Multiple risk expert systems interventions: impact of simultaneous stage-matched expert system interventions for smoking, high-fat diet, and sun exposure in a population of parents

Protocol for a prospective, randomized, controlled trial of Mental Contrasting with Implementation Intentions (MCII) to enhance the effectiveness of VA's MOVE! weight management program: WOOP (Wish, Outcome, Obstacle, Plan) VA

INTRODUCTION

Intensive weight management programs are effective but often have low enrollment and high attrition. Lack of motivation is a key psychological barrier to enrollment, engagement, and weight loss. Mental Contrasting with Implementation Intentions (MCII) is a unique imagery technique that increases motivation for behavior change. We describe our study protocol to assess the efficacy and implementation of MCII to enhance the effectiveness of VA's MOVE! or TeleMOVE! weight management programs using a procedure called "WOOP" (Wish, Outcome, Obstacle, Plan) for Veterans. We hypothesize that WOOP+MOVE! or TeleMOVE! (intervention) will lead to greater MOVE!/TeleMOVE! program engagment and consequently weight loss than MOVE!/TeleMOVE! alone (control).

METHOD

Veterans are randomized to either the intervention or control. Both arms receive the either MOVE! or TeleMOVE! weight management programs. The intervention group receives an hour long WOOP training while the control group receives patient education. Both groups receive telephone follow up calls at 3 days, 4 weeks, and 2 months post-baseline. Eligible participants are Veterans (ages 18-70 years) with either obesity (BMI ≥ 30 kg/m2) or overweight (BMI ≥ 25 kg/m2) and an obesity-associated co-morbidity. At baseline, 6 and 12 months, we assess weight, diet, physical activity in both groups. The primary outcome is mean percent weight change at 6 months. Secondary outcomes include changes in waist circumference, diet, physical activity, and dieting self-efficacy and engagement in regular physical activity. We assess implementation using the RE-AIM framework.

CONCLUSION

If WOOP VA is found to be efficacious, it will be an important tool to facilitate weight management and improve weight outcomes.

CLINICAL TRIAL REGISTRATION

NCT05014984.

Smoking Behavior and Wellness among Individuals in Substance Use Disorder Treatment

Tobacco-related morbidity and mortality disproportionately affect people with substance use disorders (SUD). Encouraging overall wellness may support tobacco use cessation. We investigated relationships between wellness (health status, physical activity, sugar-sweetened beverage (SSB) consumption), cigarette smoking, and smoking cessation among SUD treatment patients to inform clinical care. Cross-sectional surveys were conducted with 395 patients in 20 California residential SUD programs. Using multivariate regression, we examined associations between smoking status and wellness. Among smokers, we examined associations between lifetime smoking exposure, cessation behaviors and attitudes, and wellness. Compared to nonsmokers (n = 121), smokers (n = 274) reported more SSB consumption, poorer physical health, and more respiratory symptoms. Among smokers, SSB consumption and respiratory symptoms increased per ten pack-years of smoking. Smokers with respiratory symptoms reported higher motivation to quit and more use of nicotine replacement therapy (NRT). Smokers with more days of poor mental health reported lower motivation to quit. Overall, cigarette smoking was associated with other health-risk behaviors among SUD treatment patients. Respiratory symptoms may increase, and poor mental health may decrease, SUD patients' intent to quit smoking. To reduce chronic disease risk among SUD patients, treatment programs should consider promoting overall wellness concurrently with smoking cessation.

Adherence to Healthy Lifestyle and the Risk of Function Limitations in Late Life: The Atherosclerosis Risk in Communities Study

Background: Physiological function impairment is the main precursor of assisted living, movement disorder, and disability in the elderly. The relationship between a combination of healthy lifestyle factors and functional limitations is unclear. We investigated the association between healthy lifestyle scores and the risk of functional impairment in community residents.

Methods: A total of 10,602 participants (aged 40–64 years) of the Atherosclerosis Risk in Communities (ARIC) study with no history of cardiovascular events and tumors and who came for their fourth visit (1997–1999) were included in the final analysis. Primary outcomes were recorded during the fourth visit; these included impaired lower extremity function, activities of daily living, and instrumental activities of daily living. A logistic regression model was used to test the associations between healthy lifestyle scores and functional impairment. The lifestyle score comprised six factors: healthy diet, moderate alcohol consumption, coffee consumption, physical activity, normal body weight, and no smoking.

Results: Among the 10,602 participants with a median follow-up of 9 years, the prevalence rates of impaired lower extremity function, activities of daily living, and instrumental activities of daily living were 50.6%, 14.7%, and 21.6%, respectively. In the adjusted Cox regression model, participants with a healthy lifestyle score of 5 plus 6 had a significant lower risk of impaired lower extremity function (odds ratio = 0.252, 95% confidence interval: 0.184–0.344, P < 0.001), activities of daily living (odds ratio = 0.201, 95% confidence interval: 0.106–0.380, P < 0.001), and instrumental activities of daily living (odds ratio = 0.274, 95% confidence interval: 0.168–0.449, P < 0.001) than did participants with a score of 0. The association of healthy lifestyle scores with impaired activities of daily living and instrumental activities of daily living was stronger for individuals without diabetes than for those with it (P for interaction < 0.05). This can be partly explained by the fact that the lowest risk of functional impairment among the participants with diabetes was associated with being overweight.

Conclusion: Adherence to an overall healthy lifestyle was associated with a lower risk of physiological function limitation. This study highlights the importance of behavioral interventions in the prevention of disabilities.

Clinical Trial Registration: www.ClinicalTrials.gov; Unique identifier: NCT00005131.

Smoking cessation, metabolic risk behaviors, and stress management over time in a sample of young adult smokers

Smoking cessation may support changes in metabolic risk behaviors (e.g., high-fat diet, physical inactivity, poor sleep, low fruit and vegetable consumption [FVC]). We examined the association between smoking cessation and metabolic risk behavior profiles, mediated by readiness to change risk behaviors and moderated by stress management. Participants were young adult smokers in a randomized controlled trial of a Facebook smoking cessation intervention. Measures included stage of change for five metabolic risk behaviors: FVC, diet, physical activity, sleep hygiene, and stress management. Moderated mediation was used to examine relationships between smoking cessation at T1 (predictor), readiness to change metabolic risk behaviors at T2 (mediators), stress management at T3 (moderator), and metabolic risk behavior profile at T3 (outcome) over 9 months. T1 smoking abstinence was associated with greater readiness to increase FVC at T2, which predicted lower likelihood of T3 metabolic risk (β = -0.22, 95% confidence interval [CI] [-0.53, -0.03]). This indirect effect was moderated by stress management such that greater readiness to increase FVC at T2 was associated with lower T3 metabolic risk for participants with unmanaged stress (β = -0.90, 95% CI [-1.32, -0.49], p < .001), but not for participants with well-managed stress (β = -.22, 95% CI [-0.48, 0.04], p = .096). Young adults who quit smoking subsequently had lower metabolic risk behaviors. Among participants with unmanaged stress, those who quit smoking had greater readiness to increase FVC and lower likelihood of subsequent metabolic risk. Smoking cessation interventions could aim to teach broadly applicable behavior change skills and build confidence for decreasing metabolic risk.

A Tribute to the Mind, Methodology and Mentoring of Wayne Velicer

Wayne Velicer is remembered for a mind where mathematical concepts and calculations intrigued him, behavioral science beckoned him, and people fascinated him. Born in Green Bay, Wisconsin on March 4, 1944, he was raised on a farm, although early influences extended far beyond that beginning. His Mathematics BS and Psychology minor at Wisconsin State University in Oshkosh, and his PhD in Quantitative Psychology from Purdue led him to a fruitful and far-reaching career. He was honored several times as a high-impact author, was a renowned scholar in quantitative and health psychology, and had more than 300 scholarly publications and 54,000+ citations of his work, advancing the arenas of quantitative methodology and behavioral health. In his methodological work, Velicer sought out ways to measure, synthesize, categorize, and assess people and constructs across behaviors and time, largely through principal components analysis, time series, and cluster analysis. Further, he and several colleagues developed a method called Testing Theory-based Quantitative Predictions, successfully applied to predicting outcomes and effect sizes in smoking cessation, diet behavior, and sun protection, with the potential for wider applications. With $60,000,000 in external funding, Velicer also helped engage a large cadre of students and other colleagues to study methodological models for a myriad of health behaviors in a widely applied Transtheoretical Model of Change. Unwittingly, he has engendered indelible memories and gratitude to all who crossed his path. Although Wayne Velicer left this world on October 15, 2017 after battling an aggressive cancer, he is still very present among us.

