Adherence Across Behavioral Domains in Treatment Promoting Smoking Cessation Plus Weight Control

The Implementation of Behavior Change Techniques in mHealth Apps for Sleep: Systematic Review

Background

Mobile health (mHealth) apps targeting health behaviors using behavior change techniques (BCTs) have been successful in promoting healthy behaviors; however, their efficacy with sleep is unclear. Some work has shown success in promoting sleep through mHealth, whereas there have been reports that sleep apps can be adverse and lead to unhealthy obsessions with achieving perfect sleep.

Objective

This study aims to report and describe the use of BCTs in mHealth apps for sleep with the following research questions: How many BCTs are used on average in sleep apps, and does this relate to their effectiveness on sleep outcomes? Are there specific BCTs used more or less often in sleep apps, and does this relate to their effectiveness on sleep outcomes? Does the effect of mHealth app interventions on sleep change when distinguishing between dimension and measurement of sleep?

Methods

We conducted a systematic review following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to review articles on mHealth app interventions for sleep published between 2010 and 2020.

Results

A total of 12 studies met the eligibility criteria. Most studies reported positive sleep outcomes, and there were no negative effects reported. Sleep quality was the most common dimension of sleep targeted. Subjective measures of sleep were used across all apps, whereas objective measures were often assessed but rarely reported as part of results. The average number of BCTs used was 7.67 (SD 2.32; range 3-11) of 16. Of the 12 studies, the most commonly used BCTs were feedback and monitoring (n=11, 92%), shaping knowledge (n=11, 92%), goals and planning (n=10, 83%), and antecedents (n=10, 83%), whereas the least common were scheduled consequences (n=0, 0%), self-belief (n=0, 0%), and covert learning (n=0, 0%). Most apps used a similar set of BCTs that unfortunately did not allow us to distinguish which BCTs were present when studies reported more positive outcomes.

Conclusions

Our study describes the peer-reviewed literature on sleep apps and provides a foundation for further examination and optimization of BCTs used in mHealth apps for sleep. We found strong evidence that mHealth apps are effective in improving sleep, and the potential reasons for the lack of adverse sleep outcome reporting are discussed. We found evidence that the type of BCTs used in mHealth apps for sleep differed from other health outcomes, although more research is needed to understand how BCTs can be implemented effectively to improve sleep using mHealth and the mechanisms of action through which they are effective (eg, self-efficacy, social norms, and attitudes).

The Effectiveness of Sequentially Delivered Web-Based Interventions on Promoting Physical Activity and Fruit-Vegetable Consumption Among Chinese College Students: Mixed Methods Study

Background

Web-based interventions for multiple health behavior change (MHBC) appear to be a promising approach to change unhealthy habits. Limited research has tested this assumption in promoting physical activity (PA) and fruit-vegetable consumption (FVC) among Chinese college students. Moreover, the timing of MHBC intervention delivery and the order of components need to be addressed.

Objective

This study aims to examine the effectiveness of 2 sequentially delivered 8-week web-based interventions on physical activity, FVC, and health-related outcomes (BMI, depression, and quality of life) and the differences in the intervention effects between the 2 sequential delivery patterns. The study also aims to explore participants’ experiences of participating in the health program.

Methods

We conducted a randomized controlled trial, in which 552 eligible college students (mean 19.99, SD 1.04 years, 322/552, 58.3% female) were randomly assigned to 1 of 3 groups: PA-first group (4 weeks of PA followed by 4 weeks of FVC intervention), FVC-first group (4 weeks of FVC followed by 4 weeks of PA intervention), and a control group (8 weeks of placebo treatment unrelated to PA and FVC). The treatment content of two intervention groups was designed based on the Health Action Process Approach (HAPA) framework. A total of four web-based assessments were conducted: at baseline (T1, n=565), after 4 weeks (T2, after the first behavior intervention, n=486), after 8 weeks (T3, after the second behavior intervention, n=420), and after 12 weeks (T4, 1-month postintervention follow-up, n=348). In addition, after the completion of the entire 8-week intervention, 18 participants (mean 19.56, SD 1.04 years, 10/18, 56% female) who completed the whole program were immediately invited to attend one-to-one and face-to-face semistructured interviews. The entire study was conducted during the fall semester of 2017.

