Predicting intention and behaviour following participation in a theory-based intervention to improve gluten free diet adherence in coeliac disease

Utilizing Telemedicine Applications in Celiac Disease and Other Gluten-Free-Diet-Dependent Conditions: Insights from the COVID-19 Pandemic

BACKGROUND

Globally, approximately 1.4% of people have celiac disease (CD), induced by gluten sensitivity. If left untreated, it causes small intestinal inflammation and villous atrophy, which can result in failure to thrive, anemia, osteoporosis, malabsorption, and even malignancy. The only treatment option available is a gluten-free diet (GFD). Few studies have looked at the role and perception of telehealth in relation to CD and selective nutrition both before and after the COVID-19 pandemic.

AIM

Our goal was to screen and investigate the research conducted both before and after the COVID-19 pandemic concerning the utilization of telehealth applications and solutions in CD and other GFD-dependent circumstances.

METHODS

We employed a narrative review approach to explore articles that were published in scholarly journals or organizations between the years 2000 and 2024. Only English-language publications were included. PubMed and Google Scholar searches were mainly conducted using the following keywords: telemedicine, telehealth, telecare, eHealth, m-health, COVID-19, SARS-CoV-2, celiac disease, and gluten-free diet (GFD). Manual searches of the references in the acquired literature were also carried out, along with the authors' own personal contributions of their knowledge and proficiency in this field.

RESULTS

Only a few studies conducted prior to the COVID-19 outbreak examined the viewpoints and experiences of adult patients with CD with relation to in-person clinic visits, as well as other options such as telehealth. The majority of patients believed that phone consultations were appropriate and beneficial. Video conferencing and telemedicine became more popular during the COVID-19 pandemic, demonstrating the effectiveness of using these technologies for CD on a global basis. In recent years, urine assays for gluten identification have become accessible for use at home. These tests could be helpful for CD monitoring with telemedicine assistance.

CONCLUSIONS

The extended knowledge gathered from the COVID-19 pandemic is expected to complement pre-COVID-19 data supporting the usefulness of telemedicine even after the emergent pandemic, encouraging its wider adoption in standard clinical practice. The monitoring and follow-up of CD patients and other GFD-dependent conditions can greatly benefit from telemedicine.

Training Australian Dietitians in Behavior Change Techniques Through Educational Workshops: Protocol for a Randomized Controlled Trial

BACKGROUND

The use of education alone as a technique to change behavior in interventions is usually insufficient, particularly in health interventions. Behavior change techniques have been shown to be effective in fostering positive changes in health behaviors such as diet and physical activity. The upskilling of health professionals can increase perceived capability and motivation toward eliciting change in clients' behaviors. However, to date, dietitians have received limited training in behavior change and have expressed a need for continuous professional development.

OBJECTIVE

The study objectives are to (1) develop and evaluate the effectiveness and acceptability of two 2-hour behavior change workshops on changing dietitians behavior (ie, range of behavior change techniques used and frequency of use) across 3 time points; (2) determine if participation in these workshops will elicit changes in dietitians' perceived capability, opportunity, and motivation toward using behavior change techniques; and (3) determine the acceptability of the training and its application in practice by dietitians.

METHODS

We will recruit registered dietitians (N=140) in Australia to participate in this randomized controlled trial. Participants will be randomly assigned to either the intervention or 3-month waitlist control condition and complete outcome measures at 3 time points: baseline, after the workshop, and follow-up at 3 months. Both groups will complete 2 workshops on behavior change that are guided by the COM-B (Capability, Opportunity, Motivation, and Behavior) Model and embedded with behavior change techniques. The primary outcome is changes in behavior, (ie, the range of behavior change techniques used and their frequency of use). Secondary outcomes include changes in perceived capability, opportunity, motivation, and preparedness as a health professional toward delivering behavior change techniques. The acceptability of the workshops will also be assessed after the workshop through the postworkshop survey and semistructured interviews. A series of 2-way repeated measures ANOVAs and regressions will be used. Qualitative data will be analyzed using thematic analysis.

RESULTS

Participant recruitment commenced in June 2023. The results of the study are expected to be published in November 2024. The results will allow us to assess comparisons between the intervention and waitlist control groups, as well as changes in perceived capability, opportunity, motivation, and preparedness over a 3-month period. It will also provide an understanding of the acceptability of the training as a form of continuous professional development for dietitians.

