How to promote healthy behaviours in patients? An overview of evidence for behaviour change techniques

Exploring timing and delivery of lifestyle advice following an acute cardiac event hospitalization: The cardiac patient's perspective

OBJECTIVE

To explore the perspective of cardiac patients regarding the timing and manner of delivering lifestyle advice following an acute cardiac event hospitalization.

METHODS

Dutch cardiac patients who experienced a cardiac event hospitalization participated in a semi-structured interview (n = 14) or a cross-sectional survey study (n = 119).

RESULTS

Our findings indicate that cardiac patients are receptive to lifestyle advice throughout the care trajectory. Advice delivered by a cardiologist had the highest self-reported impact. Furthermore, receiving advice at multiple phases during the care trajectory was associated with a greater intention to change lifestyle (B = 0.37, CI = 0.17 - 0.57). Patients favored clear-cut, feasible, and friendly but confronting advice. Moreover, they stressed the importance of advice being aligned with their identity and beliefs about the causes of their disease.

CONCLUSION

The period following an acute cardiac event provides a unique opportunity to offer tailored and patient-centered lifestyle advice. This "teachable window" for lifestyle change, when used wisely, may improve health outcomes for cardiac patients.

PRACTICE IMPLICATIONS

Healthcare professionals should initiate lifestyle advice already during hospitalization and continue during follow-up appointments and cardiac rehabilitation. Advice should be feasible and empathy-based, as well as tailored to the patient's needs, values, and perceptions of the causes of their cardiovascular disease.

Allied health professionals knowledge and clinical practice in telehealth exercise behavioural change for multiple sclerosis

BACKGROUND

The growing importance of telehealth in multiple sclerosis (MS) necessitates an understanding of current practices and training needs of health professionals. We aimed to evaluate the knowledge, preparedness, and training preferences of Australian allied health professionals (AHPs) in telehealth exercise therapy and exercise behavioural change for MS patients to inform the development of educational training.

METHODS

An online survey was completed by 58 Australian AHPs, including 34 physiotherapists, 14 exercise physiologists, and 10 occupational therapists, focusing on their current practices, preparedness, and training preferences in telehealth exercise and behavioural change for MS. The survey included multiple-choice, Likert scale, and free-text response questions. Data were analysed using binary and multinomial logistic regressions.

RESULTS

Not all AHPs were aware of MS exercise guidelines (67% awareness), with exercise physiologists showing the highest familiarity. There was a significant understanding of the difference between physical activity and exercise, though definitions often lacked clarity. Most AHPs (91%) employed behavioural change strategies in their practice, especially goal-setting (95%), identifying facilitators (67%), and reinforcing progress (66%). While most (72%) felt prepared in promoting exercise to MS clients, there were differences in confidence levels concerning the prescription, modification, and teaching of telehealth exercise programs, with occupational therapists have significant less confidence in those domains compared to other AHPs. Most AHPs expressed interest in additional training, with a preference for online workshops focusing on exercise prescription for MS, behaviour change, and telehealth delivery methods.

CONCLUSION

In our Australian AHP sample we identified that a quarter to a third of AHPs in MS care may not be confident or prepared to promote telehealth exercise and behavioural change to people with MS. Moreover, the findings highlight some disparity in knowledge and confidence levels amongst different AHPs concerning exercise therapy for MS, indicating the need for tailored multidisciplinary training programs. Such programs should address profession-specific educational gaps and training preferences, ensuring effective and safe telehealth exercise prescription in MS care.

What did we learn about changing behaviour during the COVID-19 pandemic? A systematic review of interventions to change hand hygiene and mask use behaviour

BACKGROUND

behaviour change interventions were central in the COVID-19 response and are vital for strengthening pandemic preparedness and resilience. To be effective, interventions must target specific behavioural determinants, but determinants are complex and multifaceted and there is a gap in robust, theory driven evidence on which behavioural determinants are most effective at changing mask usage and hand hygiene behaviour.

PURPOSE

to map available evidence on the types of hand hygiene and mask usage behaviour change interventions conducted during the COVID-19 pandemic and assess their effectiveness, feasibility and acceptability.

METHODS

we conducted a systematic review, searching four peer-reviewed databases for terms related to COVID-19, targeted behaviours (hand hygiene and mask usage) and interventions. Eligible studies were those which focused on adults or children in naturalistic, non-experimental settings; reported on an intervention designed to change hand hygiene and or mask usage to reduce COVID-19 transmission; provided clear outcome measures, including through self-report, proxy indicators or observation. Studies were excluded if they were purely qualitative, opinion pieces or based on secondary data alone; focused on health workers; measured intended rather than enacted behaviour; were conducted in laboratory or health care-based settings; involved infants; were published before the 11th of March 2020 (when COVID-19 was declared a pandemic) and published in a language other than English. There were no geographical limits set. Descriptive summaries were produced and the quality of evidence and reporting was evaluated. Studies were divided into three sub-groups according to the behaviour targeted and behaviour change techniques (BCTs) were mapped. Effect estimates were summarised and the relationship between BCTs and effect was explored. Feasibility and acceptability was summarised where reported. Due to the heterogeneity of studies included, meta-analysis could not be conducted.

FINDINGS

sixteen citations met the criteria, with sub-studies (two citations including multiple studies) totalling nineteen eligible studies. The majority were randomised controlled trials which targeted hand hygiene only and were conducted in high income nations, with none conducted in crisis settings. Due to the constraints of the pandemic, many interventions were delivered online. The quality of studies was low, with the majority demonstrating a medium risk of bias (Likert scale: low, medium, high). Whilst acceptability and feasibility was good, both were rarely evaluated. 'Natural consequences' was the most commonly used BCT group. Fourteen of the studies elicited positive or potentially positive effects in at least one intervention arm and/or targeted behaviour. Effective interventions typically targeted multiple individual BCTs, including 'Instruction on how to perform a behaviour', 'Information about health consequences', and group 'Reward and threat', through repeated engagement over a sustained period of time.

CONCLUSION

there is a substantial knowledge gap, particularly in low resource and crisis settings, and available evidence is of low quality. We must address these gaps to enable evidence-based practice and strengthen pandemic preparedness and resilience. Future research should include another systematic review which includes grey literature and different languages, as well as more robust evaluations which use implementation research to explore the impact of multiple BCTs in low resource and crisis settings. Evaluations should include assessments of acceptability, practicability, affordability and equity.

Effects of transition programmes to adulthood for adolescents and young adults with CHD: a systematic review with meta-analysis

BACKGROUND

The increased survival rate among individuals with CHD has sparked interest in their transition to adult healthcare. Although there is a general agreement on the importance of transition interventions, the empirical evidence supporting them is insufficient. Therefore, this study aimed to conduct a systematic review and meta-analysis of transition interventions for adult healthcare in adolescents and young adults.

METHODS AND RESULTS

A literature search was conducted for studies comparing the quantitative effects of transition interventions with control groups, published up to March 15, 2023, in major databases (CENTRAL, Embase, PubMed, Web of Science, CINAHL, KISS, and KMbase), major clinical trial registries, academic journal sites related to the topic, and grey literature databases. Ten studies involving a total of 1,297 participants were identified. Transition interventions proved effective in enhancing disease-related knowledge (Hedge's g = 0.89, 95% CI = 0.29-1.48) and self-management (Hedge's g = 0.67, 95% CI = 0.38-0.95), as well as reducing loss to follow-up (OR = 0.41, 95% CI = 0.22-0.77). The certainty of evidence for the estimated values of each major outcome was low or very low.

CONCLUSIONS

This study supports the implementation of transition interventions by demonstrating that they can improve patients' disease knowledge and self-management, while also promoting treatment continuity. However, since the available data on transition interventions for adolescents and young adults with CHD remain limited, the widespread adoption of structured transition interventions in the future may alter the conclusions of this study.

REGISTRATION

URL: https://www.crd.york.ac.uk/PROSPERO. Unique identifier: CRD42023399026.

A Scoping Review of Group Nutrition Education and Cooking Programs for People Affected by Cancer

BACKGROUND

Group nutrition education and cooking programs for people affected by cancer have the potential to address commonly reported unmet needs for dietary information, as well as provide opportunities for practical and social support.

OBJECTIVE

To report the nutrition-related content, delivery methods, and outcomes measured in group nutrition education and cooking programs for people affected by cancer in the published literature, and describe how these programs were developed, implemented, and evaluated.

METHODS

A scoping review of academic literature is reported using the preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews guidelines. Key terms such as cancer, nutrition education, and cooking were searched across 4 databases (PubMed, Embase, Cumulative Index of Nursing and Allied Health Literature, and Web of Science) on June 1, 2023, for records published over the past 10 years. Records were independently screened by 2 reviewers. Data extracted included program participants, components, nutrition-related content, delivery methods, outcomes measured, and information about how the program was developed, implemented, and evaluated.

RESULTS

Of 2,254 records identified, 41 articles met eligibility criteria, reporting on 37 programs. Most programs were designed for adult cancer survivors (89%) and conducted after primary treatment (81%). Four programs invited caregivers to attend. Almost all programs (97%) included a nutrition education component, and more than half (59%) included cooking activities, with a predominant focus on recommendations and practical skills for healthy eating. Most programs were delivered byregistered dietitians and/or nutritionists (54%) and included group discussions (57%) and active involvement in cooking activities (57%) in program delivery. The participant outcomes that were measured covered dietary, psychosocial, clinical, and anthropometric domains. Many programs were developed with cancer survivors, dietitians or nutritionists, and researchers. No studies reported on sustainability of program implementation or overall costs. Programs were evaluated using data from surveys, focus groups, interviews, and field notes, with articles typically reporting on participation rates, reasons for nonparticipation, program acceptability, aspects of the nutrition-related programs valued by participants, and suggestions for improvement.

CONCLUSIONS

Future research should prioritize assessing the effectiveness of these programs for participants. Future development, implementation, and evaluation of these programs should include family members and friends and assess the sustainability of program delivery, including cost-effectiveness.