Peer-Assisted Lifestyle (PAL) intervention: a protocol of a cluster-randomised controlled trial of a health-coaching intervention delivered by veteran peers to improve obesity treatment in primary care

INTRODUCTION

Among US veterans, more than 78% have a body mass index (BMI) in the overweight (≥25 kg/m²) or obese range (≥30 kg/m²). Clinical guidelines recommend multicomponent lifestyle programmes to promote modest, clinically significant body mass (BM) loss. Primary care providers (PCPs) often lack time to counsel and refer patients to intensive programmes (≥6 sessions over 3 months). Using peer coaches to deliver obesity counselling in primary care may increase patient motivation, promote behavioural change and address the specific needs of veterans. We describe the rationale and design of a cluster-randomised controlled trial to test the efficacy of the Peer-Assisted Lifestyle (PAL) intervention compared with enhanced usual care (EUC) to improve BM loss, clinical and behavioural outcomes (aim 1); identify BM-loss predictors (aim 2); and increase PCP counselling (aim 3).

METHODS AND ANALYSIS

We are recruiting 461 veterans aged 18-69 years with obesity or overweight with an obesity-associated condition under the care of a PCP at the Brooklyn campus of the Veterans Affairs NY Harbor Healthcare System. To deliver counselling, PAL uses in-person and telephone-based peer support, a tablet-delivered goal-setting tool and PCP training. Patients in the EUC arm receive non-tailored healthy living handouts. In-person data collection occurs at baseline, month 6 and month 12 for patients in both arms. Repeated measures modelling based on mixed models will compare mean BM loss (primary outcome) between study arms.

ETHICS AND DISSEMINATION

The protocol has been approved by the Institutional Review Board and the Research and Development Committee at the VA NY Harbor Health Systems (#01607). We will disseminate the results via peer-reviewed publications, conference presentations and meetings with stakeholders.

TRIAL REGISTRATION NUMBER

NCT03163264; Pre-results.

Multiple Health Risk Behaviors in Young Adult Smokers: Stages of Change and Stability over Time

BACKGROUND

Health risk behaviors (HRBs) are common, yet not well understood in young adult smokers.

PURPOSE

We examined HRB profiles over 12 months in young adult smokers participating in a Facebook smoking cessation intervention clinical trial.

METHODS

Participants (N = 500; age M = 20.9 years; 54.6% women) were recruited online and randomized to receive either a 3-month Facebook smoking cessation intervention or referral to Smokefree.gov (control). A Health Risk Assessment determined risk for 10 behaviors at baseline and 3, 6, and 12 months. Latent class analysis (LCA) and latent transition analysis (LTA) were used to identify patterns of HRBs and changes over time.

RESULTS

At baseline, participants reported an average of 5.4 (standard deviation [SD] = 1.7) risk behaviors, including smoking (100%), high-fat diet (84.8%), poor sleep hygiene (71.6%), and low fruit and vegetable intake (69.4%). A 3-class model fit the data best at baseline and all follow-up time points: low risk (28.8% at baseline) with low likelihood of risk on all behaviors except smoking, substance use risk (14.0% at baseline) characterized by heavy episodic drinking, cannabis use, and other illicit drug use, and metabolic risk (57.2% at baseline), with a high percentage of members at risk for a low fruit and vegetable intake, high-fat diet, inactivity, stress, and poor sleep hygiene. Classes were very stable at 3, 6, and 12 months, with few participants transitioning between classes.

CONCLUSIONS

Most young adult smokers engaged in multiple risk behaviors, with meaningful clustering of behaviors, and demonstrated stability over a year's time. In addition to smoking, targets for intervention are co-occurring substance use and metabolic risk behaviors.

CLINICAL TRIALS REGISTRATION

NCT02207036.

Factors associated with readiness to quit smoking among young adults enrolled in a Facebook-based tobacco and alcohol intervention study

INTRODUCTION

Young adults who smoke cigarettes often report heavy episodic drinking (HED) and co-use of other psychoactive substances which may complicate efforts to quit cigarette smoking. The current study examined factors associated with readiness to quit cigarette smoking among young adults who smoke and engage in HED.

METHODS

One hundred seventy-nine young adults aged 18 to 25 who reported regular cigarette smoking and past month HED enrolled in the 90-day Facebook-based Smoking Tobacco and Drinking (STAND) intervention study. Analyses compared baseline differences in patterns of cigarette smoking and alcohol and cannabis use, thoughts about abstinence, use of nicotine replacement therapy (NRT), sociodemographic characteristics, and other health behaviors between participants who were ready to quit cigarette smoking in the next 30 days and those who were not.

RESULTS

Participants were 40.2% female, 49.7% male, 10.1% non-binary, and 80.4% Non-Hispanic White. They reported on average moderate nicotine dependence (FTCD), moderate risk for alcohol use disorder (AUDIT), and occasional or regular cannabis use. Readiness to quit cigarette smoking in the next 30 days (33.5%) was positively associated with age (p = .021), NRT use in the past 30 days (p = .037) and perceived importance to also reduce alcohol use (p = .033).

CONCLUSIONS

Findings indicate that readiness to quit cigarette smoking among young adults who drink is positively associated with importance to reduce alcohol use, but not with use patterns or levels of dependence. Interventions addressing polysubstance use may be better suited to help young adults reduce or quit cigarette smoking once they signal readiness for behavior change.

The complex genetics and biology of human temperament: a review of traditional concepts in relation to new molecular findings

Recent genome-wide association studies (GWAS) have shown that temperament is strongly influenced by more than 700 genes that modulate associative conditioning by molecular processes for synaptic plasticity and long-term learning and memory. The results were replicated in three independent samples despite variable cultures and environments. The identified genes were enriched in pathways activated by behavioral conditioning in animals, including the two major molecular pathways for response to extracellular stimuli, the Ras-MEK-ERK and the PI3K-AKT-mTOR cascades. These pathways are activated by a wide variety of physiological and psychosocial stimuli that vary in positive and negative valence and in consequences for health and survival. Changes in these pathways are orchestrated to maintain cellular homeostasis despite changing conditions by modulating temperament and its circadian and seasonal rhythms. In this review we first consider traditional concepts of temperament in relation to the new genetic findings by examining the partial overlap of alternative measures of temperament. Then we propose a definition of temperament as the disposition of a person to learn how to behave, react emotionally, and form attachments automatically by associative conditioning. This definition provides necessary and sufficient criteria to distinguish temperament from other aspects of personality that become integrated with it across the life span. We describe the effects of specific stimuli on the molecular processes underlying temperament from functional, developmental, and evolutionary perspectives. Our new knowledge can improve communication among investigators, increase the power and efficacy of clinical trials, and improve the effectiveness of treatment of personality and its disorders.

Sustainable effect of individualised sun protection advice on sun protection behaviour: a 10-year follow-up of a randomised controlled study in primary care

Background

In the light of increasing skin cancer incidences worldwide, preventive measures to promote sun protection in individuals with risky sun habits have continued relevance and importance.

Aim

To report the long-term effect of individualised sun protection advice given in primary health care (PHC), on sun habits and sun protection behaviour.

Design & setting

In 2005, 309 PHC patients were enrolled in a randomised controlled study performed in a Swedish PHC setting.

Method

At baseline, the study participants completed a Likert scale-based questionnaire, mapping sun habits, propensity to increase sun protection, and attitudes towards sun exposure, followed by randomisation into three intervention groups, all receiving individualised sun protection advice: in Group 1 (n = 116) by means of a letter, and in Group 2 (n = 97) and 3 (n = 96) communicated personally by a GP. In Group 3, participants also underwent a skin ultraviolet-sensitivity phototest, with adjusted sun protection advice based on the result. A repeated questionnaire was administered after 3 and 10 years.

