Identifying Behaviour Change Techniques and Motivational Interviewing Techniques in Small Steps for Big Changes: A Community-Based Program for Adults at Risk for Type 2 Diabetes

Development of Public Health Center-Based Culturally Tailored Hypertension Self-Care Intervention Among Adults in Rural Ghana

OBJECTIVES

Develop a primary health care-based nurse-led culturally tailored hypertension self-care intervention for rural residents.

DESIGN

The culturally tailored hypertension self-care intervention was developed using a six-step intervention mapping approach that involved: needs assessment using literature review and interviews; setting program goals using integrated thematic synthesis method; selecting intervention modules through the process dimension of the self-care theory of chronic illness; producing program components and materials by developing intervention modules using the motivational interviewing and behavior change techniques; planning program adoption by encouraging sustainable behavior; and evaluation using the education content validity index in health and the intervention acceptability, appropriateness, and feasibility scale.

MEASUREMENTS

Education content validity index in health and the intervention acceptability, appropriateness, and feasibility scale.

INTERVENTION

The culturally tailored hypertension self-care intervention modules included health literacy, adherence to therapy, continuous monitoring, reduction of the modifiable risk factors of hypertension; self-care management strategies, and strategies for sustaining behavior.

RESULTS

The culturally tailored hypertension self-care intervention addresses community-based facilitators and barriers to self-care behavior and ultimately blood pressure control as described in the process dimension of the self-care theory of chronic illness.

CONCLUSION

This culturally tailored hypertension self-care intervention is to be implemented by nurses working in primary health care settings in Ghana where they have direct access to and daily interaction with patients with uncontrolled hypertension.

Identifying motivational interviewing techniques in Quitline smoking cessation counselling sessions from Queensland, Australia

Motivational interviewing (MI) is a common approach for smoking cessation counselling, yet little is known about the use of MI techniques in practice. This qualitative content analysis applied a published classification of content and relational MI techniques to a sample of 30 Quitline transcripts (January-March 2019) from Queensland, Australia. Overall, 36 MI techniques (94.7%) were identified at least once within the total sample. On average, 20 techniques (52.6%) were used in an individual conversation with a small difference observed between initial and follow-up calls. Techniques most frequently applied across conversations were largely relational, while techniques addressing client ambivalence/resistance were less frequently/never applied. Variability in techniques between individual initial and follow-up calls highlights the high degree of personalisation when applying MI to smoking cessation. Further investigations exploring associations of individual techniques and cessation outcomes are warranted. The classification may prove useful for assessments of fidelity for training and monitoring activities.

Improving retrospective intervention descriptions: Lessons learned from research on type 2 diabetes programmes in the United Kingdom and the Republic of Ireland

In recent years, multiple countries worldwide have implemented behavioural interventions within national healthcare systems. Describing the content of these interventions is critical to improve their implementation, replication, and effectiveness, as well as to advance behavioural science. Tools, such as the Behaviour Change Technique Taxonomy, can enhance the quality of intervention description and reporting. As interventions are frequently developed without the use of such tools, retrospective coding of existing interventions to accurately characterise their content is becoming more common. However, the use of these tools for retrospective coding poses various challenges, the discussion of which has been neglected to date. This commentary discusses the challenges encountered when retrospectively describing the content of five nationally implemented programmes for type 2 diabetes in the United Kingdom and the Republic of Ireland and suggests recommendations to tackle these challenges. We present important methodological, practical, and ethical considerations for researchers to reflect on, relevant to the retrospective description of existing interventions. Specifically, we discuss (i) the importance of positive relationships and collaboration with intervention stakeholders, (ii) the practical and ethical considerations when analysing the content of implemented interventions, (iii) the independence of research teams and the potential for misclassification of intervention content, and (iv) the challenges associated with the analysis of intervention content using behavioural science tools. There is a growing demand for more robust approaches to address the methodological, practical, and ethical challenges associated with such studies. The present commentary describes key issues to be considered by research teams, as well as concrete recommendations to improve the retrospective characterisation of intervention content.

