Results of the Healthy Body Healthy Spirit Trial

Effectiveness of behavioural interventions with motivational interviewing on physical activity outcomes in adults: systematic review and meta-analysis

OBJECTIVE

To evaluate the effectiveness of behavioural interventions that include motivational interviewing on physical activity outcomes in adults.

DESIGN

Systematic review and meta-analysis.

STUDY SELECTION

A search of seven databases for randomised controlled trials published from inception to 1 March 2023 comparing a behavioural intervention including motivational interviewing with a comparator without motivational interviewing on physical activity outcomes in adults. Outcomes of interest were differences in change in quantitative measures of total physical activity, moderate to vigorous physical activity (MVPA), and sedentary time.

DATA EXTRACTION AND SYNTHESIS

Two reviewers extracted data and assessed risk of bias. Population characteristics, intervention components, comparison groups, and outcomes of studies were summarised. For overall main effects, random effects meta-analyses were used to report standardised mean differences (SMDs) and 95% confidence intervals (CIs). Differential effects based on duration of follow-up, comparator type, intervention duration, and disease or health condition of participants were also examined.

RESULTS

129 papers reporting 97 randomised controlled trials totalling 27 811 participants and 105 comparisons were included. Interventions including motivational interviewing were superior to comparators for increases in total physical activity (SMD 0.45, 95% CI 0.33 to 0.65, equivalent to 1323 extra steps/day; low certainty evidence) and MVPA (0.45, 0.19 to 0.71, equivalent to 95 extra min/week; very low certainty evidence) and for reductions in sedentary time (-0.58, -1.03 to -0.14, equivalent to -51 min/day; very low certainty evidence). Evidence for a difference in any outcome compared with comparators of similar intensity was lacking. The magnitude of effect diminished over time, and evidence of an effect of motivational interviewing beyond one year was lacking. Most interventions involved patients with a specific health condition, and evidence of an effect of motivational interviewing to increase MVPA or decrease sedentary time was lacking in general population samples.

CONCLUSIONS

Certainty of the evidence using motivational interviewing as part of complex behavioural interventions for promoting total physical activity in adults was low, and for MVPA and sedentary time was very low. The totality of evidence suggests that although interventions with motivational interviewing increase physical activity and decrease sedentary behaviour, no difference was found in studies where the effect of motivational interviewing could be isolated. Effectiveness waned over time, with no evidence of a benefit of motivational interviewing to increase physical activity beyond one year.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020219881.

Effect of Intermittent vs. Continuous Energy Restriction on Visceral Fat: Protocol for The Healthy Diet and Lifestyle Study 2 (HDLS2)

Obesity in the United States and Western countries represents a major health challenge associated with an increased risk of metabolic diseases, including cardiovascular disease, hypertension, diabetes, and certain cancers. Our past work revealed a more pronounced obesity-cancer link in certain ethnic groups, motivating us to develop a tailored dietary intervention called the Healthy Diet and Lifestyle 2 (HDLS2). The study protocol is described herein for this randomized six-month trial examining the effects of intermittent energy restriction (5:2 Diet) plus the Mediterranean dietary pattern (IER + MED) on visceral adipose tissue (VAT), liver fat, and metabolic biomarkers, compared to a standard MED with daily energy restriction (DER + MED), in a diverse participant group. Using MRI and DXA scans for body composition analysis, as well as metabolic profiling, this research aims to contribute to nutritional guidelines and strategies for visceral obesity reduction. The potential benefits of IER + MED, particularly regarding VAT reduction and metabolic health improvement, could be pivotal in mitigating the obesity epidemic and its metabolic sequelae. The ongoing study will provide essential insights into the efficacy of these energy restriction approaches across varied racial/ethnic backgrounds, addressing an urgent need in nutrition and metabolic health research. Registered Trial, National Institutes of Health, ClinicalTrials.gov (NCT05132686).

Cultural Sensitivity and Cultural Tailoring: Lessons Learned and Refinements After Two Decades of Incorporating Culture in Health Communication Research

In this article, we examine progress and challenges in designing, implementing, and evaluating culturally sensitive behavioral interventions by tailoring health communication to groups or individuals. After defining common tailoring constructs (i.e., culture, race, and ethnicity), cultural sensitivity, and cultural tailoring, we examine when it is useful to culturally tailor and address cultural sensitivity in health communication by group tailoring or individual tailoring and when tailoring health communication may not be necessary or appropriate for achieving behavior change. After reviewing selected approaches to cultural tailoring, we critique the quality of research in this domain with a focus on the internal validity of empirical findings. Then we explore the ways in which cultural sensitivity, group targeting, and individual tailoring have incorporated culture in health promotion and health communication. We conclude by articulating yet unanswered questions and suggesting future directions to move the field forward.

Assessing Hair Concerns and Physical Activity Measures Among African American Women: a Mixed-Method Exploratory Study

OBJECTIVES

Research on the association between hair concerns and physical activity (PA) constructs among African American (AA) women is lacking. Demographics such as age and income are indicated to influence hair concerns. In this study, quantitative methods were used to assess demographic differences in hair concerns and associations between hair concerns and PA. Qualitative interviewing explored AA women's views about their hair and engagement in PA.

METHODS

Participants (n = 48; M age = 37.57, SD = 13.72) completed a survey that included demographics, hair type and hairstyle management (HTHM), decisional balance (pros, cons), perceived benefits and perceived barriers scale, and level of physical activity. HTHM consists of six items measuring different factors related to hair concerns. 25 completed a qualitative interview. Chi-square or analysis of variance tests were conducted as appropriate. Qualitative data were analyzed using content analysis.

RESULTS

Proportion differences were noted between age groups (≤ 32 vs. ≥ 33) and average cost of haircare per month (p = .048). A statistically significant effect was noted for average monthly haircare cost and pros (p = .05), and for alter behavior due to hair concerns and perceived benefits to physical activity (p = .05). For level of physical activity, proportion differences were noted between exercisers and non-exercisers for average minutes spent on hair care (p = .009). Qualitative results showed few participants view hair concern as an important barrier to PA. Some participants suggested strategies for overcoming hair concerns to exercise (e.g., braids, twists).

CONCLUSION

Implications of findings including development of PA intervention approaches that may appeal to AA women are discussed.

Mighty Men: A Pilot Test of the Feasibility and Acceptability of a Faith-Based, Individually Tailored, Cluster-Randomized Weight Loss Trial for Middle-Aged and Older African American Men

Two in five African American men have obesity, but they are underrepresented in community-based weight loss interventions. This pilot effectiveness trial examines the acceptability and feasibility of the first weight loss study for African American men that includes randomization and individual tailoring. Using a community-based, cluster-randomized, longitudinal parallel group design, four churches were randomized to a control condition or a weight loss condition. Each church received physical activity equipment, a coordinator, and small group physical activity sessions. A total of 71 African American men (mean age: 58.5) enrolled and received a Fitbit, Bluetooth-enabled scale, a t-shirt, gift cards for participation, and 45 min of small group physical activity led by a certified personal trainer. Men in the weight loss condition also received 45 min of health education and individually tailored SMS text messages. Multiple metrics suggest that Mighty Men was feasible, yet the acceptability of the intervention components was mixed. Participants in both the weight loss and control conditions lost weight between zero and 6 months (p < .001), but body fat (p = .005) and visceral fat percentage (p = .001) of men in the weight loss condition decreased while men in the control condition did not (p < .05). An increase in physical activity was seen among men in the weight loss condition (p = .030) but not among men in the control condition (p < .05). It is acceptable and feasible to conduct a 6-month weight loss intervention with African American men that includes randomization and individually tailored text messages.

Rationale and design of the Heart-to-Heart study: A church-based intervention to reduce blood pressure in African Americans

Heart-to-Heart (H2H) is a church-based behavioral cluster randomized trial to measure the effectiveness of a lifestyle education program for reducing blood pressure (BP) in African American adults with uncontrolled BP. Design and implementation of this study were informed by our ALIVE pilot study conducted with church pastors and leaders using a community-based participatory research methodology. The current study employs a cross-over design in which all participants receive two 6-month programs in different orders: the intervention arm receives the H2H program first, followed by a financial education program, and the comparator arm receives the programs in the reverse order. Approximately 34 churches will be randomized with the aim of including at least 272 participants across churches. The H2H program consists of 24 weekly dietitian-led diet and lifestyle virtual education sessions, 12 Bible studies taught by the church pastor reinforcing positive dietary behaviors from a biblical perspective, daily self-monitoring of BP, and, as needed, one-on-one support from a community health worker to assist with medication adherence. The Money Smart program consists of 14 financial education sessions and 12 Bible studies teaching the biblical basis of good financial management over a 6-month period. The primary outcome measure is systolic BP at 6 months with a follow-up at 12 months. Secondary outcome measures include medication adherence, Dietary Approaches to Stop Hypertension (DASH) diet adherence, self-efficacy for hypertension self-care, social support for eating a healthy diet, hypertension and nutrition knowledge, beliefs about medicines, barriers to medication use, depression, and financial knowledge and behaviors.

Cooking Interventions for Improving Diet Quality Among Black Americans: A Randomized Controlled Trial

BACKGROUND

Non-Hispanic Black Americans experience the highest, and most rapidly increasing, rates of obesity. Despite evidence that this is at least somewhat related to poor diet quality, we have yet to identify effective interventions for improving diet quality long-term. Restrictive diets can be ineffective and often harmful. In contrast, there is a well-established connection between home cooking and lower body mass index, better diet quality, and improved health.

PURPOSE

The present study applied the Theory of Planned Behavior (TPB) to examine the effect of an intervention delivering cooking instruction, rather than nutrition information, on beliefs, attitudes, and behaviors pertaining to diet quality and cooking among Black adults in the USA.

METHODS

An online sample of Black Americans (N = 147), ages 18-76 (M = 30.69, SD = 10.42) were recruited via Prolific and randomized to view either a cooking tutorial video or a "standard of care" control webpage followed by either an implementation intentions (II) writing activity or a "freestyle" control writing activity. Cognitions and behavior related to healthy eating and cooking were measured at baseline, post-intervention, and 1-week follow-up.