Results

Statistically significant declines were observed in all groups for sun exposure mean scores over time. When using a cumulative score, according to the Sun Exposure and Protection Index (SEPI), significantly greater decrease in SEPI mean score was observed in Groups 2 and 3 (GP), compared to Group 1 (letter); P<0.01. The addition of a phototest did not enhance the effect of the intervention.

Conclusion

Individualised sun protection advice mediated verbally by the GP can lead to sustained improvement of sun protective behaviour.

Protocol for a cluster-randomized controlled trial of a technology-assisted health coaching intervention for weight management in primary care: The GEM (goals for eating and moving) study

INTRODUCTION

Over one-third of American adults have obesity with increased risk of chronic disease. Primary care providers often do not counsel patients about weight management due to barriers such as lack of time and training. To address this problem, we developed a technology-assisted health coaching intervention called Goals for Eating and Moving (GEM) to facilitate obesity counseling within the patient-centered medical home (PCMH) model of primary care. The objective of this paper is to describe the rationale and design of a cluster-randomized controlled trial to test the GEM intervention when compared to Enhanced Usual Care (EUC).

METHOD

We have randomized 19 PCMH teams from two NYC healthcare systems (VA New York Harbor Healthcare System and Montefiore Medical Group practices) to either the GEM intervention or EUC. Eligible participants are English and Spanish-speaking primary care patients (ages 18-69 years) with obesity or who are overweight with comorbidity (e.g., arthritis, sleep apnea, hypertension). The GEM intervention consists of a tablet-delivered goal setting tool, a health coaching visit and twelve telephone calls for patients, and provider counseling training. Patients in the EUC arm receive health education materials. The primary outcome is mean weight loss at 1 year. Secondary outcomes include changes in waist circumference, diet, and physical activity. We will also examine the impact of GEM on obesity-related provider counseling competency and attitudes.

CONCLUSION

If GEM is found to be efficacious, it could provide a structured approach for improving weight management for diverse primary care patient populations with elevated cardiovascular disease risk.

Longitudinal analysis of intervention effects on temptations and stages of change for dietary fat using parallel process latent growth modeling

The Dietary Guidelines for Americans recommend a 20-35 percent daily intake of fat. Resisting the temptation to eat high-fat foods, in conjunction with stage of readiness to avoid these foods, has been shown to influence healthy behavior change. Data ( N = 6516) from three randomized controlled trials were pooled to examine the relationships among direct intervention effects on temptations and stage of change for limiting high-fat foods. Findings demonstrate separate simultaneous growth processes in which baseline level of temptations, but not the rate of change in temptations, was significantly related to the change in readiness to avoid high-fat foods.

Print-based self-help interventions for smoking cessation

BACKGROUND

Many smokers give up smoking on their own, but materials that provide a structured programme for smokers to follow may increase the number who quit successfully.

OBJECTIVES

The aims of this review were to determine the effectiveness of different forms of print-based self-help materials that provide a structured programme for smokers to follow, compared with no treatment and with other minimal contact strategies, and to determine the comparative effectiveness of different components and characteristics of print-based self-help, such as computer-generated feedback, additional materials, tailoring of materials to individuals, and targeting of materials at specific groups.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Trials Register, ClinicalTrials.gov, and the International Clinical Trials Registry Platform (ICTRP). The date of the most recent search was March 2018.

SELECTION CRITERIA

We included randomised trials of smoking cessation with follow-up of at least six months, where at least one arm tested print-based materials providing self-help compared with minimal print-based self-help (such as a short leaflet) or a lower-intensity control. We defined 'self-help' as structured programming for smokers trying to quit without intensive contact with a therapist.

DATA COLLECTION AND ANALYSIS

We extracted data in accordance with standard methodological procedures set out by Cochrane. The main outcome measure was abstinence from smoking after at least six months' follow-up in people smoking at baseline. We used the most rigorous definition of abstinence in each study and biochemically validated rates when available. Where appropriate, we performed meta-analysis using a random-effects model.

MAIN RESULTS

We identified 75 studies that met our inclusion criteria. Many study reports did not include sufficient detail to allow judgement of risk of bias for some domains. We judged 30 studies (40%) to be at high risk of bias for one or more domains.Thirty-five studies evaluated the effects of standard, non-tailored self-help materials. Eleven studies compared self-help materials alone with no intervention and found a small effect in favour of the intervention (n = 13,241; risk ratio (RR) 1.19, 95% confidence interval (CI) 1.03 to 1.37; I² = 0%). We judged the evidence to be of moderate certainty in accordance with GRADE, downgraded for indirect relevance to populations in low- and middle-income countries because evidence for this comparison came from studies conducted solely in high-income countries and there is reason to believe the intervention might work differently in low- and middle-income countries. This analysis excluded two studies by the same author team with strongly positive outcomes that were clear outliers and introduced significant heterogeneity. Six further studies of structured self-help compared with brief leaflets did not show evidence of an effect of self-help materials on smoking cessation (n = 7023; RR 0.87, 95% CI 0.71 to 1.07; I² = 21%). We found evidence of benefit from standard self-help materials when there was brief contact that did not include smoking cessation advice (4 studies; n = 2822; RR 1.39, 95% CI 1.03 to 1.88; I² = 0%), but not when self-help was provided as an adjunct to face-to-face smoking cessation advice for all participants (11 studies; n = 5365; RR 0.99, 95% CI 0.76 to 1.28; I² = 32%).Thirty-two studies tested materials tailored for the characteristics of individual smokers, with controls receiving no materials, or stage-matched or non-tailored materials. Most of these studies used more than one mailing. Pooling studies that compared tailored self-help with no self-help, either on its own or compared with advice, or as an adjunct to advice, showed a benefit of providing tailored self-help interventions (12 studies; n = 19,190; RR 1.34, 95% CI 1.20 to 1.49; I² = 0%) with little evidence of difference between subgroups (10 studies compared tailored with no materials, n = 14,359; RR 1.34, 95% CI 1.19 to 1.51; I² = 0%; two studies compared tailored materials with brief advice, n = 2992; RR 1.13, 95% CI 0.86 to 1.49; I² = 0%; and two studies evaluated tailored materials as an adjunct to brief advice, n = 1839; RR 1.72, 95% CI 1.17 to 2.53; I² = 10%). When studies compared tailored self-help with non-tailored self-help, results favoured tailored interventions when the tailored interventions involved more mailings than the non-tailored interventions (9 studies; n = 14,166; RR 1.42, 95% CI 1.20 to 1.68; I² = 0%), but not when the two conditions were contact-matched (10 studies; n = 11,024; RR 1.07, 95% CI 0.89 to 1.30; I² = 50%). We judged the evidence to be of moderate certainty in accordance with GRADE, downgraded for risk of bias.Five studies evaluated self-help materials as an adjunct to nicotine replacement therapy; pooling three of these provided no evidence of additional benefit (n = 1769; RR 1.05, 95% CI 0.86 to 1.30; I² = 0%). Four studies evaluating additional written materials favoured the intervention, but the lower confidence interval crossed the line of no effect (RR 1.20, 95% CI 0.91 to 1.58; I² = 73%). A small number of other studies did not detect benefit from using targeted materials, or find differences between different self-help programmes.

AUTHORS' CONCLUSIONS

Moderate-certainty evidence shows that when no other support is available, written self-help materials help more people to stop smoking than no intervention. When people receive advice from a health professional or are using nicotine replacement therapy, there is no evidence that self-help materials add to their effect. However, small benefits cannot be excluded. Moderate-certainty evidence shows that self-help materials that use data from participants to tailor the nature of the advice or support given are more effective than no intervention. However, when tailored self-help materials, which typically involve repeated assessment and mailing, were compared with untailored materials delivered similarly, there was no evidence of benefit.Available evidence tested self-help interventions in high-income countries, where more intensive support is often available. Further research is needed to investigate effects of these interventions in low- and middle-income countries, where more intensive support may not be available.

Using Facebook to address smoking and heavy drinking in young adults: Protocol for a randomized, controlled trial

INTRODUCTION

Tobacco and alcohol often are used simultaneously by young adults, and their co-use is associated with greater health consequences than from single use. Social media platforms offer low cost and highly accessible channels to reach and engage young people in substance use interventions. The current trial seeks to compare the Facebook Tobacco Status Project (TSP) smoking cessation intervention to an intervention targeting both tobacco use and heavy episodic drinking (TSP + ALC) among young adults who use both substances.