Can In-Task Affect During Interval and Continuous Exercise Predict 12-Month Physical Activity Behavior? Findings from a Randomized Trial

BACKGROUND

In-task affective responses to moderate-intensity continuous exercise training (MICT) have been shown to predict future physical activity behavior. However, limited research has investigated whether this affect-behavior relationship is similar for high-intensity interval training (HIIT) and whether it holds true over the longer term. This study aims to determine (1) if in-task affect during 2 weeks of supervised MICT and HIIT predicted changes to unsupervised moderate-to-vigorous physical activity (MVPA) behavior 12 months post-intervention and (2) if this predictive relationship was moderated by exercise type (MICT vs. HIIT).

METHOD

Ninety-nine adults (69.7% female; 50.9 ± 9.4 years) who were low active and overweight were randomized to 2 weeks of exercise training of MICT (n = 52) or HIIT (n = 47), followed by 12 months of accelerometry-assessed free-living MVPA.

RESULTS

The pooled moderation model was not significant, F(3, 94) = 2.54, p = .07 (R2 = 0.085), with a non-significant group by affect interaction (p = .06). The conditional effect for MICT was significant (B = 17.27, t = 2.17, p = .03), suggesting that 12-month change in MVPA increased by 17.27 min/week for every one-point increase in in-task affect. The conditional effect for HIIT was not significant (p = .85), suggesting that in-task affect was not predictive of 12-month change in MVPA.

CONCLUSION

The current findings raise important questions about whether the affect-behavior relationship may vary depending on exercise type. For HIIT-based exercise in particular, additional psychological constructs beyond in-task affect should be considered when attempting to predict future physical activity behavior.

Key process features of personalized diet counselling in metabolic syndrome: secondary analysis of feasibility study in primary care

BACKGROUND

Personalized diet counselling, as part of lifestyle change programs for cardiometabolic risk conditions (combinations of prediabetes or type 2 diabetes, hypertension, dyslipidemia and high waist circumference) has been shown to reduce progression to type 2 diabetes overall. To identify key process of care measures that could be linked to changes in diet, we undertook a secondary analysis of a Canadian pre-post study of lifestyle treatment of metabolic syndrome (MetS). Diet counselling process measures were documented and association with diet quality changes after 3 months were assessed. Results of the primary study showed 19% reversal of MetS after 1 year.

METHODS

Registered dietitians (RDs) reported on contact time, specific food behaviour goals (FBG), behaviour change techniques (BCT; adapted from the Michie CALO-RE taxonomy) and teaching resources at each contact. Diet quality was measured by 2005 Canadian Healthy Eating Index (HEI-C) and assessed for possible associations with individual BCT and FBG.

RESULTS

Food behaviour goals associated with improved HEI-C at 3 months were: poultry more than red meat, increased plant protein, increased fish, increased olive oil, increased fruits and vegetables, eating breakfast, increased milk and alternatives, healthier fats, healthier snacks and increased nuts, with an adverse association noted for more use (> 2 times/ 3 months) of the balanced meal concept (F test; p < 0.001). Of 16 BCT, goal setting accounted for 15% of all BCT recorded, yet more goal setting (> 3 times/3 months) was associated with poorer HEI-C at 3 months (F test; p = 0.007). Only self-monitoring, feedback on performance and focus on past success were associated with improved HEI-C.

CONCLUSIONS

These results identify key aspects of process that impact diet quality. Documentation of both FBG and BCT is highly relevant in diet counselling and a summary diet quality score is a promising target for assessing short-term counselling success.

Developing Mobile Health Interventions With Implementation in Mind: Application of the Multiphase Optimization Strategy (MOST) Preparation Phase to Diabetes Prevention Programming