Pharmacists' perceptions and delivery of health behaviour change recommendations: Mapping the COM-B model

BACKGROUND

Pharmacists are trusted and accessible healthcare professionals who are well-positioned to deliver brief health behaviour change technique-based interventions for chronic health conditions. However, little is known about the factors influencing pharmacists' use of behaviour change techniques and their capacity to deliver these interventions within community pharmacy.

OBJECTIVES

This study employed the COM-B model to explore the factors that explain pharmacists' delivery of behaviour change techniques in practice. A secondary objective was to ascertain whether capability, opportunity, and motivation are associated with and explain significant variance in the use of behaviour change techniques during patient interactions.

METHODS

Two-hundred and eleven Australian pharmacists (mean age = 36.1, SD = 10.7) completed a survey on their capability, opportunity, and motivation to deliver behaviour change techniques, and their delivery and frequency of use in practice.

RESULTS

Most pharmacists (91.3%) use behaviour change techniques during patient interactions. Results from a simple linear regression showed that a composite COM score was associated with pharmacists' behaviour change technique use F(1,195) = 47.12, β = 0.44, 95 % CI [0.09, 0.16], p < .001, and their frequency of use (F(1,198) = 44.19, β = 0.43, 95 % CI [0.02, 0.06], p < .001). While capability, opportunity, and motivation were individually associated with the range and frequency of behaviour change technique used, motivation was the only significant variable in the composite model for range (β = 0.35, 95 % CI [0.11, 0.41], p < .001) and frequency of behaviour change technique use (β = 0.22, 95 % CI [0.01, 0.09], p < .05).

CONCLUSIONS

Pharmacist motivation was the most important construct explaining behaviour change technique use. Interventions should seek to foster pharmacist motivation and may benefit from adopting COM-B as a behaviour change framework, to understand the factors influencing the delivery of behaviour change interventions.

eHealth interventions to support colorectal cancer patients' self-management after discharge from surgery-an integrative literature review

INTRODUCTION

Colorectal cancer (CRC) creates elevated self-management demands and unmet support needs post-discharge. Follow-up care through eHealth post-primary surgery may be an effective means of supporting patients' needs. This integrative review describes the evidence regarding eHealth interventions post-hospital discharge focusing on delivery mode, user-interface and content, patient intervention adherence, impact on patient-reported outcomes and experiences of eHealth.

METHODS

A university librarian performed literature searches in 2021 using four databases. After screening 1149 records, the authors read 30 full-text papers and included and extracted data from 26 papers. Two authors analysed the extracted data using the 'framework synthesis approach'.

RESULTS

The 26 papers were published between 2012 and 2022. The eHealth interventions were mainly delivered by telephone with the assistance of healthcare professionals, combined with text messages or video conferencing. The user interfaces included websites, applications and physical activity (PA) trackers. The interventions comprised the monitoring of symptoms or health behaviours, patient information, education and counselling. Evidence showed a better psychological state and improved PA. Patients reported high satisfaction with eHealth. However, patient adherence was inadequately reported.

CONCLUSIONS

eHealth interventions may positively impact CRC patients' anxiety and PA regardless of the user interface. Patients prefer technology combined with a human element.

A Digital Lifestyle Program for Psychological Distress, Wellbeing and Return-to-Work: A Proof-of-Concept Study

OBJECTIVE

To demonstrate proof-of-concept for a chatbot-led digital lifestyle medicine program in aiding rehabilitation for return-to-work.

DESIGN

Retrospective cohort study with pre-post measures.

SETTING

Community setting, Australia.

PARTICIPANTS

78 adult participants (mean age 46 years, 32% female) with an active workers' compensation claim (N=78).

INTERVENTIONS

A 6-week digital lifestyle medicine program led by an artificially intelligent virtual health coach and weekly telehealth calls with a health coach.

MAIN OUTCOME MEASURES

Adherence (% program completions) and engagement (% of daily and weekly sessions completed), changes in depression, anxiety and distress (K10), psychological wellbeing (WHO-5), return-to-work confidence and anxiety and change in work status.

RESULTS

Sixty participants completed the program (72%), with improvements in psychological distress (P≤.001, r=.47), depression (P<.001, r=.55), anxiety (P<.001, r=.46) and wellbeing (P<.001, r=.62) were noted, as well as increased confidence about returning to work (P≤.001, r=.51) and improved work status (P≤.001). Anxiety about returning to work remained unchanged. Participants completed an average of 73% of daily virtual coach sessions and 95% of telehealth coaching sessions.

CONCLUSIONS

Artificial intelligence technology may be able to provide a practical, supportive, and low-cost intervention to improve psychosocial outcomes among individuals on an active workers' compensation claim. Further, controlled research is needed to confirm these findings.

Dietary behaviour change intervention for managing sarcopenic obesity among community-dwelling older people: a pilot randomised controlled trial

BACKGROUND

The effects of dietary intervention in managing sarcopenic obesity are controversial, and behavior change techniques are lacking in previous studies which are important for the success of dietary intervention. This study aimed to evaluate the feasibility and preliminary effects of a dietary behaviour change (DBC) intervention on managing sarcopenic obesity among community-dwelling older people in the community.

METHODS

A two-armed, RCT was conducted. Sixty community-dwelling older adults (≥ 60 years old) with sarcopenic obesity were randomised into either the experimental group (n = 30), receiving a 15-week dietary intervention combined with behaviour change techniques guided by the Health Action Process Approach model, or the control group (n = 30), receiving regular health talks. Individual semi-structured interviews were conducted with 21 experimental group participants to determine the barriers and facilitators of dietary behaviour changes after the intervention.

RESULTS

The feasibility of the DBC intervention was confirmed by an acceptable recruitment rate (57.14%) and a good retention rate (83.33%). Compared with the control group, the experimental group significantly reduced their body weight (p = 0.027, d = 1.22) and improved their dietary quality (p < 0.001, d = 1.31). A positive improvement in handgrip strength (from 15.37 ± 1.08 kg to 18.21 ± 1.68 kg), waist circumference (from 99.28 ± 1.32 cm to 98.42 ± 1.39 cm), and gait speed (from 0.91 ± 0.02 m/s to 0.99 ± 0.03 m/s) was observed only in the experimental group. However, the skeletal muscle mass index in the experimental group decreased. The interview indicated that behaviour change techniques enhanced the partcipants' compliance with their dietary regimen, while cultural contextual factors (e.g., family dining style) led to some barriers.

CONCLUSION

The DBC intervention could reduce body weight, and has positive trends in managing handgrip strength, gait speed, and waist circumference. Interestingly, the subtle difference between the two groups in the change of muscle mass index warrants futures investigation. This study demonstrated the potential for employing dietary behaviour change interventions in community healthcare.

TRIAL REGISTRATION

Registered retrospectively on ClinicalTrailas.gov (31/12/2020, NCT04690985).

A call for action: Educating pharmacists and pharmacy students in behaviour change techniques

The increasing impact of chronic disease, including cancer and heart disease on mortality signifies a need for the upskilling of health professionals in health behaviour change. Solely providing education and information to patients is generally not sufficient to change behaviour, and for any change to be sustained. The nature of pharmaceutical practice allows pharmacists to have frequent contact with patients in the community. Historically, pharmacists have often effectively engaged with patients to assist with behaviour change initiatives related to smoking cessation, weight loss or medication adherence. Unfortunately, such initiatives do not work for everyone, and more tailored and varied interventions are urgently needed to reduce the effects of chronic disease. In addition, with greater inaccessibility to hospitals and GP's (e.g., appointment wait times), it is imperative that pharmacists are upskilled in providing opportunistic health behaviour change techniques and interventions. Pharmacists need to practice to their full scope consistently and confidently, including the use of behavioural interventions. The following commentary therefore describes and provides recommendations for the upskilling of pharmacists and pharmacy students in opportunistic behaviour change. We outline nine key evidence-based behaviour change techniques, the active-ingredients of a behaviour change intervention, that are relevant to common encounters in professional practice by pharmacists, such as improving adherence to medications/treatments and health promotion initiatives. These include social support (practical and emotional), problem solving, anticipated regret, habit formation, behaviour substitution, restructuring the environment, information about others' approval, pros and cons, and monitoring and providing feedback on behaviour. Recommendations are then provided for how this upskilling can be taught to pharmacists and pharmacy students, as well as how they can use these techniques in their everyday practice.

Integration of nurse-led virtual reviews with growth hormone device-linked patient adherence information: a mixed methods feasibility study

Introduction

Easypod-connect™ for childhood growth disorders is a unique connected system that enables transmission of injection adherence information for recombinant human growth hormone (r-hGH). Although this system has the potential to facilitate greater adherence, observational studies have shown declining adherence over prolonged periods when used without additional support. Supplemental nurse practitioner support has been envisaged but not investigated; in this study, we have undertaken feasibility analysis of nurse-led virtual reviews (NVR) in combination with easypod-connect™ in a single centre using quantitative and qualitative analyses.

Aims

We aimed to test feasibility by assessing compliance with NVR, height standard deviation score (SDS) gain, adherence improvement and patient opinions.

Methods

Patients using easypod™ r-hGH were recruited prospectively to a 12-month study with two telephone NVR appointments in addition to standard of care in-person hospital outpatient visits. A subset was recruited for a semi-structured interview for qualitative thematic analysis.

Results

Forty-three patients of median (range) age 10.7 (6.7, 15.2) were recruited for a period of 1.1 (0.7, 1.8) years. Thirty-three (76.7%) patients were fully compliant with NVR integration with easypod-connect™, establishing feasibility. Median (inter-quartile range, IQR) height SDS improved from -1.85 (-2.44, -1.37) to -1.48 (-2.14, -1.07) (p<0.001) while adherence remained similar in the majority from study start [96.5 (88.8, 100.0)] to end [99.0 (94.0, 100.0)]. Qualitative analysis identified themes supporting patient benefit: practicalities of appointments, perceived purpose and significance of virtual reviews, and the importance of optimising growth. Four patients complained of injection pain, of whom two switched to an alternative r-hGH device.