METHODS

This randomized clinical trial will evaluate the feasibility and initial efficacy of TSP + ALC compared to TSP with 225 US young adult smokers reporting heavy drinking. Participants will be recruited online and randomized to one of two conditions (TSP or TSP + ALC), both with assignment to a Facebook group tailored to readiness to quit smoking. Groups will receive a 90-day intervention including daily Facebook postings and weekly live counseling sessions. The TSP + ALC group will include content related to alcohol use. All participants will be offered a 2-week introductory supply of nicotine patch. Participants will complete baseline, 3-, 6-, and 12-month online assessments of substance use and other health risk behaviors. The primary efficacy outcome is biochemically-verified 7-day point prevalence abstinence. Secondary outcomes include alcohol and tobacco use, combined use, and thoughts about each substance.

DISCUSSION

This trial examines an innovative and scalable approach to engaging young adults online in tobacco and alcohol use treatment. Study findings will inform digital health interventions and best practices for treating multiple substance use in young adults.

Sustainable Transportation Attitudes and Health Behavior Change: Evaluation of a Brief Stage-Targeted Video Intervention

Promoting physical activity and sustainable transportation is essential in the face of rising health care costs, obesity rates, and other public health threats resulting from lack of physical activity. Targeted communications can encourage distinct population segments to adopt active and sustainable transportation modes. Our work is designed to promote the health, social, and environmental benefits of sustainable/active transportation (ST) using the Transtheoretical Model of Change (TTM), which has been successfully applied to a range of health, and more recently, sustainability behaviors. Earlier, measurement development confirmed both the structure of ST pros and cons and efficacy measures as well as the relationship between these constructs and ST stages of change, replicating results found for many other behaviors. The present paper discusses a brief pre-post video pilot intervention study designed for precontemplators and contemplators (N = 604) that was well received, effective in moving respondents towards increased readiness for ST behavior change, and improving some ST attitudes, significantly reducing the cons of ST. This research program shows that a brief stage-targeted behavior change video can increase readiness and reduce the cons for healthy transportation choices.

Baseline Predictors of Singular Action Among Participants With Multiple Health Behavior Risks

PURPOSE

Previous studies found that treatment effects can change two behaviors, but not one. This study examined baseline transtheoretical model constructs as three alternative predictors (stage of change, effort, and severity) of singular action among participants with co-occurring health behavior risks.

DESIGN

The study examined participants at risk for three pairs of behaviors (sun and smoking; smoking and diet; and diet and sun). Analyses were conducted with participants who changed only one behavior in a pair (singular action).

SETTING

School and home-based behavior change programs recruited participants via schools, worksites, and physician practices. School, worksite, medical, and home-based prevention programs were the study setting.

SUBJECTS

The sample (N = 3213) was age 44.6 years (SD, 11.1 years), 94.6% white, and 63.7% female.

MEASURES

Stages of change, effort, and severity variables were measured.

ANALYSIS

Pooled data were analyzed using logistic regressions from three randomized controlled trials.

RESULTS

Across all three behaviors, stage of change, effort, and severity effects were consistently related to behavior change at 24 months. Change efforts on one behavior were related to change on another behavior. Baseline sun severity (odds ratio, .97 [.94, 1.00]; p = .046) and smoking severity (odds ratio, .89 [.80, .98]; p = .019) were significant predictors of change on diet at final follow-up.

CONCLUSION

Stage of change was the biggest predictor. Problem severity was the smallest predictor of change at 2-year follow-up. Four of six predictors were within behaviors, whereas two were between.

Intervening on Exercise and Nutrition in Older Adults

Presented are the basic design, methods, and baseline data analyses for the Study of Exercise and Nutrition in Older Rhode Islanders (SENIOR Project) an experimental study to investigate the relative effectiveness of a 12-month, stage of readiness to change-based multiple-behavior intervention (exercise and nutrition) compared to single-behavior interventions in a community-dwelling population of 1,277 older adults. Relationships between stage of readiness to change in the two target behaviors, as well as the relationship between stage of readiness and self-reported exercise levels and fruit and vegetable consumption, were examined using a combination of Pearson chi-squares, analyses of variance (ANOVA), and Spearman’s rank order correlations. Stage of change (SOC) for fruit and vegetable consumption was significantly associated with the dietary measure, and SOC for exercise was associated with both the three physical activity measures and servings of fruits and vegetables per day. Overall, individual older adult's readiness to change seems largely to be behavior-specific.

Population Treatment for Addictions

Addictive behaviors are major causes of chronic disease, premature death, and high health care costs. Such behaviors have not been treated seriously by health care systems, and this is a major reason why such systems face an unhealthy future. Treating addictions seriously requires complementing a traditional individual-patient paradigm with a population paradigm, an action paradigm with a stage paradigm, clinic practices with home-based practices, a clinician paradigm with a computer paradigm, and programs that focus on changing single behaviors with programs that focus on changing multiple behaviors.

Stages of change and factors associated with misperceived eating behavior in obese individuals

ABSTRACT Objective: To evaluate the stages of behavior change related to fat and fruit/vegetable intakes and the factors associated with misperceived eating behavior (pseudo-maintenance). Methods: This cross-sectional study collected sociodemographic, socioeconomic, health, and food intake data from obese individuals (n=103) aged ≥20 years. Stages of behavior change according to the Transtheoretical Model were measured for fat and fruit/vegetable intakes. The pseudo-maintenance stage was reclassified in subjects in the action/maintenance stage who had inappropriate food habits. Multiple logistic regression models were proposed to assess the factors associated with misperceptions. Results: The prevalences of pseudo-maintenance for fat and fruit/vegetable intakes were 23.3 and 19.4%, respectively. The factors associated with misperceived fat intake were overconsumption of saturated fatty acids (OR=3.84; 1.18-12.56) and age (OR=1.06; 1.02-1.11), and with fruit and vegetable intake, income (OR=0.99; 0.98-0.99). Conclusion: The results reveal that perceived eating behavior and actual food intake diverge from anthropometric and health data, signaling the need of different intervention strategies to raise awareness in this group for the need of modifications.

Motivation for HPV Vaccination among Young Adult Men: Validation of TTM Decisional Balance and Self-Efficacy Constructs

Purpose.

In the United States, 36% of human papillomavirus (HPV)–related cancers occur among men. HPV vaccination can substantially reduce the risk of HPV infection; however, the vast majority of men are unvaccinated. This study developed and validated transtheoretical model–based measures for HPV vaccination in young adult men.

Design.

Cross-sectional measurement development.

Setting.

Online survey of young adult men.

Subjects.

Three hundred twenty-nine mostly college-attending men, ages 18 to 26.

Measures.

Stage of change, decisional balance (pros/cons), and self-efficacy.

Analysis.

The sample was randomly split into halves for exploratory principal components analysis (PCA), followed by confirmatory factor analyses (CFA) to test measurement models. Multivariate analyses examined relationships between scales.

Results.

For decisional balance, PCA revealed two uncorrelated five-item factors (pros α = .78; cons α = .83). For the self-efficacy scale, PCA revealed a single-factor solution (α = .83). CFA confirmed that the two-factor uncorrelated model for decisional balance and a single-factor model for self-efficacy. Follow-up analyses of variance supported the theoretically predicted relationships between stage of change, pros, and self-efficacy.

Conclusion.

This study resulted in reliable and valid measures of pros and self-efficacy for HPV vaccination that can be used in future clinical research.

Fat Reduction Efforts

This research examined dynamic transtheoretical model (TTM) constructs for dietary fat reduction. This secondary data analysis pooled three large population-based TTM-tailored school, worksite, medical, and home-based intervention studies and examined use of constructs across three groups organized by longitudinal progress (dynatypes): Maintainers, Relapsers, and Stable Non-Changers. The criteria for successful change, at the time, were that less than 30% of calories came from fat. A total of 2,718 adults met criteria for an unhealthy diet at baseline. The majority of participants were female, White, married, and middle-aged. Demographics, Stage of Change, Processes of Change, Decisional Balance, and Temptations were measured. Dynatype groups were assessed with reliable and valid scales assessing constructs at baseline and 6, 12, and 24 months. Analyses included a multivariate analysis of variance followed by a series of analyses of variance, with Tukey follow-up tests assessing differences in use of TTM constructs across the three groups at each time point. Relapsers and Maintainers were similar in their use of all TTM Processes of Change at baseline, with the exception of Self-Liberation (η2 = 0.15, p < .001) and Reinforcement Management (η2 = 0.01, p < .001). Although Relapsers reverted to an unhealthy diet, their overall greater use of Processes of Change suggests that their behaviors and strategy use remain better than that of the Stable Non-Changer group. Results suggest that specific cognitive and behavioral constructs may contribute differentially to intervention outcomes.