Results

The quantitative data supported superior effects on physical activity, FVC, and BMI in the 2 sequential intervention groups compared with the control group. There were no significant differences in physical activity, FVC, and health-related outcomes between the 2 intervention groups after 8 weeks. The FVC-first group contributed to more maintenance of FVC compared with the PA-first group after 12 weeks. Four major themes with several subthemes were identified in the qualitative thematic analysis: PA and FVC behavior, health-related outcomes, correlates of behavior change, and contamination detection.

Conclusions

This study provides empirical evidence for the effectiveness of sequentially delivered, web-based MHBC interventions on PA and FVC among Chinese college students. The timing issue of MHBC intervention delivery was preliminarily addressed. Qualitative findings provide an in-depth understanding and supplement the quantitative findings. Overall, this study may contribute considerably to future web-based MHBC interventions.

Trial Registration

ClinicalTrials.gov NCT03627949; https://clinicaltrials.gov/ct2/show/NCT03627949

International Registered Report Identifier (IRRID)

RR2-10.1186/s12889-019-7438-1

Assessment of factors related to smokers' adherence to a short-term support group for smoking cessation: a longitudinal study in a developing country

Objective:

The aim of this study was to determine which individual characteristics of smokers are associated with their adherence to a support group for smoking cessation.

Methods:

Smokers from Porto Alegre, Brazil, were invited to participate in a support group for smoking cessation consisting of four weekly sessions. Demographic data, smoking history, presence of tobacco-related diseases, severity of nicotine dependence, stage of motivation, and symptoms of anxiety and depression were evaluated at baseline. Adherence was defined as attendance at group sessions and was measured at the second and fourth sessions of the program.

Results:

The study recruited 167 smokers who attended the first meeting and met criteria for admission to the study. One hundred and two of the participants returned to the second session and only 55 of those who attended the first meeting completed the four-week program. For immediate adherence (second session), adult smokers over the age of 35 were more likely to adhere to the treatment (p = 0.004), whereas smoking higher numbers of cigarettes per day was associated with lower adherence to attendance at group meetings (p = 0.031). For final adherence (fourth session), only minimal level symptoms of anxiety were associated with a higher likelihood of adherence (p = 0.02).

Conclusions:

Older smokers, those who smoked fewer cigarettes per day, and those with lower levels of anxiety exhibited higher rates of adherence to a smoking cessation support group.

Comparative efficacy of simultaneous versus sequential multiple health behavior change interventions among adults: A systematic review of randomised trials

BACKGROUND

Growing evidence points to the benefits of addressing multiple health behaviors rather than single behaviors.

PURPOSE

This review evaluates the relative effectiveness of simultaneous and sequentially delivered multiple health behavior change (MHBC) interventions. Secondary aims were to identify: a) the most effective spacing of sequentially delivered components; b) differences in efficacy of MHBC interventions for adoption/cessation behaviors and lifestyle/addictive behaviors, and; c) differences in trial retention between simultaneously and sequentially delivered interventions.

METHODS

MHBC intervention trials published up to October 2015 were identified through a systematic search. Eligible trials were randomised controlled trials that directly compared simultaneous and sequential delivery of a MHBC intervention. A narrative synthesis was undertaken.

RESULTS

Six trials met the inclusion criteria and across these trials the behaviors targeted were smoking, diet, physical activity, and alcohol consumption. Three trials reported a difference in intervention effect between a sequential and simultaneous approach in at least one behavioral outcome. Of these, two trials favoured a sequential approach on smoking. One trial favoured a simultaneous approach on fat intake. There was no difference in retention between sequential and simultaneous approaches.

CONCLUSIONS

There is limited evidence regarding the relative effectiveness of sequential and simultaneous approaches. Given only three of the six trials observed a difference in intervention effectiveness for one health behavior outcome, and the relatively consistent finding that the sequential and simultaneous approaches were more effective than a usual/minimal care control condition, it appears that both approaches should be considered equally efficacious. PROSPERO registration number: CRD42015027876.

Club drug use in Hispanic college students

Club drug use and correlates were examined among 251 Hispanic college students on the Texas-México border. Participants completed questionnaires on substance use, club drug attitudes and beliefs, sexual risk-taking behaviors, depressive symptoms, and acculturation. One-quarter of participants reported club drug use. Regression analyses demonstrated that frequency and history of lifetime use were consistently associated with more permissive drug attitudes and other substance use but not sexual risk-taking, depression symptoms, or acculturation. Acculturation was negatively associated with frequency of club drug use, yet positively associated with use of other illicit substances. Avenues for future studies are suggested.