With thousands of mobile health (mHealth) solutions on the market, patients and health care providers struggle to identify which solution to use and prescribe. The lack of evidence-based mHealth solutions may be because of limited research on intervention development and the continued use of traditional research methods for mHealth evaluation. The Multiphase Optimization Strategy (MOST) is a framework that aids in developing interventions that produce the best-expected outcomes (ie, effectiveness), given constraints imposed on affordability, scalability, and efficiency (also known as achieving intervention EASE). The preparation phase of the MOST highlights the importance of formative intervention development-a stage often overlooked and rarely published. The aim of the preparation phase of the MOST is to identify candidate intervention components, create a conceptual model, and define the optimization objective. Although the MOST sets these 3 targets, no guidance is provided on how to conduct quality research within the preparation phase and what specific steps can be taken to identify potential intervention components, develop the conceptual model, and achieve intervention EASE with the implementation context in mind. To advance the applicability of the MOST within the field of implementation science, this study provides an account of the methods used to develop an mHealth intervention using the MOST. Specifically, we provide an example of how to achieve the goals of the preparation phase by outlining the formative development of an mHealth-prompting intervention within a diabetes prevention program. In addition, recommendations are proposed for future researchers to consider when conducting formative research on mHealth interventions with implementation in mind. Given its considerable reach, mHealth has the potential to positively affect public health by decreasing implementation costs and improving accessibility. The MOST is well-suited for the efficient development and optimization of mHealth interventions. By using an implementation-focused lens and outlining the steps in developing an mHealth intervention using the preparation phase of the MOST, this study may guide future intervention developers toward maximizing the impact of mHealth outside academia.

Implementation of a diabetes prevention program within two community sites: a qualitative assessment

Background

Despite numerous translations of diabetes prevention programs, implementation evaluations are rarely conducted. The purpose of this study was to examine the implementation process and multilevel contextual factors as an evidence-based diabetes prevention program was implemented into two local community organization sites to inform future scale-up. To build the science of implementation, context and strategies must be identified and explored to understand their impact.

Methods

The program was a brief-counseling diet and exercise modification program for individuals at risk of developing type 2 diabetes. A 1-year collaborative planning process with a local not-for-profit community organization co-developed an implementation plan to translate the program. A pragmatic epistemology guided this research. Semi-structured interviews were conducted with staff who delivered the program (n = 8), and a focus group was completed with implementation support staff (n = 5) at both community sites. Interviews were transcribed verbatim and thematically analyzed using a template approach. The consolidated framework for implementation research (CFIR) is a well-researched multilevel implementation determinant framework and was used to guide the analysis of this study. Within the template approach, salient themes were first inductively identified, then identified themes were deductively linked to CFIR constructs.

Results

Implementation strategies used were appropriate, well-received, and promoted effective implementation. The implementation plan had an impact on multiple levels as several CFIR constructs were identified from all five domains of the framework: (a) process, (b) intervention characteristics, (c) outer setting, (d) inner setting, and (e) individual characteristics. Specifically, results revealed the collaborative 1-year planning process, program components and structure, level of support, and synergy between program and context were important factors in the implementation.

Conclusion

This study offers insights into the process of implementing a community-based diabetes prevention program in two local sites. Successful implementation benefited from a fully engaged, partnered approach to planning, and subsequently executing, an implementation effort. The CFIR was a useful and thorough framework to evaluate and identify multilevel contextual factors impacting implementation. Results can be used to inform future implementation and scale-up efforts.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-022-00258-6.

Fitness Facility Staff Can Be Trained to Deliver a Motivational Interviewing-Informed Diabetes Prevention Program

Background: Training programs must be evaluated to understand whether the training was successful at enabling staff to implement a program with fidelity. This is especially important when the training has been translated to a new context. The aim of this community case study was to evaluate the effectiveness of the in-person Small Steps for Big Changes training for fitness facility staff using the 4-level Kirkpatrick training evaluation model. Methods: Eight staff were trained to deliver the motivational interviewing-informed Small Steps for Big Changes program for individuals at risk of developing type 2 diabetes. Between August 2019 and March 2020, 32 clients enrolled in the program and were allocated to one of the eight staff. The Kirkpatrick 4-level training evaluation model was used to guide this research. Level one assessed staff satisfaction to the training on a 5-point scale. Level two assessed staff program knowledge and motivational interviewing knowledge/skills. Level three assessed staff behaviors by examining their use of motivational interviewing with each client. Level four assessed training outcomes using clients' perceived satisfaction with their staff and basic psychological needs support both on 7-point scales. Results: Staff were satisfied with the training (M = 4.43; SD = 0.45; range = 3.86-4.71). All learning measures demonstrated high post-training scores that were retained at implementation follow-up. Staff used motivational interviewing skills in practice and delivered the program at a client-centered level (≥6; M = 6.34; SD = 0.83; range = 3.75-7.80). Overall, clients perceived staff supported their basic psychological needs (M = 6.55; SD = 0.64; range = 6.17-6.72) and reported high staff satisfaction scores (M = 6.88; SD = 0.33; range = 6-7). Conclusion: The Small Steps for Big Changes training was successful and fitness facility staff delivered a motivational interviewing-informed program. While not all staff operated at a client-centered level, clients perceived their basic psychological needs to be supported. Findings support the training for future scale-up sites. Community fitness staff represent a feasible resource through which to run evidence-based counseling programs.