Reducing Sun Exposure for Prevention of Skin Cancers: Factorial Invariance and Reliability of the Self-Efficacy Scale for Sun Protection

The Self-Efficacy Scale for Sun Protection consists of two correlated factors with three items each for Sunscreen Use and Avoidance. This study evaluated two crucial psychometric assumptions, factorial invariance and scale reliability, with a sample of adults (N = 1356) participating in a computer-tailored, population-based intervention study. A measure has factorial invariance when the model is the same across subgroups. Three levels of invariance were tested, from least to most restrictive: (1) Configural Invariance (nonzero factor loadings unconstrained); (2) Pattern Identity Invariance (equal factor loadings); and (3) Strong Factorial Invariance (equal factor loadings and measurement errors). Strong Factorial Invariance was a good fit for the model across seven grouping variables: age, education, ethnicity, gender, race, skin tone, and Stage of Change for Sun Protection. Internal consistency coefficient Alpha and factor rho scale reliability, respectively, were .84 and .86 for Sunscreen Use, .68 and .70 for Avoidance, and .78 and .78 for the global (total) scale. The psychometric evidence demonstrates strong empirical support that the scale is consistent, has internal validity, and can be used to assess population-based adult samples.

Transtheoretical Model Constructs' Longitudinal Prediction of Sun Protection Over 24 Months

PURPOSE

This research examined dynamic transtheoretical model (TTM) constructs for adopting sun protection practices. This secondary data analysis pooled four large population-based TTM-tailored intervention studies and examined use of constructs across three groups, organized by longitudinal progress: maintainers, relapsers, and stable non-changers.

METHODS

A total of 3463 adults, in the USA, who met criteria for unsafe sun exposure at baseline received a TTM-tailored computerized intervention at baseline, 6 months, and 12 months. The final analytic sample consisted of 1894 participants; the majority were female, White, married, and middle-aged. The three groups were assessed with reliable and valid scales assessing use of TTM constructs at baseline, 6 months, 12 months, and 24 months. Analyses included a MANOVA followed by a series of ANOVAs, with Tukey follow-up tests assessing differences in use of TTM constructs across the three groups at each timepoint.

RESULTS

Findings demonstrated that relapsers and maintainers were similar in their use of most TTM processes of change at baseline, with the exception of Consciousness Raising, Stimulus Control, Reinforcement Management, and Self-Liberation.

CONCLUSIONS

These findings suggest that although relapsers reverted to unsafe sun practices, their overall greater use of processes of change indicates that their change efforts remain better than that of stable non-changers.

Brazilian consensus on photoprotection

Brazil is a country of continental dimensions with a large heterogeneity of climates and massive mixing of the population. Almost the entire national territory is located between the Equator and the Tropic of Capricorn, and the Earth axial tilt to the south certainly makes Brazil one of the countries of the world with greater extent of land in proximity to the sun. The Brazilian coastline, where most of its population lives, is more than 8,500 km long. Due to geographic characteristics and cultural trends, Brazilians are among the peoples with the highest annual exposure to the sun. Epidemiological data show a continuing increase in the incidence of non-melanoma and melanoma skin cancers. Photoprotection can be understood as a set of measures aimed at reducing sun exposure and at preventing the development of acute and chronic actinic damage. Due to the peculiarities of Brazilian territory and culture, it would not be advisable to replicate the concepts of photoprotection from other developed countries, places with completely different climates and populations. Thus the Brazilian Society of Dermatology has developed the Brazilian Consensus on Photoprotection, the first official document on photoprotection developed in Brazil for Brazilians, with recommendations on matters involving photoprotection.

Mediation analysis of decisional balance, sun avoidance and sunscreen use in the precontemplation and preparation stages for sun protection

OBJECTIVE

Mediation analyses of sun protection were conducted testing structural equation models using longitudinal data with three waves. An effect was said to be mediated if the standardised path between processes of change, decisional balance and sun protection outcomes was significant.

DESIGN

Longitudinal models of sun protection using data from individuals in the precontemplation (N = 964) and preparation (N = 463) stages who participated of an expert system intervention.

MAIN OUTCOME MEASURES

Nine processes of change for sun protection, decisional balance constructs of sun protection (pros and cons), sun avoidance behaviour and sunscreen use.

RESULTS

With the exception of two processes in the preparation stage, processes of change predicted the pros (r = .126-.614), and the pros predicted the outcomes (r = .181-.272). Three models with the cons as mediator in the preparation stage, and none in the precontemplation stage, showed a mediated relationship between processes and outcomes.

CONCLUSION

In general, mediation analyses found both the process of change-to-pros and pros-to-behaviour paths significant for both precontemplation and preparation stages, and for both sun avoidance and sunscreen use outcomes. Findings provide support for the importance of assessing the role of underlying risk cognitions in improving sun protection adherence.

Understanding self-reported staging of dietary behavior in low-income women

This study examined self-reported staging for the goal of eating a low-fat diet and several specific dietary consumption behaviors to understand better readiness for dieting. Self-assessed motivation, food frequency measures, and psychosocial variables were obtained from 2057 low-income women enrolled in the Maryland Food for Life Program. Results indicated that staging of specific dietary consumption behaviors was significantly related to staging for the global goal of eating a low-fat diet. Women evaluate their motivation about eating low-fat diets based on perceived efforts and specific activities related to dietary consumption with important implications for dietary behavior change measurement and interventions.

Differential attrition in health behaviour change trials: a systematic review and meta-analysis

OBJECTIVE

Attrition is a common problem in health behaviour change (HBC) trials. When the degree of attrition differs between treatment conditions, then this is called differential attrition and is regarded as a major threat to internal validity. The primary research question of this study was: how often and to what degree does differential attrition occur in HBC trials?

DESIGN

A systematic review and meta-analysis of a random selection of HBC trials (k = 60). We meta-analysed the relative attrition rates using a random-effects model and examined the relationship between the relative attrition rates and the potential moderators: the amount of human contact in delivery and the intensity of the intervention/control condition, the type of control condition, and the follow-up intensity and duration.

MAIN OUTCOME MEASURES

Relative attrition rates.

RESULTS

The average attrition rate was 18% (SD = .15; M = .15) in the intervention and 17% (SD = .13; M = .13) in the control conditions. The estimated average relative attrition rate was 1.10 (95% CI: 1.01-1.20, p = .02), suggesting an overall higher attrition rate of 10% in the intervention conditions. This relative attrition rate was not related to any of the potential moderators.

CONCLUSION

There is indication of a slightly higher amount of attrition on average in the intervention conditions of HBC trials.

Randomized trial outcomes of a TTM-tailored condom use and smoking intervention in urban adolescent females

Smoking and sexual risk behaviors in urban adolescent females are prevalent and problematic. Family planning clinics reach those who are at most risk. This randomized effectiveness trial evaluated a transtheoretical model (TTM)-tailored intervention to increase condom use and decrease smoking. At baseline, a total of 828 14- to 17-year-old females were recruited and randomized within four urban family planning clinics. Participants received TTM or standard care (SC) computerized feedback and stage-targeted or SC counseling at baseline, 3, 6 and 9 months. Blinded follow-up telephone surveys were conducted at 12 and 18 months. Analyses revealed significantly more consistent condom use in the TTM compared with the SC group at 6 and 12, but not at 18 months. In baseline consistent condom users (40%), significantly less relapse was found in the TTM compared with the SC group at 6 and 12, but not at 18 months. No significant effects for smoking prevention or cessation were found, although cessation rates matched those found previously. This TTM-tailored intervention demonstrated effectiveness for increasing consistent condom use at 6 and 12 months, but not at 18 months, in urban adolescent females. This intervention, if replicated, could be disseminated to promote consistent condom use and additional health behaviors in youth at risk.