RESULTS

Results of mixed-effects modeling indicated that participants randomized to the video condition reported significantly greater post-intervention intentions to cook (p < .001), which positively correlated with cooking behavior over the subsequent week (p < .01). There was no effect of the II intervention on subsequent-week behavior (ps > .413). Importantly, 75% (n = 105) indicated experiencing food insecurity at the time of data collection.

CONCLUSIONS

These results highlight a promising pathway for improving nutrition and diet-related health outcomes among Black Americans while highlighting that any intervention must account for food insecurity in this population.

Effects of Sports, Exercise Training, and Physical Activity in Children with Congenital Heart Disease-A Review of the Published Evidence

Children and adolescents with congenital heart disease (CHD) should be encouraged to adopt a physically active lifestyle, ideally by participating in sports activities at school and sports clubs. Children with complex CHD or other risk factors (for example, pacemakers, cardioverter-defibrillators, channelopathies) may, however, need specific individualized training programs. This review article summarizes the current knowledge regarding the clinical effects of sports and exercise training on CHD and its pathophysiologic mechanisms. An evidence-based approach based on a literature search, using PubMed, Medline, CINHAL, Embase, and the Cochrane Library was conducted, last completed on 30 December 2021. In studies with 3256 CHD patients in total, including 10 randomized controlled trials, 14 prospective interventional trials, 9 observational trials, and 2 surveys, exercise training has been shown to improve exercise capacity and physical activity, motoric skills, muscular function, and quality of life. Sports and exercise training appears to be effective and safe in CHD patients. Despite being cost-efficient, training programs are currently scarcely reimbursed; therefore, support from healthcare institutions, commissioners of healthcare, and research-funding institutions is desirable. There is a strong need to establish specialized rehabilitation programs for complex CHD patients to enhance these patients' access to this treatment intervention. Further studies may be desirable to confirm these data to investigate the impact on risk profiles and to identify the most advantageous training methodology and underlying pathophysiological mechanisms.

The Effectiveness of Nutritional Education Interventions on Dietary Intake in Young Black Males: A Near-Empty Systematic Review

The incidence of several diet and lifestyle-related diseases, previously seen only in adults, is increasing in prevalence in young people. The Black population, and particularly Black males, are at high risk of developing lifestyle-related diseases. Adolescence and young adulthood are considered a transitional period with increasing independence and responsibility, along with the development of lifelong lifestyle habits. This systematic review aimed to establish which methods and approaches to nutritional education interventions are the most effective in improving the nutritional/dietary intake in healthy young Black males. Eligibility criteria were designed using PICOS and included controlled trials of nutrition education interventions designed to improve dietary intake in healthy young Black or mixed-race males aged 14–21 years old. Medline, Cinahl and Scopus were searched in April 2021, resulting in 20,375 records being screened, and subsequently 72 full-text articles were reviewed. Risk of bias was assessed using the ROBINS-I tool. One study met the eligibility criteria. Results are presented in a narrative format as meta-analysis was not possible. This systematic review revealed a lack of evidence on the effectiveness of nutritional education interventions in this high-risk population. Limitations are noted and recommendations have been made.

Low body mass and high-quality sleep maximize the ability of aerobic fitness to promote improved cognitive function in older African Americans

ABSTRACTObjectives: Because African Americans are at elevated risk for cognitive decline and Alzheimer's disease, it is important to understand which health and lifestyle factors are most important for reducing this risk. Obesity and poor sleep quality are common in lower-income, urban African Americans and have been linked to cognitive decline in older age. Fortunately, increasing aerobic fitness via regular exercise can improve cognitive function. This study sought to (1) examine the cross-sectional relationship between aerobic fitness and cognitive function in older African Americans, and (2) determine whether body mass index and sleep quality moderated the relationship between aerobic fitness and cognition.Design: 402 older African Americans, ages 60-90 (84% female, mean education level = 14 years) completed neuropsychological testing, computerized behavioral tasks, physical performance measures, and health and lifestyle questionnaires. Hierarchical linear regressions were performed to determine associations between aerobic fitness and cognition and whether body mass index and sleep quality moderate the fitness-cognition relationship while controlling for age, sex, education, depressive symptoms, and literacy.Results: Higher aerobic fitness levels were significantly associated with better executive function. The relationships between fitness and hippocampal-dependent cognitive functions (learning and memory, generalization) were attenuated in those who are obese (body mass index ≥ 30 kg/m²) or rated their sleep quality as poor, ps < .05.Conclusion: Our results suggest that while exercise and associated improvements in aerobic fitness are key for improved cognition, these benefits are maximized in those who maintain low body weight and get sufficient, high quality sleep. Exercise programs for older African Americans will be most effective if they are integrated with education programs that emphasize healthy eating, weight control, and sleep hygiene and conceptualize individuals as part of their broader social and environmental context.

Effectiveness of community-based cardiovascular disease prevention interventions to improve physical activity: A systematic review and meta-regression

Cardiovascular diseases (CVDs) remain a leading cause of morbidity and mortality globally. Despite preventive community-based interventions (CBIs) seem efficacious in reducing CVD risks, a comprehensive up-to-date synthesis on the effectiveness of such interventions in improving physical activity (PA) is lacking. We performed a systematic review and meta-analysis of community-based CVD preventive interventions aimed at improving PA level. MEDLINE, EMBASE, CINAHL, Cochrane register and PSYCINFO databases were searched in October 2019 for studies reported between January 2000 and June 2019. We assessed the methodological quality of included studies using the Cochrane risk of bias tools. We performed a random-effects meta-analysis and meta-regression to pool estimates of various effect measures. Results are reported in line with the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guideline. Our study protocol was registered in the PROSPERO database (CRD42019119885). A total of 44 randomized and 20 non-randomized controlled studies involving 98,919 participants were included. Meta-analyses found that CBIs improved the odds of attaining the recommended PA level (at least 150 min of moderate and vigorous PA (MVPA)/week) at 12 month (OR: 1.62; 95%CI: 1.25-2.11) and 18 to 24 months of follow-up (OR: 1.46; 95%CI: 1.12-1.91). Furthermore, interventions were effective in improving metabolic equivalents of task at 12 month (standardized mean difference (SMD): 0.28; 95% CI: 0.03-0.53), MVPA time at 12 to 18 months (SMD: 0.34; 95%CI: 0.05-0.64), steps per day (SMD: 0.32; 95%CI: 0.08-0.55), and sitting time (SMD: -0.25; 95%CI: -0.34 to -0.17). Subgroup analyses found that interventions in low- and middle-income countries showed a greater positive effect on attainment of recommended PA level (OR: 1.40; 95%CI: 1.02-1.92) than those in high-income countries (OR: 1.31; 95%CI: 0.96-1.78). Moreover, interventions targeting high-risk groups showed greater effectiveness than those targeting the general population (OR: 1.76; 95%CI: 1.30-2.39 vs. 1.17; 95%CI: 0.89-1.55). In conclusion, community-based CVD preventive interventions have a positive impact on improving the PA level, albeit that relevant studies in lower-middle and low-income countries are limited. With the rising burden of CVDs, rolling out CBIs targeting the general population and high-risk groups are needed to control the growing CVD-burden.

Community and Social Context: An Important Social Determinant of Cardiovascular Disease

Disease prevention frameworks and clinical practice guidelines in the United States (US) have traditionally ignored upstream social determinants of health (SDOH), which are critical for reducing disparities in cardiovascular disease (CVD)-the leading cause of death in the US. Existing evidence demonstrates a protective effect of social support, social cohesion, and community engagement on overall health and wellbeing. Increasing community and social support is a major objective of the Healthy People 2030 initiative, with special provisions for vulnerable populations. However, to date, existing evidence of the association between community and social context (CSC)-an integral SDOH domain-and CVD has not been reviewed extensively. In particular, the individual and cumulative impact of CSC on CVD risk and the pathways linking CSC to cardiovascular outcomes are not well understood. In this review, we critically appraise current knowledge of the association between CSC and CVD, describe potential pathways linking CSC to CVD, and identify opportunities for evidence-based policy and practice interventions to improve CVD outcomes.

A Cluster Randomized Trial of a Community-Based Intervention Among African-American Adults: Effects on Dietary and Physical Activity Outcomes

Evidence of the effectiveness of community-based lifestyle behavior change interventions among African-American adults is mixed. We implemented a behavioral lifestyle change intervention, Heart Matters, in two rural counties in North Carolina with African-American adults. Our aim was to evaluate the effect of Heart Matters on dietary and physical activity behaviors, self-efficacy, and social support. We used a cluster randomized controlled trial to compare Heart Matters to a delayed intervention control group after 6 months. A total of 143 African-American participants were recruited and 108 completed 6-month follow-up assessments (75.5%). We used mixed regression models to evaluate changes in outcomes from baseline to 6-month follow-up. The intervention had a significant positive effect on self-reported scores of encouragement of healthy eating, resulting in an increase in social support from family of 6.11 units (95% CI [1.99, 10.22]) (p < .01). However, intervention participants also had an increase in discouragement of healthy eating compared to controls of 5.59 units (95% CI [1.46, 9.73]) among family (p < .01). There were no significant differences in changes in dietary behaviors. Intervention participants had increased odds (OR = 2.86, 95% CI [1.18, 6.93]) of increased frequency of vigorous activity for at least 20 min per week compared to control participants (p < .05). Individual and group lifestyle behavior counseling can have a role in promoting physical activity levels among rural African-American adults, but more research is needed to identify the best strategies to bolster effectiveness and influence dietary change. Trial Registration: Clinical Trials, NCT02707432. Registered 13 March 2016.

A Systematic Review of Church-Based Health Interventions Among Latinos

Latinos face healthcare access barriers and are highly religious. Church-based health interventions could help address these disparities. We conducted a systematic review of church-based health interventions among Latinos using multiple search terms and databases. The 21 articles reviewed represented 19 interventions. Only six were tested through full-scale randomized controlled trials and five had statistically significant improvements in health-related outcomes. Most (16) utilized groups classes, eight promoted screening or preventive services, and three provided these on-site. Few intervened at multiple levels (e.g., individual, group, and community) and only three utilized pastors' sermons to deliver health-related messages. Church-based health interventions among Latinos are nascent, with only a handful of full-scale trials. Various pilot studies demonstrating feasibility across diverse health conditions suggest model adaptability. Larger studies with objectively measured outcomes and interventions that address multiple levels and structural issues are needed to ensure improvements in Latinos' access and health.

