Mental contrasting for health behaviour change: a systematic review and meta-analysis of effects and moderator variables

An Ecological Mobile Momentary Intervention to Support Dynamic Goal Pursuit: Feasibility and Acceptability Study

BACKGROUND

Individuals can experience difficulties pursuing their goals amid multiple competing priorities in their environment. Effective goal dynamics require flexible and generalizable pursuit skills. Supporting successful goal pursuit requires a perpetually adapting intervention responsive to internal states.

OBJECTIVE

The purpose of this study was to (1) develop a flexible intervention that can adapt to an individual's changing short to medium-term goals and be applied to their daily life and (2) examine the feasibility and acceptability of the just-in-time adaptive intervention for goal pursuit.

METHODS

This study involved 3 iterations to test and systematically enhance all aspects of the intervention. During the pilot phase, 73 participants engaged in an ecological momentary assessment (EMA) over 1 month. After week 1, they attended an intervention training session and received just-in-time intervention prompts during the following 3 weeks. The training employed the Capability, Opportunity, Motivation, and Behavior (COM-B) framework for goal setting, along with mental contrasting with implementation intentions (MCII). Subsequent prompts, triggered by variability in goal pursuit, guided the participants to engage in MCII in relation to their current goal. We evaluated feasibility and acceptability, efficacy, and individual change processes by combining intensive (single-case experimental design) and extensive methods.

RESULTS

The results suggest that the digital intervention was feasible and acceptable to participants. Compliance with the intervention was high (n=63, 86%). The participants endorsed high acceptability ratings relating to both the study procedures and the intervention. All participants (N=73, 100%) demonstrated significant improvements in goal pursuit with an average difference of 0.495 units in the outcome (P<.001). The results of the dynamic network modeling suggest that self-monitoring behavior (EMA) and implementing the MCII strategy may aid in goal reprioritization, where goal pursuit itself is a driver of further goal pursuit.

CONCLUSIONS

This pilot study demonstrated the feasibility and acceptability of a just-in-time adaptive intervention among a nonclinical adult sample. This intervention used self-monitoring of behavior, the COM-B framework, and MCII strategies to improve dynamic goal pursuit. It was delivered via an Ecological Momentary Intervention (EMI) procedure. Future research should consider the utility of this approach as an additional intervention element within psychological interventions to improve goal pursuit. Sustaining goal pursuit throughout interventions is central to their effectiveness and warrants further evaluation.

Low working memory reduces the use of mental contrasting

Mentally contrasting a desired future with reality is a self-regulation strategy that helps people effectively pursue important personal wishes. People with higher self-regulation skills are more likely to spontaneously use mental contrasting. Because one central cognitive function underlying self-regulation is working memory capacity, we investigated whether people with low rather than high working memory capacity are less likely to spontaneously use mental contrasting. Study 1 provided correlational evidence that participants with lower working memory capacity, as measured by the Operation-Span Task, were less likely to use mental contrasting when elaborating an important interpersonal wish. Study 2 provided experimental evidence that manipulating low working memory capacity by inducing cognitive load (vs. no load) led fewer participants to use mental contrasting. The findings have theoretical implications by illuminating the processes that impede mental contrasting, and they have applied implications for understanding how to foster the use of mental contrasting in everyday life.

Mental contrasting of a negative future facilitates COVID-19 preventative behaviors: two randomized controlled trials

Objective: The present research examined whether mentally contrasting a negative, feared future (i.e., infection with the Coronavirus) with a still positive reality can promote preventative actions in the context of the pandemic. Design: In two randomized controlled trials, we varied participants' mode of thought (mental contrasting of a negative future with a positive reality versus fantasizing of a negative future). Study 2 took into account the interpersonal nature of the pandemic and manipulated the mode of thought in a vicarious manner (vicarious mental contrasting versus vicarious negative fantasizing). Main Outcome Measures: After the manipulation, we assessed participants' intentions to learn about COVID-19 (Study 1) and attention to COVID-19 information (Study 1 and 2). Three days later, we measured the amount of physical distancing (Study 1 and 2). Results: Study 1 found that mental contrasting leads to more COVID-19 preventative behaviors than mere negative fantasizing. In Study 2, we observed that vicarious mental contrasting facilitates physical distancing among people who initially showed low compliance with COVID-19 preventative behaviors and thus were in most need of a boost in preventative behavior. Conclusion: The findings suggest that mental contrasting of negative fantasies may be an effective way to encourage COVID-19 preventative behaviors.