Adherence is a multi-dimensional construct in the POUNDS LOST trial

Research on the conceptualization of adherence to treatment has not addressed a key question: Is adherence best defined as being a uni-dimensional or multi-dimensional behavioral construct? The primary aim of this study was to test which of these conceptual models best described adherence to a weight management program. This ancillary study was conducted as a part of the POUNDS LOST trial that tested the efficacy of four dietary macronutrient compositions for promoting weight loss. A sample of 811 overweight/obese adults was recruited across two clinical sites, and each participant was randomly assigned to one of four macronutrient prescriptions: (1) Low fat (20% of energy), average protein (15% of energy); (2) High fat (40%), average protein (15%); (3) Low fat (20%), high protein (25%); (4) High fat (40%), high protein (25%). Throughout the first 6 months of the study, a computer tracking system collected data on eight indicators of adherence. Computer tracking data from the initial 6 months of the intervention were analyzed using exploratory and confirmatory analyses. Two factors (accounting for 66% of the variance) were identified and confirmed: (1) behavioral adherence and (2) dietary adherence. Behavioral adherence did not differ across the four interventions, but prescription of a high fat diet (vs. a low fat diet) was found to be associated with higher levels of dietary adherence. The findings of this study indicated that adherence to a weight management program was best conceptualized as being multi-dimensional, with two dimensions: behavioral and dietary adherence.

Sequential Treatment for Nicotine Dependence and Postcessation Weight Concern in a Female Diagnosed with Paranoid Schizophrenia

Despite declines in smoking prevalence, some populations represent significant challenges to tobacco cessation programs, including smokers with psychiatric comorbidity and/or weight concerns. Few studies have found effective interventions for tobacco cessation or addressed the prevalence of smoking-related concerns in psychiatric populations. The side effects of many psychotropic medications, decreased participation in physical activity, and weight gain following cessation suggest that postcessation weight concerns and actual weight gain may be significant barriers to cessation as well. Therefore, serial interventions, rather than simultaneous ones, seem well suited to address these issues. This case study represents the piloting of serial cessation and postcessation weight gain prevention interventions in a female diagnosed with paranoid schizophrenia. Results suggested that the serial implementation of cognitive-behavioral interventions can be effective in promoting tobacco cessation in individuals with co-occurring disorders.

Can following the caloric restriction recommendations from the Dietary Guidelines for Americans help individuals lose weight?

BACKGROUND

The Dietary Guidelines for Americans recommend creating an energy deficit of at least 500 kcal a day to facilitate weight loss. This investigation examined the relationship between creating a consistent, self-reported energy deficit of at least 500 kcal a day and weight loss. The relationship between self-monitoring adherence and daily energy intake and expenditure and weight loss was also examined.

METHODS

Fifty-four overweight or obese adults (BMI>or=27 kg/m(2)) participating in a 14-week weight loss program were given a 5% total body weight loss goal and instructed to create an energy deficit of at least 500 kcal a day to facilitate weight loss. Participants provided daily records of total energy intake and expenditure, physical activity, and weekly and overall weight loss during treatment.

RESULTS

Individuals who averaged an energy deficit in excess of 500 kcal per day lost nearly four times the weight as individuals whose average energy deficit was below 500 kcal per day (p<.01). Individuals who lost 5% of their body weight during the intervention self-monitored more than twice as many days than individuals who failed to lose 5% of their body weight (p<.01).

CONCLUSION

Individuals interested in losing weight should continue to be advised to regularly self-monitor energy intake and expenditure as well as to create a consistent daily energy deficit (e.g., 500 kcal day).

Outcomes of a Home-Based Walking Program for African-American Women

Purpose.

As compared with minimal treatment (MT), to determine the effectiveness of a home-based walking intervention enhanced by behavioral strategies targeted and tailored to African-American women (enhanced treatment [ET]) on adherence, physical activity, fitness, and body composition at 24 and 48 weeks.

Design.

Using a quasi-experimental design, treatments were randomly assigned to one of two community health centers.

Setting.

The centers were in predominately African-American communities.

Participants.

Sedentary women (156 ET, 125 MT) 40 to 65 years were recruited within a 3-mile radius of each center.

Intervention.

Both treatments had the same orientation. The ET group had four targeted workshops followed by weekly tailored telephone calls over 24 weeks.

Methods.

Generalized linear mixed models were used to test effects of treatments on adherence, physical activity, aerobic fitness, and body composition.