CONCLUSIONS

If found to be effective, the results of this 2-arm randomized controlled trial will guide future training and continuous professional development for health professionals in changing behavior in practice. Our findings will contribute to our understanding of the application of behavior change techniques in practice with clients and identify components of COM-B where dietitians may need future support.

TRIAL REGISTRATION

ACTRN12623000525684; https://www.anzctr.org.au/ACTRN12623000525684.aspx.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/49723.

The Effect of a Theory-Based Educational Intervention on Reducing Aggressive Behavior among Male Students: A Randomized Controlled Trial Study

Introduction

One of the most challenging issues in public health is preventing aggression and violent behavior, generally in the adolescent population. Intervention studies in this field, especially in Iran, were few. Moreover, their findings are controversial. Therefore, this study was conducted to investigate the effect of educational intervention based on the theory of planned behavior (TPB) on reducing aggression among male students.

Method

This study used a randomized controlled trial design. The sample comprised 98 middle school students aged between 13 and 16 years (14.28 ± 0.7). Educational intervention for the experimental group consisted of five sessions of 45-60 minutes. Data were collected using two self-administered questionnaires to measure aggression and constructs of TPB. Data were analyzed using paired t-test, independent t-test, and chi-square test at a significance level of 0.05.

Results

After the intervention, the experimental group showed a significant increase in all TPB constructs except the subjective norms, compared to the control group (p < 0.001). After two months of intervention, the mean score of the aggression behaviors in students in the experimental group showed a remarkable improvement in the experimental group, while the control group showed no significant difference.

Conclusion

The findings of this study showed that the theory-based educational intervention was effective on the improvement of aggressive behavior. To achieve a significant change in perceived mental norms, more training sessions are recommended, and emphasis is placed on educating parents, peers, and school staff.

Correlates of participation in physical activity among older women in Israel: does ethno-cultural background matter?

Osteoporosis and its related fractures are major public health concerns. Physical activity (PA) is crucial for bone density preservation and fractures prevention. Yet, gaps in understanding exist regarding how ethno-cultural backgrounds might shape attitudes, intentions and actual PA participation. Based on the theory of planned behaviour (TPB) for predicting PA, the aims of this study were: (i) to compare attitudes, subjective norms, perceived control, intentions and knowledge, across four ethno-cultural groups; (ii) to evaluate the fit of the model we constructed across four ethno-cultural groups of women: Israeli-born Jews and Israeli-born Bedouin-Muslims, immigrants from the Former Soviet Union (FSU) and Ethiopian immigrants. Four hundred women (one hundred from each group), aged >65, completed valid and reliable questionnaires assessing knowledge, TPB components and actual PA. The level of knowledge on osteoporosis was relatively low among all four ethno-cultural groups. Intention to participate in PA was the only variable that directly predicted actual PA. Intention to participate in PA served as a mediator among attitudes, subjective norms, perceived control and actual PA. The structural equation models (SEMs) revealed that among Israeli-born Jews and Ethiopian immigrants, TPB components mediated the link between knowledge and intention to participate in PA. Among FSU immigrants and Israeli Bedouin-Muslims, the knowledge variable was not included in the final model, as its contribution was not significant. It is essential to better understand and augment interventions that enhance PA in the community, and to address the unique needs of each ethno-cultural group.

Why people follow a gluten-free diet? An application of health behaviour models

PURPOSE

To understand factors affecting adherence to GFD by celiac and non-celiac people through the application of behavioural theories, Integrative Model (IM) and Multi Theory Model (MTM).

METHODS

Analyses were conducted for a sample of 308 subjects, majority females, celiac and non-celiac. Adherence to GFD was measured considering two scales, self-declared adherence and scored adherence, in order to discern possible inconsistencies between what subjects believe and what they really do. Subsequently, adherence to GFD was modelled by considering constructs of MTM and IM. Moreover, the constructs were designed based on literature review. Ordered logit (OL) model was used to test the IM and MTM theoretical models.

RESULTS

The findings show that adherence to GFD is affected mainly by attitudes towards GFD, self-efficacy, injunctive norms, knowledge about GFD and health conditions. Between the two models, IM and MTM, results show that all constructs of IM explain the behaviour. Contrary, for MTM, results indicate only some constructs of the MTM explain adherence to GFD.