What makes an action plan "100% me"? Think aloud interviews about CVD prevention tools for varying health literacy needs

ISSUE ADDRESSED

Health behaviour change can be difficult to maintain. Action plans can address this issue, however, there has been little qualitative research to understand how to optimise action plan interventions. This study explored how people engage with a specific type of action plan intervention, the "volitional help sheet," in a cardiovascular disease (CVD) prevention context.

METHODS

Twenty adults in the target age for CVD risk assessment (45 to 74 years) with varying health literacy participated in interviews and created an action plan to change their behaviour. Transcripts were analysed using framework analysis.

RESULTS

Participants described how engagement with plans was related to how personally relevant the target behaviour and the options within the plan were. Also important was participants visualising themselves enacting the plan when deciding which option to choose. Amongst participants who already engaged in a target behaviour, some did not perceive the plan was useful; others perceived the plan as a helpful prompt or a formalisation of existing plans. For some, the barriers to behaviour change were out of the scope of an action plan, highlighting the need for alternative supports.

CONCLUSION

This study provides qualitative insights into unanticipated ways that people with varying health literacy use action plans, providing new guidance for future developers. SO WHAT?: Not all action plans are created equal. Careful selection of behavioural targets and plan options and encouraging users to imagine the plan may enhance user engagement. Alternative behaviour change strategies should be available if key barriers cannot be addressed by the plan.

Motivational communication skills to improve motivation and adherence in cardiovascular disease prevention: A narrative review

Lifestyle optimization is one of the most essential components of cardiovascular disease prevention. Motivational counseling provided by health care professionals could promote lifestyle modification. The purpose of the review is to identify possible evidence-based psychological principles that may be applicable to motivational counseling in the prevention of cardiovascular disease. These motivational communication skills promote behavioral change, improved motivation and adherence to cardiovascular disease prevention. A personal collection of the relevant publications. The review identified and summarized the previous evidence of implementation intentions, mental contrasting, placebo effect and nocebo effects and identity-based regulations in behavior change interventions and proposed their potential application in cardiovascular disease prevention. However, it is challenging to provide real support in sustainable CVD-risk reduction and encourage patients to implement lifestyle changes, while avoiding being unnecessarily judgmental, disrespectful of autonomy, or engaging patients in burdensome efforts that have little or no effect on the long run. Motivational communication skills have a great potential for effectuating sustainable lifestyle changes that reduce CVD-related risks, but it is also surrounded by ethical issues that should be appropriately addressed in practice. It is key to realize that motivational communication is nothing like an algorithm that is likely to bring about sustainable lifestyle change, but a battery of interventions that requires specific expertise and long term joint efforts of patients and their team of caregivers.

Protocol for a cluster randomised waitlist-controlled trial of a goal-based behaviour change intervention for employees in workplaces enrolled in health and wellbeing initiatives

Many workplaces offer health and wellbeing initiatives to their staff as recommended by international and national health organisations. Despite their potential, the influence of these initiatives on health behaviour appears limited and evaluations of their effectiveness are rare. In this research, we propose evaluating the effectiveness of an established behaviour change intervention in a new workplace context. The intervention, 'mental contrasting plus implementation intentions', supports staff in achieving their health and wellbeing goals by encouraging them to compare the future with the present and to develop a plan for overcoming anticipated obstacles. We conducted a systematic review that identified only three trials of this intervention in workplaces and all of them were conducted within healthcare organisations. Our research will be the first to evaluate the effectiveness of mental contrasting outside a solely healthcare context. We propose including staff from 60 organisations, 30 in the intervention and 30 in a waitlisted control group. The findings will contribute to a better understanding of how to empower and support staff to improve their health and wellbeing. Trial registration: ISRCTN17828539.

Effects of mental contrasting on sleep and associations with stress: A randomized controlled trial

Mental contrasting with implementation intentions (MCII) has been successfully applied to improve health-related behaviors (e.g. exercise). We explored its effectiveness to improve sleep outcomes beyond effects of sleep hygiene (SH) information, and investigated associations with stress. Eighty university employees (mean age: 29.6, SD = 4.5) were randomized to either a MCII + SH or a SH-only condition. During a baseline-week and a post-intervention week, sleep duration (Fitbit Alta and self-report), sleep quality, and stress were assessed daily and saliva was collected to assess the cortisol awakening response (CAR). In total, self-reported sleep quality and duration increased, but there was no meaningful condition*week interaction for sleep parameters or CAR. Higher average stress was associated with shorter sleep duration and lower sleep quality. Within-person, days with higher stress were followed by nights with lower sleep quality. Despite overall improvements, effects of MCII were not confirmed. MCII might be less effective to improve behaviors which are less controllable.

