CEOS Theory: A Comprehensive Approach to Understanding Hard to Maintain Behaviour Change

Designing an evidence-based working method for medical work disability prognosis evaluation-an intervention mapping approach

Purpose

Performing evidence-based work disability prognosis evaluation (WDPE) of clients on sick leave is a difficult task for physicians. The aim was to develop a working method to support physicians in performing evidence-based WDPE and to improve WDPE quality.

Materials and methods

Intervention Mapping (IM) supplemented with elements of the Behavior Change Wheel (BCW) guided project planning for developing the working method. This approach allowed combination with other frameworks and, e.g., behavior change theories. WDPE quality challenges were analyzed on various ecological levels, e.g., the individual (i.e., the physician), interpersonal (i.e., the client) and organizational level, culminating into a multilevel logic model of the problem. Determinants that contributed to this problem, e.g., lack of physicians' knowledge on performing evidence-based WDPE, were identified. Performance objectives were formulated that could contribute to a desired change in WDPE quality. From the performance objectives and determinants (e.g., knowledge), change objectives were derived. In order to achieve these change objectives, suitable intervention functions (e.g., education) and policy categories (e.g., service provision) were identified, allowing the formulation of intervention components. Behavior change techniques (e.g., feedback on outcomes of a behavior) were selected to serve the intervention functions to deliver the desired change. This led to the conceptualization of an intervention plan.

Results

The intervention "Prognosable" is presented. It consists of a stepwise working method (SWM) for evidence-based WDPE. The SWM offers an overview of important aspects (e.g., medical condition, clients' confidence in return-to-work) to consider in individual clients' WDPE. The SWM helps physicians to identify crucial functional limitations, find and appraise evidence-based information, weigh all relevant prognostic aspects and it supports physicians to conclude with an evidence-based WDPE, tailored to the individual client. The intervention "Prognosable" was designed, which also includes an educational program and a supportive software tool to enable implementation of the SWM.

Conclusion

IM combined with BCW elements guided the development of a SWM for evidence-based WDPE. The SWM will be delivered through an educational program for physicians supported by a digital tool. The SWM, educational program and digital tool are ready to be implemented and evaluated in practice as the intervention "Prognosable."

The need for a personalized, core digital resource to facilitate health self-management

High quality healthcare is becoming increasingly unaffordable and inaccessible. To reverse this trend, people need to self-manage as much of their health as possible. They need to take appropriate preventive actions and use health services in a timely and efficient manner. Yet health self-management is challenging in an increasingly complex environment that involves competing demands and sometimes contradictory advice as well as increasingly fragmented delivery of health services. Digital tools have added a new dimension to healthcare and hold the potential to help bridge these challenges. Unfortunately, much of the potential benefit of digital resources is not being realized, partly because of difficulties people face in identifying appropriate and effective resources in a haystack of mainly unevaluated and often poorly conceived resources. Underuse and failure to maintain use of resources found to be effective also retards progress. Furthermore, people need more help to understand their needs and establish priorities around their health self-management. We argue that these needs can be met with a person-centered, digital self-management core resource that supports people to better understand their needs and priorities and has links to find the resources they need to manage their health, alone or by judicious use of health services.

My quitting stories: A qualitative study exploring Aboriginal women's experiences of smoking cessation and preventing relapse in the context of pregnancy

BACKGROUND

Most women who give up smoking during pregnancy relapse to smoking postnatally. Evidence on strategies that are helpful in maintaining smoking cessation during and beyond pregnancy is limited.

AIM

This paper aims to explore Aboriginal women's experiences of quitting smoking, relapsing, and preventing relapse, focusing on the strategies they applied for attaining and maintaining abstinence and the support they received.

METHODS

Qualitative interviews were conducted between October 2020 and June 2021, in urban New South Wales, Australia, with 12 Aboriginal women who either smoked tobacco or quit smoking and had been pregnant in the last five years. Aboriginal Research Assistants recruited participants, participated in data collection and data analysis. Data were thematically analysed.

