up.

ANALYSIS

We interchanged modeling the FV intake and PA change variables as the independent and dependent variables. We conducted multiple imputation and both linear and multinomial regression.

RESULTS

The sample (n = 168) was 59% female and mainly split between white (42%) and African American (42%). Change in self-efficacy for PA was predictive of change in self-efficacy for FV intake and vice versa. When compared with participants with no change in FV intake, someone with a positive change in FV intake was more likely to have a positive change in self-reported PA (adjusted risk ratio [RR] = 6.72, 95% confidence interval [CI] = 1.69-26.68). Likewise, when compared with no change, participants with a positive change in self-reported PA were more likely to report a positive change in FV intake (adjusted RR = 6.79, 95% CI = 1.70-27.17).

CONCLUSION

Findings suggest coaction between self-efficacy for FV intake and PA as well as between FV intake and PA. Coaction could be capitalized on to more effectively promote both energy-balance behaviors.

Are you more concerned about or relieved by medicines? An explorative randomized study of the impact of telephone counseling by pharmacists on patients' beliefs regarding medicines and blood pressure control

OBJECTIVES

The aim was to determine the impact of a telephone counseling service, provided bi-monthly by pharmacist, on patients' beliefs about antihypertensive medicines and blood pressure (BP) control.

METHODS

Either hypertensive patients were randomly assigned to a control group (CG, usual care) or an intervention group (IG). All patients had BP values registered and filled in the Italian version of the Belief Medicine Questionnaire (BMQ). After 12 months, patients filled in the BMQ again and had their self-reported BP registered. The intervention consisted of an educational/counseling session based on patients' needs assessment provided bi-monthly by a pharmacist for one year via telephone.

RESULTS

80 CG and 84 IG patients were recruited. After 12 months, there were significant differences between IG and CG for both BMQ's Necessity and Concern score (p < 0.001; p < 0.001 respectively) and a significant reduction in BP values in IG (p < 0.001).

CONCLUSIONS

The intervention improves BP control by modifying patients' perception about treatments and involving patients as participants in the management of their health.

PRACTICE IMPLICATIONS

This paper could serve as a guideline for other studies to confirm the effectiveness of this intervention in modifying health behavior, and the role of hospital pharmacist.

A Systematic Review Exploring the Social Cognitive Theory of Self-Regulation as a Framework for Chronic Health Condition Interventions

Background

Theory is often recommended as a framework for guiding hypothesized mechanisms of treatment effect. However, there is limited guidance about how to use theory in intervention development.

Methods

We conducted a systematic review to provide an exemplar review evaluating the extent to which use of theory is identified and incorporated within existing interventions. We searched electronic databases PubMed, PsycINFO, CENTRAL, and EMBASE from inception to May 2014. We searched clinicaltrials.gov for registered protocols, reference lists of relevant systematic reviews and included studies, and conducted a citation search in Web of Science. We included peer-reviewed publications of interventions that referenced the social cognitive theory of self-regulation as a framework for interventions to manage chronic health conditions. Two reviewers independently assessed articles for eligibility. We contacted all authors of included studies for information detailing intervention content. We describe how often theory mechanisms were addressed by interventions, and report intervention characteristics used to address theory.

Results

Of 202 articles that reported using the social cognitive theory of self-regulation, 52% failed to incorporate self-monitoring, a main theory component, and were therefore excluded. We included 35 interventions that adequately used the theory framework. Intervention characteristics were often poorly reported in peer-reviewed publications, 21 of 35 interventions incorporated characteristics that addressed each of the main theory components. Each intervention addressed, on average, six of eight self-monitoring mechanisms, two of five self-judgement mechanisms, and one of three self-evaluation mechanisms. The self-monitoring mechanisms ‘Feedback’ and ‘Consistency’ were addressed by all interventions, whereas the self-evaluation mechanisms ‘Self-incentives’ and ‘External rewards’ were addressed by six and four interventions, respectively. The present review establishes that systematic review is a feasible method of identifying use of theory as a conceptual framework for existing interventions. We identified the social cognitive theory of self-regulation as a feasible framework to guide intervention development for chronic health conditions.

A systematic review and meta-analysis of social cognitive theory-based physical activity and/or nutrition behavior change interventions for cancer survivors

Purpose

Little is known about how to improve and create sustainable lifestyle behaviors of cancer survivors. Interventions based on social cognitive theory (SCT) have shown promise. This review examined the effect of SCT-based physical activity and nutrition interventions that target cancer survivors and identified factors associated with their efficacy.

