Challenges and solutions for N-of-1 design studies in health psychology

Evaluating the Let's Move It intervention programme theory for adolescents' physical activity: Theorized psychosocial mechanisms of behavioural changes

OBJECTIVES

Behaviour change theories have extensively been used in health behaviour change interventions and their programme theories. However, they are rarely evaluated in randomized field studies. The Let's Move It intervention targeted various psychosocial constructs to increase adolescents' physical activity. A theory-based process evaluation aiming to illuminate the trial findings as well as to test the programme theory used is conducted. Specifically, we investigate whether the intervention influenced the theorized determinants of change immediately post-intervention and after 1 year, and whether these determinants were associated with changes in physical activity.

DESIGN

A cluster-randomized controlled trial (n = 1166).

METHODS

We measured theorized determinants with self-report, and physical activity (PA) with accelerometry and self-report. The effects are evaluated with repeated measures ANOVA and regression models.

RESULTS

No changes were detected in most theorized determinants but intervention arm reported higher enactment of behaviour change techniques used during intervention immediately post-intervention and lower descriptive norms for PA throughout. Autonomous motivation was associated with PA immediately post-intervention.

CONCLUSIONS

The lack of intervention effects may be due to many factors, for example insensitive measures, ceiling effects. However, reporting these null effects advances understanding of behaviour change processes. We introduce methodologic possibilities for future intervention programme theory evaluation efforts.

Predicting Physical Activity in Survivors of Breast Cancer: the Health Action Process Approach at the Intrapersonal Level

BACKGROUND

Benefits have been established for regular physical activity (PA) and exercise after breast cancer, but a decline of PA has also been a reported result of breast cancer diagnosis and treatments. The Health Action Process Approach (HAPA) model has been shown to predict various health behaviors, but few studies have tested it at the intrapersonal level. The aim of the present study was to test whether the HAPA constructs that are well confirmed at the interpersonal level also hold at the intrapersonal level in a group of women survivors of breast cancer.

METHOD

PA behaviors (N = 338) by nine survivors of breast cancer were observed for 6 weeks, and the associations between the HAPA constructs and PA over time were examined. Participants completed a questionnaire with the HAPA constructs related to PA behavior (direct step count and self-reported).

RESULTS

A multilevel model of behavior prediction found that optimistic beliefs about ability to initiate and maintain PA (self-efficacy) were positively related to intentions to be active, and these intentions predicted plans to be active. PA was directly and positively predicted by planning and by confidence in the ability to resume PA after a break.

CONCLUSION

Self-efficacy and planning are associated with PA behavior within women survivors of breast cancer over time, which was not the case for the outcome expectancies, social support, and action control at this intrapersonal level. A multilevel approach for psychological predictors of PA can be useful in grounding interventions for survivors of breast cancer.

Attractor landscapes: a unifying conceptual model for understanding behaviour change across scales of observation

Models and theories in behaviour change science are not in short supply, but they almost exclusively pertain to a particular facet of behaviour, such as automaticity or reasoned action, or to a single scale of observation such as individuals or communities. We present a highly generalisable conceptual model which is widely used in complex systems research from biology to physics, in an accessible form to behavioural scientists. The proposed model of attractor landscapes can be used to understand human behaviour change on different levels, from individuals to dyads, groups and societies. We use the model as a tool to present neglected ideas in contemporary behaviour change science, such as hysteresis and nonlinearity. The model of attractor landscapes can deepen understanding of well-known features of behaviour change (research), including short-livedness of intervention effects, problematicity of focusing on behavioural initiation while neglecting behavioural maintenance, continuum and stage models of behaviour change understood within a single accommodating framework, and the concept of resilience. We also demonstrate potential methods of analysis and outline avenues for future research.

Biofeedback and Digitalized Motivational Interviewing to Increase Daily Physical Activity: Series of Factorial N-of-1 Randomized Controlled Trials Piloting the Precious App

BACKGROUND

Insufficient physical activity is a public health concern. New technologies may improve physical activity levels and enable the identification of its predictors with high accuracy. The Precious smartphone app was developed to investigate the effect of specific modular intervention elements on physical activity and examine theory-based predictors within individuals.

OBJECTIVE

This study pilot-tested a fully automated factorial N-of-1 randomized controlled trial (RCT) with the Precious app and examined whether digitalized motivational interviewing (dMI) and heart rate variability-based biofeedback features increased objectively recorded steps. The secondary aim was to assess whether daily self-efficacy and motivation predicted within-person variability in daily steps.