CONCLUSIONS

Results of this study should be considered for improving the adherence to GFD for celiac people. Furthermore, it is important to consider the non-celiac people's perceptions for GFD and GF products. In other words an accurate information about the diet and products it is relevant for supporting people to make healthier food choices. Finally, as the results show, IM explain adherence to GFD better than MTM.

The potential benefits of camps for children and adolescents with celiac disease on social support, illness acceptance, and health-related quality of life

Among N = 165 14-22-year-old bearers of celiac disease (CD), the German-based study examined if participation in camps for children with CD is related to higher CD-related quality of life (CD-QoL); N = 48 of the study participants attended at least one camp. Camp participation was found to be related to higher CD-QoL, an effect mediated by having more friends with CD and by perceiving higher social support. Camp participation was also associated with higher illness acceptance and lower anxiety. Results show the potential benefits of recreational activities in CD treatment, to be further examined in experimental research.

Telephone clinic improves gluten-free dietary adherence in adults with coeliac disease: sustained at 6 months

BACKGROUND

A gluten-free (GF) diet is the only treatment for coeliac disease (CD), non-adherence to the diet is associated with greater morbidity. The study aimed to examine the effect of a telephone clinic, designed to increase GF dietary knowledge and adherence, in adults with CD.

METHODS

A prospective study of 125 patients with histologically confirmed CD. Patients, not adhering to a GF diet (n=30), engaged in a personalised telephone clinic. Validated questionnaires were used to assess GF dietary adherence (Coeliac Disease Adherence Test; CDAT), knowledge of GF foods and CD-related quality of life (QoL). GF dietary adherence was assessed up to 12 months post telephone clinic. The control group completed the questionnaires only.

RESULTS

GF dietary adherence (CDAT) median scores significantly improved at 3 and 6 months after the telephone clinic compared with baseline (16, 13 and 13, respectively, p<0.01). Reassuringly, the dietary burden QoL score remained similar to baseline values. No change in CDAT scores were observed in the control group. Change in GF dietary knowledge score was associated with improved GF dietary adherence CDAT score (r=-0.22; p=0.039). At 9 and 12 months, CDAT scores were similar to baseline values.

CONCLUSIONS

Telephone clinics have a positive impact on dietary knowledge and GF dietary adherence in adults with CD, promoting health-benefitting behaviours in those previously not adhering to a GF diet. The study highlights the need for patients to have regular follow-up, with targeted reviews for those not adhering to a GF diet.

Interventions to Increase Adherence to a Gluten Free Diet in Patients with Coeliac Disease: A Scoping Review

Coeliac disease is a chronic inflammatory disorder of the small bowel, characterised by permanent intolerance to gluten. The only current and effective treatment for coeliac disease is a gluten free diet [GFD], however this is challenging for patients to adhere to. The review aims to identify published interventions designed to improve patients’ adherence to a GFD. Ten intervention studies were identified and included within the review; whilst heterogeneous in delivery, all included an educational, behavioural, and practical element. Five interventions significantly improved dietary adherence, these included follow-up appointments, a telephone clinic, an online course, cooking sessions and psychological support. All studies were small and used varied methods to assess adherence. There is a paucity of well-designed interventions to promote dietary adherence, in future more robust methods for ascertaining adherence is needed, we recommend greater inclusion of dietetic assessment and combining more than one method for assessing adherence.

Behaviour model for diabetic ulcer prevention

Purpose

Diabetic ulcers are one of the complications that often occur in patients with DM. The aim is to develop a behaviour model for diabetic ulcer prevention by integrating Lawrance Green Theory and the Theory of Planned Behaviour.

Methods

An explanative observational design was used with a cross-sectional approach. The population consisted of DM patients who had underwent treatment at the internal medicine clinic of Sidoarjo District Hospital. The sample size of 133 respondents was obtained through purposive sampling. The data analysis used Partial Least Square.

Results

Predisposing factors (knowledge), supporting factors (availability of health facilities and accessibility of health resources) and driving factors (the role of health workers and family support) significantly influence the main factors (attitudes toward behaviour, subjective norms and perceptions of self-control) with a statistical T value>1.96. The main factor influences intention (T = 48.650) and intention influences behaviour (T = 4.891).

Conclusion

Intention is influenced by the attitudes toward behaviour, subjective norms and self-control perceptions. Good intentions can increase the preventive behaviour related to diabetic ulcers. Increasing the diabetic ulcer prevention behaviour can be done by providing regular education to both the patients and their families about diabetic ulcers and their prevention through the appropriate management of DM, lifestyle modification and regular foot care that requires active involvement from the family and health care workers.