Results.

Adherence was significantly higher in the ET than the MT group and was related to the number of workshops attended (r = .58) and tailored calls (r = .25) received. On-treatment analysis showed significant postintervention improvement in waist circumference and fitness in the ET group; however, these improvements were not statistically different between the two groups. Intent to treat analysis showed a significant increase in fitness, decrease in waist circumference, and no change in body mass index in both treatments.

Conclusion.

Findings suggest the potential impact of workshop group support on adherence in African-American women.

A randomized trial of sequential and simultaneous multiple behavior change interventions for physical activity and fat intake

BACKGROUND

Major questions remain unanswered about how best to accomplish multiple behavior change. The purpose of this study was to evaluate whether there are differences in successfully changing multiple behaviors in computer-tailored sequential and simultaneous interventions for physical activity (PA) promotion and fat intake (FI) reduction.

METHODS

Participants (N=567) were randomly assigned to receive an intervention for PA and FI simultaneously; PA at baseline and FI at 3 months; or FI at baseline and PA at 3 months. Successful behavior change at 6 months was defined as: >60 min PA increase and/or 5% FI reduction. Using multinomial logistic regression the odds ratios of successful behaviors change (none, PA only, FI only, or both) were determined for intervention mode, gender, age, BMI and education.

RESULTS

Overall drop-out was 26%. There was no behavior change for 20.2% of participants; 30.5% successfully decreased FI; 15.8% successfully increased PA; 33.5% successfully changed both behaviors. Intervention mode, gender and age were not associated with successful behavior change. Compared to those that did not change any behaviors: participants that successfully changed FI were more likely to be overweight/obese (OR=1.85); and participants that successfully changed both behaviors were more likely to be overweight/obese (OR=2.13) and have lower education (OR=2.46).

CONCLUSIONS

Success in changing multiple behaviors was not associated with intervention mode; both simultaneous and sequential interventions can be applied. Being overweight might be an extra motivator to change health behaviors.

Workplace Stressors and Lifestyle‐Related Cancer Risk Factors among Female Physicians: Assessment Using the Occupational Stress Index

This study examined the relationship between work stressors and lifestyle-related cancer risk factors (LRCRF): smoking, obesity, sedentariness and alcohol consumption, among 112 female physicians in Novi Sad, a region of high LRCRF prevalence. The participation rate was 92.6%. Participants completed the physician-specific version of the Occupational Stress Index (OSI). Self-reported data concerning LRCRF and working conditions were cross-validated with medical records, as well as with worksite measurements and expert observations. A total of 35 (31.3%) of the physicians were current smokers and 10 (8.9%) were heavy smokers (>20 cigarettes/day); 23 (20.5%) had a body mass index (BMI) of 28 or more, and 11 (9.8%) were obese (BMI> or =30). Only 27 (24.1%) regularly engaged in recreational physical activity (PA). Slightly over 5% consumed alcohol daily. Altogether 15 (13.4%) had a low lifestyle-related cancer risk profile (not a current smoker, BMI<28, regular recreational PA and no daily alcohol consumption). Total OSI and several OSI aspects, particularly threat avoidance alone or in combination, showed significant multivariate associations with LRCRF, as did individual OSI elements. The latter included long work hours, restricted problem-solving strategy, insufficient help with clinical difficulties and supervisory responsibility (obesity and/or sedentariness) and problems hampering patient care (smoking). There is an urgent need to lower the LRCRF among female physicians in this high risk region. Our findings suggest that diminishing the work stressor burden should be considered when developing intervention strategies aimed at these risk factors.

Effect of nicotine on negative affect among more impulsive smokers

In the present study, the authors tested the hypothesis that nicotine would provide greater relief from negative affect for more impulsive smokers than for less impulsive smokers. Euthymic adult smokers (N=70) participated in 2 laboratory sessions, during which they underwent a negative mood induction (music + autobiographical memory), then smoked either a nicotinized or de-nicotinized cigarette. Mixed-effects regression yielded a significant Impulsivity x Condition (nicotinized vs. de-nicotinized) x Time interaction. Simple effects analyses showed that heightened impulsivity predicted greater negative affect relief after smoking a nicotinized cigarette but not after smoking a de-nicotinized cigarette. These data suggest that nicotine may be a disproportionately powerful negative reinforcer for highly impulsive smokers, promoting higher levels of nicotine dependence and inhibiting smoking cessation.