METHODS

In total, 15 adults recruited from newspaper advertisements participated in a 40-day factorial N-of-1 RCT. They installed 2 study apps on their phones: one to receive intervention elements and one to collect ecological momentary assessment (EMA) data on self-efficacy, motivation, perceived barriers, pain, and illness. Steps were tracked using Xiaomi Mi Band activity bracelets. The factorial design included seven 2-day biofeedback interventions with a Firstbeat Bodyguard 2 (Firstbeat Technologies Ltd) heart rate variability sensor, seven 2-day dMI interventions, a wash-out day after each intervention, and 11 control days. EMA questions were sent twice per day. The effects of self-efficacy, motivation, and the interventions on subsequent steps were analyzed using within-person dynamic regression models and aggregated data using longitudinal multilevel modeling (level 1: daily observations; level 2: participants). The analyses were adjusted for covariates (ie, within- and between-person perceived barriers, pain or illness, time trends, and recurring events).

RESULTS

All participants completed the study, and adherence to activity bracelets and EMA measurements was high. The implementation of the factorial design was successful, with the dMI features used, on average, 5.1 (SD 1.0) times of the 7 available interventions. Biofeedback interventions were used, on average, 5.7 (SD 1.4) times out of 7, although 3 participants used this feature a day later than suggested and 1 did not use it at all. Neither within- nor between-person analyses revealed significant intervention effects on step counts. Self-efficacy predicted steps in 27% (4/15) of the participants. Motivation predicted steps in 20% (3/15) of the participants. Aggregated data showed significant group-level effects of day-level self-efficacy (B=0.462; P<.001), motivation (B=0.390; P<.001), and pain or illness (B=-1524; P<.001) on daily steps.

CONCLUSIONS

The automated factorial N-of-1 trial with the Precious app was mostly feasible and acceptable, especially the automated delivery of the dMI components, whereas self-conducted biofeedback measurements were more difficult to time correctly. The findings suggest that changes in self-efficacy and motivation may have same-day effects on physical activity, but the effects vary across individuals. This study provides recommendations based on the lessons learned on the implementation of factorial N-of-1 RCTs.

What drives change in children receiving telephone-delivered Common Elements Treatment Approach (t-CETA)? A multiple n = 1 study with Syrian refugee children and adolescents in Lebanon

BACKGROUND

Although the evidence-base for mental health and psychosocial support (MHPSS) interventions in humanitarian settings is growing rapidly, their mechanisms of change remain poorly understood despite the potential to improve the effectiveness and reach of interventions.

OBJECTIVE

This study aimed to explore the mechanisms or factors that drive change in a modular transdiagnostic telephone-delivered mental health intervention, Common Elements Treatment Approach (t-CETA).

PARTICIPANTS AND SETTING

Participants were Syrian refugee children and adolescents living in tented settlements in Lebanon.

METHODS

We used a multiple n = 1 design, drawing on secondary data from 9 children who completed t-CETA during a pilot randomized controlled trial.

RESULTS

Children with historical war-related trauma were more likely to show significant improvement across symptom clusters by the end of treatment compared to children presenting with depression related to daily living conditions. Children also showed fluctuating symptoms during the early stages of treatment (engagement and cognitive restructuring) but significant decline in symptoms after the trauma module (prolonged imaginal exposure) and depression module (behavioral activation). Salient external life events identified were starting or dropping out of school, working, change in living conditions, family conflict and the October Revolution; and interpersonal factors of parental engagement (with or without full attendance) and counsellor skills in building rapport were also identified as having an impact on treatment success.

CONCLUSIONS

Implications of our findings are discussed in terms of integrating active ingredients into MHPSS programming, and building on parental and multi-sector involvement in child and adolescent mental health care in humanitarian settings.

A Series of Remote Melatonin Supplement Interventions for Poor Sleep: Protocol for a Feasibility Pilot Study for a Series of Personalized (N-of-1) Trials

BACKGROUND

Poor sleep, defined as short-duration or poor-quality sleep, is a frequently reported condition with many deleterious effects including poorer cognitive functioning, increased accidents, and poorer health. Melatonin has been shown to be an efficacious treatment to manage symptoms of poor sleep. However, the treatment effects of melatonin on sleep can vary greatly between participants. Personalized, or N-of-1, trial designs represent a method for identifying the best treatment for individual participants. Although using N-of-1 trials of melatonin to treat poor sleep is possible, the feasibility, acceptability, and effectiveness of N-of-1 trials using melatonin are unknown. Using the National Institutes of Health Stage Model for Behavioral Intervention Development, a stage IB (intervention refinement, modification, and adaptation and pilot testing) design appeared to be needed to address these feasibility questions.

OBJECTIVE

This trial series evaluates the feasibility, acceptability, and effectiveness of a series of personalized interventions for remote delivery of melatonin dose (3 and 0.5 mg) versus placebo supplements for self-reported poor sleep among 60 participants. The goal of this study is to provide valuable information about implementing remote N-of-1 randomized controlled trials to improve poor sleep.

METHODS

Participants will complete a 2-week baseline followed by six 2-week alternating intervention periods of 3 mg of melatonin, 0.5 mg of melatonin, and placebo. Participants will be randomly assigned to 2 intervention orders. The feasibility and acceptability of the personalized trial approach will be determined with participants' ratings of usability and satisfaction with the remote, personalized intervention delivery system. The effectiveness of the intervention will be measured using participants' self-reported sleep quality and duration and Fitbit tracker-measured sleep duration and efficiency. Additional measures will include ecological momentary assessment measures of fatigue, stress, pain, mood, concentration, and confidence as well as measures of participant adherence to the intervention, use of the Fitbit tracker, and survey data collection.