The effect of self-efficacy expectations in the adherence to a gluten free diet in celiac disease

Objective: To analyse the effect of general and specific self-efficacy on the adherence to a gluten free diet (GFD) in patients with celiac disease along with the effect of other relevant variables.Design: 271 patients with celiac disease participated in this transversal descriptive study and completed a series of questionnaires regarding adherence (CDAT), general self-efficacy (GSES) and specific self-efficacy (Celiac-SE) and quality of life (CD-Qol), among others.Main Outcome Measures: Dependent variable was adherence to the Gluten Free Diet (GFD). Main independent variables were general self-efficacy, specific self-efficacy and quality of life. Model tests were conducted using regression analysis.Results: 71.9% of patients show an excellent or good adherence to the diet. Higher levels of adherence are positively associated to a high expectancy of specific self-efficacy, to the perceived adoption of recommended behaviours, risk perception and better quality of life (these variables accounted for 36.4% of the variance in the adherence to a GFD, p < .001).Conclusions: Specific self-efficacy rather than general has a predictive value in adherence to a GFD. Therefore, we need to develop and transculturally adapt new instruments to assess specific self-efficacy. Celiac-SE has proved to be a useful scale for this objective.

The roles of autonomous motivation and self-control lapses in concurrent adherence to a gluten-free diet and a self-chosen weight loss plan in adults with coeliac disease

Objective: Examine the correspondence between autonomous motivation, self-control lapses, and adherence, to a gluten-free diet (GFD) and weight loss plan in adults with coeliac disease; and assess the impact of the interaction of motivation style and self-control lapses on adherence to both diets. Design: Cross-sectional survey in 519 adults with coeliac disease, 238 of whom were also attempting weight loss. Main outcome measures: Adherence, motivation style, frequency of temptation and self-control lapses (e.g. when tired, stressed, happy) for GFD and weight loss plan. Results: Autonomous motivation was higher, and amotivation lower, for the GFD than weight loss; adherence to the two diets was unrelated. Similar circumstances led to temptation and self-control lapses across diets; both were less frequent for the GFD than weight loss. Motivation and self-control lapses explained 21% and 35% of the variance in adherence, respectively; the interaction between motivation and lapse frequency did not explain additional variance for either diet. Conclusions: There are clear benefits to developing autonomous motivations and strategies to resist temptation for both the GFD and weight loss. Understanding how these processes differ and interact across diets may lead to the design of interventions to improve adherence and weight outcomes in coeliac disease.

Identifying and improving adherence to the gluten-free diet in people with coeliac disease

Coeliac disease (CD) is an autoimmune gastrointestinal disorder whereby the ingestion of gluten, a storage protein found in wheat, barley and rye, causes damage to intestinal mucosa with resultant malabsorption, increased risk of anaemia and osteoporosis. Worldwide estimates suggest 1% of the population have CD. With no cure, the only treatment is a gluten-free diet (GFD). Adhering to a GFD can be very challenging; it requires knowledge, motivation and modified behaviours. Assessing adherence to a GFD is methodologically challenging. This review aims to provide an overview of the literature reporting adherence to a GFD in people with CD and the methodological challenges encountered. From six studies it has been reported that rates of adherence to a GFD range between 45 and 90% in patients of different ethnicities with CD. GF dietary adherence can be influenced by age at diagnosis, coexisting depression, symptoms on ingestion of gluten, nutrition counselling, knowledge of GF foods, understanding of food labels, cost and availability of GF foods, receiving GF foods on prescription and membership of a coeliac society. To date only five intervention studies in adults with CD have been undertaken to improve GF dietary adherence. These have included dietary and psychological counselling, and the use of online training programmes, apps, text messages and telephonic clinics. Future interventions should include people of all ethnicities, consider patient convenience and the cost-effectiveness for the healthcare environment.

The effect of the "Follow in my Green Food Steps" programme on cooking behaviours for improved iron intake: a quasi-experimental randomized community study

BACKGROUND

Nutritional iron deficiency is one of the leading factors for disease, disability and death. A quasi-experimental randomized community study in South-West Nigeria explored whether a branded behaviour change programme increased the use of green leafy vegetables (greens) and iron-fortified bouillon cubes in stews for improved iron intake.