A systematic review of the impact of future-oriented thinking on academic outcomes

Future-oriented thought is a broad construct that characterize the ability to generate mental representations of the future and project oneself into a variety of hypothetical states. It is well established that the degree to which one is focused more on the past, present, or future has a variety of implications on psychological functioning. This study focuses on the relationship between future-oriented thought and academic performance of students. To bridge this gap, we conducted the first systematic review investigating the benefit of future-oriented thought on promoting positive outcomes in academic settings. Our systematic review comprised 21 studies (k = 21). Results identified a clear relationship between future-oriented thought and positive outcomes in academic settings. Furthermore, our systematic review reveals important relationships between future-oriented thought and academic engagement, as well as future-oriented thought and academic performance. Our findings suggest that those who are more future-oriented demonstrate higher levels of academic engagement compared to those who were less future-oriented. Our findings suggest that probing and guiding students toward a future goal may increase their academic engagement and performance.

Activation Versus Change as a Principle Underlying Intervention Strategies to Promote Health Behaviors

BACKGROUND AND PURPOSE

Interventions are effective in promoting health behavior change to the extent that (a) intervention strategies modify targets (i.e., mechanisms of action), and (b) modifying targets leads to changes in behavior. To complement taxonomies that characterize the variety of strategies used in behavioral interventions, we outline a new principle that specifies how strategies modify targets and thereby promote behavior change. We distinguish two dimensions of targets-value (positive vs. negative) and accessibility (activation level)-and show that intervention strategies operate either by altering the value of what people think, feel, or want (target change) or by heightening the accessibility of behavior-related thoughts, feelings, and goals (target activation).

METHODS AND RESULTS

We review strategies designed to promote target activation and find that nudges, cue-reminders, goal priming, the question-behavior effect, and if-then planning are each effective in generating health behavior change, and that their effectiveness accrues from heightened accessibility of relevant targets. We also identify several other strategies that may operate, at least in part, via target activation (e.g., self-monitoring, message framing, anticipated regret inductions, and habits).

CONCLUSIONS

The Activation Vs. Change Principle (AVCP) offers a theoretically grounded and parsimonious means of distinguishing among intervention strategies. By focusing on how strategies modify targets, the AVCP can aid interventionists in deciding which intervention strategies to deploy and how to combine different strategies in behavioral trials. We outline a research agenda that could serve to further enhance the design and delivery of interventions to promote target activation.

Mental contrasting with implementation intentions as a technique for media-mediated persuasive health communication

Mental Contrasting with Implementation Intentions (MCII) is a self-regulation strategy that combines the strategies mental contrasting (MC) in which individualscontrast a desired future with the current reality with the strategy of forming implementation intentions (II), which involves making concrete if-then plans (implementation intentions, II) to overcome the obstacles standing in the way of the desired future. Numerous studies across behavioral domains have demonstrated the effectiveness of this strategy in supporting people to adopt health-promoting behaviors or changing unhealthy behaviors. However, research on MCII has so far neglected the applicability of the concept in media-mediated persuasive health communication. This conceptual review aims to demonstrate and examine the potentials and effects of MCII as a technique to tailor media-mediated persuasive health messages and their dissemination through different media channels. In doing so, it draws on existing models of health behavior change, especially individuals' threat and coping appraisals. Potential effects of MCII on these cognitive factors are discussed, and practical implications for health message design are outlined.

Mental contrasting and implementation of physical activity intentions in Ugandan primary care patients with mental health problems: A real-world intervention involving support partners