Conclusion

Our study has demonstrated the feasibility of nurse-led virtual review integration with easypod-connect™ in a mixed methods study, laying the foundation for research in larger groups over longer periods. Nurse practitioner supported application of easypod-connect™ offers the potential for improved growth outcomes in all r-hGH devices providing adherence information.

Co-design of a behaviour change intervention to equip geriatricians and pharmacists to proactively deprescribe medicines that are no longer needed or are risky to continue in hospital

BACKGROUND

Trials of hospital deprescribing interventions have demonstrated limited changes in practitioner behaviour. Our previous research characterised four barriers and one enabler to geriatricians and pharmacists deprescribing in hospital that require addressing by a behaviour change intervention. Six behaviour change techniques (BCTs) have also been selected by the target audience using the hospital Deprescribing Implementation Framework (hDIF). This research aimed to co-design and operationalise the content, mode of delivery and duration/intensity of the six selected BCTs to develop the CompreHensive geriAtRician-led MEdication Review (CHARMER) deprescribing intervention.

METHODS

We established co-design panels at three hospitals representing contextual factors likely to influence CHARMER implementation. Panels comprised geriatricians, pharmacists and other hospital staff likely to be involved in implementation. We convened two rounds of co-design workshops with each hospital to design a prototype for each BCT, which went for feedback at a final workshop attended by all three hospital panels.

RESULTS

The six BCTs were co-designed into an intervention comprising:(^1&2) Pharmacists' workshop with pros and cons of deprescribing activities, and videos of salient patient cases³ Regular geriatrician and pharmacist deprescribing briefings⁴ Videos of geriatricians navigating challenging deprescribing consultations⁵ Hospital deprescribing action plan⁶ Dashboard to benchmark deprescribing activitiesAutomated prompts to flag high-risk patients for deprescribing and a primary and secondary care deprescribing forum were proposed as additional BCTs by stakeholders. These were later excluded as they were not fidelitous to the theoretical determinants of geriatricians' and pharmacists' deprescribing behaviours.

CONCLUSIONS

This study illustrates the integration of theory and co-design methodology with the target audience and staff likely to be involved in implementation of a hospital deprescribing behaviour change intervention. The development of an intervention that remains faithful to the underpinning mechanisms of action of behaviour change is a strength of this approach.

Do congenital and acquired causes of visible difference predict distinct appearance-related psychosocial outcomes?

Having a visible difference caused by an appearance-altering condition or injury can impact psychosocial wellbeing. It remains unestablished whether the time at which a visible difference manifests, namely pre-memory (congenital) or later (acquired), predicts psychosocial outcomes associated with adjustment. In this survey study of 331 adults with visible differences, we tested whether their type, congenital (n = 161) or acquired (n = 170), would predict four key psychosocial outcomes: Appearance satisfaction, social appearance anxiety, life disengagement and intimacy distress. To account for other potential predictors and to test whether other variables would moderate any predictive effect found from the type of visible difference, the analyses also included demographic variables, visible difference characteristics and history, and interpersonal and intrapersonal factors. Four regression models were tested. With all variables entered, we found no evidence of type of visible difference as a significant predictor of any psychosocial outcome. Instead, the only consistent predictors of outcomes were optimism, social support and the extent to which participants felt able to disguise their difference. Overall, findings do not support the idea that there is a psychosocial advantage to having a congenital nor acquired visible difference, and broadly reinforce commonalities in adjusting to any cause.

Identifying behavioural barriers and facilitators to engaging men in a community-based lifestyle intervention to improve physical and mental health and well-being

BACKGROUND

There are few community-based lifestyle interventions designed to target physical and mental health of men. We conducted a qualitative focus group study with men to explore their perceived barriers and facilitators to uptake and engagement with interventions designed to improve their physical and mental health and wellbeing.

METHODS

A volunteer sampling approach (advertisements posted on a premier league football club's social media) was used to recruit men aged 28 to 65 years who were interested in improving their physical and/or mental health and wellbeing. Focus group discussions were conducted at a local premier league football club to 1) explore men's perceived barriers and facilitators to uptake of community-based interventions; 2) identify health issues considered important to address; 3) obtain participant views on how to best engage men in community-based interventions; and 4) use the findings to inform the development of a multibehavioural complex community-based intervention (called 'The 12^th Man').

RESULTS

Six focus group discussions were conducted (duration 27 to 57 min) involving 25 participants (median age 41 years, IQR = 21 years). Thematic analyses generated seven themes: 'Lifestyle behaviours for both mental health and physical health'; 'work pressures are barriers to engaging with lifestyle behaviour change'; previous injuries are barriers to engagement in physical activity and exercise'; personal and peer group relationships impact on lifestyle behaviour change'; relationships between body image and self-confidence on mastery of skills for physical activity and exercise'; building motivation and personalised goal setting'; and 'credible individuals increase uptake and continued engagement with lifestyle behaviour change'.

CONCLUSIONS

Findings suggest that a multibehavioural community-based lifestyle intervention designed for men should promote parity of esteem between physical and mental health. It should also acknowledge individual needs and preferences, emotions in the context of goal setting and planning, and be delivered by a knowledgeable and credible professional. The findings will inform the development of a multibehavioural complex community-based intervention ('The 12^th Man').

The behaviour change behind a successful pilot of hypoglycaemia reduction with HYPO-CHEAT

Background

Children with hypoglycaemia disorders, such as congenital hyperinsulinism (CHI), are at constant risk of hypoglycaemia (low blood sugars) with the attendant risk of brain injury. Current approaches to hypoglycaemia detection and prevention vary from fingerprick glucose testing to the provision of continuous glucose monitoring (CGM) to machine learning (ML) driven glucose forecasting. Recent trends for ML have had limited success in preventing free-living hypoglycaemia, due to a focus on increasingly accurate glucose forecasts and a failure to acknowledge the human in the loop and the essential step of changing behaviour. The wealth of evidence from the fields of behaviour change and persuasive technology (PT) allows for the creation of a theory-informed and technologically considered approach.

Objectives

We aimed to create a PT that would overcome the identified barriers to hypoglycaemia prevention for those with CHI to focus on proactive prevention rather than commonly used reactive approaches.

Methods

We used the behaviour change technique taxonomy and persuasive systems design models to create HYPO-CHEAT (HYpoglycaemia-Prevention-thrOugh-Cgm-HEatmap-Assisted-Technology): a novel approach that presents aggregated CGM data in simple visualisations. The resultant ease of data interpretation is intended to facilitate behaviour change and subsequently reduce hypoglycaemia.

Results

HYPO-CHEAT was piloted in 10 patients with CHI over 12 weeks and successfully identified weekly patterns of hypoglycaemia. These patterns consistently correlated with identifiable behaviours and were translated into both a change in proximal fingerprick behaviour and ultimately, a significant reduction in aggregated hypoglycaemia from 7.1% to 5.4% with four out of five patients showing clinically meaningful reductions in hypoglycaemia.

Conclusions

We have provided pilot data of a new approach to hypoglycaemia prevention that focuses on proactive prevention and behaviour change. This approach is personalised for individual patients with CHI and is a first step in changing our approach to hypoglycaemia prevention in this group.

Welche Kommunikationstechniken sind bei Physiotherapeut*innen während einer Bewegungsberatung mit Personen mit axialer Spondyloarthritis identifizierbar? – Eine Querschnittstudie

Hintergrund Die Schweizerische Vereinigung Morbus Bechterew (SVMB) hat kürzlich das BeFit-Konzept in der Gruppentherapie für Personen mit axialer Spondyloarthritis (axSpA, umgangssprachlich M. Bechterew) implementiert. Ein wichtiger Bestandteil des BeFit-Konzepts ist eine gezielte Bewegungsberatung zur Förderung von selbstständigem Training. Die Kommunikationskompetenz von Physiotherapeut*innen (PT) gilt dabei als Voraussetzung für eine gelungene und wirksame Patientenedukation (PE), ist bisher aber wenig untersucht.

Ziel Analyse, welche Kommunikationstechniken PT während der Bewegungsberatung mit Personen mit axSpA anwenden.

Methode Es wurde eine Querschnittstudie mit PT und Personen mit axSpA der SVMB-Gruppentherapien durchgeführt. Die Bewegungsberatungen wurden mit Audio aufgenommen, die Kommunikationstechniken anhand des Manuals „The Calgary Cambridge Referenced Observation Guide One“ identifiziert. Das Manual enthält 5 Gesprächsabschnitte (1. Einleiten der Sitzung, 2. Informationssammlung, 3. Strukturierung der Konsultation, 4. Beziehungsaufbau, 5. Beenden der Sitzung) mit 38 Techniken, wovon 6 nicht analysiert werden konnten. Eingeschlossen wurden die Techniken, die mindestens einmal identifiziert wurden. Je strukturierter die Beratung war und je mehr Techniken identifiziert wurden, desto besser konnte die Kommunikation der PT während der Beratungsgespräche bewertet werden.

Ergebnisse Es nahmen 12 PT und 41 Personen mit axSpA teil. Somit wurden 41 Bewegungsberatungen ausgewertet. Insgesamt wurden bei 10 von 12 (85 %) der PT in allen Beratungen die 32 eingeschlossenen Kommunikationstechniken mit einer Häufigkeit der einzelnen Techniken zwischen einmal und 41-mal identifiziert. Der Gesprächsabschnitt „Strukturierung der Konsultation“ zeigte die höchste Häufigkeit zwischen 29- und 41-mal.

Schlussfolgerung Die strukturierte Kommunikation ist ein wesentlicher Bestandteil der PE. Die Ergebnisse zeigen, dass die Mehrheit der PT die Bewegungsberatungen mit Patient*innen mit axSpA strukturiert durchführten und die Kommunikationstechniken umfassend identifiziert werden konnten. Die unterschiedlich häufige Anwendung der einzelnen Techniken kann dazu genutzt werden, die Kommunikation der PT in den Bewegungsberatungen für Personen mit axSpA gezielt zu schulen und zu optimieren.