Assessing Health Needs in African American Churches: A Mixed-Methods Study

Among major racial and ethnic groups in the USA, African Americans are the most religious, and faith-based organizations play an important role in health promotion for African Americans. This study aimed to assess health needs in African American churches using a mixed-methods approach. Based on quantitative and qualitative data collected from eight African American churches in Nebraska in 2017, the most prevalent chronic conditions among participating African American church members (n = 388) included hypertension (60.8%), allergies (41.0%), arthritis (36.4%), high cholesterol (35.8%), and diabetes (28.1%). Significant predictors of fair or poor health were identified as male sex, unemployment, delayed utilization of health care in the past 12 months due to cost, lower frequency of church attendance, and feeling down, depressed, or hopeless in the past 2 weeks. Pastors from participating churches identified cost as one of the primary barriers to providing church-based health services. There were substantial unmet health needs in African American faith communities, especially in the areas of chronic disease prevention and management, and churches would need more support to realize their full potential in faith-based health promotion.

Expanding Implementation Research to Prevent Chronic Diseases in Community Settings

Chronic disease prevention continues to be inadequate, overall and in achieving health equity, in spite of the many evidence-based practices and policies (EBPPs) available to address risk behaviors such as unhealthful eating, lack of physical activity, and tobacco use. Although clinical settings are needed for EBPPs that involve medical procedures such as immunization or early detection, dissemination of EBPPs can be effective in a variety of settings such as schools and childcare centers, worksites, social service organizations, and religious organizations. More implementation research is needed to meet challenges of effective application of EBPPs in such community settings, in which primary missions, capacity, cultures, and values do not focus on health services delivery. To address health equity, consideration of social and economic contexts of people reached in these settings is essential. This review presents lessons learned from past studies to guide future implementation research and practice across diverse settings and geographies.

A randomized controlled trial comparing community lifestyle interventions to improve adherence to diet and physical activity recommendations: the VitalUM study

Worldwide, adherence to national guidelines for physical activity (PA), and fruit and vegetable consumption is recommended to promote health and reduce the risk for (chronic) disease. This study reports on the effectiveness of various social-cognitive interventions to improve adherence to guidelines and the revealed adherence predictors. Participants (n = 1,629), aged 45-70 years, randomly selected and recruited in 2005-2006 from 23 Dutch general practices, were randomized (centralized stratified allocation) to four groups to receive a 12-month lifestyle intervention targeting guideline adherence for PA and fruit and vegetable consumption. Study groups received either four computer-tailored print communication (TPC) letters (n = 405), four telephone motivational interviewing (TMI) sessions (n = 407), a combined intervention (two TPC letters and two TMI sessions, n = 408), or no intervention (control group, n = 409). After the baseline assessment, all parties were aware of the treatment groups. Outcomes were measured with self-report postal questionnaires at baseline, 25, 47 and 73 weeks. For PA, all three interventions were associated with better guideline adherence than no intervention. Odds ratios for TPC, TMI and the combined intervention were 1.82 (95% CI 1.31; 2.54), 1.57 (95% CI 1.13; 2.18), and 2.08 (95% CI 1.50; 2.88), respectively. No pedometer effects were found. For fruit and vegetable consumption, TPC seemed superior to those in the other groups. Odd ratio for fruit and vegetable consumption were 1.78 (95% CI 1.32; 2.41) and 1.73 (95% CI 1.28; 2.33), respectively. For each behaviour, adherence was predicted by self-efficacy expectations, habit strength and stages of change, whereas sex, awareness and the number of action plans predicted guideline adherence for fruit and vegetable intake. The season predicted the guideline adherence for PA and fruit consumption. The odds ratios revealed were equivalent to modest effects sizes, although they were larger than those reported in systematic reviews. This study indicated that less resource intensive interventions might have the potential for a large public health impact when widely implemented. The strengths of this study were the participation of lower educated adults and evaluation of maintenance effects. (Trial NL1035, 2007-09-06).

Utility of self-rated adherence for monitoring dietary and physical activity compliance and assessment of participant feedback of the Healthy Diet and Lifestyle Study pilot

Background

We examined the utility of self-rated adherence to dietary and physical activity (PA) prescriptions as a method to monitor intervention compliance and facilitate goal setting during the Healthy Diet and Lifestyle Study (HDLS). In addition, we assessed participants’ feedback of HDLS. HDLS is a randomized pilot intervention that compared the effect of intermittent energy restriction combined with a Mediterranean diet (IER + MED) to a Dietary Approaches to Stop Hypertension (DASH) diet, with matching PA regimens, for reducing visceral adipose tissue area (VAT).

Methods

Analyses included the 59 (98%) participants who completed at least 1 week of HDLS. Dietary and PA adherence scores were collected 8 times across 12 weeks, using a 0–10 scale (0 = not at all, 4 = somewhat, and 10 = following the plan very well). Adherence scores for each participant were averaged and assigned to high and low adherence categories using the group median (7.3 for diet, 7.1 for PA). Mean changes in VAT and weight from baseline to 12 weeks are reported by adherence level, overall and by randomization arm. Participants’ feedback at completion and 6 months post-intervention were examined.

Results

Mean ± SE, dietary adherence was 6.0 ± 0.2 and 8.2 ± 0.1, for the low and high adherence groups, respectively. For PA adherence, mean scores were 5.9 ± 0.2 and 8.5 ± 0.2, respectively. Compared to participants with low dietary adherence, those with high adherence lost significantly more VAT (22.9 ± 3.7 cm² vs. 11.7 ± 3.9 cm² [95% CI, − 22.1 to − 0.3]) and weight at week 12 (5.4 ± 0.8 kg vs. 3.5 ± 0.6 kg [95% CI, − 3.8 to − 0.0]). For PA, compared to participants with low adherence, those with high adherence lost significantly more VAT (22.3 ± 3.7 cm² vs. 11.6 ± 3.6 cm² [95% CI, − 20.7 to − 0.8]). Participants’ qualitative feedback of HDLS was positive and the most common response, on how to improve the study, was to provide cooking classes.

Conclusions

Results support the use of self-rated adherence as an effective method to monitor dietary and PA compliance and facilitate participant goal setting. Study strategies were found to be effective with promoting compliance to intervention prescriptions.

Trial registration

ClinicalTrials.gov Identifier: NCT03639350. Registered 21st August 2018—retrospectively registered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-021-00786-3.

Program Implementation and Church Members' Health Behaviors in a Countywide Study of the Faith, Activity, and Nutrition Program

Implementation research of health programs in faith-based organizations is lacking. The Faith, Activity, and Nutrition (FAN) program helps churches improve physical activity and fruit and vegetable behaviors of members. This study examined associations between implementation of FAN intervention components and church members' physical activity, fruit and vegetable behaviors, and self-efficacy for improving these behaviors. FAN was implemented in 35 churches in a southeastern US county. After attending in-person training, led by community health advisors, church committees received 12 months of telephone-delivered technical assistance to implement FAN according to 4 components: increasing opportunities, increasing guidelines and policies, increasing pastor support, and increasing messages for physical activity and healthy eating in their church. In this correlational study, FAN coordinators (n = 35) for each church reported baseline practices in 2015 and 12-month follow-up implementation of the 4 components for physical activity and healthy eating in 2016. Church members (n = 893) reported perceived implementation, physical activity and fruit and vegetable behaviors, and self-efficacy at 12-month follow-up in 2016. Independent variables were coordinator-reported baseline practices, baseline-adjusted 12-month implementation, and member-perceived 12-month implementation. Multilevel modeling examined associations between independent variables and member-reported 12-month physical activity and fruit and vegetable behaviors and self-efficacy. Coordinator-reported 12-month implementation of fruit and vegetable opportunities was associated with member fruit and vegetable consumption. Member perceptions at 12 months of church physical activity opportunities, pastor support, and messages were associated with higher self-efficacy for physical activity; pastor support and messages were positively associated with physical activity. Member perceptions at 12 months of fruit and vegetable opportunities, pastor support, and messages were associated with higher fruit and vegetable consumption and self-efficacy. Member-perceived implementation was more strongly associated with member behaviors than coordinator-reported implementation. Providing opportunities for healthy eating during already scheduled events may be an effective strategy for improving fruit and vegetable behavior.

Church-based interventions to address obesity among African Americans and Latinos in the United States: a systematic review

CONTEXT

Multilevel church-based interventions may help address racial/ethnic disparities in obesity in the United States since churches are often trusted institutions in vulnerable communities. These types of interventions affect at least two levels of socio-ecological influence which could mean an intervention that targets individual congregants as well as the congregation as a whole. However, the extent to which such interventions are developed using a collaborative partnership approach and are effective with diverse racial/ethnic populations is unclear, and these crucial features of well-designed community-based interventions.

OBJECTIVE

The present systematic literature review of church-based interventions was conducted to assess their efficacy for addressing obesity across different racial/ethnic groups (eg, African Americans, Latinos).

DATA SOURCES AND EXTRACTION

In total, 43 relevant articles were identified using systematic review methods developed by the Center for Disease Control and Prevention (CDC)'s Task Force on Community Preventive Services. The extent to which each intervention was developed using community-based participatory research principles, was tailored to the particular community in question, and involved the church in the study development and implementation were also assessed.

DATA ANALYSIS

Although 81% of the studies reported significant results for between- or within-group differences according to the study design, effect sizes were reported or could only be calculated in 56% of cases, and most were small. There was also a lack of diversity among samples (eg, few studies involved Latinos, men, young adults, or children), which limits knowledge about the ability of church-based interventions to reduce the burden of obesity more broadly among vulnerable communities of color. Further, few interventions were multilevel in nature, or incorporated strategies at the church or community level.