RESULTS

Major themes that emerged from the data include: a) aspiration to be abstinent; b) strong mindset; c) strategies to stay smoke-free; d) supports received; and e) service and policy recommendations. Protecting children from second-hand smoke had salience for the maintenance of abstinence. Having a strong mindset was perceived as a prerequisite to staying smoke-free. Use of multiple coping strategies in combination was frequently expressed. Knowledge about tobacco-related harms, the way nicotine dependence works, and the available support options was empowering and enabled informed decision making and actions around smoking cessation.

CONCLUSION

This qualitative study conducted with 12 Aboriginal women revealed that Aboriginal women employ multiple strategies (cognitive, behavioural and social) to quit smoking and stay smoke-free. The strategies warrant further exploration with different Aboriginal communities across Australia and consideration of inclusion in smoking cessation care.

The Predictive Utility of Valuing the Future for Smoking Cessation: Findings from the ITC 4 Country Surveys

Background: Delay discounting (DD) and time perspective (TP) are conceptually related constructs that are theorized as important determinants of the pursuit of future outcomes over present inclinations. This study explores their predictive relationships for smoking cessation. Methods: 5006 daily smokers at a baseline wave provided 6710 paired observations of quitting activity between two waves. Data are from the International Tobacco Control (ITC) smoking and vaping surveys with samples from the USA, Canada, England, and Australia, across three waves conducted in 2016, 2018 and 2020. Smokers were assessed for TP and DD, plus smoking-specific predictors at one wave of cessation outcomes defined as either making a quit attempt and/or success among those who tried to quit which was ascertained at the subsequent survey wave. Results: TP and DD were essentially uncorrelated. TP predicted making quit attempts, both on its own and controlling for other potential predictors but was negatively associated with quit success. By contrast, DD was not related to making quit attempts, but high DD predicted relapse. The presence of financial stress at baseline resulted in some moderation of effects. Conclusions: Understanding the mechanisms of action of TP and DD can advance our understanding of, and ability to enhance, goal-directed behavioural change. TP appears to contribute to future intention formation, but not necessarily practical thought of how to achieve goals. DD is more likely an index of capacity to effectively generate competing future possibilities in response to immediate gratification.

Age-Related Interactions on Key Theoretical Determinants of Smoking Cessation: Findings from the ITC Four Country Smoking and Vaping Surveys (2016-2020)

BACKGROUND

This paper explores whether plans to quit, wanting to quit, and quit efficacy add predictive value over measures of habit strength and dependence in making quit attempts and/or attaining smoking abstinence.

AIMS AND METHODS

We used three waves of the International Tobacco Control (ITC) Four Country Smoking and Vaping Survey conducted in 2016, 2018, and 2020. Baseline daily smokers (N = 6710) who provided data for at least one wave-to-wave transition (W1 to W2, N = 3511 or W2 to W3, N = 3199) and provided outcome data at the next wave (follow-up) formed the analytic sample. Generalized estimating equations (GEE) logistic regression analyses examined predictors of quit attempts and abstinence at follow-up (1- and 6-month sustained abstinence).

RESULTS

Wanting and planning to quit were significantly positively associated with making quit attempts, but negatively associated with smoking abstinence. A significant interaction between the Heaviness of Smoking Index and age warranted an age-stratified analysis for both abstinence outcomes. Lower HSI predicted abstinence in only the younger smokers Motivation and plans to quit were positively associated with abstinence in younger smokers, but surprisingly were negatively associated with abstinence in older smokers. Quit efficacy was associated with abstinence in the older, but not the younger smokers.

CONCLUSIONS

Models of smoking abstinence are significantly improved by including motivational predictors of smoking. Age was an important moderator of the association between abstinence for both dependence and motivational variables.

IMPLICATIONS

The findings from this large cohort study indicate there are age-related differences in predictors of smoking abstinence but not quit attempts. These associations may reflect differential experiences of older and younger cohorts of smokers, which may have implications for interventions to motivate and assist smokers in quitting.