Behavior Change Training for Health Professionals: Evaluation of a 2-Hour Workshop

Background

Rates of noncommunicable diseases continue to rise worldwide. Many of these diseases are a result of engaging in risk behaviors. Without lifestyle and behavioral intervention, noncommunicable diseases can worsen and develop into more debilitating diseases. Behavioral interventions are an effective strategy to reduce the burden of disease. Behavior change techniques can be described as the “active ingredients” in behavior change and address the components that need to be altered in order for the target behavior to change. Health professionals, such as pharmacists and nurses, can engage in opportunistic behavior change with their patients, to encourage positive health behaviors.

Objective

We aimed to develop, implement, and evaluate a behavior change workshop targeted at health professionals in Australia, with the goal of increasing knowledge of behavior change techniques and psychological variables.

Methods

A prospective study design was used to develop and evaluate a 2-hour behavior change workshop targeted at health professionals. The workshop was developed based on the Capability, Opportunity, Motivation, and Behavior Model and had five core objectives: (1) to detail the role of health professionals in delivering optimal care, (2) to demonstrate opportunities to change behavior, (3) to describe principles of behavior change, (4) to explain behavior change techniques, and (5) to determine the most appropriate behavior change techniques to use and when to use them. A total of 10 workshops were conducted. To evaluate the workshops and identify any potential long-term changes in behavior, we collected pre- and postworkshop data on knowledge and psychological constructs from the attendees.

Results

A final sample of 41 health professionals comprising general practitioners, nurses, and pharmacists completed the pre- and postworkshop surveys. Following the workshops, there were significant improvements in knowledge of behavior change techniques (t40=–5.27, P<.001), subjective norms (t40=–3.49, P=.001), descriptive norms (t40=–3.65, P<.001), perceived behavioral control (t40=–3.30, P=.002), and intention (t36=–3.32, P=.002); each had a large effect size. There was no significant difference in postworkshop attitude (t40=0.78, P=.44). The participants also found the workshops to be highly acceptable.

Conclusions

A 2-hour, theoretically informed workshop designed to facilitate the use of behavior change techniques by health professionals was shown to be largely effective. The workshops resulted in increases in knowledge, descriptive and subjective norms, perceived behavioral control, and intention, but not in attitude. The intervention was also shown to be highly acceptable, with the large majority of participants deeming the intervention to be needed, useful, appropriate, and applicable, as well as interesting and worth their time. Future research should examine the lasting impacts of the workshop on health professionals’ practices.

Effectiveness of public health education on the uptake of iron and folic acid supplements among pregnant women: a stepped wedge cluster randomised trial

INTRODUCTION

Iron deficiency is the most prevalent micronutrient deficiency in pregnancy globally responsible for nearly 120 000 maternal deaths per year and a fifth of maternal mortality. Over 46% of pregnant women in Africa and 62% of pregnant women in Kenya are anaemic. Anaemia has severe economic and health consequences. Daily iron and folic acid supplementation (IFAS) is an efficacious strategy recommended in pregnancy to reduce the risk of anaemia and improve maternal and neonatal survival. However, most pregnant women do not consume IFAS as recommended. Limited knowledge on IFAS, its benefits and its connection with anaemia, and mitigation of its side effects lead to poor consumption. The main objective of this trial is to determine the effectiveness of public health education on uptake of antenatal IFAS.

METHODS AND ANALYSIS

A stepped wedge cluster randomised trial with antenatal clinics as units of randomisation. Twelve clusters will be randomised to receive the intervention and levels of IFAS uptake compared with preintervention period. The 9-month trial will enrol 1205 pregnant women. The primary outcome will be the proportion of pregnant women effectively taking up IFAS measured through self-reports, residual pill count and inspection of pill reminder cards. Routine clinical data on haemoglobin counts and fetal growth monitoring will also be used. Descriptive and bivariate analysis will be conducted in Stata using Pearson's χ2 test for association, and multivariate logistic regression to identify determinants of uptake. The potential public health benefits will be estimated using the number needed to treat and the preventable fraction.

ETHICS AND DISSEMINATION

Ethical approval was granted by Kenyatta University Ethics Review Committee (PKU/2443/11575). The research permit is obtained from Kenya National Commission for Science, Technology and Innovation (NACOSTI/P/22/16168). Findings will be disseminated through peer-reviewed publications and public health conferences.

TRIAL REGISTRATION NUMBER

PACTR202202775997127.

PPSV-23 recommendation and vaccination coverage in China: a cross-sectional survey among healthcare workers, older adults and chronic disease patients

BACKGROUND

: 23-valent pneumococcal polysaccharide vaccine (PPSV-23) is crucial to protecting high-risk groups. This study aimed to investigate the influencing factors of PPSV-23 recommendation among healthcare workers, and PPSV-23 coverage among Chinese older adults and chronic disease patients.

RESEARCH DESIGN AND METHODS

: In 2019, a cross-sectional questionnaire survey was conducted in ten provinces in China among older adults aged ≥65 years, chronic disease patients aged 18-64 years, and primary healthcare workers. Multiple logistic regression model was adopted to identify the influencing factors of PPSV-23 recommendation and vaccination uptake.

RESULTS

: Of the 1138 healthcare workers, 46.75% often recommended PPSV-23 to target groups, and public health workers were more likely to recommend than general practitioners. PPSV-23 vaccination rate was 3.29% among chronic disease patients aged <65 years, 6.69% among older adults without chronic disease(s), and 8.87% among chronic disease patients aged ≥65 years. Multiple logistic regression revealed that only general practitioners' recommendation was associated with increased PPSV-23 coverage (p < 0.05).

CONCLUSIONS

: The findings highlighted the suboptimal PPSV-23 coverage rate in China and the strong association between healthcare workers' recommendation and residents' vaccination uptake. Targeted and coherent PPSV-23-related training is suggested for general practitioners to encourage effective health promotion in clinical practices.

Health Behaviors and Behavior Change during Pregnancy: Theory-Based Investigation of Predictors and Interrelations

(1) Background: Preventing pregnancy complications and maternal deaths and helping women stay healthy before, during, and after pregnancy by means of sexual health and behavior is imperative. Previous research demonstrated that a lack of social support and perceived discrimination have adverse effects on pregnancy outcomes. These determinants may impact health behavior as an important mediator of pregnancy outcomes. To better understand this relation, the Compensatory Carry-Over Action Model (CCAM) was applied. The research question was: how do predictors of health behavior, specifically intention, planning, self-efficacy, social support, and discrimination, interrelate with different health behaviors during pregnancy? (2) Methods: By means of qualitative interviews with ten pregnant women (20–39 years, mean = 28.6) from different cultural backgrounds, the predictors of health behaviors and experiences with pregnancy, including racial discrimination, were investigated. (3) Results: Not all women changed their unhealthy behaviors even though their higher-level goal was to ensure their baby’s and their own health. This appeared partially due to lack of social support, racial discrimination, and unexpected pregnancy side effects. The women who previously performed health behaviors revealed a healthier pattern with maintaining or even expanding their health behaviors, while those performing no health behavior in the past reported more obstacles with a healthy lifestyle. (4) Conclusions: Pregnant women appear to be having difficulties translating good intentions into behavior. The reasons include lack of support, fear, and insecurity, which impact self-efficacy and planning. Improvements in health behaviors were facilitated by specific circumstances, such as working from home. Policy and practice should take these aspects into account and help mobilize support and overcome discrimination by means of more rights and support for pregnant women while also empowering the individuals.

A Narrative Review of Peer-Led Positive Psychology Interventions: Current Evidence, Potential, and Future Directions

Positive psychology interventions are an effective means for cultivating flourishing, addressing low levels of wellbeing, and preventing languishing. Peer-led interventions can be a particularly advantageous delivery method of positive psychology interventions, as participants tend to respond more favourably to people that they can identify with personally. Such interventions have been applied in a variety of settings and populations, but the literature on peer-led positive psychology interventions has not yet been summarised. This paper provides a narrative overview of peer-led positive psychology interventions. We reviewed relevant peer-led interventions, assessed the available evidence on their effectiveness, and highlighted promising opportunities for peer-led positive psychology interventions. We found that the majority of the studies were observational in design but showed a high level of acceptability for participants across the reviewed domains. In particular, schools, workplaces, the aged care sector, and community settings are noted as promising target domains for these interventions. However, more studies—particularly high-quality research—will be needed to comprehensively test the effectiveness of peer-led positive psychology interventions. We discuss opportunities for future research in this field.

Behaviour change interventions to promote health and well-being among older migrants: A systematic review

Background

Whether behaviour change interventions are effective for the maintenance of older migrants’ health and well-being is uncertain. A systematic review was conducted to assess evidence for the capacity of behaviour change techniques (BCTs) to promote the health and well-being of older migrants.

Methods

Electronic databases (Cochrane CENTRAL, Embase, Ovid MEDLINE and Web of Science) were searched systematically to identify relevant randomised controlled trials, pre–post studies and quasi-experimental studies published before March 2021. Additional articles were identified through citation tracking. Studies examining BCTs used to promote the health and/or well-being of older migrants were eligible. Two independent reviewers used the Behaviour Change Technique Taxonomy version 1 to extract data on BCTs. Data on intervention functions (IFs) and cultural adaption strategies were also extracted. Intervention contents (BCTs, IFs, culture adaption strategies) were compared across effective and ineffective interventions according to health and well-being outcome clusters (anthropometrics, health behaviour, physical functioning, mental health and cognitive functioning, social functioning and generic health and well-being).

Results

Forty-three studies (23 randomised controlled trials, 13 pre–post studies and 7 quasi-experimental studies) reporting on 39 interventions met the inclusion criteria. Thirteen BCTs were identified as promising for at least one outcome cluster: goal-setting (behaviour), problem-solving, behavioural contract, self-monitoring of behaviour, social support (unspecified), instruction on how to perform the behaviour, information about health consequences, information about social and environmental consequences, demonstration of the behaviour, social comparison, behavioural practice/rehearsal, generalisation of a target behaviour and addition of objects to the environment. Three BCTs (instruction on how to perform the behaviour, demonstration of the behaviour, and social comparison) and two IFs (modelling and training) were identified as promising for all outcome clusters.