RESULTS

As of the submission of this protocol, recruitment for this National Institutes of Health stage IB personalized trial series is approximately 78.3% complete (47/60). We expect recruitment and data collection to be finalized by June 2023.

CONCLUSIONS

Evaluating the feasibility, acceptability, and effectiveness of a series of personalized interventions of melatonin will address the longer term aim of this program of research-is integrating N-of-1 trials useful patient care? The personalized trial series results will be published in a peer-reviewed journal and will follow the CONSORT (Consolidated Standards of Reporting Trials) extension for N-of-1 trials (CENT 2015) reporting guidelines. This trial series was approved by the Northwell Health institutional review board.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05349188; https://www.clinicaltrials.gov/study/NCT05349188.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/45313.

Does sports therapy affect momentary affective states? Feasibility of intensive longitudinal case studies in forensic psychiatry

Physical exercise interventions improve quality of life in people with mental disorders and improve abstinence and cravings in substance use disorders patients in both the short term and long term. In people with mental illness, physical exercise interventions significantly reduce psychiatric symptoms of schizophrenia and symptoms of anxiety. For forensic psychiatry, there is little empirical evidence supporting mental health-enhancing effects of physical exercise interventions. Interventional studies in forensic psychiatry deal mainly with three problems: heterogeneity of the individuals, a small sample size, and a low compliance rate. Intensive longitudinal case studies could be a suitable approach to address these methodological challenges in forensic psychiatry. This study uses an intensive longitudinal design to determine whether forensic psychiatric patients are content to complete several data assessments per day over the course of several weeks. The feasibility of this approach is operationalized by the compliance rate. Additionally, single-case studies examine the effects of sports therapy (ST) on momentary affective states (energetic arousal, valence, and calmness). The results of these case studies reveal one aspect of feasibility and offer insights into the effects of forensic psychiatric ST on the affective states among patients with different conditions. The patients' momentary affective states were recorded before (PRE), after (POST) and 1 h after (FoUp1h) ST by questionnaires. Ten individuals (M_age = 31.7, SD = 11.94; 60% male) participated in the study. A total of 130 questionnaires were completed. To perform the single-case studies, data of three patients were considered. Repeated-measures ANOVA was performed for the individual affective states to test for main effects of ST. Due to the results, ST has no significant effect on none of the three affect dimensions. However, effect sizes varied between small to medium (energetic arousal: η² = 0.01, η² = 0.07, η² = 0.06; valence: η² = 0.07; calmness: η² = 0.02) in the three patients. Intensive longitudinal case studies are a possible approach to address heterogeneity and the low sample size. The low compliance rate in this study reveals that the study design needs to be optimized for future studies.

Application of Ecological Momentary Assessment in Studies with Rotation Workers in the Resources and Related Construction Sectors: A Systematic Review

Whilst Ecological momentary assessment (EMA) can provide important insights over time and across contexts among rotation workers whose work periods alternate with leave at home, it can also be challenging to implement in the resources and construction sectors. This review aimed to provide a summary of the methodological characteristics of EMA studies assessing health outcomes and related behaviors in rotation workers. Systematic searches in PubMed, Medline, EMBASE, CINAHL, PsycINFO, and Scopus were done to include 23 studies using EMA methods in assessing health-related outcomes and behaviors. EMA designs included daily diary: assessments once per day typically fixed at the end of day (47.8%), within day fixed interval time-based design: assessments on multiple times per day at certain times of day (17.4%) and combination of both designs (34.8%). Studies employed paper and pencil diaries (73.9%) and one or more electronic methods (60.9%): wrist-worn actigraphy device (52.2%) and online-based diaries (26.1%) for data collection. Most of the studies (91.3%) did not report prompting -EMAs by schedule alerts or compliance. Daily diary and within day fixed interval dairies designs are common, with the increasing use of electronic EMA delivery techniques. It is unclear how well participants adhere to assessment schedules, as these are inadequately reported. Researchers should report compliance-related information.