Methods

A systematic search of seven databases identified randomized controlled trials that (i) targeted adult cancer survivors (any point from diagnosis); (ii) reported a primary outcome of physical activity, diet, or weight management; and (iii) included an SCT-based intervention targeting physical activity or diet. Qualitative synthesis and meta-analysis were conducted. Theoretical constructs and intervention characteristics were examined to identify factors associated with intervention efficacy.

Results

Eighteen studies (reported in 33 publications) met review inclusion criteria. Meta-analysis (n = 12) revealed a significant intervention effect for physical activity (standardized mean difference (SMD) = 0.33; P < 0.01). Most studies (six out of eight) that targeted dietary change reported significant improvements in at least one aspect of diet quality. No SCT constructs were associated with intervention effects. There were no consistent trends relating to intervention delivery method or whether the intervention targeted single or multiple behaviors.

Conclusions

SCT-based interventions demonstrate promise in improving physical activity and diet behavior in cancer survivors, using a range of intervention delivery modes. Further work is required to understand how and why these interventions offer promise for improving behavior.

Implications for Cancer Survivors

SCT-based interventions targeting diet or physical activity are safe and result in meaningful changes to diet and physical activity behavior that can result in health improvements.

Do primary health care nurses address cardiovascular risk in diabetes patients?

AIMS

To identify factors associated with assessment and nursing management of blood pressure, smoking and other major cardiovascular risk factors by primary health care nurses in Auckland, New Zealand.

METHODS

Primary health care nurses (n = 287) were randomly sampled from the total (n=1091) identified throughout the Auckland region and completed a self-administered questionnaire (n = 284) and telephone interview. Nurses provided details for 86% (n =265) of all diabetes patients they consulted on a randomly selected day.

RESULTS

The response rate for nurses was 86%. Of the patients sampled, 183 (69%) patients had their blood pressure measured, particularly if consulted by specialist (83%) and practice (77%) nurses compared with district (23%, p = 0.0003). After controlling for demographic variables, multivariate analyses showed patients consulted by nurses who had identified stroke as a major diabetes-related complication were more likely to have their blood pressure measured, and those consulted by district nurses less likely. Sixteen percent of patients were current smokers. Patients consulted by district nurses were more likely to smoke while, those >66 years less likely. Of those who wished to stop, only 50% were offered nicotine replacement therapy. Patients were significantly more likely to be advised on diet and physical activity if they had their blood pressure measured (p < 0.0001).

CONCLUSIONS

Measurement of blood pressure and advice on diet or physical activity were not related to patient's cardiovascular risk profile and management of smoking cessation was far from ideal. Education of the community-based nursing workforce is essential to ensure cardiovascular risk management becomes integrated into diabetes management.

Future prospects of health management systems using cellular phones

BACKGROUND

Cellular phones enable communication between healthcare providers and patients for prevention, diagnosis, and treatment of diseases. However, few studies have examined the user-friendliness or effectiveness of cellular phone-based medical informatics (CPBMI) for healthcare.

MATERIALS AND METHODS

This study investigated the use of CPBMI to identify its current status within the medical field, advantages and disadvantages, practicability, clinical effectiveness, costs, and cost-saving potential.

RESULTS

CPBMI was validated in terms of practicality and provision of medical benefits. It is critical to use CPBMI in accordance with the different features of each disease and condition. Use of CPBMI is expected to be especially useful for patients with chronic disease.

CONCLUSIONS

We discussed the current status of the clinical use, benefits, and risks of CPBMI. CPBMI and information technology-based health management tools are anticipated to become useful and effective components of healthcare management in the future.

Results from the dissemination of an evidence-based telephone-delivered intervention for healthy lifestyle and weight loss: the Optimal Health Program

Despite proven efficacy, there are few published evaluations of telephone-delivered interventions targeting physical activity, healthy eating, and weight loss in community dissemination contexts. This study aims to evaluate participant and program outcomes from the Optimal Health Program, a telephone-delivered healthy lifestyle and weight loss program provided by a primary health care organization. Dissemination study used a single-group, repeated measures design; outcomes were assessed at 6-month (mid-program; n = 166) and 12-month (end of program; n = 88) using paired analyses. The program reached a representative sample of at-risk, primary care patients, with 56 % withdrawing before program completion. Among completers, a statistically significant improvement between baseline and end of program was observed for weight [mean change (SE) -5.4 (7.0) kg] and waist circumference [-4.8 (9.7) cm], underpinned by significant physical activity and dietary change. Findings suggest that telephone-delivered weight loss and healthy lifestyle programs can provide an effective model for use in primary care settings, but participant retention remains a challenge.