METHODS

A coinflip assigned the intervention to Ile-Ife (Intervention town). Osogbo (Control town) received no information. At baseline 602 mother-daughter pairs (daughters aged 12-18) were enrolled (Intervention: 300; Control: 302). A Food Frequency Questionnaire assessed the addition of cubes and greens to stews, the primary outcome. Secondary outcomes were the addition of cubes and greens to soups and changes in behavioural determinants measured using the Theory of Planned Behaviour. Structural Equation Modelling (SEM) evaluated the impact of the intervention on behavioural determinants and behaviour.

RESULTS

The data of 527 pairs was used (Intervention: 240; Control: 287). The increase in greens added to stews was larger in the Intervention town compared to the Control town (M_Intervention = 0.3 [SE = 0.03]; M_Control = 0.0 [SE = 0.04], p < 0.001, r = 0.36). Change in iron-fortified cubes added to stews did not differ between towns (p = 0.07). The increase in cubes added to soups was larger in the Intervention town compared to the Control Town (M_Intervention = 0.9 [SE = 0.2] vs M_Control = 0.4 [SE = 0.1], p < .0001, r = 0.20). Unexpectedly, change in greens added to soups was larger in the Control town compared to the Intervention town (M_Intervention = - 0.1 [SE = 0.1]; M_Control = 0.5 [SE = 0.1], p = 0.003, r = 0.15). The intervention positively influenced awareness of anaemia and the determinants of behaviour in the Intervention town, with hardly any change in the Control town. Baseline SEMs could not be established, so no mediation analyses were done. Post-intervention SEMs highlighted the role of habit in cooking stews.

CONCLUSIONS

The behaviour change programme increased the amount of green leafy vegetables added to stews and iron-fortified cubes added to soups. Future research should assess the long-term impact and the efficacy of the programme as it is scaled up and rolled out.

The Theory of Planned Behavior and Physical Activity Change: Outcomes of the Aging Well and Healthily Intervention Program for Older Adults

The predictive value of the Theory of Planned Behavior (TPB) on intention and physical activity (PA) over time was examined. Data from the Aging Well and Healthily intervention program (targeting perceived behavioral control and attitude, not subjective norm) were analyzed, including pretest (T0), posttest (T1, except subjective norm) and 4-6 months follow-up (T2, PA outcomes only) (N = 387, M age 72 years). Structural equation modeling was used to test a TPB model. PA was measured subjectively using the Voorrips sports subscale (T0 and T2), items measured perceived increase in PA (T1), and adherence to exercises (T1 and T2). Model fit was good. The TPB explained variation in intention well (R² .54-.60) and some PA behavior (R² .13-.16). The intervention successfully got participants to exercise independent of the measured TPB concepts. More TPB studies in the context of interventions are needed.

Outcomes in coeliac disease: a qualitative exploration of patients' views on what they want to achieve when seeing a dietitian

BACKGROUND

Coeliac disease (CD) is managed by life-long adherence to a gluten-free diet and dietitians have the potential to facilitate this. Patient involvement through shared decision-making is central to behaviour-change skills used by dietitians, although there is little evidence supporting its inclusion in evaluating dietetic interventions. The present study aimed to explore patients' preferences for diet and nutrition-related outcomes in CD.

METHODS

Adults with CD or adult carers of children with CD were invited through support networks. Participants took part in a telephone, face-to-face interview or focus group which was audio-recorded and transcribed. Themes were developed using a framework method. Ethical approval was obtained.

RESULTS

Twenty-nine adult patients and five parents of CD children participated 0-34 years after diagnosis. Four main outcome-related themes emerged: (i) Participants wanted information specific to their lifestyle and time since diagnosis, focussing on food containing gluten, practical issues, prescribable items and general nutrition. (ii) The degree of satisfaction with the consultation process impacted on participants' experience, including the dietitian's CD expertise, consistency of the dietitian seen, and the frequency and length of appointments. (iii) Health concerns were important to participants and focussed on risk of osteoporosis, unwanted weight gain, and the fat and sugar content of manufactured gluten-free products. (iv) Clinical monitoring, including bone scans and antibody measurements, was mentioned but was not described as being of importance for most participants.

CONCLUSIONS

The outcomes preferred by CD patients and carers focussed primarily on information and resources received and satisfaction with their dietetic consultation.