CONCLUSIONS

Church-based interventions to address obesity will have greater impact if they consider the diversity among populations burdened by this condition and develop programs that are tailored to these different populations (eg, men of color, Latinos). Programs could also benefit from employing multilevel approaches to move the field away from behavioral modifications at the individual level and into a more systems-based framework. However, effect sizes will likely remain small, especially since individuals only spend a limited amount of time in this particular setting.

Mighty men: A faith-based weight loss intervention to reduce cancer risk in African American men

According to the American Cancer Society's guidelines on nutrition and physical activity for cancer prevention, weight control, eating practices and physical activity are second only to tobacco use as modifiable determinants of cancer risk. However, no evidence-based interventions have been targeted to African American men or tailored to individual African American men's preferences, needs or identities. The goal of this chapter is to describe the rationale for the components, aims and setting of Mighty Men: A Faith-Based Weight Loss Intervention for African American Men. We begin by discussing the rationale for focusing on weight loss in the context of cancer prevention, and argue that obesity and obesogenic behaviors are important yet modifiable determinants of cancer risk. Next, we briefly review the scarce literature on interventions to promote healthy eating, physical activity and weight loss in our population of interest, and then discuss the rationale for conducting the intervention in faith- based organizations rather than other common settings for recruiting African American men. We conclude with a discussion of the conceptual foundations and components of Mighty Men, and discuss our focus and goals in the context of the larger literature in this area.

Development and Testing of a Personalized Web-Based Diet and Physical Activity Intervention Based on Motivational Interviewing and the Self-Determination Theory: Protocol for the MyLifestyleCoach Randomized Controlled Trial

Background

Unhealthy dietary patterns and insufficient physical activity (PA) are associated with negative health outcomes, such as cardiovascular diseases, type 2 diabetes, cancer, overweight, and obesity. This makes the promotion of healthy dietary and PA behaviors a public health priority.

Objective

This paper describes the development, design, and evaluation protocol of a Web-based computer-tailored (CT) dietary and PA promotion intervention, MyLifestyleCoach. A Web-based format was chosen for its accessibility and large-scale reach and low-cost potential. To achieve effective and persistent behavioral change, this innovative intervention is tailored to individual characteristics and is based on the self-determination theory and motivational interviewing (MI).

Methods

The 6 steps of the intervention mapping protocol were used to systematically develop MyLifestyleCoach based on the existing effective CT PA promotion intervention I Move. The MyLifestyleCoach intervention consists of 2 modules: I Move, which is aimed at promoting PA, and I Eat, which is aimed at promoting healthy eating. Development of the I Eat module was informed by the previously developed I Move. Both modules were integrated to form the comprehensive MyLifestyleCoach program. Furthermore, I Move was slightly adapted, for example, the new Dutch PA guidelines were implemented. A randomized controlled trial consisting of an intervention condition and waiting list control group will be used to evaluate the effectiveness of the intervention on diet and PA.

Results

Self-reported measures take place at baseline, 6 months, and 12 months after baseline. Enrollment started in October 2018 and will be completed in June 2020. Data analysis is currently under way, and the first results are expected to be submitted for publication in 2020.

Conclusions

MyLifestyleCoach is one of the first interventions to translate and apply self-determination theory and techniques from MI in Web-based computer tailoring for an intervention targeting PA and dietary behavior. Intervention mapping served as a blueprint for the development of this intervention. We will evaluate whether this approach is also successful in promoting eating healthier and increasing PA using an randomized controlled trial by comparing the intervention to a waiting list control condition. The results will provide an insight into the short- and long-term efficacy and will result in recommendations for the implementation and promotion of healthy eating and PA among adults in the Netherlands.

Trial Registration

Dutch Trial Register NL7333; https://www.trialregister.nl/trial/7333

International Registered Report Identifier (IRRID)

DERR1-10.2196/14491

Adaptation of a brief smoke-free homes intervention for American Indian and Alaska Native families

BACKGROUND

The goal of adaptation is to maintain the effectiveness of the original intervention by preserving the core elements that account for its success while delivering an intervention that is tailored to the new community and/or cultural context. The current study describes the process of adapting an evidence-based smoke-free homes (SFH) intervention for use in American Indian/Alaska Native (AI/AN) households.

METHODS

We followed a systematic adaptation process. We first assessed the community through focus groups coordinated in collaboration with tribal partners. Because our team included the original developers of the intervention, the steps of understanding the intervention, selecting the intervention and consulting with experts were simplified. Additional steps included consulting with stakeholders through a national work group and collaboratively deciding what needed adaptation.

RESULTS

A number of key themes pertinent to the adaptation of the SFH intervention were identified in the focus groups. These included the gravity of messaging about commercial tobacco use; respect, familialism, and intergenerationalism; imagery, including significant symbolism, colors, and representative role models; whether and how to address traditional tobacco; and, barriers to a SFH not adequately addressed in the original materials.

CONCLUSIONS

Adaptation of an intervention to create smoke-free homes in AI/AN families necessitated both surface structure changes such as appearance of role models and deep structure changes that addressed core values, and beliefs and traditions.

Effects of Intermittent Energy Restriction Combined with a Mediterranean Diet on Reducing Visceral Adiposity: A Randomized Active Comparator Pilot Study

Intermittent energy restriction combined with a Mediterranean diet (IER+MED) has shown promise to reduce body fat and insulin resistance. In the Multiethnic Cohort Adiposity Phenotype Study, Japanese Americans had the highest visceral adipose tissue (VAT) when adjusting for total adiposity. We conducted this pilot study to demonstrate feasibility and explore efficacy of following IER+MED for 12 weeks to reduce VAT among East Asians in Hawaii. Sixty volunteers (aged 35-55, BMI 25-40 kg/m2, VAT ≥ 90 cm2 for men and ≥ 80 cm2 for women) were randomized to IER+MED (two consecutive days with 70% energy restriction and 5 days euenergetic MED) or an active comparator (euenergetic Dietary Approaches to Stop Hypertension (DASH) diet). Participants and clinic staff (except dietitians) were blinded to group assignments. IER+MED had significantly larger reductions in DXA-measured VAT and total fat mass (-22.6 ± 3.6 cm2 and -3.3 ± 0.4 kg, respectively) vs. DASH (-10.7 ± 3.5 cm2 and -1.6 ± 0.4 kg) (p = 0.02 and p = 0.005). However, after adjusting for total fat mass, change in VAT was not statistically different between groups; whereas, improvement in alanine transaminase remained significantly greater for IER+MED vs. DASH (-16.2 ± 3.8 U/L vs. -4.0 ± 3.6 U/L, respectively, p = 0.02). Attrition rate was 10%, and participants adhered well to study prescriptions with no reported major adverse effect. Results demonstrate IER+MED is acceptable, lowers visceral and total adiposity among East Asian Americans, and may improve liver function more effectively than a healthful diet pattern. ClinicalTrials.gov Identifier: NCT03639350.

Eat, Pray, Move: A Pilot Cluster Randomized Controlled Trial of a Multilevel Church-Based Intervention to Address Obesity Among African Americans and Latinos

PURPOSE

To implement a multilevel, church-based intervention with diverse disparity populations using community-based participatory research and evaluate feasibility, acceptability, and preliminary effectiveness in improving obesity-related outcomes.

DESIGN

Cluster randomized controlled trial (pilot).

SETTING

Two midsized (∼200 adults) African American baptist and 2 very large (∼2000) Latino Catholic churches in South Los Angeles, California.

PARTICIPANTS

Adult (18+ years) congregants (n = 268 enrolled at baseline, ranging from 45 to 99 per church).

INTERVENTION

Various components were implemented over 5 months and included 2 sermons by pastor, educational handouts, church vegetable and fruit gardens, cooking and nutrition classes, daily mobile messaging, community mapping of food and physical activity environments, and identification of congregational policy changes to increase healthy meals.

MEASURES

Outcomes included objectively measured body weight, body mass index (BMI), and systolic and diastolic blood pressure (BP), plus self-reported overall healthiness of diet and usual minutes spent in physical activity each week; control variables include sex, age, race-ethnicity, English proficiency, education, household income, and (for physical activity outcome) self-reported health status.

ANALYSIS

Multivariate linear regression models estimated the average effect size of the intervention, controlling for pair fixed effects, a main effect of the intervention, and baseline values of the outcomes.

RESULTS

Among those completing follow-up (68%), the intervention resulted in statistically significantly less weight gain and greater weight loss (-0.05 effect sizes; 95% confidence interval [CI] = -0.06 to -0.04), lower BMI (-0.08; 95% CI = -0.11 to -0.05), and healthier diet (-0.09; 95% CI = -0.17 to -0.00). There was no evidence of an intervention impact on BP or physical activity minutes per week.

CONCLUSION

Implementing a multilevel intervention across diverse congregations resulted in small improvements in obesity outcomes. A longer time line is needed to fully implement and assess effects of community and congregation environmental strategies and to allow for potential larger impacts of the intervention.

A Community-Partnered Approach to Developing Church-Based Interventions to Reduce Health Disparities Among African-Americans and Latinos

Faith and public health partnerships offer promise to addressing health disparities, but examples that incorporate African-Americans and Latino congregations are lacking. Here we present results from developing a multi-ethnic, multi-denominational faith and public health partnership to address health disparities through community-based participatory research (CBPR), focusing on several key issues: (1) the multi-layered governance structure and activities to establish the partnership and identify initial health priority (obesity), (2) characteristics of the congregations recruited to partnership (n = 66), and (3) the lessons learned from participating congregations' past work on obesity that informed the development of a multi-level, multi-component, church-based intervention. Having diverse staff with deep ties in the faith community, both among researchers and the primary community partner agency, was key to recruiting African-American and Latino churches. Involvement by local health department and community health clinic personnel provided technical expertise and support regarding health data and clinical resources. Selecting a health issue-obesity-that affected all subgroups (e.g., African-Americans and Latinos, women and men, children and adults) garnered high enthusiasm among partners, as did including some innovative aspects such as a text/e-mail messaging component and a community mapping exercise to identify issues for advocacy. Funding that allowed for an extensive community engagement and planning process was key to successfully implementing a CBPR approach. Building partnerships through which multiple CBPR initiatives can be done offers efficiencies and sustainability in terms of programmatic activities, though long-term infrastructure grants, institutional support, and non-research funding from local foundations and health systems are likely needed.