Can skin cancer prevention and early detection be improved via mobile phone text messaging? A randomised, attention control trial

OBJECTIVE

To test the impact of a theory-based, SMS (text message)-delivered behavioural intervention (Healthy Text) targeting sun protection or skin self-examination behaviours compared to attention control.

METHOD

Overall, 546 participants aged 18-42 years were randomised using a computer-generated number list to the skin self-examination (N=176), sun protection (N=187), or attention control (N=183) text messages group. Each group received 21 text messages about their assigned topic over 12 months (12 weekly messages for 3 months, then monthly messages for the next 9 months). Data were collected via telephone survey at baseline, 3, and 12 months across Queensland from January 2012 to August 2013.

RESULTS

One year after baseline, the sun protection (mean change 0.12; P=0.030) and skin self-examination groups (mean change 0.12; P=0.035) had significantly greater improvement in their sun protection habits (SPH) index compared to the attention control group (reference mean change 0.02). The increase in the proportion of participants who reported any skin self-examination from baseline to 12 months was significantly greater in the skin self-examination intervention group (103/163; 63%; P<0.001) than the sun protection (83/173; 48%) or attention control (65/165; 36%) groups. There was no significant effect of the intervention for participants' self-reported whole-body skin self-examination, sun tanning, or sunburn behaviours.

CONCLUSION

The Healthy Text intervention was effective in inducing significant improvements in sun protection and any type of skin self-examination behaviours.

TRIAL REGISTRATION

The Australian and New Zealand Clinical Trials register (ACTRN12612000577819).

FUNDING

Cancer Australia 1011999.

Adaptation of a counseling intervention to address multiple cancer risk factors among overweight/obese Latino smokers

More than 60% of cancer-related deaths in the United States are attributable to tobacco use, poor nutrition, and physical inactivity, and these risk factors tend to cluster together. Thus, strategies for cancer risk reduction would benefit from addressing multiple health risk behaviors. We adapted an evidence-based intervention grounded in social cognitive theory and principles of motivational interviewing originally developed for smoking cessation to also address physical activity and fruit/vegetable consumption among Latinos exhibiting multiple health risk behaviors. Literature reviews, focus groups, expert consultation, pretesting, and pilot testing were used to inform adaptation decisions. We identified common mechanisms underlying change in smoking, physical activity, and diet used as treatment targets; identified practical models of patient-centered cross-cultural service provision; and identified that family preferences and support as particularly strong concerns among the priority population. Adaptations made to the original intervention are described. The current study is a practical example of how an intervention can be adapted to maximize relevance and acceptability and also maintain the core elements of the original evidence-based intervention. The intervention has significant potential to influence cancer prevention efforts among Latinos in the United States and is being evaluated in a sample of 400 Latino overweight/obese smokers.

Stages and Processes of Change Utilized by Female Sex Workers Participating in an Alcohol-Reduction Intervention in Mombasa, Kenya

BACKGROUND

According to the transtheoretical model (TTM) behavior change occurs through a series of steps when an individual becomes aware of a behavior, prepares to change, and executes those changes using certain processes. This model has not yet been used to describe alcohol-reduction behavior change processes in resource-limited settings.

OBJECTIVE

This qualitative analysis aimed to describe and characterize the stages and processes of change employed by female sex workers in Mombasa, Kenya during the course of their participation in a 6-month alcohol reduction intervention.

METHODS

In 2011-2012, clinical interviews were conducted with 45 female sex workers. One interview was conducted each month during the intervention period, resulting in a total of six transcripts per participant. During each interview, the counselor noted the participant's stage of change and recent alcohol use. The clinical notes were analyzed via qualitative coding techniques and organized into matrices to classify alcohol reduction strategies discussed by participants.

RESULTS

Participants discussed using the stage-specific processes of change described by the TTM to reduce their alcohol use and maintain the behavior change. Participants who were HIV-positive at the start of the intervention seemed to progress to the action/maintenance stage more quickly than HIV-negative participants.

CONCLUSIONS/IMPORTANCE

Results suggest that the TTM constructs may be relevant in understanding the alcohol reduction behavior change process of an at-risk population in a resource-limited setting. Future quantitative research should seek to validate the TTM's application internationally. Alcohol interventions should consider tailoring content to participants' stages of change and HIV-status for increased effectiveness.

Validity and stability of the decisional balance for sun protection inventory

The 8-item Decisional Balance for sun protection inventory (SunDB) assesses the relative importance of the perceived advantages (Pros) and disadvantages (Cons) of sun protective behaviors. This study examined the psychometric properties of the SunDB measure, including invariance of the measurement model, in a population-based sample of N = 1336 adults. Confirmatory factor analyses supported the theoretically based 2-factor (Pros, Cons) model, with high internal consistencies for each subscale (α ≥ .70). Multiple-sample CFA established that this factor pattern was invariant across multiple population subgroups, including gender, racial identity, age, education level, and stage of change subgroups. Multivariate analysis by stage of change replicated expected patterns for SunDB (Pros η² = .15, Cons η² = .02). These results demonstrate the internal and external validity and measurement stability of the SunDB instrument in adults, supporting its use in research and intervention.

Concurrent occurrence of multiple positive lifestyle behaviors and depression among adults in the United States

BACKGROUND

To our knowledge, no studies have examined the dose-response association between concurrent occurrence of multiple positive health behaviors and depression. As a result, the purpose of this study was to examine the dose-response association between concurrent occurrence of lifestyle behaviors (i.e., diet, physical activity, and smoking) on depression symptoms among a national sample of U.S. adults (20-85 yr).

METHODS

Using data from the 2005-2006 NHANES (n=2574), diet was assessed from the healthy eating index variable; physical activity was assessed via accelerometry; smoking was assessed from cotinine levels; and depression was assessed from the Patient Health Questionnaire 9 (PHQ-9).

RESULTS

Each lifestyle behavior was independently associated with depression in the expected direction, and there was also evidence of a dose-response relationship. Compared to those having 0 positive lifestyle factors, those with 1, 2, and 3 positive lifestyle factors, respectively, were 15% (p=0.38), 67% (p=0.001), and 82% (p=0.01) less likely to be classifed as having moderate or greater depression symptoms (PHQ-9 ≥10).

LIMITATIONS

The main limitation of this study was the cross-sectional design.

CONCLUSION

there is a dose-response relationship between concurrent occurrence of positive lifestyle behaviors and depression symptoms.

Development and evaluation of a mobile intervention for heavy drinking and smoking among college students

Nearly all college student smokers also drink alcohol, and smoking and heavy episodic drinking (HED) commonly co-occur. However, few studies have examined the factors that concurrently influence smoking and HED among college students and, to date, no interventions have been developed that target both HED and smoking in this population. The objective of the current study was to develop and evaluate a mobile feedback intervention that targets HED and smoking. Participants (N = 94) were non-treatment-seeking college students (M(age) = 20.5 years, SD = 1.7) who engaged in at least a single HED episode in the past 2 weeks and reported concurrent smoking and drinking at least once a week. Participants were randomized to receive either the mobile intervention for 14 days, complete mobile assessments (without intervention) for 14 days, or complete minimal assessments (without intervention or mobile assessments). At a 1-month follow-up, compared with the minimal assessment condition, we observed significant reductions in the number of cigarettes per smoking day in both the mobile intervention (d = 0.55) and mobile assessment (d = 0.45) conditions. Among those randomized to the mobile intervention, receiving more modules of the intervention was significantly associated with a lower likelihood of any drinking during the 14-day assessment period and significant reductions in smoking at 1-month follow-up. The mobile intervention did not result in significant reductions in HED or concurrent smoking and drinking. Future research should continue to examine ways of using technology and the real-time environment to improve interventions for HED and smoking.

A systematic review of single health behavior change interventions vs. multiple health behavior change interventions among older adults

Multiple behavior change is widely used to reduce targeted health behaviors; however, its effect on behaviors such as physical activity, nutrition, and alcohol and tobacco use among older adults remains inconclusive. The primary purpose of this systematic review was to evaluate the effects of single health behavior change (SHBC) interventions vs. multiple health behavior change (MHBC) interventions among older age individuals. PubMed was searched for publications on health behavior interventions from 2006 to 2011. Twenty-one randomized clinical trials assessed the effects of health behavior change in older individuals. Results were reviewed by a number of health behaviors and effectiveness. Results revealed that within SHBC interventions, physical activity or exercise behavior revealed that interventions were the most common and showed the most promise in influencing positive outcomes in physical activity behavior among community-dwelling older adults. There were too few MHBC studies identified to allow confident comparison to SHBC interventions. The MHBC field is still at an early stage within the older adult literature, and more attention is recommended to investigate if the benefits of MHBC apply to this age group.