Coaction in multiple behavior change interventions: consistency across multiple studies on weight management and obesity prevention

OBJECTIVE

Coaction refers to the extent to which taking action on one behavior increases the odds of taking action on a second behavior. This integrative study examines the generalization of coaction in three studies on weight-related behaviors.

METHOD

Data from three randomized trials of tailored interventions (n = 1,277, n = 1,800, and n = 6,000) were examined to determine if coaction of behavior change occurred differentially in treatment and control groups. In each analysis, the likelihood of progressing to the Action or Maintenance stages for the target behaviors was evaluated using logistic regression.

RESULTS

Despite differences in populations, targeted behaviors, levels of tailoring in interventions, and timing of follow-up assessments, 17 out of 24 (70.8%) logistic regressions revealed significant coaction in the treatment group as opposed to only three out of 24 (12.5%) in the control condition. In 23/24 analyses, coaction of behavior change was larger on an absolute basis in the treatment group. Individuals in the treatment group progressing to Action/Maintenance for one behavior were 1.4-5 times more likely to make progress on another behavior compared to those in the treatment group who did not make such progress on the first behavior.

CONCLUSIONS

This study demonstrates that despite considerable variability in study design, coaction reliably occurs more in the presence of Transtheoretical-Model based multiple behavior change interventions. Additional studies are needed to replicate these results in other behavioral areas and to examine the predictors of differential coaction. The ability to consistently create coaction within multiple behavior interventions can increase the efficacy and cost-effectiveness of multiple behavior change interventions.

Implementation of permutation testing to determine clustering of social and behavioral risk factors for coronary heart disease, National Health and Nutrition Examination Survey 2001-2004

PURPOSE

To determine whether social and behavioral risk factors for coronary heart disease, including education, physical activity, fruit/vegetable intake, and smoking, cluster (i.e., co-occur more than expected as the result of chance) in U.S. adults.

METHODS

The study included 4305 male and 4673 female subjects aged ≥20 years from the National Health and Nutrition Examination Survey. Risk factors included: ≤high school diploma/general educational development certificate; <150 minutes of moderate/vigorous physical activity per week; <3 or <2 servings of vegetables and fruit, respectively, per day; and smoking cigarettes. Indicator variables were summed into a sociobehavioral risk index (SRI, range 0 [no risk factors] to 4 [all risk factors]). Ratios of observed-to-expected prevalence (under the assumption of independence) of the SRI were assessed. Statistical significance was evaluated by the use of randomly permuted average observed-to-expected SRI ratios and 95% confidence intervals (95% CIs).

RESULTS

In male subjects, the ratio of observed-to-expected prevalence of SRI = 0 was 1.70 (permuted ratio = 1.00; 95% CI: 0.92-1.08), and SRI = 4 was 2.10 (permuted ratio = 1.00, 95% CI: 0.86-1.14), demonstrating significant clustering. In females, the ratio of observed-to-expected prevalence of SRI = 0 was 1.67 (permuted ratio = 1.00, 95% CI: 0.92-1.08), and SRI = 4 was 1.86 (permuted ratio = 1.00, 95% CI: 0.85-1.15).

CONCLUSIONS

Social and behavioral risk factors for coronary heart disease cluster in this sample of U.S. adults.

Baseline results from Hawaii's Nā Mikimiki Project: a physical activity intervention tailored to multiethnic postpartum women

During the postpartum period, ethnic minority women have higher rates of inactivity/under-activity than white women. The Nā Mikimiki ("the active ones") Project is designed to increase moderate-to-vigorous physical activity over 18 months among multiethnic women with infants 2-12 months old. The study was designed to test, via a randomized controlled trial, the effectiveness of a tailored telephone counseling of moderate-to-vigorous physical activity intervention compared to a print/website materials-only condition. Healthy, underactive women (mean age = 32 ± 5.6 years) with a baby (mean age = 5.7 ± 2.8 months) were enrolled from 2008-2009 (N = 278). Of the total sample, 84% were ethnic minority women, predominantly Asian-American and Native Hawaiian. Mean self-reported baseline level of moderate-to-vigorous physical activity was 40 minutes/week with no significant differences by study condition, ethnicity, infant's age, maternal body mass index, or maternal employment. Women had high scores on perceived benefits, self-efficacy, and environmental support for exercise but low scores on social support for exercise. This multiethnic sample's demographic and psychosocial characteristics and their perceived barriers to exercise were comparable to previous physical activity studies conducted largely with white postpartum women. The Nā Mikimiki Project's innovative tailored technology-based intervention and unique population are significant contributions to the literature on moderate-to-vigorous physical activity in postpartum women.