Effectiveness of Interventions to Increase Physical Activity Among Minority Populations: An Umbrella Review

PURPOSE

Numerous interventions have been tested to increase physical activity (PA) among minority adults, and several review papers have examined the results from these studies. The primary purpose of this umbrella review is to summarize evidence from existing reviews regarding effectiveness of PA interventions in minority populations.

PROCEDURES

Searches were conducted in five electronic databases to identify English-language articles reviewing the effects of interventions to increase PA in minority adults living in the United States. Reviews that met the inclusion criteria were critically assessed using umbrella review procedures. Review quality was assessed using the PRISMA statement and checklist.

FINDINGS

Twenty-two reviews fulfilled inclusion criteria. The sample included one meta-analysis, 11 integrated reviews, and 10 narrative reviews published between 1998 and 2012. The reviews documented modest improvements in PA with considerable variation in intervention effectiveness across primary studies. Integrative reviews generally were of higher overall quality than narrative reviews with regard to fulfilling PRISMA criteria.

CONCLUSIONS

Integrated and narrative reviews were unable to validly determine the characteristics of effective interventions. Future reviews should employ meta-analytic methods in order to quantitatively identify those intervention characteristics that are most likely to increase PA behavior in minority adults.

Engaging Black Churches to Address Cancer Health Disparities: Project CHURCH

African Americans in the United States suffer disproportionately from cancer, having the highest mortality rate of any racial/ethnic group across all cancers for the past several decades. In addition, significant disparities exist in several cancer risk behaviors, including obesity, intake of fruits and vegetables, leisure time physical activity and cancer screening. Addressing these disparities require successful development of relationships with minority communities to partner in the research process, in order to understand areas of critical need and develop interventions that are compatible with this community. In this manuscript we describe Project CHURCH (Creating a Higher Understanding of Cancer Research and Community Health), a collaborative partnership between The University of Texas MD Anderson Cancer Center and Houston-area African American churches. Project CHURCH was developed to understand disparities in cancer prevention risk factors and engage African Americans as partners in the research process. Using community-based participatory research principles, we describe the development and infrastructure of the research partnership, as well as how the church community has been engaged in the development and implementation of a large African American cohort study (N = 2,338). Finally, the characteristics of the cohort are presented along with cohort success in addressing community need while having significant contribution to the scientific literature. Project CHURCH serves as a valuable resource for cancer prevention in the African American community.

Faith, Activity, and Nutrition Randomized Dissemination and Implementation Study: Countywide Adoption, Reach, and Effectiveness

INTRODUCTION

Faith-based organizations can contribute to improving population health, but few dissemination and implementation studies exist. This paper reports countywide adoption, reach, and effectiveness from the Faith, Activity, and Nutrition dissemination and implementation study.

DESIGN

This was a group-randomized trial. Data were collected in 2016. Statistical analyses were conducted in 2017.

SETTING/PARTICIPANTS

Churches in a rural, medically underserved county in South Carolina were invited to enroll, and attendees of enrolled churches were invited to complete questionnaires (n=1,308 participated).

INTERVENTION

Churches (n=59) were randomized to an intervention or control (delayed intervention) condition. Church committees attended training focused on creating opportunities, setting guidelines/policies, sharing messages, and engaging pastors for physical activity (PA) and healthy eating (HE). Churches also received 12 months of telephone-based technical assistance. Community health advisors provided the training and technical assistance.

MAIN OUTCOMES MEASURES

The Reach, Efficacy/Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework guided measurement of adoption and reach. To assess effectiveness, church attendees completed post-test only questionnaires of perceptions of church environment, PA and fruit and vegetable (FV) self-efficacy, FV intake, and PA. Regression models controlled for church clustering and predominant race of congregation, as well as member age, gender, education, and self-reported cancer diagnosis.

RESULTS

Church adoption was 42% (55/132). Estimated reach was 3,527, representing 42% of regular church attendees and 15% of county residents. Intervention church attendees reported greater church-level PA opportunities, PA and HE messages, and PA and HE pastor support (p<0.0001), but not FV opportunities (p=0.07). PA self-efficacy (p=0.07) and FV self-efficacy (p=0.21) were not significantly higher in attendees of intervention versus control churches. The proportion of inactive attendees was lower in intervention versus control churches (p=0.02). The proportion meeting FV (p=0.27) and PA guidelines (p=0.32) did not differ by group.

CONCLUSIONS

This innovative dissemination and implementation study had high adoption and reach with favorable environmental impacts, positioning it for broader dissemination.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.gov NCT02868866.

Optimizing Tailored Communications for Health Risk Assessment: A Randomized Factorial Experiment of the Effects of Expectancy Priming, Autonomy Support, and Exemplification

Background

Health risk assessments with tailored feedback plus health education have been shown to be effective for promoting health behavior change. However, there is limited evidence to guide the development and delivery of online automated tailored feedback.

Objective

The goal of this study was to optimize tailored feedback messages for an online health risk assessment to promote enhanced user engagement, self-efficacy, and behavioral intentions for engaging in healthy behaviors. We examined the effects of three theory-based message factors used in developing tailored feedback messages on levels of engagement, self-efficacy, and behavioral intentions.

Methods

We conducted a randomized factorial experiment to test three different components of tailored feedback messages: tailored expectancy priming, autonomy support, and use of an exemplar. Individuals (N=1945) were recruited via Amazon Mechanical Turk and randomly assigned to one of eight different experimental conditions within one of four behavioral assessment and feedback modules (tobacco use, physical activity [PA], eating habits, and weight). Participants reported self-efficacy and behavioral intentions pre- and postcompletion of an online health behavior assessment with tailored feedback. Engagement and message perceptions were assessed at follow-up.

Results

For the tobacco module, there was a significant main effect of the exemplar factor (P=.04); participants who received exemplar messages (mean 3.31, SE 0.060) rated their self-efficacy to quit tobacco higher than those who did not receive exemplar messages (mean 3.14, SE 0.057). There was a three-way interaction between the effect of message conditions on self-efficacy to quit tobacco (P=.02), such that messages with tailored priming and an exemplar had the greatest impact on self-efficacy to quit tobacco. Across PA, eating habits, and weight modules, there was a three-way interaction among conditions on self-efficacy (P=.048). The highest self-efficacy scores were reported among those who were in the standard priming condition and received both autonomy supportive and exemplar messages. In the PA module, autonomy supportive messages had a stronger effect on self-efficacy for PA in the standard priming condition. For PA, eating habits, and weight-related behaviors, the main effect of exemplar messages on behavioral intentions was in the hypothesized direction but did not reach statistical significance (P=.08). When comparing the main effects of different message conditions, there were no differences in engagement and message perceptions.

Conclusions

Findings suggest that tailored feedback messages that use exemplars helped improve self-efficacy related to tobacco cessation, PA, eating habits, and weight control. Combining standard priming and autonomy supportive message components shows potential for optimizing tailored feedback for tobacco cessation and PA behaviors.

Efficacy and Mediation of a Theory-Based Physical Activity Intervention for African American Men Who Have Sex with Men: A Randomized Controlled Trial

BACKGROUND

Few trials have tested physical-activity interventions among sexual minorities, including African American men who have sex with men (MSM).

PURPOSE

We examined the efficacy and mediation of the Being Responsible for Ourselves (BRO) physical-activity intervention among African American MSM.

METHOD

African American MSM were randomized to the physical-activity intervention consisting of three 90-min one-on-one sessions or an attention-matched control intervention and completed pre-intervention, immediately post-intervention, and 6- and 12-month post-intervention audio computer-based surveys.

RESULTS

Of the 595 participants, 503 completed the 12-month follow-up. Generalized estimating equation models revealed that the intervention increased self-reported physical activity compared with the control intervention, adjusted for pre-intervention physical activity. Mediation analyses suggested that the intervention increased reasoned action approach variables, subjective norm and self-efficacy, increasing intention immediately post-intervention, which increased physical activity during the follow-up period.

CONCLUSIONS

Interventions targeting reasoned action approach variables may contribute to efforts to increase African American MSM's physical activity.

CLINICAL TRIAL REGISTRATION

The trial was registered with the ClinicalTrials.gov Identifier NCT02561286 .

Effects of Minimal Versus Intensive Intervention to Enhance Motivational Interviewing in HIV Care

We conducted a randomized trial comparing the effect of two different levels of motivational interviewing training on clinician communication behaviors and patient experiences. We enrolled 12 HIV clinicians who attended a one-day MI workshop focusing on behavior change counseling skills. We then randomized clinicians to receive (or not) 3-5 rounds of personalized feedback from the MI trainer. We compared outcomes before and after the interventions and between the intervention groups. We tested time-by-study arm interactions to determine if one group improved more than the other. For all analyses, we used generalized estimating equations to account for clustering of patients within clinicians, with Gaussian or negative binomial distributions as appropriate. Patients of clinicians in both intervention groups rated their visits as more MI consistent (6.86 vs. 6.65, p = 0.005) and audio-recording analysis revealed that visits were more patient-centered (1.34 vs. 0.96, p = 0.003) with a more positive patient affect (22.36 vs. 20.84, p < 0.001) after versus before the intervention, without differences between intervention arms. Several specific clinician behaviors such as empathic statements, asking patient opinions and open-ended questions improved more in the workshop+feedback versus the workshop-only intervention arm. A few specific communication behaviors increased (total and complex reflections) after versus before the intervention, without differences between intervention arms. The workshop alone was as effective as the workshop plus feedback in improving patient experiences and overall communication measures. Certain communication behaviors improved more with the more intensive intervention, but these additional benefits may not warrant the extra financial and logistical resources required.