Print-based self-help interventions for smoking cessation

BACKGROUND

Many smokers give up smoking on their own, but materials giving advice and information may help them and increase the number who quit successfully.

OBJECTIVES

The aims of this review were to determine: the effectiveness of different forms of print-based self-help materials, compared with no treatment and with other minimal contact strategies; the effectiveness of adjuncts to print-based self help, such as computer-generated feedback, telephone hotlines and pharmacotherapy; and the effectiveness of approaches tailored to the individual compared with non-tailored materials.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group trials register. Date of the most recent search April 2014.

SELECTION CRITERIA

We included randomized trials of smoking cessation with follow-up of at least six months, where at least one arm tested a print-based self-help intervention. We defined self help as structured programming for smokers trying to quit without intensive contact with a therapist.

DATA COLLECTION AND ANALYSIS

We extracted data in duplicate on the participants, the nature of the self-help materials, the amount of face-to-face contact given to intervention and to control conditions, outcome measures, method of randomization, and completeness of follow-up.The main outcome measure was abstinence from smoking after at least six months follow-up in people smoking at baseline. We used the most rigorous definition of abstinence in each trial, and biochemically validated rates when available. Where appropriate, we performed meta-analysis using a fixed-effect model.

MAIN RESULTS

We identified 74 trials which met the inclusion criteria. Many study reports did not include sufficient detail to judge risk of bias for some domains. Twenty-eight studies (38%) were judged at high risk of bias for one or more domains but the overall risk of bias across all included studies was judged to be moderate, and unlikely to alter the conclusions.Thirty-four trials evaluated the effect of standard, non-tailored self-help materials. Pooling 11 of these trials in which there was no face-to-face contact and provision of structured self-help materials was compared to no intervention gave an estimate of benefit that just reached statistical significance (n = 13,241, risk ratio [RR] 1.19, 95% confidence interval [CI] 1.04 to 1.37). This analysis excluded two trials with strongly positive outcomes that introduced significant heterogeneity. Six further trials without face-to-face contact in which the control group received alternative written materials did not show evidence for an effect of the smoking self-help materials (n = 7023, RR 0.88, 95% CI 0.74 to 1.04). When these two subgroups were pooled, there was no longer evidence for a benefit of standard structured materials (n = 20,264, RR 1.06, 95% CI 0.95 to 1.18). We failed to find evidence of benefit from providing standard self-help materials when there was brief contact with all participants (5 trials, n = 3866, RR 1.17, 95% CI 0.96 to 1.42), or face-to-face advice for all participants (11 trials, n = 5365, RR 0.97, 95% CI 0.80 to 1.18).Thirty-one trials offered materials tailored for the characteristics of individual smokers, with controls receiving either no materials, or stage matched or non-tailored materials. Most of the trials used more than one mailing. Pooling these showed a benefit of tailored materials (n = 40,890, RR 1.28, 95% CI 1.18 to 1.37) with moderate heterogeneity (I² = 32%). The evidence is strongest for the subgroup of nine trials in which tailored materials were compared to no intervention (n = 13,437, RR 1.35, 95% CI 1.19 to 1.53), but also supports tailored materials as more helpful than standard materials. Part of this effect could be due to the additional contact or assessment required to obtain individual data, since the subgroup of 10 trials where the number of contacts was matched did not detect an effect (n = 11,024, RR 1.06, 95% CI 0.94 to 1.20). In two trials including a direct comparison between tailored materials and brief advice from a health care provider, there was no evidence of a difference, but confidence intervals were wide (n = 2992, RR 1.13, 95% CI 0.86 to 1.49).Only four studies evaluated self-help materials as an adjunct to nicotine replacement therapy, with no evidence of additional benefit (n = 2291, RR 1.05, 95% CI 0.88 to 1.25). A small number of other trials failed to detect benefits from using additional materials or targeted materials, or to find differences between different self-help programmes.

AUTHORS' CONCLUSIONS

Standard, print-based self-help materials increase quit rates compared to no intervention, but the effect is likely to be small. We did not find evidence that they have an additional benefit when used alongside other interventions such as advice from a healthcare professional, or nicotine replacement therapy. There is evidence that materials that are tailored for individual smokers are more effective than non-tailored materials, although the absolute size of effect is still small. Available evidence tested self-help interventions in high income countries; further research is needed to investigate their effect in contexts where more intensive support is not available.

Examining Relationships between Multiple Health Risk Behaviors, Well-Being, and Productivity

Traditionally, the concept of health promotion has emphasized the reduction of health risk behaviors to reduce disease and impairment. Well-being research expands this focus to include positive constructs such as thriving, productivity, life-evaluation, and emotional and physical health. The objective of the present study was to examine the relationships between health risk behaviors and specific measures of individual well-being. Participants ( N = 790) from 49 states completed a one-time online assessment that included the Life-Evaluation Index, Emotional and Physical Health Ladders, the Health Risk Intervention Assessment, and the Work Productivity and Activity Improvement Questionnaire for General Health. Life Evaluation and physical and emotional health were all inversely related to the number of health risk behaviors, with higher well-being scores associated with lower number of risk behaviors. Across the three Life Evaluation categories (Suffering, Struggling, and Thriving) the number of health risk behaviors decreased, productivity loss decreased, and emotional and physical health increased. The results add to previous research on how reducing multiple health risk behaviors can be combined with well-being, i.e., an emphasis on increasing life-evaluation, emotional and physical health, better functioning, and productivity.

Multiple risk-behavior profiles of smokers with serious mental illness and motivation for change

OBJECTIVE

Individuals with serious mental illness (SMI) are dying on average 25 years prematurely. The leading causes are chronic preventable diseases. In the context of a tobacco-treatment trial, this exploratory study examined the behavioral risk profiles of adults with SMI to identify broader interventional needs.

METHOD

Recruited from five acute inpatient psychiatry units, participants were 693 adult smokers (recruitment rate = 76%, 50% male, 45% Caucasian, age M = 39, 49% had income < $10,000) diagnosed with mood disorders (71%), substance-use disorders (63%), posttraumatic stress disorder (39%), psychotic disorders (25%), and attention deficit-hyperactivity disorder (25%). The Staging Health Risk Assessment, the primary measure used in this study, screened for risk status and readiness to change 11 health behaviors, referencing the period prior to acute hospitalization.

RESULTS

Participants averaged 5.2 (SD = 2.1) risk behaviors, including smoking (100%), high-fat diet (68%), inadequate fruits/vegetables (67%), poor sleep (53%), physical inactivity (52%), and marijuana use (46%). The percent prepared to change ranged from 23% for tobacco and marijuana to 76% for depression management. Latent class analysis differentiated three risk groups: the global higher risk group included patients elevated on all risk behaviors; the global lower risk group was low on all risks; and a mood and metabolic risk group, characterized by inactivity, unhealthy diet, sleep problems, and poor stress and depression management. The global higher risk group (11% of sample) was younger, largely male, and had the greatest number of risk behaviors and mental health diagnoses; had the most severe psychopathologies, addiction-treatment histories, and nicotine dependence; and the lowest confidence for quitting smoking and commitment to abstinence.

CONCLUSION

Most smokers with SMI engaged in multiple risks. Expanding targets to treat co-occurring risks and personalizing treatment to individuals' multibehavioral profiles may increase intervention relevance, interest, and impact on health.

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.

Co-occurrence and coaction of stress management with other health risk behaviors

This study provides a preliminary investigation of the role of stress management in multiple behavior change. Risk status on stress management and five health behaviors (healthy eating, exercise, alcohol, smoking, and depression management) was assessed before and after a multiple behavior change intervention. Findings suggested a link between stress management and a worse health risk behavior profile at baseline. Results also showed relationships between improved stress management over 6 months and heightened odds of improving on specific behaviors as well as improving one's overall behavioral risk profile. Particularly strong links between stress management and energy balance and other affective behaviors were observed.