This study explored the efficacy of lay health worker (LHW)-led physical activity (PA) counselling for primary care patients with mental health problems (PCMH) and their support partners. Forty-nine (41♀, median age=47, interquartile range=22) PCMH and 49 support partners [9♀, 31(9)years] participated in once weekly counselling based on the mental contrasting and implementation of intentions framework for 8 weeks. All participants completed the Simple Physical Activity Questionnaire (SIMPAQ) and World Health Organization Disability Assessment Schedule 2 (WHODAS 2), while PCMH completed the Multidimensional Scale for Perceived Social Support (MSPSS), Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), and Alcohol Use Disorders Identification Test (AUDIT) pre- and immediately post-intervention. In PCMH significant (P<0.001) increases in walking, exercising and incidental PA (SIMPAQ) levels, reductions in depressive (PHQ-9) and anxiety (GAD-7) symptoms and improvements in mobility and participation (WHODAS 2) were observed. Perceived support from significant others (MSPSS) significantly increased. In support partners, a significant reduction in time spent sedentary, increase in incidental PA (SIMPAQ) and improvement in the perception of getting alone with others (WHODAS 2) was seen. Our study demonstrates that LHW-led PA counselling is beneficial for PCMH and their support partners. Randomized controlled trials are warranted to confirm these positive findings.

Mental imagery-based self-regulation: Effects on physical activity behaviour and its cognitive and affective precursors over time

OBJECTIVES

(1) Test whether a mental imagery-based self-regulation intervention increases physical activity behaviour over 90 days; (2) Examine cognitive and affective precursors of change in physical activity behaviour.

DESIGN

A randomized control trial with participants (N = 500) randomized to one of six intervention conditions in a 3 (risk communication format: bulleted list, table, risk ladder) x 2 (mental imagery behaviour: physical activity, active control [sleep hygiene]) factorial design.

METHODS

After receiving personalized risk estimates via a website on a smartphone, participants listened to an audiorecording that guided them through a mental imagery activity related to improving physical activity (intervention group) or sleep hygiene behaviour (active control). Participants received text message reminders to complete the imagery for 3 weeks post-intervention, 4 weekly text surveys to assess behaviour and its cognitive and affective precursors, and a mailed survey 90 days post-baseline.

RESULTS

Physical activity increased over 90 days by 19.5 more minutes per week (95%CI: 2.0, 37.1) in the physical activity than the active control condition. This effect was driven by participants in the risk ladder condition, who exercised 54.8 more minutes (95%CI 15.6, 94.0) in the physical activity condition than participants in the active control sleep hygiene group. Goal planning positively predicted physical activity behaviour (b = 12.2 minutes per week, p = 0.002), but self-efficacy, image clarity, and affective attitudes towards behaviours did not (p > 0.05).

CONCLUSIONS

Mental imagery-based self-regulation interventions can increase physical activity behaviour, particularly when supported by personalized disease risk information presented in an easy-to-understand format.

Persistence and Disengagement in Personal Goal Pursuit

Persistence in and timely disengagement from personal goals are core components of successful self-regulation and therefore relevant to well-being and performance. In the history of motivation psychology, there has been a clear emphasis on persistence. Only recently have researchers become interested in goal disengagement, as mirrored by the amount of pertinent research. In this review, we present an overview of the most influential motivational theories on persistence and disengagement that address situational and personal determinants, cognitive and affective mechanisms, and consequences for well-being, health, and performance. Some of these theories use a general approach, whereas others focus on individual differences. The theories presented incorporate classical expectancy-value constructs as well as contemporary volitional concepts of self-regulation. Many of the theoretical approaches have spread to applied fields (e.g., education, work, health). Despite numerous important insights into persistence and disengagement, we also identify several unresolved research questions. Expected final online publication date for the Annual Review of Psychology, Volume 73 is January 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

A Meta-Analysis of the Effects of Mental Contrasting With Implementation Intentions on Goal Attainment

Mental contrasting with implementation intentions (MCII) is a self-regulation strategy that enhances goal attainment. This meta-analysis evaluated the efficacy of MCII for goal attainment and explored potential moderators. A total of 21 empirical studies with 24 independent effect sizes (15,907 participants) were included in the analysis. Results showed that MCII to be effective for goal attainment with a small to medium effect size (g = 0.336). The effect was mainly moderated by intervention style. Specifically, studies with interventions based on interactions between participants and experimenters (g = 0.465) had stronger effects than studies with interventions based on interactions between participants and documents (g = 0.277). The results revealed that MCII is a brief and effective strategy for goal attainment with a small to moderate effect; however, because of some publication bias, the actual effect sizes may be smaller. Due to small number of studies in this meta-analysis, additional studies are needed to determine the role of moderator variables.