Understanding health behaviours in context: A systematic review and meta-analysis of ecological momentary assessment studies of five key health behaviours

Ecological Momentary Assessment (EMA) involves repeated, real-time sampling of health behaviours in context. We present the state-of-knowledge in EMA research focused on five key health behaviours (physical activity and sedentary behaviour, dietary behaviour, alcohol consumption, tobacco smoking, sexual health), summarising theoretical (e.g., psychological and contextual predictors) and methodological aspects (e.g., study characteristics, EMA adherence). We searched Ovid MEDLINE, Embase, PsycINFO and Web of Science until February 2021. We included studies focused on any of the aforementioned health behaviours in adult, non-clinical populations that assessed ≥1 psychological/contextual predictor and reported a predictor-behaviour association. A narrative synthesis and random-effects meta-analyses of EMA adherence were conducted. We included 633 studies. The median study duration was 14 days. The most frequently assessed predictors were 'negative feeling states' (21%) and 'motivation and goals' (16.5%). The pooled percentage of EMA adherence was high at 81.4% (95% CI = 80.0%, 82.8%, k = 348) and did not differ by target behaviour but was somewhat higher in student (vs. general population) samples, when EMAs were delivered via mobile phones/smartphones (vs. handheld devices), and when event contingent (vs. fixed) sampling was used. This review showcases how the EMA method has been applied to improve understanding and prediction of health behaviours in context.

Characteristics of smartphone-based dietary assessment tools: a systematic review

Smartphones have become popular in assessing eating behaviour in real-life and real-time. This systematic review provides a comprehensive overview of smartphone-based dietary assessment tools, focusing on how dietary data is assessed and its completeness ensured. Seven databases from behavioural, social and computer science were searched in March 2020. All observational, experimental or intervention studies and study protocols using a smartphone-based assessment tool for dietary intake were included if they reported data collected by adults and were published in English. Out of 21,722 records initially screened, 117 publications using 129 tools were included. Five core assessment features were identified: photo-based assessment (48.8% of tools), assessed serving/ portion sizes (48.8%), free-text descriptions of food intake (42.6%), food databases (30.2%), and classification systems (27.9%). On average, a tool used two features. The majority of studies did not implement any features to improve completeness of the records. This review provides a comprehensive overview and framework of smartphone-based dietary assessment tools to help researchers identify suitable assessment tools for their studies. Future research needs to address the potential impact of specific dietary assessment methods on data quality and participants' willingness to record their behaviour to ultimately improve the quality of smartphone-based dietary assessment for health research.

White Paper: Open Digital Health - accelerating transparent and scalable health promotion and treatment

In this White Paper, we outline recommendations from the perspective of health psychology and behavioural science, addressing three research gaps: (1) What methods in the health psychology research toolkit can be best used for developing and evaluating digital health tools? (2) What are the most feasible strategies to reuse digital health tools across populations and settings? (3) What are the main advantages and challenges of sharing (openly publishing) data, code, intervention content and design features of digital health tools? We provide actionable suggestions for researchers joining the continuously growing Open Digital Health movement, poised to revolutionise health psychology research and practice in the coming years. This White Paper is positioned in the current context of the COVID-19 pandemic, exploring how digital health tools have rapidly gained popularity in 2020-2022, when world-wide health promotion and treatment efforts rapidly shifted from face-to-face to remote delivery. This statement is written by the Directors of the not-for-profit Open Digital Health initiative (n = 6), Experts attending the European Health Psychology Society Synergy Expert Meeting (n = 17), and the initiative consultant, following a two-day meeting (19-20th August 2021).

An Overview of Innovative Approaches to Support Timely and Agile Health Communication Research and Practice

Innovative approaches are needed to make health communication research and practice more timely, responsive, and effective in a rapidly changing information ecosystem. In this paper we provide an overview of strategies that can enhance the delivery and effectiveness of health communication campaigns and interventions, as well as research approaches that can generate useful data and insights for decisionmakers and campaign designers, thereby reducing the research-to-practice gap. The discussion focuses on the following approaches: digital segmentation and microtargeting, social media influencer campaigns, recommender systems, adaptive interventions, A/B testing, efficient message testing protocols, rapid cycle iterative message testing, megastudies, and agent-based modeling. For each method highlighted, we also outline important practical and ethical considerations for utilizing the approach in the context of health communication research and practice, including issues related to transparency, privacy, equity, and potential for harm.

Defining and assessing immediacy in single-case experimental designs

Immediacy is one of six data aspects (alongside level, trend, variability, overlap, and consistency) that has to be accounted for when visually analyzing single-case data. Given that it is one of the aspects that has received considerably less attention than other data aspects, the current text offers a review of the proposed conceptual definitions of immediacy (i.e., what it refers to) and also of the suggested operational definitions (i.e., how exactly is it assessed and/or quantified). Provided that a variety of conceptual and operational definitions is identified, we propose following a sensitivity analysis using a randomization test for assessing immediate effects in single-case experimental designs, by identifying when changes were most clear. In such a sensitivity analysis, the immediate effects are tested for multiple possible intervention points and for different possible operational definitions. Robust immediate effects can be detected if the results for the different operational definitions converge.

What helps to form a healthy nutrition habit? Daily associations of intrinsic reward, anticipated regret, and self-efficacy with automaticity

BACKGROUND

High automaticity in healthy nutrition behaviors is related to long-term maintenance of these behaviors. Drawing upon theoretical frameworks of habit formation, proposed antecedents such as intrinsic reward, anticipated regret, and self-efficacy are important correlates of automaticity, but not much is known about their day-by-day relationships with automaticity in healthy nutrition behaviors. This study tested previous-day within-person (i.e., from one day to the next) and same-day within-person associations of intrinsic reward, anticipated regret, and self-efficacy with automaticity of a healthy nutrition behavior, for which participants attempted to form a new habit.