Conclusions

Thirteen distinct BCTs are promising for use in future interventions to optimise health and well-being among older migrants. Future research should focus on the effectiveness of these BCTs (combinations) in various contexts and among different subgroups of older migrants, as well as the mechanisms through which they act. Given the scarcity of interventions in which cultural adaption has been taken into account, future behavioural change interventions should consider cultural appropriateness for various older migrant (sub)groups.

Trial registration

PROSPERO CRD42018112859.

Music and Movement for Health: Protocol for a pragmatic cluster-randomised feasibility pilot trial of an arts-based programme for the health and wellbeing of older adults

Background: Arts-based health programmes (ABHP) can enhance the physical and psychosocial health and wellbeing of older people. However, the feasibility and usefulness of such programmes in Ireland are currently unknown. The primary aim of this study is to examine the feasibility of the study design, its application to a music and movement for health programme and associated costs. The secondary aim is to obtain preliminary effect estimates of an ABHP on health and wellbeing in older adults. Methods: This study is a pragmatic cluster-randomised controlled feasibility trial. Community-dwelling adults, aged 65 years or older will be recruited in the mid-west region of Ireland via methods including social prescription, traditional and social media. The clusters, based on geographical region, will be block randomised to either the ABHP or control using 1:1 allocation ratio. The programme will comprise a 1.5-hour music and dance session each week for 12-weeks together with a 1-hour home-based music and movement programme for 12-weeks. A qualitative and quantitative process evaluation of the arts-based health programme will be performed. Outcomes: Primary outcomes for feasibility include recruitment rates (the number of participants recruited per cluster per month); retention rate (the number of participants who complete measures at baseline and at follow up post intervention, and minimum average attendance. Secondary outcomes will include physical function, balance, physical activity, loneliness, social isolation, cognition, mood, as well as quality of life and cost. Conclusions: If this pioneering study finds evidence to support feasibility and acceptability, a future larger-scale definitive trial will be conducted to examine the effectiveness of an arts-based health programme for older adults. This research aims to strengthen collaborative efforts to implement effective, sustainable and cost-effective programmes for older adults to support community connection, enhancing health and wellbeing, in turn reducing demands on the healthcare system. ISRCTN registration: ISRCTN35313497 (18/02/2022).

Primary Tooth Decay Prevention Program in Children: Application of Intervention Mapping Approach

Background. As the most common diseases globally, oral and dental diseases are closely related to people’s behavior. The present study is aimed at developing a program to prevent primary teeth decay in children using the intervention mapping approach. Methods. This study protocol is aimed at using the intervention mapping approach as the planning framework. The study consists of six steps of intervention mapping, including needs assessment based on the relevant literature review, development of an objectives matrix for changing people’s behaviors and environmental factors, program preparation, program implementation, and program evaluation to develop a family-centered program. Results. The use of the intervention mapping approach helped us identify the outcomes and functional objectives, develop an appropriate intervention program, and evaluate the program. Conclusions. The intervention mapping approach is an appropriate guide to developing a systematic and evidence-based program.

Impact of a Clinical Decision Support System for Addressing Physical Activity and/or Healthy Eating during Smoking Cessation Treatment: Hybrid Type I Randomized Controlled Trial (Preprint)

Background

People who smoke have other risk factors for chronic diseases, such as low levels of physical activity and poor diet. Clinical decision support systems (CDSSs) might help health care practitioners integrate interventions for diet and physical activity into their smoking cessation programming but could worsen quit rates.

Objective

The aims of this study are to assess the effects of the addition of a CDSS for physical activity and diet on smoking cessation outcomes and to assess the implementation of the study.

Methods

We conducted a pragmatic hybrid type I effectiveness-implementation trial with 232 team-based primary care practices in Ontario, Canada, from November 2019 to May 2021. We used a 2-arm randomized controlled trial comparing a CDSS addressing physical activity and diet to treatment as usual and used the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework to measure implementation outcomes. The primary outcome was self-reported 7-day tobacco abstinence at 6 months.

Results

We enrolled 5331 participants in the study. Of these, 2732 (51.2%) were randomized to the intervention group and 2599 (48.8%) to the control group. At the 6-month follow-up, 29.7% (634/2137) of respondents in the intervention arm and 27.3% (552/2020) in the control arm reported abstinence from tobacco. After multiple imputation, the absolute group difference was 2.1% (95% CI −0.5 to 4.6; F_1,1000.42=2.43; P=.12). Mean exercise minutes changed from 32 (SD 44.7) to 110 (SD 196.1) in the intervention arm and from 32 (SD 45.1) to 113 (SD 195.1) in the control arm (group effect: B=−3.7 minutes; 95% CI −17.8 to 10.4; P=.61). Servings of fruit and vegetables changed from 2.64 servings to 2.42 servings in the intervention group and from 2.52 servings to 2.45 servings in the control group (incidence rate ratio for intervention group=0.98; 95% CI 0.93-1.02; P=.35).

Conclusions

A CDSS for physical activity and diet may be added to a smoking cessation program without affecting the outcomes. Further research is needed to improve the impact of integrated health promotion interventions in primary care smoking cessation programs.

Trial Registration

ClinicalTrials.gov NCT04223336 https://www.clinicaltrials.gov/ct2/show/NCT04223336

International Registered Report Identifier (IRRID)

RR2-10.2196/19157

Study Protocol of a Comprehensive Activity Promotion Program for the Prevention of Dementia: A Randomized Controlled Trial Protocol

BACKGROUND

Several technical devices are available to monitor and promote changes in behavior toward higher activity. In particular, smartphones are becoming the primary platform for recognizing human activity. However, the effects of behavior change techniques that promote physical, cognitive, and social activities on incident dementia in older adults remain unknown.

OBJECTIVES

This randomized controlled trial aims to examine the effects of behavior change techniques on the prevention of dementia among community-dwelling older adults using a smartphone as a behavior change tool.

DESIGN

A randomized controlled trial.

SETTING

Community in Japan.

PARTICIPANTS

The study cohort comprises 3,498 individuals, aged ≥60 years, randomized into two groups: the smartphone group (n = 1,749) and the control group (n = 1,749).

INTERVENTION

The smartphone group will be asked to use smartphone applications for at least 30 minutes daily to self-manage and improve their physical, cognitive, and social activities. The smartphone group will perform 60-minute group walking sessions using application-linked Nordic walking poles with cognitive stimulation twice a week during the intervention period. The walking poles are a dual-task exercise tool that works with a smartphone to perform cognitive tasks while walking, and the poles are equipped with switches to answer questions for simple calculation and memory tasks. The smartphone and control groups will receive lectures about general health that will be provided during the baseline and follow-up assessments.

MEASUREMENTS

Incident dementia will be detected using cognitive tests (at baseline, after 15 months, and after 30 months) and by preparing diagnostic monthly reports based on data from the Japanese Health Insurance System. Participants without dementia at baseline who will be diagnosed with dementia over the 30-month follow-up period will be considered to have incident dementia.

CONCLUSIONS

This study has the potential to provide the first evidence of the effectiveness of information communication technology and Internet of Things in incident dementia. If our trial results show a delayed dementia onset for self-determination interventions, the study protocol will provide a cost-effective and safe method for maintaining healthy cognitive aging.

Music and Movement for Health: Protocol for a pragmatic cluster-randomised feasibility pilot trial of an arts-based programme for the health and wellbeing of older adults

Background: Arts-based health programmes (ABHP) can enhance the physical and psychosocial health and wellbeing of older people. However, the feasibility and usefulness of such programmes in Ireland are currently unknown. The primary aim of this study is to examine the feasibility of the study design, its application to a music and movement for health programme and associated costs. The secondary aim is to obtain preliminary effect estimates of an ABHP on health and wellbeing in older adults. Methods: This study is a pragmatic cluster-randomised controlled feasibility trial. Community-dwelling adults, aged 65 years or older will be recruited in the mid-west region of Ireland via methods including social prescription, traditional and social media. The clusters, based on geographical region, will be block randomised to either the ABHP or control using 1:1 allocation ratio. The programme will comprise a 1.5-hour music and dance session each week for 12-weeks together with a 1-hour home-based music and movement programme for 12-weeks. A qualitative and quantitative process evaluation of the arts-based health programme will be performed. Outcomes: Primary outcomes for feasibility include recruitment rates (the number of participants recruited per cluster per month); retention rate (the number of participants who complete measures at baseline and at follow up post intervention, and minimum average attendance. Secondary outcomes will include physical function, balance, physical activity, loneliness, social isolation, cognition, mood, as well as quality of life and cost. Conclusions: If this pioneering study finds evidence to support feasibility and acceptability, a future larger-scale definitive trial will be conducted to examine the effectiveness of an arts-based health programme for older adults. This research aims to strengthen collaborative efforts to implement effective, sustainable and cost-effective programmes for older adults to support community connection, enhancing health and wellbeing, in turn reducing demands on the healthcare system. ISRCTN registration: ISRCTN35313497 (18/02/2022).

Association between MS-related knowledge, health literacy, self-efficacy, resilience, and quality of life in a large cohort of MS community members: A cross-sectional study

BACKGROUND

Despite their potential importance, little is known about the associations between multiple sclerosis (MS) knowledge and other outcomes among MS community members.

OBJECTIVE

To examine the relationships between MS-related knowledge, health literacy, self-efficacy, resilience, quality of life (QoL), and MS symptom severity in a cohort of MS community members.

METHODS

In this cross-sectional study (N = 1993), we assessed a cohort of Understanding MS online course enrolees using means and standard deviations. We evaluated the impact of participant characteristics on outcomes using chi square, t-tests, and linear regression models, and assessed associations between outcomes using Pearson correlation.

RESULTS

We found that the total cohort had moderate to high scores on all outcomes. People living with MS had an above average mean MS knowledge score, but below average QoL, resilience, and health literacy scores. The association of MS status with outcome scores was supported by linear regression models. MS knowledge was not correlated with any other outcome for either people living with MS or without MS.

CONCLUSIONS

MS knowledge was not associated with the other study outcomes, suggesting that educational interventions that solely aim to increase knowledge may be ineffective in improving health-related outcomes within the MS community.