Counselor competence for telephone Motivation Interviewing addressing lifestyle change among Dutch older adults

Counselor competence in telephone Motivation Interviewing (MI) to change lifestyle behaviors in a primary care population was assessed using the Motivational Interviewing Treatment Integrity (MITI) rating system. Counselor behavior was evaluated by trained raters. Twenty minutes of a random sample of 336 MI sessions were coded representing 232 counselees. Ninety-four sessions (28%) were double coded to assess inter-rater agreement. The MI fidelity was examined by comparing the MI fidelity scores direction, empathy, spirit, % open questions, % complex reflections, reflections-to-questions ratio, % MI-adherent responses with the matching beginner proficiency MITI threshold. The inter-rater agreements for the MI fidelity summary scores were good (spirit, reflections-to-questions ratio), fair (empathy, % open questions, % MI-adherent responses) or poor (direction, % complex reflection). The MI fidelity scores for direction, empathy, spirit and the percentage of complex reflections exceeded the MITI threshold, but lower scores were found for the percentage of open questions, the reflections-to-questions ratio and the percentage of MI-adherent responses. In conclusion, evidence that MI was implemented was revealed. However, the inter-rater agreements scores and some fidelity scores leave room for improvement indicating that raters and counselors may need more ongoing training and feedback to achieve and maintain adequate competence. These findings apply to more complex skills (as rating complex reflections) in particular.

Understanding the Role of Message Frames on African-American Willingness to Participate in a Hypothetical Diabetes Prevention Study

The objective of this research was to evaluate the impact of message framing (e.g., highlighting health disparities vs. progress toward reducing disparities) on willingness to enroll in a hypothetical research study. African-American (AA, n = 1513) and White (n = 362) adults completed an online survey about diabetes, health behaviors including physical activity, and attitudes about research. AA participants were randomized to view a general message (same message as provided to all White participants) or 1 of 4 alternate messages that framed the need for people to participate in research in terms of race and/or health disparities. Among AAs, there were no differences in willingness to enroll in the study by message frame. However, individual characteristics including younger age, female sex, attitudes about research, a sense of obligation, and community responsibility were significant predictors of willingness to enroll in the study. AA participants who received the general message were equally willing as White participants to enroll in the study. Highlighting race and health disparities in study recruitment materials may not be needed to increase interest among AAs. Factors beyond race appear to be stronger motivators for participation. Unlike previous research, racial framing did not suppress motivation to enroll in our hypothetical study.

Multiple Risk Behavior Interventions: Meta-analyses of RCTs

CONTEXT

Multiple risk behaviors are common and associated with developing chronic conditions such as heart disease, cancer, or Type 2 diabetes. A systematic review, meta-analysis, and meta-regression of the effectiveness of multiple risk behavior interventions was conducted.

EVIDENCE ACQUISITION

Six electronic databases including MEDLINE, EMBASE, and PsycINFO were searched to August 2016. RCTs of non-pharmacologic interventions in general adult populations were selected. Studies targeting specific at-risk groups (such as people screened for cardiovascular risk factors or obesity) were excluded. Studies were screened independently. Study characteristics and outcomes were extracted and risk of bias assessed by one researcher and checked by another. The Behaviour Change Wheel and Oxford Implementation Index were used to code intervention content and context.

EVIDENCE SYNTHESIS

Random-effects meta-analyses were conducted. Sixty-nine trials involving 73,873 individuals were included. Interventions mainly comprised education and skills training and were associated with modest improvements in most risk behaviors: increased fruit and vegetable intake (0.31 portions, 95% CI=0.17, 0.45) and physical activity (standardized mean difference, 0.25; 95% CI=0.13, 0.38), and reduced fat intake (standardized mean difference, -0.24; 95% CI=-0.36, -0.12). Although reductions in smoking were found (OR=0.78, 95% CI=0.68, 0.90), they appeared to be negatively associated with improvement in other behaviors (such as diet and physical activity). Preliminary evidence suggests that sequentially changing smoking alongside other risk behaviors was more effective than simultaneous change. But most studies assessed simultaneous rather than sequential change in risk behaviors; therefore, comparisons are sparse. Follow-up period and intervention characteristics impacted effectiveness for some outcomes.

CONCLUSIONS

Interventions comprising education (e.g., providing information about behaviors associated with health risks) and skills training (e.g., teaching skills that equip participants to engage in less risky behavior) and targeting multiple risk behaviors concurrently are associated with small changes in diet and physical activity. Although on average smoking was reduced, it appeared changes in smoking were negatively associated with changes in other behaviors, suggesting it may not be optimal to target smoking simultaneously with other risk behaviors.

A comparative effectiveness education trial for lifestyle health behavior change in African Americans

Obesity and excess weight are significant clinical and public health issues that disproportionately affect African Americans because of physical inactivity and unhealthy eating. We compared the effects of alternate behavioral interventions on obesity-related health behaviors. We conducted a comparative effectiveness education trial in a community-based sample of 530 adult African Americans. Outcomes variables were physical activity (PA) and fruit and vegetable intake. Outcomes were evaluated at baseline and 1-month following interventions about shared risk factors for cancer and cardiovascular disease (CVD) (integrated, INT) or CVD only (disease-specific). Significant increases were found in the proportion of participants who met PA guidelines from baseline (47.4%) to follow-up (52.4%) (P = 0.005). In the stratified analysis that were conducted to examine interaction between education and intervention group assignment, this effect was most apparent among participants who had ≤high school education and were randomized to INT (OR = 2.28, 95% CI = 1.04, 5.00, P = 0.04). Completing the intervention was associated with a 1.78 odds of meeting PA guidelines (95% CI = 1.02, 3.10, P = 0.04). Education about risk factors for chronic disease and evidence-based strategies for health behavior change may be useful for addressing obesity-related behaviors among African Americans.

Longitudinal relationships between self-concept for physical activity and neighborhood social life as predictors of physical activity among older African American adults

Background

Engaging in regular physical activity (PA) as an older adult has been associated with numerous physical and mental health benefits. The aim of this study is to directly compare how individual-level cognitive factors (self-efficacy for PA, self-determined motivation for PA, self-concept for PA) and neighborhood perceptions of the social factors (neighborhood satisfaction, neighborhood social life) impact moderate-to-vigorous physical activity (MVPA) longitudinally among older African American adults.

Methods

Data were analyzed from a sub-set of older African American adults (N = 224, M_age = 63.23 years, SD = 8.74, 63.23% female, M_{Body Mass Index} = 32.01, SD = 7.52) enrolled in the Positive Action for Today’s Health trial. MVPA was assessed using 7-day accelerometry-estimates and psychosocial data (self-efficacy for PA, self-determined motivation for PA, self-concept for PA, neighborhood satisfaction, neighborhood social life) were collected at baseline, 12-, 18-, and 24-months.

Results

Multilevel growth modeling was used to examine within- and between-person effects of individual-level cognitive and social environmental factors on MVPA. At the between-person level, self-concept (b = 0.872, SE = 0.239, p < 0.001), and neighborhood social life (b = 0.826, SE = 0.176, p < 0.001) predicted greater MVPA, whereas neighborhood satisfaction predicted lower MVPA (b = −0.422, SE = 0.172, p = 0.015). Among the between-person effects, only average social life was moderated by time (b = 0.361, SE = 0.147, p = 0.014), indicating that the impact of a relatively positive social life on MVPA increased across time. At the within-person level, positive increases in self-concept (b = 0.294, SE = 0.145, p = 0.043) and neighborhood social life (b = 0.270, SE = 0.113, p = 0.017) were associated with increased MVPA.

Conclusions

These results suggest that people with a higher average self-concept for PA and a more positive social life engaged in greater average MVPA. Additionally, changes in perceptions of one’s neighborhood social life and one’s self-concept for PA were associated with greater MVPA over 2 years. These factors may be particularly relevant for future interventions targeting long-term change and maintenance of MVPA in older African Americans.

Trial registration

ClinicalTrials.Gov #NCT01025726 registered 1 December 2009.

Targeted mass media interventions promoting healthy behaviours to reduce risk of non-communicable diseases in adult, ethnic minorities

BACKGROUND

Physical activity, a balanced diet, avoidance of tobacco exposure, and limited alcohol consumption may reduce morbidity and mortality from non-communicable diseases (NCDs). Mass media interventions are commonly used to encourage healthier behaviours in population groups. It is unclear whether targeted mass media interventions for ethnic minority groups are more or less effective in changing behaviours than those developed for the general population.

OBJECTIVES

To determine the effects of mass media interventions targeting adult ethnic minorities with messages about physical activity, dietary patterns, tobacco use or alcohol consumption to reduce the risk of NCDs.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, ERIC, SweMed+, and ISI Web of Science until August 2016. We also searched for grey literature in OpenGrey, Grey Literature Report, Eldis, and two relevant websites until October 2016. The searches were not restricted by language.

SELECTION CRITERIA

We searched for individual and cluster-randomised controlled trials, controlled before-and-after studies (CBA) and interrupted time series studies (ITS). Relevant interventions promoted healthier behaviours related to physical activity, dietary patterns, tobacco use or alcohol consumption; were disseminated via mass media channels; and targeted ethnic minority groups. The population of interest comprised adults (≥ 18 years) from ethnic minority groups in the focal countries. Primary outcomes included indicators of behavioural change, self-reported behavioural change and knowledge and attitudes towards change. Secondary outcomes were the use of health promotion services and costs related to the project.

DATA COLLECTION AND ANALYSIS

Two authors independently reviewed the references to identify studies for inclusion. We extracted data and assessed the risk of bias in all included studies. We did not pool the results due to heterogeneity in comparisons made, outcomes, and study designs. We describe the results narratively and present them in 'Summary of findings' tables. We judged the quality of the evidence using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) methodology.