Physical activity and dietary behavior change in Internet-based weight loss interventions: comparing two multiple-behavior change indices

OBJECTIVE

To investigate the effects of two Internet-based weight loss interventions on physical activity (PA) and dietary behaviors using two approaches for computing combined behavior change.

METHOD

Participants were 352 overweight/obese women and men completing 12-month interventions in San Diego, California during 2002-2007. Moderate-to-vigorous PA (MVPA) and sedentary time were measured with accelerometers, and dietary fat and fruit and vegetable intake were assessed with food frequency questionnaires. Longitudinal analyses tested the effect of the intervention on combined health behavior change quantified using a standardized residualized change index (SRCI) and a risk factor change index (RFCI).

RESULTS

At baseline, participants engaged in an average of 153 min/week of MVPA and 525 min/day of sedentary time, and consumed 37% of calories from fat and <3 fruits and vegetables per day. The interventions had a significant effect on combined behavior change as measured with each approach (p<0.001). The intervention effect was larger (p<0.001) when evaluated using the SRCI (standardized regression coefficient [Beta]=0.30) than the RFCI (β=-0.18).

CONCLUSION

Interventions that target both PA and dietary behaviors appear effective. The SRCI was more sensitive for evaluating the intervention, but the RFCI may be easier to use for communicating public health significance.

The mPED randomized controlled clinical trial: applying mobile persuasive technologies to increase physical activity in sedentary women protocol

Background

Despite the significant health benefits of regular physical activity, approximately half of American adults, particularly women and minorities, do not meet the current physical activity recommendations. Mobile phone technologies are readily available, easily accessible and may provide a potentially powerful tool for delivering physical activity interventions. However, we need to understand how to effectively apply these mobile technologies to increase and maintain physical activity in physically inactive women. The purpose of this paper is to describe the study design and protocol of the mPED (mobile phone based physical activity education) randomized controlled clinical trial that examines the efficacy of a 3-month mobile phone and pedometer based physical activity intervention and compares two different 6-month maintenance interventions.

Methods

A randomized controlled trial (RCT) with three arms; 1) PLUS (3-month mobile phone and pedometer based physical activity intervention and 6-month mobile phone diary maintenance intervention), 2) REGULAR (3-month mobile phone and pedometer based physical activity intervention and 6-month pedometer maintenance intervention), and 3) CONTROL (pedometer only, but no intervention will be conducted). A total of 192 physically inactive women who meet all inclusion criteria and successfully complete a 3-week run-in will be randomized into one of the three groups. The mobile phone serves as a means of delivering the physical activity intervention, setting individualized weekly physical activity goals, and providing self-monitoring (activity diary), immediate feedback and social support. The mobile phone also functions as a tool for communication and real-time data capture. The primary outcome is objectively measured physical activity.

Discussion

If efficacy of the intervention with a mobile phone is demonstrated, the results of this RCT will be able to provide new insights for current behavioral sciences and mHealth.

Trial Registration

ClinicalTrials.gov#:NCTO1280812

Brief behavioral self-regulation counseling for HIV treatment adherence delivered by cell phone: an initial test of concept trial

Affordable and effective antiretroviral therapy (ART) adherence interventions are needed for many patients to promote positive treatment outcomes and prevent viral resistance. We conducted a two-arm randomized trial (n = 40 men and women receiving and less than 95% adherent to ART) to test a single office session followed by four biweekly cell phone counseling sessions that were grounded in behavioral self-management model of medication adherence using data from phone-based unannounced pill counts to provide feedback-guided adherence strategies. The control condition received usual care and matched office and cell phone/pill count contacts. Participants were baseline assessed and followed with biweekly unannounced pill counts and 4-month from baseline computerized interviews (39/40 retained). Results showed that the self-regulation counseling delivered by cell phone demonstrated significant improvements in adherence compared to the control condition; adherence improved from 87% of pills taken at baseline to 94% adherence 4 months after baseline, p < 0.01. The observed effect sizes ranged from moderate (d = 0.45) to large (d = 0.80). Gains in adherence were paralleled with increased self-efficacy (p < 0.05) and use of behavioral strategies for ART adherence (p < 0.05). We conclude that the outcomes from this test of concept trial warrant further research on cell phone-delivered self-regulation counseling in a larger and more rigorous trial.