METHODS

Secondary analyses of a randomized controlled trial with two planning intervention conditions including a longitudinal sample of n = 135 participants (age: M = 24.82 years; SD = 7.27) are reported. Participants formed a plan on a self-selected healthy nutrition behavior to become a new habit and were followed up over 12 weeks assessing daily levels of plan-specific intrinsic reward, anticipated regret, self-efficacy, and automaticity. Lagged multilevel models with 84 study days nested in participants estimated previous-day within-person, same-day within-person, and between-person relationships of intrinsic reward, anticipated regret, and self-efficacy with automaticity.

FINDINGS

Regarding within-level relationships, higher-than-usual levels of intrinsic reward, anticipated regret, and self-efficacy of the same day but not of the previous day were associated with higher within-person automaticity. With respect to between-level relationships, higher between-levels (i.e., higher person mean levels across the study period) of intrinsic reward, anticipated regret, and self-efficacy were linked with higher automaticity.

DISCUSSION

Findings point towards the potential to intervene on intrinsic reward, anticipated regret, and self-efficacy when aiming to promote a new healthy nutrition habit.

A mobile self-control training app to improve self-control and physical activity in people with severe mental illness: Protocol for two single-case experiment designs (Preprint)

BACKGROUND

Lack of physical activity is a common issue with detrimental consequences for the health of people with severe mental illness (SMI). Existing physical activity interventions show suboptimal effects as they require substantial cognitive skills, including goal setting and writing, whereas cognitive deficits are common in this population. To bolster the effectiveness of physical activity interventions, self-control training (SCT), in which users practice the ability to override unwanted thoughts and behaviors, can be used in addition. Recent research has demonstrated the initial effectiveness of a mobile SCT app, but this has not been studied in psychiatric clinical practice.

OBJECTIVE

This study aims to evaluate to what extent adding a mobile SCT app designed for and with people with SMI to a mobile lifestyle intervention aimed at increasing physical activity increases physical activity and self-control levels.

METHODS

A mixed methods approach incorporating 2 single-case experimental designs (SCEDs) and qualitative interviews was used to evaluate and optimize SCT. Overall, 12 participants with SMI will be recruited from 2 organizations offering outpatient and inpatient care to people with SMI. Each experiment will include 6 patients. SCED I is a concurrent multiple-baseline design across participants that explores initial effectiveness and optimal intervention duration. Using accelerometry and experience sampling questionnaires, participants' physical activity and self-control will be monitored for ≥5 days from baseline, followed by the sequential introduction of Google Fit, the physical activity intervention, for 7 days and the addition of SCIPP: Self-Control Intervention App for 28 days. SCED II is an introduction/withdrawal design in which optimized SCT will be introduced and withdrawn to validate the findings from SCED I. In both experiments, the daily average of total activity counts per hour and the state level of self-control will serve as the primary and secondary outcome measures. Data will be analyzed using visual analysis and piecewise linear regression models.

RESULTS

The study was designated as not subject to the Dutch Medical Research Involving Human Subjects Act by the Medical Research Ethical Committee Oost-Nederland and approved by the Ethics Committee/domain Humanities and Social Sciences of the Faculty of Behavioural, Management, and Social Sciences at the University of Twente. Participant recruitment started in January 2022, and we expect to publish the results in early 2023.

CONCLUSIONS

The mobile SCT app is expected to be feasible and effective. It is self-paced and scalable and can increase patient motivation, making it a suitable intervention for people with SMI. SCED is a relatively novel yet promising method for gaining insights into whether and how mobile apps work that can handle heterogeneous samples and makes it possible to involve a diverse population with SMI without having to include a large number of participants.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/37727.

A personalized mobile app for physical activity: An experimental mixed-methods study

Objectives

To investigate the feasibility of the be.well app and its personalization approach which regularly considers users’ preferences, amongst university students.

Methods

We conducted a mixed-methods, pre-post experiment, where participants used the app for 2 months. Eligibility criteria included: age 18–34 years; owning an iPhone with Internet access; and fluency in English. Usability was assessed by a validated questionnaire; engagement metrics were reported. Changes in physical activity were assessed by comparing the difference in daily step count between baseline and 2 months. Interviews were conducted to assess acceptability; thematic analysis was conducted.

Results

Twenty-three participants were enrolled in the study (mean age = 21.9 years, 71.4% women). The mean usability score was 5.6 ± 0.8 out of 7. The median daily engagement time was 2 minutes. Eighteen out of 23 participants used the app in the last month of the study. Qualitative data revealed that people liked the personalized activity suggestion feature as it was actionable and promoted user autonomy. Some users also expressed privacy concerns if they had to provide a lot of personal data to receive highly personalized features. Daily step count increased after 2 months of the intervention (median difference = 1953 steps/day, p-value <.001, 95% CI 782 to 3112).