MAIN RESULTS

Six studies met the inclusion criteria, including three RCTs, two cluster-RCTs and one ITS. All were conducted in the USA and comprised targeted mass media interventions for people of African descent (four studies), Spanish-language dominant Latino immigrants (one study), and Chinese immigrants (one study). The two latter studies offered the intervention in the participants' first language (Spanish, Cantonese, or Mandarin). Three interventions targeted towards women only, one pregnant women specifically. We judged all studies as being at unclear risk of bias in at least one domain and three studies as being at high risk of bias in at least one domain.We categorised the findings into three comparisons. The first comparison examined mass media interventions targeted at ethnic minorities versus an equivalent mass media intervention intended for the general population. The one study in this category (255 participants of African decent) found little or no difference in effect on self-reported behavioural change for smoking and only small differences in attitudes to change between participants who were given a culturally specific smoking cessation booklet versus a booklet intended for the general population. We are uncertain about the effect estimates, as assessed by the GRADE methodology (very low quality evidence of effect). No study provided data for indicators of behavioural change or adverse effects.The second comparison assessed targeted mass media interventions versus no intervention. One study (154 participants of African decent) reported effects for our primary outcomes. Participants in the intervention group had access to 12 one-hour live programmes on cable TV and received print material over three months regarding nutrition and physical activity to improve health and weight control. Change in body mass index (BMI) was comparable between groups 12 months after the baseline (low quality evidence). Scores on a food habits (fat behaviours) and total leisure activity scores changed favourably for the intervention group (very low quality evidence). Two other studies exposed entire populations in geographical areas to radio advertisements targeted towards African American communities. Authors presented effects on two of our secondary outcomes, use of health promotion services and project costs. The campaign message was to call smoking quit lines. The outcome was the number of calls received. After one year, one study reported 18 calls per estimated 10,000 targeted smokers from the intervention communities (estimated target population 310,500 persons), compared to 0.2 calls per estimated 10,000 targeted smokers from the control communities (estimated target population 331,400 persons) (moderate quality evidence). The ITS study also reported an increase in the number of calls from the target population during campaigns (low quality evidence). The proportion of African American callers increased in both studies (low to very low quality evidence). No study provided data on knowledge and attitudes for change and adverse effects. Information on costs were sparse.The third comparison assessed targeted mass media interventions versus a mass media intervention plus personalised content. Findings are based on three studies (1361 participants). Participants in these comparison groups received personal feedback. Two of the studies recorded weight changes over time. Neither found significant differences between the groups (low quality evidence). Evidence on behavioural changes, and knowledge and attitudes typically found some effects in favour of receiving personalised content or no significant differences between groups (very low quality evidence). No study provided data on adverse effects. Information on costs were sparse.

AUTHORS' CONCLUSIONS

The available evidence is inadequate for understanding whether mass media interventions targeted toward ethnic minority populations are more effective in changing health behaviours than mass media interventions intended for the population at large. When compared to no intervention, a targeted mass media intervention may increase the number of calls to smoking quit line, but the effect on health behaviours is unclear. These studies could not distinguish the impact of different components, for instance the effect of hearing a message regarding behavioural change, the cultural adaptation to the ethnic minority group, or increase reach to the target group through more appropriate mass media channels. New studies should explore targeted interventions for ethnic minorities with a first language other than the dominant language in their resident country, as well as directly compare targeted versus general population mass media interventions.

Increasing Use of a Healthy Food Incentive: A Waiting Room Intervention Among Low-Income Patients

INTRODUCTION

Diet-related disease is disproportionately concentrated in low-income communities where fruit and vegetable consumption is far below guidelines. To address financial barriers, Double Up Food Bucks (DUFB)-a statewide healthy food incentive-matches Supplemental Nutrition Assistance Program (SNAP) funds spent at farmers markets. However, incentive use is limited. This study examined the impact of a brief waiting room-based intervention about DUFB on program utilization and produce consumption.

STUDY DESIGN

Longitudinal, repeated measures, quasi-experimental trial.

SETTING/PARTICIPANTS

SNAP-enrolled adults at a health center in a low-income, racially and ethnically diverse area of Southeast Michigan.

INTERVENTION

Participants received a brief explanation of DUFB, written program materials, a map highlighting market locations and hours, and an initial $10 market voucher. DUFB use and produce consumption were measured through four surveys over 5 months (August 2014-January 2015).

MAIN OUTCOME MEASURES

Outcome measures included DUFB use and fruit and vegetable consumption (analyses conducted in 2015-2016).

RESULTS

A total of 302 eligible adults were identified, and 177 (59%) enrolled. One hundred twenty-seven (72%) completed all surveys. At baseline, 57% of participants reported shopping at a farmers market within the last year; 18% had previously used DUFB. By the end of the DUFB season, participants were significantly more likely to report DUFB use than at baseline (AOR=19.2, 95% CI=10.3, 35.5, p<0.001), with 69% of participants reporting use of DUFB at least once, and 34% reporting use of DUFB three or more times. Adjusted fruit and vegetable consumption increased from baseline by 0.65 servings/day (95% CI=0.37, 0.93, p<0.001) at 3 months, and remained 0.62 servings/day (95% CI=0.32, 0.92, p<0.001) higher than baseline 2 months post-DUFB season.

CONCLUSIONS

A brief clinic-based intervention was associated with a nearly fourfold increase in uptake of a SNAP incentive program, as well as clinically and statistically significant increases in produce consumption. Results suggested sustained behavior change even once the financial incentive was no longer available. Providing information about healthy food incentives is a low-cost, easily implemented intervention that may increase produce consumption among low-income patients.

Improving heart health among Black/African American women using civic engagement: a pilot study

BACKGROUND

Despite increased risk for cardiovascular disease (CVD) and related conditions, evaluations of health interventions indicate that Black/African American women are less likely to benefit than their white counterparts and are not as likely to engage in behaviors that reduce CVD risk. The purpose of this study was to test the feasibility and effectiveness of civic engagement as an intervention strategy to address heart health in Black/African American women.

METHODS

Using a quasi-experimental pre-post study design, civic engagement was tested by convening a convenience sample of self-identified Black/African American women, ages 30-70 years, English-speaking, and BMI ≥25.0 (n = 28) into "Change Clubs" in four churches. Feasibility was examined through adherence, satisfaction, retention, and ability of Change Clubs to meet at least 50% of self-identified action steps for community change. Effectiveness data included: dietary intake, measures of physical activity, cardiorespiratory fitness, blood pressure, and anthropometrics. Psychosocial factors hypothesized to serve as the mechanisms by which civic engagement enacts behavior change were also assessed.

RESULTS

At baseline, the study sample (n = 28) had a mean age of 50.5 y; 53.6% had an associate degree or higher; 60.7% had an income of $35,000 or higher; and 57.4% were employed full time. At the conclusion of the study, all participants were satisfied with the progress of their Change Club and with the overall experience and Change Clubs met their self-identified action steps for community change. The intervention had a significant effect on finish time on the cardiorespiratory fitness test (p < 0.001) and systolic blood pressure (p < 0.001).

CONCLUSIONS

Study results suggest feasibility and evidence of preliminary effectiveness of using a civic engagement approach to address behavior change in a way that is appealing and acceptable to Black/African American women.

TRIAL REGISTRATION

NCT02173366.

Church-Based Health Promotion Focused on Advance Care Planning and End-of-Life Care at Black Baptist Churches: A Cross-Sectional Survey

BACKGROUND

African Americans with serious illnesses receive substandard palliative care (PC) and end-of-life care (EOLC) with a disproportionate number having worse symptom-related suffering, poorer health-related communication and knowledge of advance care planning (ACP) wishes, and increased utilization of hospitals and intensive care units at EOL. Previous research emphasizes the importance of spirituality and the church in African American communities. We are pioneering an innovative partnership between two Baptist African American churches and an interdisciplinary research team with a goal of developing and implementing a community-based, church-centered ACP program. We hypothesize that a church-based approach-which embraces and celebrates religion and spirituality as a means to discuss ACP and EOLC-can improve the quality of EOLC.

OBJECTIVE

The aim of the study was to determine parishioner experiences and beliefs about EOLC and their potential desire for a church-based program that would address ACP and EOLC.

METHODS

A cross-sectional survey of parishioners at two large black Baptist churches across four weekend services in December 2014 was conducted using a five-question, Likert-scale survey completed on a note card.

RESULTS

There were 930 responses submitted. Approximately 70% of parishioners care, or have cared, for someone with multiple medical problems and/or who is dying, and a vast majority (97%) believed that good EOLC is "important" or "very important." Only 60% of respondents noted having spoken with someone who could make decisions for them if they are unable to speak for themselves and that number decreased to 28% of respondents between the ages of 65 and 80. A majority (93%) would welcome church-provided information about EOLC.

CONCLUSIONS

A majority of parishioners care for someone with multiple health problems and believe that good EOLC is important. However, significantly less had designated a surrogate decision maker, particularly in parishioners over the age of 65. Respondents would welcome a church-based program focused on improving EOLC.

What are Hospice Providers in the Carolinas Doing to Reach African Americans in Their Service Area?

BACKGROUND

Experts and national organizations recommend that hospices work to increase service to African Americans, a group historically underrepresented in hospice.

OBJECTIVE

The study objective was to describe strategies among hospices in North and South Carolina to increase service to African Americans and identify hospice characteristics associated with these efforts.

METHODS

The study was a cross-sectional survey using investigator-developed scales to measure frequency of community education/outreach, directed marketing, efforts to recruit African American staff, cultural sensitivity training, and goals to increase service to African Americans. We used nonparametric Wilcoxon tests to compare mean scale scores by sample characteristics.

RESULTS

Of 118 eligible hospices, 79 (67%) completed the survey. Over 80% were at least somewhat concerned about the low proportion of African Americans they served, and 78.5% had set goals to increase service to African Americans. Most were engaged in community education/outreach, with 92.4% reporting outreach to churches, 76.0% to social services organizations, 40.5% to businesses, 35.4% to civic groups, and over half to health care providers; 48.0% reported directed marketing via newspaper and 40.5% via radio. The vast majority reported efforts to recruit African American staff, most often registered nurses (63.75%). Nearly 90% offered cultural sensitivity training to staff. The frequency of strategies to increase service to African Americans did not vary by hospice characteristics, such as profit status, size, or vertical integration, but was greater among hospices that had set goals to increase service to African Americans.

CONCLUSIONS

Many hospices are engaged in efforts to increase service to African Americans. Future research should determine which strategies are most effective.