Baseline transtheoretical and dietary behavioral predictors of dietary fat moderation over 12 and 24 months

Longitudinal predictors of dietary behavior change are important and in need of study. This secondary data analysis combined primary data across three randomized trials to examine transtheoretical model (TTM) and specific dietary predictors of successful dietary change at 12 and 24 months separately in treatment and control groups (N = 4178). The treatment group received three TTM-tailored print interventions over 12 months between 1995 and 2000. Chi-square and MANOVA analyses were used to examine baseline predictors of dietary outcome at 12 and 24 months. Last, a multivariable logistic regression was conducted with all baseline variables included. Across all analyses in both treatment and control groups, the most robust predictors of successful change were for TTM-tailored treatment group, preparation stage of change, and increased use of dietary behavior variables such as moderating fat intake, substitution of lower fat foods, and increasing intake of healthful foods. These results provide strong evidence for treatment, stage and behavioral dietary severity effects predicting dietary behavior change over time, and for targeting these variables with the strongest relationships to outcome in interventions, such as TTM-tailored dietary interventions.

Person-centered Health Promotion in Chronic Disease

Health promotion must be person-centered, not organ- or disease-centered, in order to be effective because physical, mental, social, and spiritual aspects of human functioning are inextricably intertwined. Chronic medical disorders, such as heart disease, chronic obstructive pulmonary disease, diabetes, cancer, asthma, and arthritis, are strongly associated with immature personality, emotional instability, and social dysfunction. All indicators of physical, mental, and social well-being are strongly related to the level of maturity and integration of personality, so personality is a useful focus for the promotion of well-being. Assessment of personality also facilitates the awareness of the clinician and the patient about the patient's strengths, weaknesses, and goals, thereby contributing to an effective therapeutic alliance. Health, well-being, resilience, and recovery of function all involve increasing levels of the character traits of Self-directedness, Cooperativeness, and Self-transcendence. Person-centered programs that enhance self-regulation of functioning to achieve personally valued goals improve compliance with medical treatment and quality of life in people with chronic disease. Effective therapeutic approaches to health promotion activate a complex adaptive system of feedback interactions among functioning, plasticity, and virtuous ways of thinking and acting. The probability of personality change can be predicted by high levels of Self-transcendence, which give rise to an outlook of unity and connectedness, particularly when combined with the temperament traits of high Novelty Seeking and high Persistence. In summary, person-centered psychobiological treatments that facilitate the development of well-being and personality development are crucial in the prevention, treatment, and rehabilitation of chronic medical diseases.

Promotion of Sun-Protective Behaviors

Promoting sun-protective behaviors is important because decreased exposure to ultraviolet radiation (UVR) reduces the risk of skin cancer. However, many individuals deliberately engage in overexposure to UVR for cosmetic purposes. Due to this and other factors, the need for prevention programs is clear. Several efficacious prevention strategies have been developed for the health care setting.

Treatment-enhanced paired action contributes substantially to change across multiple health behaviors: secondary analyses of five randomized trials

The dominant paradigm of changing multiple health behaviors (MHBs) is based on treating, assessing, and studying each behavior separately. This study focused on individuals with co-occurring baseline health-risk behavior pairs and described whether they changed over time on both or only one of the behaviors within each pair. Data from five randomized trials of computer-tailored interventions (CTIs) that simultaneously treated MHBs were analyzed. The differences between treatment and control proportions that achieved paired action and singular action at 24 months follow-up, and the proportional contribution of paired action to overall change on each behavior, were assessed across 12 behavior pairs (including energy balance, addictive, and appearance-related behaviors). CTIs consistently produced more paired action across behavior pairs. Paired action contributed substantially more to the treatment-related outcomes than singular action. Studying concurrent changes on MHBs as demonstrated allows the effect of simultaneously treating MHBs to be assessed.

A systematic review of randomized controlled trials on the effectiveness of computer-tailored physical activity and dietary behavior promotion programs: an update

Background

A review update is necessary to document evidence regarding the effectiveness of computer-tailored physical activity and nutrition education.

Purpose

The purpose of this study was to summarize the latest evidence on the effectiveness of computer-tailored physical activity and nutrition education, and to compare the results to the 2006 review.

Methods

Databases were searched for randomized controlled trials evaluating computer-tailored physical activity and nutrition education aimed at primary prevention in adults, published from September 2004 through June 2011.

Results

Compared to the findings in 2006, a larger proportion of studies found positive effects for computer-tailored programs compared to generic or no information, including those for physical activity promotion. Effect sizes were small and generally at short- or medium-term follow-up.

Conclusions

The results of the 2006 review were confirmed and reinforced. Future interventions should focus on establishing larger effect sizes and sustained effects and include more generic health education control groups and objective measurements of dietary behavior.

Electronic supplementary material

The online version of this article (doi:10.1007/s12160-012-9384-3) contains supplementary material, which is available to authorized users.

Multiple behavior interventions to prevent substance abuse and increase energy balance behaviors in middle school students

This study examined the effectiveness of two transtheoretical model-tailored, computer-delivered interventions designed to impact multiple substance use or energy balance behaviors in a middle school population recruited in schools. Twenty middle schools in Rhode Island including sixth grade students (N=4,158) were stratified and randomly assigned by school to either a substance use prevention (decreasing smoking and alcohol) or an energy balance (increasing physical activity, fruit and vegetable consumption, and limiting TV time) intervention group in 2007. Each intervention involved five in-class contacts over a 3-year period with assessments at 12, 24, and 36 months. Main outcomes were analyzed using random effects modeling. In the full energy balance group and in subsamples at risk and not at risk at baseline, strong effects were found for physical activity, healthy diet, and reducing TV time, for both categorical and continuous outcomes. Despite no direct treatment, the energy balance group also showed significantly lower smoking and alcohol use over time than the substance use prevention group. The energy balance intervention demonstrated strong effects across all behaviors over 3 years among middle school students. The substance use prevention intervention was less effective than the energy balance intervention in preventing both smoking and alcohol use over 3 years in middle school students. The lack of a true control group and unrepresented secular trends suggest the need for further study.

Outcomes of cluster profiles within stages of change for sun protection behavior

OBJECTIVE

Predictive and external validity was studied among cluster profiles for sun protection behavior within stages from Transtheoretical Model of behavior change using follow-up data.

METHODS

Data from participants in a home-based expert system were analyzed. Longitudinal patterns of clusters on the precontemplation, contemplation, and preparation stages of change were assessed. Differences between clusters on membership in action/maintenance stages and scores on the Sun Protection Behavior Scale (SPBS) were measured at 12 and 24 months after intervention.

RESULTS

Differences between clusters on stage progression and on scores from the SPBS were found at 12 and 24 months after intervention at all stages.

DISCUSSION

Predictive and external validity of sun protection subtypes was established using sun protection variables after a stage-matched intervention. Results provide information to improve interventions for sun protection.

Latent class analysis of stages of change for multiple health behaviors: results from the Special Diabetes Program for Indians Diabetes Prevention Program

This study sought to identify latent subgroups among American Indian and Alaska Native (AI/AN) patients with pre-diabetes based on their stages of change for multiple health behaviors. We analyzed baseline data from participants of the Special Diabetes Program for Indians Diabetes Prevention (SDPI-DP) Program, a lifestyle intervention program to prevent diabetes among AI/ANs. A total of 3,135 participants completed baseline questionnaires assessing stages of change for multiple health behaviors, specifically exercise, healthy eating, and weight loss. Latent class analysis was used to identify subgroups of people based on their answers to stages of change questions. Covariates were added to the latent class analyses to investigate how class membership was related to sociodemographic, behavioral, and psychosocial factors. Three classes were identified based on the distributions of the stages of change variables: Contemplation, Preparation, and Action/Maintenance classes. Male and retired participants were more likely to be in more advanced stages. Those who exercised more, ate healthier diets, and weighed less were significantly more likely to be in the Action/Maintenance class. Further, the participants who had higher self-efficacy, stronger family support, and better health-related quality of life had higher odds of being in the Action/Maintenance class. In conclusion, we found that stages of change for multiple behaviors can be summarized by a three-class model in this sample. Investigating the relationships between latent classes and intervention outcomes represents important next steps to extend the findings of the current study.