Food Integrity Climate in Food Businesses: Conceptualization, Development, and Validation of a Self-Assessment Tool

Current scientific research and industry guidelines focus on food safety, aiming to reduce unintentional food contaminations through technological and managerial measures. Due to the deceptive nature of food fraud, the fight to prevent intentional food adulteration and counterfeiting threats requires an approach that goes beyond the common food safety-based strategies and falls into the sphere of food integrity. With food integrity being an emerging discipline, a definition was proposed and the concept of food integrity climate was introduced. A food integrity climate (FIC) self-assessment tool in the form of a questionnaire, with twenty indicators and a five-point Likert rating scale was developed, expert-validated, and tested in practice in a large-scale meat distribution company. The questionnaire was designed to measure the performance level of food integrity in food businesses along the supply chain through managers’ and operators’ perceptions. Minor but interesting differences were found in the food integrity climate perceived between managers and operators as well as among the company’s affiliates. The tool helps food businesses to get a deeper insight on the human dimension behind food integrity through the assessment of five climate components in relation to four food integrity elements, identifying strengths and weaknesses regarding a company’s food integrity climate.

"It was just for us": qualitative evaluation of an exercise intervention for African-American couples

Background

Promoting long-term exercise adherence should be a key focus for health and fitness professionals working to reduce obesity and cardiometabolic health disparities, and all-cause mortality in inactive African-American (AA) adults. Data have suggested that romantic partners can improve long-term exercise adherence and that this dyadic approach should be examined in exercise interventions. Therefore, the purpose of this study was to conduct a qualitative evaluation of a pilot exercise intervention conducted in older AA couples.

Methods

Two semi-structured focus groups were utilized to compare participants’ perceptions of and experiences during the pilot intervention across two randomly assigned treatment conditions (exercising together with partner [ET; n = 8] versus exercising separately [ES: n = 6]). Participants (mean age: 64.7 ± 6.8 years) of a previous 12-week pilot exercise intervention (walking ≥3 days/week, 30 min/day plus supervised resistance training 2 days/week) were interviewed. Verbatim transcripts were coded using an open coding approach.

Results

Three key themes (intervention value/benefits, intervention difficulties, and suggested improvements) emerged. Although all couples identified health and relationship benefits of the intervention, some differences surfaced within themes across the two intervention groups.

Conclusions

Overall, these qualitative data suggest that couples had a positive experience while participating in the pilot study. In addition, key learning points to improve the intervention were identified including a more gradual transition to independent exercise, more flexibility training, and the incorporation of tangential education. These data will help investigators continue to develop the intervention, which is ultimately designed to promote long-term exercise adherence to reduce cardiometabolic health disparities in the AA community.

Co-designing Behavior Change Resources With Treatment-Seeking Smokers: Engagement Events' Findings

Background: Primary care organizations are well-suited to help patients change their unhealthy behaviors. Evidence shows that risk communication and self-monitoring of behavior are is an effective strategy practitioners can use to promote health behavior change with their patients. In order for this evidence to be actionable, it is important to understand how patients would like this information to be communicated and to operationalize the self-monitoring resources. The objective of this study was to co-create resources that encourage behavior change based on the scientific evidence and from patients with lived experiences.

Materials and Methods: Twenty-seven individuals who participated in a smoking cessation program and engaged in at least one other unhealthy behavior joined one of two engagement events. Each event was 3 h in duration and consisted of two exercises that provided support to participants in reaching a consensus about the types of messages they would like to receive from their practitioner as well as self-monitoring resources they would prefer to use. The first exercise followed an adapted version of the Consensus Methodology developed by the Institute of Cultural Affairs Canada, while the second exercise was in accordance to the Nominal Group Technique.

Results: Participants' preference was to have practitioners convey messages to promote health behavior change that include positive affirmation and to monitor all their health behaviors using a single self-reported tracking sheet.

Conclusions: This paper features the use of engagement events to reflect upon and identify potential resources that treatment seeking smokers prefer to receive while attempting to modify unhealthy behaviors. These resources can be used by health care providers in primary care settings to support health promotion interventions and assist their patients to increase their likelihood of adopting positive changes to risk behaviors.

Methodological guidelines for preparing a structured therapeutic education program: From design to evaluation

BACKGROUND AND OBJECTIVE

Therapeutic patient education (TPE) is effective and essential in the context of the growing prevalence of chronic diseases, in which tools are needed for planning structured programs. The objective of this project was to develop guidelines for designing and assessing a TPE program.

METHODS

1) We assembled a multidisciplinary group of 8 leaders in TPE, chronicity, quality and safety from the hospital and the university. 2) We conducted an exhaustive review of the scientific literature on the planning of TPE programs directed at chronically ill patients, their relatives and caregivers. 3) The final text underwent comments and suggestions by participants from the hospital and primary care centre during a course on information and TPE methodology. The recommendations were unanimously agreed upon by the writing group.

RESULTS

We obtained a standardised work procedure targeted at professionals involved in planning TPE programs, based on international recommendations. The document is structured into sections: a) Definition of the health problem and analysis of the situation; b) Program structure (human resources and materials); objectives (health-related, behaviour-related and educational) and methodology; c) Path the patient and family/caregiver follows in the program; and d) Assessment and indicators. The assessment of the procedure, in the framework of the methodology courses, was favourable.

CONCLUSIONS

The methodology provided by this document serves as an instrument for the standardised and systematic planning of educational programs and unifies the criteria in their drafting. However, the document needs to be adapted to the condition and population to which each program is directed.

Reducing sedentary behavior in individuals with COPD: healthcare professionals' perspectives

Background: Reducing sedentary behavior (SB) in individuals with chronic obstructive pulmonary disease (COPD) is being increasingly recognized as a novel health target. Understanding healthcare professionals (HCPs) behavior that influences a reduction in SB in this population could facilitate achieving this target. Objective: To explore the determinants of behavior related to HCPs targeting a reduction in SB in people with COPD. Methods: We used a qualitative semi-structured interview approach informed by the Theoretical Domains Framework (TDF). Sixteen HCPs were interviewed. Interview transcripts were mapped against the relevant TDF domain(s) and then higher order themes were generated. Results: Directed content analysis resulted in mapping 949 quotes to the TDF domains with environmental context and resources being the most coded domain. Three higher order themes were identified: 1) HCPs need more knowledge on reducing SB; 2) Strategies suggested to include in pulmonary rehabilitation (PR) to reduce SB; and 3) Barriers to adding SB to PR. Domains of environmental context and resources, knowledge, social/professional role and identity, reinforcement, social influences, skills and beliefs about capabilities were relevant to the study population to reduce SB in people with COPD. Conclusion: Knowledge of SB varied across participants. This study provided information on potential behavioral targets for future interventions that involve HCPs and aim to reduce SB among people with COPD.

Digital Intervention With Lifestyle Coach Support to Target Dietary and Physical Activity Behaviors of Adults With Nonalcoholic Fatty Liver Disease: Systematic Development Process of VITALISE Using Intervention Mapping

Background

Nonalcoholic fatty liver disease (NAFLD) is linked to excessive calorie consumption, physical inactivity, and being overweight. Patients with NAFLD can halt or decelerate progression and potentially reverse their condition by changing their lifestyle behavior. International guidelines recommend the use of lifestyle interventions; however, there remains a discordance between published guidelines and clinical practice. This is primarily due to a lack of NAFLD-specific interventions to support weight loss and improve liver function.

Objective

This study aims to use intervention mapping to systematically develop a digital intervention to support patients with NAFLD to initiate and maintain changes in their dietary and physical activity behavior to promote weight loss.

Methods

Intervention mapping consisted of 6 steps: step 1 involved a needs assessment with primary and secondary health care professionals (HCPs) and patients with NAFLD; step 2 involved identification of the social cognitive determinants of change and behavioral outcomes of the intervention; step 3 involved linking social cognitive determinants of behavioral outcomes with behavior change techniques to effectively target dietary and physical activity behavior; step 4 involved the development of a prototype digital intervention that integrated the strategies from step 3, and the information content was identified as important for improving knowledge and skills from steps 1 and 2; step 5 involved the development of an implementation plan with a digital provider of lifestyle behavior change programs to patients with NAFLD using their delivery platform and lifestyle coaches; and step 6 involved piloting the digital intervention with patients to obtain data on access, usability, and content.

Results

A digital intervention was developed, consisting of 8 modules; self-regulatory tools; and provision of telephone support by trained lifestyle coaches to help facilitate behavioral intention, enactment, and maintenance. A commercial provider of digital lifestyle behavior change programs enrolled 16 patients with NAFLD to the prototype intervention for 12 consecutive weeks. A total of 11 of the 16 participants successfully accessed the intervention and continued to engage with the content following initial log-in (on average 4 times over the piloting period). The most frequently accessed modules were welcome to the program, understanding NAFLD, and food and NAFLD. Goal setting and self-monitoring tools were accessed on 22 occasions (4 times per tool on average). A total of 3 out of 11 participants requested access to a lifestyle coach.

Conclusions

Intervention mapping provided a systematic methodological framework to guide a theory- and evidence-informed co-design intervention development process for patients and HCPs. The digital intervention with remote support by a lifestyle coach was acceptable to patients with NAFLD and feasible to deliver. Issues with initial access, optimization of information content, and promoting the value of remote lifestyle coach support require further development ahead of future research to establish intervention effectiveness.