Conclusions

Incorporating users’ preferences in personalized advice provided by a physical activity app was considered feasible and acceptable, with preliminary support for its positive effects on daily step count. Future randomized studies with longer follow up are warranted to determine the effectiveness of personalized mobile apps in promoting physical activity.

An Intervention Mapping Study: Developing the Choosing Health digital weight loss and maintenance intervention (Preprint)

Background

Digital health promotion programs tailored to the individual are a potential cost-effective and scalable solution to enable self-management and provide support to people with excess body weight. However, solutions that are widely accessible, personalized, and theory- and evidence-based are still limited.

Objective

This study aimed to develop a digital behavior change program, Choosing Health, that could identify modifiable predictors of weight loss and maintenance for each individual and use these to provide tailored support.

Methods

We applied an Intervention Mapping protocol to design the program. This systematic approach to develop theory- and evidence-based health promotion programs consisted of 6 steps: development of a logic model of the problem, a model of change, intervention design and intervention production, the implementation plan, and the evaluation plan. The decisions made during the Intervention Mapping process were guided by theory, existing evidence, and our own research—including 4 focus groups (n=40), expert consultations (n=12), and interviews (n=11). The stakeholders included researchers, public representatives (including individuals with overweight and obesity), and experts from a variety of relevant backgrounds (including nutrition, physical activity, and the health care sector).

Results

Following a structured process, we developed a tailored intervention that has the potential to reduce excess body weight and support behavior changes in people with overweight and obesity. The Choosing Health intervention consists of tailored, personalized text messages and email support that correspond with theoretical domains potentially predictive of weight outcomes for each participant. The intervention content includes behavior change techniques to support motivation maintenance, self-regulation, habit formation, environmental restructuring, social support, and addressing physical and psychological resources.

Conclusions

The use of an Intervention Mapping protocol enabled the systematic development of the Choosing Health intervention and guided the implementation and evaluation of the program. Through the involvement of different stakeholders, including representatives of the general public, we were able to map out program facilitators and barriers while increasing the ecological validity of the program to ensure that we build an intervention that is useful, user-friendly, and informative. We also summarized the lessons learned for the Choosing Health intervention development and for other health promotion programs.

International Registered Report Identifier (IRRID)

RR2-10.1136/bmjopen-2020-040183

An N-of-1 study of daily alcohol consumption following minimum unit pricing implementation in Scotland

BACKGROUND AND AIMS

Within the context of Scotland's policy change to implement a minimum unit price (MUP) per unit of alcohol sold in licensed premises, this study used an N-of-1 design to assess between-person differences in the psychological and social factors associated with daily alcohol consumption.

DESIGN AND SETTING

A mixed-methods approach combined N-of-1 observational studies, comprising daily surveys followed by qualitative social network interviews (not reported here). Peer researchers with lived experience of substance use were involved in the study design and fieldwork was conducted in towns and rural areas in the East of Scotland.

PARTICIPANTS/CASES

Twenty-five adults with current or recent history of alcohol dependence recruited for three 12-week waves: 11 in wave 1 (pre-MUP), 11 in wave 2 (pre- and post-MUP) and three in wave 3 (post MUP).

MEASUREMENTS

Gender, age, alcohol and other drug use history. Daily surveys for 12 weeks captured information about factors in the last 24 hours, e.g. amount and type of alcohol consumed, stress, social contact.

FINDINGS

Each participant was in the daily survey for a mean of 64 days [standard deviation (SD) = 42; median = 59], with a response rate of 48%; 15 participants provided sufficient data for analysis. Factors related to daily alcohol consumption differed between individuals. Models suggested that some individuals with high initial consumption reduced drinking after MUP, but explanatory factors differed, e.g. changing motivation was important for some, while alcohol availability was important for others.

CONCLUSIONS

Adapting N-of-1 methods for an observational study uncovered differences in alcohol consumption change before and after minimum unit pricing implementation in Scotland, evidence of individual differences in the factors relating to alcohol consumption patterns and some evidence that post-MUP consumption changes may be related to changing psychosocial factors.

Studying Behaviour Change Mechanisms under Complexity

Understanding the mechanisms underlying the effects of behaviour change interventions is vital for accumulating valid scientific evidence, and useful to informing practice and policy-making across multiple domains. Traditional approaches to such evaluations have applied study designs and statistical models, which implicitly assume that change is linear, constant and caused by independent influences on behaviour (such as behaviour change techniques). This article illustrates limitations of these standard tools, and considers the benefits of adopting a complex adaptive systems approach to behaviour change research. It (1) outlines the complexity of behaviours and behaviour change interventions; (2) introduces readers to some key features of complex systems and how these relate to human behaviour change; and (3) provides suggestions for how researchers can better account for implications of complexity in analysing change mechanisms. We focus on three common features of complex systems (i.e., interconnectedness, non-ergodicity and non-linearity), and introduce Recurrence Analysis, a method for non-linear time series analysis which is able to quantify complex dynamics. The supplemental website provides exemplifying code and data for practical analysis applications. The complex adaptive systems approach can complement traditional investigations by opening up novel avenues for understanding and theorising about the dynamics of behaviour change.