Comparing mental contrasting with implementation intentions against solution-focused and autonomous planning

Research suggests that mental contrasting with implementation intentions (MCII) enhances commitment and goal attainment. However, most studies have used limited comparison conditions. The present study compared MCII against two other potentially effective approaches: autonomous planning (AP), and solution-focused planning (SFP). It was thought that condition would have an indirect effect on goal progress by affecting commitment. However, goal attainment expectancy was hypothesised to be a moderator such that MCII has positive effects when expectancy is high but negative effects when expectancy is low. Ninety-eight female students were randomly assigned to one of three conditions: 1) MCII, 2) AP, or 3) SFP. All students initially set themselves a goal for the coming week regarding personal projects. Mean commitment and goal progress were marginally higher in the MCII condition than in the AP and SFP conditions but the differences were not statistically significant and (as predicted) much smaller than in previous research. Expectancy did not appear to have a moderating effect. The apparent benefits of MCII were larger relative to AP than to SFP. Results suggest that MCII may sometimes be no more effective than other approaches to goal-setting and planning, particularly if they are evidence-based and carefully-designed. Implications for schools are addressed.

Enhancing the translation of health behaviour change research into practice: a selective conceptual review of the synergy between implementation science and health psychology

Health psychology is at the forefront of developing and disseminating evidence, theories, and methods that have improved the understanding of health behaviour change. However, current dissemination approaches may be insufficient for promoting broader application and impact of this evidence to benefit the health of patients and the public. Nevertheless, behaviour change theory/methods typically directed towards health behaviours are now used in implementation science to understand and support behaviour change in individuals at different health system levels whose own behaviour impacts delivering evidence-based health behaviour change interventions. Despite contributing to implementation science, health psychology is perhaps doing less to draw from it. A redoubled focus on implementation science in health psychology could provide novel prospects for enhancing the impact of health behaviour change evidence. We report a Health Psychology Review-specific review-of-reviews of trials of health behaviour change interventions published from inception to April 2020. We identified 34 reviews and assessed whether implementation readiness of behaviour change interventions was discussed. We then narratively review how implementation science has integrated theory/methods from health psychology and related discipline. Finally, we demonstrate how greater synergy between implementation science and health psychology could promote greater follow-through on advances made in the science of health behaviour change.

Social ecological interventions to increase physical activity in children and young people living with and beyond cancer: a systematic review

Objective: To identify the behaviour change techniques and intervention components associated with the promotion of physical activity (PA) for children and young people living with and beyond cancer. Design and main outcome measures: A systematic review and narrative synthesis was conducted on the evidence on PA interventions for children and young people (up to 30 years of age) living with and beyond cancer using a social ecological framework. Results: Out of 12 studies, 8 were shown to change PA. Intervention components included (1) behavioural (Instruction on how to perform the behaviour, credible source, behavioural demonstration and rehearsal), (2) cognitive-emotional (targeting attitude, perceived behavioural control, intentions, resilience and achievement) (3) socio-cultural (family and peer support for PA), (4) environmental (providing access to resources, environmental restructuring, safety), (5) demographic (child, adolescent, young adult or mixed) and (6) medical (tailored exercise depending on age and cancer stage). Conclusions: Interventions designed to increase physical activity participation and adherence during and beyond cancer treatment for young people should integrate psychosocial (behavioural, cognitive-emotional, social), environmental and medical intervention components. Our conceptual model can be used to inform the development of interventions and guides future research objectives and priorities.

An online randomised controlled trial of mental contrasting with implementation intentions as a smoking behaviour change intervention

Objective: We assessed the effectiveness of mental contrasting with implementation intentions (MCII), an established self-regulatory strategy, as a brief online smoking behaviour change intervention. We expected that MCII would enhance smoking reduction among the highly cigarette dependent because MCII is most effective for challenging pursuits. Design: Participants interested in reducing or quitting smoking were recruited online via Amazon Mechanical Turk. At Time 1, we assessed cigarette dependence using the Cigarette Dependence Scale (CDS-5), then administered one of two brief self-help interventions: MCII (n = 172) or a government-promoted control strategy (n = 174). Participants were invited to complete an online follow-up survey 4 weeks later (Time 2). Main Outcome Measure: At Time 1 and Time 2, we measured recent cigarette smoking with a retrospective, self-report questionnaire. We used these reports to compute smoking reduction scores, with an intent-to-treat approach. Results: MCII increased smoking reduction compared to the control strategy at high, but not low, levels of cigarette dependence. Conclusion: We found preliminary evidence consistent with MCII, delivered as a brief online intervention, as an effective smoking reduction strategy for highly dependent cigarette smokers. Further research is needed on MCII as a smoking behaviour change intervention.