Lifestyle and Health Behavior Change in Traditional Acupuncture Practice: A Systematic Critical Interpretive Synthesis

Introduction: Behavioral factors are the leading cause of ill-health worldwide. Diet, physical activity, smoking, and alcohol consumption are the focus of public health targets on promotion of healthy behavior. The science of behavior change is rapidly growing and has largely evolved within mainstream health care treatments. Traditional Chinese Medicine includes self-care practices that encourage healthy behavior alongside treatments such as acupuncture. Exploring behavior change within traditional acupuncture could potentially highlight new techniques and approaches, and contribute to developing models of behavior change. Aims: In this review, the authors aimed to critically appraise research exploring health behavior change within traditional acupuncture, to highlight gaps in the field, identify questions, and enable theory development. Design/Method: The authors were guided by a critical interpretive synthesis (CIS) method to explore a diverse mixture of research including qualitative and quantitative articles. Eight databases were searched up to October 2017 for articles published in English. Eleven thousand four hundred eighty-eight articles were identified (7,149 after deduplication). Titles and abstracts were screened by one reviewer (10% by a second reviewer). Eligible articles were selected using a Population, Intervention, Comparison, Outcome framework. CIS methods, including purposive sampling of eligible articles and a reflexive, dialectic process of critiquing evidence and theory, were used to synthesize the evidence. Results: Several articles examined the prevalence and patterns of behavior change and support for change, although methods varied and reliability of results was limited. There was more evidence concerning diet/exercise than alcohol/smoking. Aspects of acupuncturists' work identified as potential key elements for promoting behavior change included: individualized advice based on symptoms; holistic/biopsychosocial explanations; therapeutic relationship; simultaneous treatment of behavior-limiting symptoms; and patients' physical involvement with intervention. A logic model of the process of behavior change was developed, proposing that perceived support, mutual understanding, and active participation may facilitate change. Possible moderators included: single/multicomponent acupuncture; setting; patient/practitioner characteristics; treatment experience; timing; and treatment duration. Conclusion: These findings suggest behavior change work is a significant part of traditional acupuncture practice, although more reliable evidence is needed to understand the effectiveness, prevalence, and patterns of this work (in particular the patterns suggesting acupuncturists are more likely to work on changes to diet and physical activity than alcohol and smoking behaviors, and more likely to support changes in long-term compared with acute conditions). The proposed model of behavior change should be developed and tested with a view to refining the model and elaborating the suggested links with a wider theory of behavior and behavior change. This review was preregistered with PROSPERO as "Health behaviour change in traditional acupuncture treatment: a protocol for a critical interpretive synthesis": CRD42018099766.

Application and Evaluation of Survivorship Care Guides for Hematopoietic Cell Transplantation Recipients

Hematopoietic cell transplantation (HCT) is a treatment for hematologic malignancies and disorders. Patients who receive HCT can face long-term physical and psychosocial effects. Survivorship care guides (care guides), which describe screening and preventive care practices were mailed to allogenic HCT recipients at clinically important timepoints (6, 12, and 24 months after HCT). The primary objective of this study was to evaluate how patients perceived and used the care guides. A cross-sectional, time-series survey was sent to all National Marrow Donor Program/Be The Match allogeneic HCT recipients from September 2012 to November 2016 after the care guides were sent; patients or caregivers could respond. Respondents who returned all 3 surveys were included (554 patients; 65 caregivers), for an overall response rate of 13% (maintenance rate of 45%). The majority of patients and caregivers strongly agreed or agreed that the care guides helped them understand that post-HCT care is important to staying healthy and that they were more familiar with recommended tests at check-up appointments. Most patients who did not share the care guides with their doctors at any of the timepoints believed their doctor knew which tests were needed. Results from this study can help inform and guide development of future tools and evaluations of educational resources for patients after HCT. Tools and educational resources, such as survivorship care guides, have the potential to help empower patients to be more knowledgeable and to understand and advocate for their survivorship care needs.

Impact of a Web-Based Clinical Decision Support System to Assist Practitioners in Addressing Physical Activity and/or Healthy Eating for Smoking Cessation Treatment: Protocol for a Hybrid Type I Randomized Controlled Trial

Background

Modifiable risk factors such as tobacco use, physical inactivity, and poor diet account for a significant proportion of the preventable deaths in Canada. These factors are also known to cluster together, thereby compounding the risks of morbidity and mortality. Given this association, smoking cessation programs appear to be well-suited for integration of health promotion activities for other modifiable risk factors. The Smoking Treatment for Ontario Patients (STOP) program is a province-wide smoking cessation program that currently encourages practitioners to deliver Screening, Brief Intervention, and Referral to treatment for patients who are experiencing depressive symptoms or consume excessive amounts of alcohol via a web-enabled clinical decision support system. However, there is no available clinical decision support system for physical inactivity and poor diet, which are among the leading modifiable risk factors for chronic diseases.

Objective

The aim of this study is to assess whether adding a computerized/web-enabled clinical decision support system for physical activity and diet to a smoking cessation program affects smoking cessation outcomes.

Methods

This study is designed as a hybrid type 1 effectiveness/implementation randomized controlled trial to evaluate a web-enabled clinical decision support system for supporting practitioners in addressing patients’ physical activity and diet as part of smoking cessation treatment in a primary care setting. This design was chosen as it allows for simultaneous testing of the intervention, its delivery in target settings, and the potential for implementation in real-world situations. Intervention effectiveness will be measured using a two-arm randomized controlled trial. Health care practitioners will be unblinded to their patients’ treatment allocation; however, patients will be blinded to whether their practitioner receives the clinical decision support system for physical activity and/or fruit/vegetable consumption. The evaluation of implementation will be guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework.

Results

Recruitment for the primary outcome of this study is ongoing and will be completed in November 2020. Results will be reported in March 2021.

Conclusions

The findings of the study will provide much needed insight into whether adding a computerized/web-enabled clinical decision support system for physical activity and diet to a smoking cessation program affects smoking cessation outcome. Furthermore, the implementation evaluation would provide insight into the feasibility of online-based interventions for physical activity and diet in a smoking cessation program. Addressing these risk factors simultaneously could have significant positive effects on chronic disease and cancer prevention.

Trial Registration

ClinicalTrials.gov NCT04223336; https://clinicaltrials.gov/ct2/show/NCT04223336

International Registered Report Identifier (IRRID)

DERR1-10.2196/19157

Effect of Self-Management Support for Elderly People Post-Stroke: A Systematic Review

A systematic review was undertaken to determine the efficacy of self-management interventions for people with stroke over the age of 65 in relation to psychosocial outcomes. PubMed, Embase, and PsycInfo were searched for randomized controlled clinical trials. Studies were eligible if the included people with stroke had a mean age ≥65 years in both the intervention and control group. Data on psychosocial measurements were extracted and an assessment of methodological quality was undertaken. Due to heterogeneity across the studies, the results were synthesized narratively. Eleven studies were identified. They included different self-management interventions in terms of theoretical rationales, delivery, and content. Seven psychosocial outcomes were identified: i) self-management, ii) self-efficacy, iii) quality of life, iv) depression, v) activities of daily living, vi) active lifestyle, and vii) other measures. Self-management interventions for people with stroke over the age of 65 may be beneficial for self-management, self-efficacy, quality of life, activity of daily living, and other psychosocial outcomes. However, low study quality and heterogeneity of interventions, as well as variation in time of follow-up and outcome measures, limit the possibility of making robust conclusions.

Database combinations to retrieve systematic reviews in overviews of reviews: a methodological study

Background

When conducting an Overviews of Reviews on health-related topics, it is unclear which combination of bibliographic databases authors should use for searching for SRs. Our goal was to determine which databases included the most systematic reviews and identify an optimal database combination for searching systematic reviews.

Methods

A set of 86 Overviews of Reviews with 1219 included systematic reviews was extracted from a previous study. Inclusion of the systematic reviews was assessed in MEDLINE, CINAHL, Embase, Epistemonikos, PsycINFO, and TRIP. The mean inclusion rate (% of included systematic reviews) and corresponding 95% confidence interval were calculated for each database individually, as well as for combinations of MEDLINE with each other database and reference checking.

Results

Inclusion of systematic reviews was higher in MEDLINE than in any other single database (mean inclusion rate 89.7%; 95% confidence interval [89.0–90.3%]). Combined with reference checking, this value increased to 93.7% [93.2–94.2%]. The best combination of two databases plus reference checking consisted of MEDLINE and Epistemonikos (99.2% [99.0–99.3%]). Stratification by Health Technology Assessment reports (97.7% [96.5–98.9%]) vs. Cochrane Overviews (100.0%) vs. non-Cochrane Overviews (99.3% [99.1–99.4%]) showed that inclusion was only slightly lower for Health Technology Assessment reports. However, MEDLINE, Epistemonikos, and reference checking remained the best combination. Among the 10/1219 systematic reviews not identified by this combination, five were published as websites rather than journals, two were included in CINAHL and Embase, and one was included in the database ERIC.

Conclusions

MEDLINE and Epistemonikos, complemented by reference checking of included studies, is the best database combination to identify systematic reviews on health-related topics.

Methodological guidelines for preparing a structured therapeutic education program: From design to evaluation

BACKGROUND AND OBJECTIVE

Therapeutic patient education (TPE) is effective and essential in the context of the growing prevalence of chronic diseases, in which tools are needed for planning structured programs. The objective of this project was to develop guidelines for designing and assessing a TPE program.

METHODS

1) We assembled a multidisciplinary group of 8 leaders in TPE, chronicity, quality and safety from the hospital and the university. 2) We conducted an exhaustive review of the scientific literature on the planning of TPE programs directed at chronically ill patients, their relatives and caregivers. 3) The final text underwent comments and suggestions by participants from the hospital and primary care centre during a course on information and TPE methodology. The recommendations were unanimously agreed upon by the writing group.

RESULTS

We obtained a standardised work procedure targeted at professionals involved in planning TPE programs, based on international recommendations. The document is structured into sections: a) Definition of the health problem and analysis of the situation; b) Program structure (human resources and materials); objectives (health-related, behaviour-related and educational) and methodology; c) Path the patient and family/caregiver follows in the program; and d) Assessment and indicators. The assessment of the procedure, in the framework of the methodology courses, was favourable.

CONCLUSIONS

The methodology provided by this document serves as an instrument for the standardised and systematic planning of educational programs and unifies the criteria in their drafting. However, the document needs to be adapted to the condition and population to which each program is directed.