Is the N-of-1 method applicable in bodywork research? Lessons learned using a trial as a methodological pilot

N-of-1 trial designs have rarely been used in bodywork research. Using a recent trial as a methodological pilot, critical issues related to the applicability of N-of-1 trials to bodywork are discussed. These include the issues of carry-over effects, bias-controlling approaches and statistical analysis. The discussion highlights the importance of mixed methods and draws some suggestions for a future research program. N-of-1 trials could be used to provide insights about some essential elements of bodywork modalities and their effectiveness.

Habit formation following routine-based versus time-based cue planning: A randomized controlled trial

OBJECTIVES

Habit formation has been identified as one of the key determinants of behaviour change. To initiate habit formation, self-regulation interventions can support individuals to form a cue-behaviour plan and to repeatedly enact the plan in the same context. This randomized controlled trial aimed to model habit formation of an everyday nutrition behaviour and examined whether habit formation and plan enactment differ when individuals plan to enact their behaviour in response to a routine-based versus time-based cue.

DESIGN

Following a baseline assessment, N = 192 adults (aged 18-77 years) were randomly assigned to a routine-based cue or a time-based cue planning intervention, in which they selected an everyday nutrition behaviour and linked it to a daily routine or a time cue.

METHODS

Participants responded to daily questionnaires over 84 days assessing plan enactment and the behaviour's automaticity (as an indicator of habit formation). Multilevel models with days nested in participants were fitted.

RESULTS

As indicated by asymptotic curves, it took a median of 59 days for participants who successfully formed habits to reach peak automaticity. Group-level analyses revealed that both routine-based and time-based cue planning led to increases in automaticity and plan enactment, but no between-condition differences were found. Repeated plan enactment was a key predictor for automaticity.

CONCLUSIONS

Linking one's nutrition behaviour to a daily routine or a specific time was similarly effective for habit formation. Interventions should encourage persons to repeatedly carry out their planned behaviour in response to the planned cue to facilitate habit formation.

Acute and Chronic Stress in Daily Police Service: A Three-Week N-of-1 Study

On duty, police officers are exposed to a variety of acute, threatening stress situations and organizational demands. In line with the allostatic load model, the resulting acute and chronic stress might have tremendous consequences for police officers' work performance and psychological and physical health. To date, limited research has been conducted into the underlying biological, dynamic mechanisms of stress in police service. Therefore, this ecological momentary assessment study examined the associations of stress, mood and biological stress markers of a 28-year-old male police officer in a N-of-1 study over three weeks (90 data points). Four times a day (directly after waking up, 30 minutes later, 6 hours later, before going to bed), he answered questions about the perceived stress and mood using a smartphone application. With each data entry, he collected saliva samples for the later assessment of salivary cortisol (sCort) and alpha-amylase (sAA). In addition, data was collected after six police incidents during duty. sCort and sAA were not related to perceived stress in daily life and did not increase in police incidents. Regarding mood measures, deterioration of calmness, but not valence and energy was associated with perceived stress. The results suggest continued police service to constitute a major chronic stressor resulting in an inability to mount a proper response to further acute stress. As an indicator of allostatic load, psychological and biological hyporesponsivity in moments of stress may have negative consequences for police officers' health and behavior in critical situations that require optimal performance. Prospectively, this research design may also become relevant when evaluating the efficacy of individualized stress management interventions in police training.

Theory-based digital intervention to promote weight loss and weight loss maintenance (Choosing Health): protocol for a randomised controlled trial

INTRODUCTION

Digital behavioural weight loss interventions have the potential to improve public health; however, these interventions are often not adequately tailored to the needs of the participants. This is the protocol for a trial that aims to determine the effectiveness and cost-effectiveness of the Choosing Health programme as a means to promote weight loss and weight loss maintenance among overweight/obese adults.

METHODS AND ANALYSIS

The proposed study is a two-group randomised controlled trial with a nested interrupted time series (ITS) within-person design. Participants (n=285) will be randomly assigned to either the Choosing Health digital intervention or a control group. For intervention participants, ecological momentary assessment will be used to identify behavioural determinants for each individual in order to tailor evidence-based behaviour change techniques and intervention content.Control group participants will receive non-tailored weight loss advice via e-book and generic emails. The primary outcome is the mean difference in weight loss between groups at 6 months controlled for baseline. Secondary outcomes include blood pressure and percentage of body fat; self-reported measures of physical activity, sitting time, quality of life, cost and theory-derived correlates of weight loss. Secondary outcomes will be measured at baseline, 3, 6 and 12 months. The primary outcome for ITS will be daily weight loss plan adherence. Data will be analysed using regression and time series analyses.