Evaluation and Refinement of a Bank of SMS Text Messages to Promote Behavior Change Adherence Following a Diabetes Prevention Program: Survey Study

Background

SMS text messaging is a low-cost and far-reaching modality that can be used to augment existing diabetes prevention programs and improve long-term diet and exercise behavior change adherence. To date, little research has been published regarding the process of SMS text message content development. Understanding how interventions are developed is necessary to evaluate their evidence base and to guide the implementation of effective and scalable mobile health interventions in public health initiatives and in future research.

Objective

This study aims to describe the development and refinement of a bank of SMS text messages targeting diet and exercise behavior change to be implemented following a diabetes prevention program.

Methods

A bank of 124 theory-based SMS text messages was developed using the Behaviour Change Wheel and linked to active intervention components (behavior change techniques [BCTs]). The Behaviour Change Wheel is a theory-based framework that provides structure to intervention development and can guide the use of evidence-based practices in behavior change interventions. Once the messages were written, 18 individuals who either participated in a diabetes prevention program or were a diabetes prevention coach evaluated the messages on their clarity, utility, and relevance via survey using a 5-point Likert scale. Messages were refined according to participant feedback and recoded to obtain an accurate representation of BCTs in the final bank.

Results

76/124 (61.3%) messages were edited, 4/124 (3.2%) were added, and 8/124 (6.5%) were removed based on participant scores and feedback. Of the edited messages, 43/76 (57%) received minor word choice and grammar alterations while retaining their original BCT code; the remaining 43% (33/76, plus the 4 newly written messages) were recoded by a reviewer trained in BCT identification.

Conclusions

This study outlines the process used to develop and refine a bank of SMS text messages to be implemented following a diabetes prevention program. This resulted in a bank of 120 theory-based, user-informed SMS text messages that were overall deemed clear, useful, and relevant by both individuals who will be receiving and delivering them. This formative development process can be used as a blueprint in future SMS text messaging development to ensure that message content is representative of the evidence base and is also grounded in theory and evaluated by key knowledge users.

Using the behavior change wheel to develop text messages to promote diet and physical activity adherence following a diabetes prevention program

Improving diet and physical activity (PA) can reduce the risk of developing type 2 diabetes (T2D); however, long-term diet and PA adherence is poor. To impact population-level T2D risk, scalable interventions facilitating behavior change adherence are needed. Text messaging interventions supplementing behavior change interventions can positively influence health behaviors including diet and PA. The Behavior Change Wheel (BCW) provides structure to intervention design and has been used extensively in health behavior change interventions. Describe the development process of a bank of text messages targeting dietary and PA adherence following a diabetes prevention program using the BCW. The BCW was used to select the target behavior, barriers and facilitators to engaging in the behavior, and associated behavior change techniques (BCTs). Messages were written to map onto BCTs and were subsequently coded for BCT fidelity. The target behaviors were adherence to diet and PA recommendations. A total of 16 barriers/facilitators and 28 BCTs were selected for inclusion in the messages. One hundred and twenty-four messages were written based on selected BCTs. Following the fidelity check a total of 43 unique BCTs were present in the final bank of messages. This study demonstrates the application of the BCW to guide the development of a bank of text messages for individuals with prediabetes. Results underscore the potential utility of having independent coders for an unbiased expert evaluation of what active components are in use. Future research is needed to demonstrate the feasibility and effectiveness of resulting bank of messages.