Group-based cognitive behavioral therapy program for improving poor sleep quality and quality of life in people with epilepsy: A pilot study

Sleep difficulties are commonly reported by patients with epilepsy and can have a detrimental impact on overall quality of life. The purpose of this pilot study was to assess the efficacy of a psychotherapeutic approach, namely Cognitive Behavioral Therapy for Insomnia (CBT-I), in improving sleep quality in patients with epilepsy. Twenty outpatients with epilepsy who reported poor sleep quality were randomized to either a control or CBT-I treatment group, which involved four group-based CBT-I sessions, delivered on a weekly basis. In addition to completing a range of standardized measures related to sleep quality and quality of life, participants also monitored their sleep with a self-completed sleep diary over a two-week period, on two separate occasions. Following CBT-I treatment, no between-group difference was found on any sleep or quality of life measure. However, both the treatment and control groups improved on measures of sleep quality, quality of life, sleep hygiene behaviors, and dysfunctional beliefs about sleep. These findings suggest that sleep monitoring alone may have the potential for prompting healthy behavior change in this clinical population.

Using intervention mapping to develop an outpatient nursing nutritional intervention to improve nutritional status in undernourished patients planned for surgery

BACKGROUND

Undernutrition in surgical patients leads to a higher risk of postoperative complications like infections and delayed recovery of gastrointestinal functions, often resulting in a longer hospital stay and lower quality of life. Nurses at outpatient clinics can deliver nutritional care during outpatient preoperative evaluation of health status to ensure that patients are properly fed in preparation for hospital admission for surgery. However, nutritional nursing care was not determined in research yet. This paper describes the structural development of an Outpatient Nursing Nutritional Intervention (ONNI).

METHODS

A project group followed the steps of the Intervention Mapping. The needs assessment included assessment of delivery of nutritional care and nutritional care needs at two anaesthesia outpatient clinics of an academic and a teaching hospital. Also, outpatient clinic nurses and patients at risk for undernutrition were interviewed. Determinants resulted from these methods were matched with theories on behaviour change and nutritional support.

RESULTS

Both patients and nurses were unaware of the consequences of undernutrition, and nurses were also unaware of their roles with regard to nutritional support. The intervention goals were: 1) enabling surgical patients to improve or maintain their nutritional status before hospital admission for surgery, and 2) enabling nurses to deliver nutritional support. The ONNI was developed for outpatients at risk for or with undernutrition. A training was developed for nurses. The ONNI included the five following components: 1) identification of the causes of undernutrition; 2) provision of a nutritional care plan including general and individually tailored advice; 3) self-monitoring of nutrient intake; 4) counselling and encouragement; and 5) support during a telephone follow-up meeting. The intervention and training were tested. A multifaceted implementation strategy was used to deliver the intervention in daily practice.

CONCLUSIONS

Despite the unique position of the nurses at outpatient clinics, nurses were unaware of their role with regard to nutritional care. The ONNI was developed and implemented along with a training program for nurses. The test confirmed that the training can improve nurses' knowledge, skills, and sense of responsibility for nutritional support. The intervention may empower patients to actively improve their nutritional status.

Informing the training of health care professionals to implement behavior change strategies for physical activity promotion in neurorehabilitation: a systematic review

Initiatives to increase physical activity (PA) are most effective when combined with behavior change strategies (BCS). However, this is not routinely done and perhaps can be attributed to health care professionals' (HCP) lack of confidence and understanding of how to best apply BCS. This review aimed to identify and synthesize the existing literature describing methods used to train HCP to deliver BCS for PA promotion for individuals living with neurological conditions. This review followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Eight databases were searched for articles describing how HCP were trained on BCS targeting PA and/or exercise for neurological pathology. Two researchers independently screened abstracts and used third-party consensus when needed. Studies must have described the planning/implementation of BCS targeting PA in adults with neurological disorders, with interventions delivered by a HCP. A data extraction table based on the study objective and the Cochrane Consumers and Communication Review Group's data extraction template was used. Risk of bias was assessed using the Quality Assessment Tools for Quantitative and Qualitative Studies. Included studies were also evaluated using the Workgroup for Intervention Development and Evaluation Research (WIDER) recommendations for reporting behavior change intervention content. Extraction and evaluation of risk of bias were completed independently by two researchers. Data were synthesized according to a who, what, when, and how approach. The search yielded 2,616 articles after duplicates removed, with 13 articles, representing eight unique interventions in individuals with spinal cord injury, stroke, multiple sclerosis, and Parkinson's disease included. Methodological quality ranged from strong to weak. Methods used to increase HCP knowledge and use of BCS were heterogeneous. Common training features included multiple resources, multiple sessions, expert input, and ongoing support, but a lack of evaluation of training effectiveness. The BCS were based on Social Cognitive Theory in seven interventions. Physiotherapists were the most common HCP trained. There was considerable variety in how HCP were trained to use BCS and a lack of evaluation of training effectiveness. Future work should include more description of the content and structure of HCP training and a direct measure of effectiveness. Researchers should consider implementation strategies during development and reporting of behavior change interventions. This review was not registered with PROSPERO.

A Study to Evaluate the Efficacy of Different Interventions for Improving Quality of Maternal Health Care Service in China

Abstract Background/Introduction: The quality of maternal health care service is a crucial determinant of maternal morbidities and mortalities. This study aimed to explore feasibility and relative efficacy of WeChat (WC), of specialist team (ST) service, and of combined of both interventions (WC-ST) for improving the quality of maternal health care in China. Materials and Methods: A four-arm randomized controlled trial of 1,400 pregnant women was conducted in three hospitals in Chengdu, Southwest China, from December 2016 to October 2017. Eligible women were randomly assigned to either of three intervention groups or the control group (service as usual; SAU). Main outcome measures were satisfaction rate and uptakes of maternal health care service at 49 days postpartum based on questionnaire survey. Results: No significant differences in satisfaction rate were found among four groups at baseline (p = 0.981), and significant group differences were noted at 49 days postpartum (p < 0.001), with the highest rate from WC-ST group (98.6%), followed by that of ST (95.2%) and WC (91.6%) groups, and SAU group being the lowest (85.2%). The same pattern of group difference was observed in measures of health care uptake behaviors. Most health care uptake measures from the baseline to post-trial were significantly improved within each of the intervention groups, while most such measures in the control group were not different from baseline to post-trial. Discussion and Conclusions: The WC and ST service is feasible and potentially effective in improving the quality of maternal health care service in China. The study has revealed limitations and options for improvement in future main trial.

Self-Management Support Needs From the Perspectives of Persons With Severe Mental Illness: A Systematic Review and Thematic Synthesis of Qualitative Research

BACKGROUND: The development of de-hospitalization policies in mental health has resulted in a growing emphasis on self-management. In the chronic care model, self-management support is an essential element. Because of the episodic nature of severe mental illness (SMI) and its high relapse rates, we assume that the extent of self-management support needs of individuals with an SMI is considerable. However, a clear overview of the nature of the self-management support needs of persons with SMI is missing. AIMS: This study aimed to identify self-management support needs from the perspective of individuals with SMI. METHOD: A systematic review was conducted using the method of thematic synthesis of qualitative studies. After searching the databases MEDLINE, PsycINFO, CINAHL, and EMBASE, we screened the papers for the eligibility criteria: individuals with an SMI, adequately representing the voice of persons with SMI and describing their self-management support needs. Thirty-one papers were included. RESULTS: The main findings showed that participants in the studies described the need for informational support, emotional support, acknowledgment, encouragement, and guidance to make sense of their illness experiences, ease suffering, obtain validation and recognition, execute self-management tasks, and be led through unfamiliar territory. CONCLUSION: The perspectives of persons with SMI can provide a road map for constructing a self-management support intervention for persons with SMI. Important others have an essential role in fulfilling support needs. Independently managing an SMI is difficult. Therefore, it is preferable to let important others participate in self-management interventions and to introduce peer support.

Flipped Exam Room

Medical education has taken a decided turn toward the "flipped classroom," in which in-class lectures are de-emphasized and engaged learning is promoted. The time has also come to make some changes in what is being taught in clinical medicine, specifically with respect to the patient-physician interaction. Because the daily management of chronic illness is primarily the responsibility of the patient, clinical encounters that prioritize patient engagement and activation are critical. The traditional medical encounter, characterized by data gathering to make a diagnosis followed by prescribing or recommending treatment to the patient, can work well for acute illnesses or injuries, but effective chronic disease management requires substantial patient ownership of their health. In a "flipped exam room," interactions with patients emphasize patient responsibility for health, such that priority is given to eliciting patient goals, what the patient knows, and how they desire to proceed with management of their health concerns and conditions. Just as medical students find engaged learning approaches to be more acceptable and satisfying, patients find collaborative interaction approaches on the part of their physicians to be more satisfying, and such approaches are associated with better outcomes. More attention to training students and residents in "flipped exam room" patient interaction skills is necessary.

A Comparison of Activity Monitor Data from Devices Worn on the Wrist and the Waist in People with Parkinson's Disease

Background

It is unclear if it is appropriate for people with Parkinson's disease (PD) to wear activity monitors on the wrist because of the potential influence of impairments on the data.

Objective

The objective of this study was to determine (1) whether activity monitor data collected from devices worn at the wrist and waist are comparable and (2) the contribution of PD impairments to any differences in step and activity counts at the wrist and waist.

Methods

A total of 46 community-dwelling people with PD wore an accelerometer at the wrist and waist simultaneously for 1 week. Motor impairments (rigidity, bradykinesia, tremor, dyskinesia) were assessed using the Movement Disorders Society Unified Parkinson's Disease Rating Scale part III (motor examination) and part IV (motor complications).

Results

Higher values were recorded by the wrist monitor for steps/day (wrist, 9236 [standard deviation (SD) 3812]; waist, 5324 [SD 2800]; difference 3912; P < 0.001) and activity counts/day (wrist, 872,590 [SD 349,148]; waist, 186,491 [SD 101,989]; difference 686,099; P < 0.001). However, the wrist and waist values were strongly correlated (steps, r = 0.89; counts, r = 0.74; P ≤ 0.001). Increased tremor and dyskinesia explained 19% of the variation in the difference in average steps/day, and these variables plus reduced bradykinesia explained 24% of the variation in the difference in average activity counts/day.

Conclusion

Wrist monitors are likely to overestimate activity, particularly in people with tremor and dyskinesia. Nonetheless, activity monitors can be worn on the wrist if the aim is to monitor change rather than accurately record activity.