Barriers to physical activity as moderators of intervention effects

The impact of interventions to increase physical activity (PA) may vary as a function of participants' barriers to PA. The aim of this paper is to determine whether individual barriers (demographic, physical health, psychological health, neighborhood factors, perceived barriers to PA, social support for PA) moderate treatment effects on increases in PA. Three treatment conditions tested the relative efficacy of a group-based PA intervention alone or supplemented by either personal or automated phone calls made between group meetings. From 2010 to 2012, 284 African American women (ages 40-65) living in the Chicago, IL, area were randomized to one of the three treatment conditions. Data collection occurred at baseline as well as 24 and 48 weeks after baseline. Moderation of intervention effects by barriers to PA were tested across four outcome measures (self-reported moderate-vigorous PA, self-reported walking, accelerometer steps, and aerobic fitness) using multilevel mixed-effects analyses. Significant condition by barrier interaction effects for the accelerometer steps outcome were found for material hardships, general health, depressive symptoms, neighborhood crime rate, and perceived barriers to PA. For aerobic fitness, intervention effects were moderated by material hardships and perceived pain. Increases in the outcome variables were greater for the conditions in which group sessions were supplemented with personal and/or automated calls. Among participants with greater barriers to PA, supplementing the intervention group meetings with between-session personal and/or automated phone calls may be an effective way to strengthen intervention effects. These results may inform the use of treatment supplements in the context of adaptive interventions.

Assessing Vocational Rehabilitation Engagement of People With Disabilities

The purpose of this study was to validate the Vocational Rehabilitation Engagement Scale (VRES) in a sample of state vocational rehabilitation (VR) service consumers. A total of 277 individuals with disabilities were recruited from Alaska, Kentucky, Florida, Michigan, New Mexico, Texas, Utah, and Wisconsin. The measurement structure of the VRES was evaluated using exploratory factor analysis and confirmatory factor analysis. Exploratory factor analysis results support a one-factor measurement structure of the VRES. Confirmatory factor analysis results also indicated a good model fit for the one-factor measurement model. Internal consistency reliability (Cronbach’s α) for the scores on the VRES was computed to be .94. VR engagement was found to be associated with working alliance, vocational self-efficacy, internal motivation, and VR outcome expectancy in the expected direction. The VRES is a brief, reliable, and valid instrument for assessing VR engagement and contributes to the use of self-determination as a paradigm for improving motivation and engagement of people with disabilities receiving services from state VR agencies.

The Brand's PREACH Model: Predicting Readiness to Engage African American Churches in Health

Despite many attempts to reduce health disparities, health professionals face obstacles in improving poor health outcomes within the African American (AA) community. To promote change for improved health measures, it is important to implement culturally tailored programming through a trusted institution, such as the AA church. While churches have the potential to play an important role in positively impacting health among AAs, it is unclear what attributes are necessary to predict success or failure for health promotion within these institutions. The purpose of this study was to create a model, the Brand's PREACH ( Predicting Readiness to Engage African American Churches in Health) Model, to predict the readiness of AA churches to engage in health promotion programming. Thirty-six semistructured key informant interviews were conducted with 12 pastors, 12 health leaders, and 12 congregants to gain information on the relationship between church infrastructure (physical structure, personnel, funding, and social/cultural support), readiness, and health promotion programming. The findings revealed that church infrastructure has an association with and will predict the readiness of a church to engage in health promotion programming. The ability to identify readiness early on will be useful for developing, implementing, and evaluating faith-based interventions, in partnership with churches, which is a key factor for sustainable and effective programs.

Digital Solutions for Informed Decision Making: An Academic-Community Partnership for the Development of a Prostate Cancer Decision Aid for African American Men

African American (AA) men are significantly more likely to die of prostate cancer (PrCA) than other racial groups, and there is a critical need to identify strategies for providing information about PrCA screening and the importance of informed decision making (IDM). To assess whether a computer-based IDM intervention for PrCA screening would be appropriate for AA men, this formative evaluation study examined their (1) PrCA risk and screening knowledge; (2) decision-making processes for PrCA screening; (3) usage of, attitudes toward, and access to interactive communication technologies (ICTs); and (4) perceptions regarding a future, novel, computer-based PrCA education intervention. A purposive convenience sample of 39 AA men aged 37 to 66 years in the Southeastern United States was recruited through faith-based organizations to participate in one of six 90-minute focus groups and complete a 45-item descriptive survey. Participants were generally knowledgeable about PrCA. However, few engaged in IDM with their doctor and few were informed about the associated risks and uncertainties of PrCA screening. Most participants used ICTs on a daily basis for various purposes including health information seeking. Most participants were open to a novel, computer-based intervention if the system was easy to use and its animated avatars were culturally appropriate. Because study participants had low exposure to IDM for PrCA, but frequently used ICTs, IDM interventions using ICTs (e.g., computers) hold promise for AA men and should be explored for feasibility and effectiveness. These interventions should aim to increase PrCA screening knowledge and stress the importance of participating in IDM with doctors.

A feasibility randomised controlled trial of a motivational interviewing-based intervention for weight loss maintenance in adults

BACKGROUND

Obesity has significant health and NHS cost implications. Relatively small reductions in weight have clinically important benefits, but long-term weight loss maintenance (WLM) is challenging. Behaviour change interventions have been identified as key for WLM. Motivation is crucial to supporting behaviour change, and motivational interviewing (MI) has been identified as a successful approach to changing health behaviours. The study was designed as an adequately powered, pragmatic randomised controlled trial (RCT); however, owing to recruitment issues, the study became a feasibility trial.

OBJECTIVES

To assess recruitment, retention, feasibility, acceptability, compliance and delivery of a 12-month intervention to support WLM. Secondary objectives were to assess the impact of the intervention on body mass index (BMI) and other secondary outcomes.

DESIGN

Three-arm individually randomised controlled trial comprising an intensive arm, a less intensive arm and a control arm.

SETTING

Community setting in South Wales and the East Midlands.

PARTICIPANTS

Individuals aged 18-70 years with a current or previous BMI of ≥ 30 kg/m(2) who could provide evidence of at least 5% weight loss during the previous 12 months.

INTERVENTION

Participants received individually tailored MI, which included planning and self-monitoring. The intensive arm received six face-to-face sessions followed by nine telephone sessions. The less intensive arm received two face-to-face sessions followed by two telephone sessions. The control arm received a leaflet advising them on healthy lifestyle.

MAIN OUTCOME MEASURES

Feasibility outcomes included numbers recruited, retention and adherence. The primary effectiveness outcome was BMI at 12 months post randomisation. Secondary outcomes included waist circumference, waist-to-hip ratio, physical activity, proportion maintaining weight loss, diet, quality of life, health service resource usage, binge eating and well-being. A process evaluation assessed intervention delivery, adherence, and participants' and practitioners' views. Economic analysis aimed to assess cost-effectiveness in terms of quality-adjusted life-years (QALYs).

RESULTS

A total of 170 participants were randomised. Retention was good (84%) and adherence was excellent (intensive, 83%; less intensive, 91%). The between-group difference in mean BMI indicated the intensive arm had BMIs 1.0 kg/m(2) lower than the controls [95% confidence interval (CI) -2.2 kg/m(2) to 0.2 kg/m(2)]. Similarly, a potential difference was found in weight (average difference of 2.8 kg, 95% CI -6.1 kg to 0.5 kg). The intensive arm had odds of maintaining on average 43% [odds ratio(OR) 1.4, 95% CI 0.6 to 3.5] higher than controls. None of these findings were statistically significant. Further analyses controlling for level of adherence indicated that average BMI was 1.2 kg/m(2) lower in the intensive arm than the control arm (95% CI -2.5 kg/m(2) to 0.0 kg/m(2)). The intensive intervention led to a statistically significant difference in weight (mean -3.7 kg, 95% CI -7.1 kg to -0.3 kg). The other secondary outcomes showed limited evidence of differences between groups. The intervention was delivered as planned, and both practitioners and participants were positive about the intervention and its impact. Although not powered to assess cost-effectiveness, results of this feasibility study suggest that neither intervention as currently delivered is likely to be cost-effective in routine practice.

CONCLUSION

This is the first trial of an intervention for WLM in the UK, the intervention is feasible and acceptable, and retention and adherence were high. The main effectiveness outcome showed a promising mean difference in the intensive arm. Owing to the small sample size, we are limited in the conclusions we can draw. However, findings suggest that the intensive intervention may facilitate long-term weight maintenance and, therefore, further testing in an effectiveness trial may be indicated. Research examining WLM is in its infancy, further research is needed to develop our understanding of WLM and to expand theory to inform the development of interventions to be tested in rigorously designed RCTs with cost-effectiveness assessed.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN35774128.

FUNDING

This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 50. See the NIHR Journals Library website for further project information.

The Promise of Tailoring Incentives for Healthy Behaviors

PURPOSE

To describe how tailoring financial incentives for healthy behaviors to employees' goals, values, and aspirations might improve the efficacy of incentives.

DESIGN/METHODOLOGY/APPROACH

We integrate insights from self-determination theory (SDT) with principles from behavioral economics in the design of financial incentives by linking how incentives could help meet an employee's life goals, values, or aspirations.

FINDINGS

Tailored financial incentives could be more effective than standard incentives in promoting autonomous motivation necessary to initiate healthy behaviors and sustain them after incentives are removed.

RESEARCH IMPLICATIONS

Previous efforts to improve the design of financial incentives have tested different incentive designs that vary the size, schedule, timing, and target of incentives. Our strategy for tailoring incentives builds on strong evidence that difficult behavior changes are more successful when integrated with important life goals and values. We outline necessary research to examine the effectiveness of this approach among at-risk employees.

PRACTICAL IMPLICATIONS

Instead of offering simple financial rewards for engaging in healthy behaviors, existing programs could leverage incentives to promote employees' autonomous motivation for sustained health improvements.

SOCIAL IMPLICATIONS

Effective application of these concepts could lead to programs more effective at improving health, potentially at lower cost.

ORIGINALITY/VALUE

Our approach for the first time integrates key insights from SDT, behavioral economics, and tailoring to turn an extrinsic reward for behavior change into an internalized, self-sustaining motivator for long-term engagement in risk-reducing behaviors.