ETHICS AND DISSEMINATION

Ethics approval was granted by Faculty of Psychology, SWPS University of Social Sciences and Humanities, Wroclaw, Poland, approval number 03/P/12/2019. The project results will be disseminated through structured strategy implemented in collaboration with the Ministry of Health.

TRIAL REGISTRATION DETAILS

This trial was registered with www.clinicaltrials.gov; registration number NCT04291482.

Practice-Based Research in Complementary Medicine: Could N-of-1 Trials Become the New Gold Standard?

Complementary medicines and therapies are popular forms of healthcare with a long history of traditional use. Yet, despite increasing consumer demand, there is an ongoing exclusion of complementary medicines from mainstream healthcare systems. A lack of evidence is often cited as justification. Until recently, high-quality evidence of treatment efficacy was defined as findings from well-conducted systematic reviews and meta-analyses of randomized controlled trials. In a recent and welcome move by the Oxford Centre for Evidence-Based Practice, however, the N-of-1 trial design has also been elevated to the highest level of evidence for treatment efficacy of an individual, placing this research design on par with the meta-analysis. N-of-1 trial designs are experimental research methods that can be implemented in clinical practice. They incorporate much of the rigor of group clinical trials, but are designed for individual patients. Individualizing treatment interventions and outcomes in research designs is consistent with the movement towards patient-centered care and aligns well with the principles of holism as practiced by naturopaths and many other complementary medicine practitioners. This paper explores whether rigorously designed and conducted N-of-1 trials could become a new 'gold standard' for demonstrating treatment efficacy for complementary medicine interventions in individual patients in clinical practice.

What research for what training in psychotherapy? Some methodological issues and a proposal

To define boundaries and links between research and training in psychotherapy we have to establish what kind of research is needed for this purpose. For defining psychotherapy as a science some basic epistemological premises should be affirmed and specific methods have to be devised, using both quantitative and qualitative approaches, diachronic and longitudinal perspectives, cumulative and meta-analytic strategies, focusing both the techniques used in the therapies and the relationship between the therapist subject and the client subject as a core mean for produce change. What should be evaluated in this research process, what methods and techniques of assessment should be preferred, what analyses of data are suitable: these are the main issues addressed in the article, as they are useful for planning the training of a therapist as a researcher, regardless of the privileged theoretical and technical approach. Science and practice have to be connected, since they both allow the monitoring of what occurs within the confines of the therapy and favor exchange among psychotherapists from differing theoretical approaches, which also increases their external visibility in the scientific community and in a wider social context. The goal of fostering scientific attitudes in the psychotherapists needs a specific training, to acquire a research mindedness also out of the academic laboratories. A cooperation among scientific associations and institutions is proposed to reach these objectives necessary for psychotherapists' trainings including competencies in evaluating and sharing the scientific aspects of their work.

Do Daily Fluctuations in Psychological and App-Related Variables Predict Engagement With an Alcohol Reduction App? A Series of N-Of-1 Studies

BACKGROUND

Previous studies have identified psychological and smartphone app-related predictors of engagement with alcohol reduction apps at a group level. However, strategies to promote engagement need to be effective at the individual level. Evidence as to whether group-level predictors of engagement are also predictive for individuals is lacking.

OBJECTIVE

The aim of this study was to examine whether daily fluctuations in (1) the receipt of a reminder, (2) motivation to reduce alcohol, (3) perceived usefulness of the app, (4) alcohol consumption, and (5) perceived lack of time predicted within-person variability in the frequency and amount of engagement with an alcohol reduction app.

METHODS

We conducted a series of observational N-of-1 studies. The predictor variables were measured twice daily for 28 days via ecological momentary assessments. The outcome variables were measured through automated recordings of the participants' app screen views. A total of nine London-based adults who drank alcohol excessively and were willing to set a reduction goal took part. Each participant's dataset was analyzed separately using generalized additive mixed models to derive incidence rate ratios (IRRs) for the within-person associations of the predictor and outcome variables. Debriefing interviews, analyzed using thematic analysis, were used to contextualize the findings.

RESULTS

Predictors of the frequency and amount of engagement differed between individuals, and for the variables 'perceived usefulness of the app' and 'perceived lack of time', the direction of associations also differed between individuals. The most consistent predictors of within-person variability in the frequency of engagement were the receipt of a daily reminder (IRR=1.80-3.88; P<.05) and perceived usefulness of the app (IRR=0.82-1.42; P<.05). The most consistent predictors of within-person variability in the amount of engagement were motivation to reduce alcohol (IRR=1.67-3.45; P<.05) and perceived usefulness of the app (IRR=0.52-137.32; P<.05).

CONCLUSIONS

The utility of the selected psychological and app-related variables in predicting the frequency and amount of engagement with an alcohol reduction app differed at the individual level. This highlights that key within-person associations may be masked in group-level designs and suggests that different strategies to promote engagement may be required for different individuals.