Improving smoking cessation support for people with multiple sclerosis: A qualitative analysis of clinicians' views and current practice

Introduction Smoking is a key modifiable risk factor in multiple sclerosis (MS). MS healthcare providers have a central role informing people of the deleterious effects of smoking on MS progression and promote smoking cessation, yet there is limited information about smoking cessation and support provided by these providers. This study aimed to gain an understanding of MS healthcare providers current practices, barriers and facilitators related to providing smoking cessation support for people with MS. Methods A total of 13 MS nurses and 6 neurologists working in public and private MS clinics across Australia were recruited through professional networks and MS organisations. Telephone interviews were conducted, transcribed and evaluated using framework analysis. Results MS nurses and neurologists reported that they routinely assess smoking status of people with MS at initial appointments and less regularly also at follow-up appointments. Clinicians considered it important to provide information about smoking impact on MS health outcomes and advise to cease smoking, but the content and delivery varies. Beyond this, some clinicians offer referral for smoking cessation support, while others stated this was not their responsibility, especially in light of competing priorities. Many were unsure about referral pathways and options, requiring more information, training and resources. Conclusion Results of this research indicate that there is potential to improve support for MS clinicians to promote smoking cessation among people with MS. Smoking cessation support may include tailored patient resources, clinician training and stronger collaboration with smoking cessation service providers.

'It's all the other stuff!' How smokers understand (and misunderstand) chemicals in cigarettes and cigarette smoke

Many people understand chemicals as entities that do not occur naturally, and which are also invariably toxic. Tobacco control messages liberally use the term 'chemicals' to evoke these meanings and create concern among smokers. This may reinforce misunderstandings, potentially leading to smokers making harmful choices. To investigate smokers' understandings of chemicals, we conducted qualitative research using 18 individual interviews and three focus groups with Australian smokers and recently quit smokers. The research was guided by the 'mental models' framework and the recently developed Context, Executive, and Operational Systems theory. We discerned two clusters of mental models: the first cluster focused on combustion as the overarching cause of harm (and were largely consistent with the science) and the second cluster focused on additives as causes of harm. We found most participants displayed limited knowledge of the causes of harm from smoking and some held mutually incompatible beliefs. Most participants believed that cigarettes differ significantly in harmfulness according to whether or not they were believed to contain additives. Only a minority understood that the bulk of the toxicants to which smokers are exposed are combustion products. These findings are directly relevant to tobacco control but also have broader relevance to risk communications about toxic exposures.

Women's exercise identity increases after a 16-week exercise RCT and is linked to behavior maintenance at follow-up

BACKGROUND

Regular exercise is critical for disease prevention, but adherence to public health guidelines is poor. Exercise identity is purported to be associated with exercise behavior maintenance, but the extant literature is largely cross-sectional and of low/modest quality.

PURPOSE

To examine change in exercise identity after completion of a supervised exercise intervention, as well as associations between change in exercise identity and exercise maintenance at 6-months follow-up.

METHODS

N = 276 insufficiently physically active women were randomized to a 16-week, supervised exercise training intervention with 4 conditions fully crossed on intensity (vigorous/moderate) and duration (long/short). Exercise identity was measured pre- and post-intervention and assessments of exercise motivation and behavior frequency were collected at 6-months post-intervention follow-up.

RESULTS

On average, participants experienced a statistically significant change in exercise identity over the course of the intervention, t(128) = 7.94, p < .001, but identity change scores did not differ across training conditions, p = .91. Identity change was significantly positively related to changes in other theory-informed, motivation-based determinants of exercise, and predicted an additional 16.17 minutes of exercise per week, on average, at follow-up, b = 16.76, t(103) = 2.30, p = .023.

CONCLUSIONS

Participants experienced increased self-identification with exercise after 16-weeks of training, but training volume did not influence the amount of identity change. As expected, greater change in exercise identity was associated with higher levels of exercise behavior at 6-months post-intervention follow-up (ClinicalTrials.gov number NCT02032628).

Understandings of the component causes of harm from cigarette smoking in Australia

INTRODUCTION AND AIMS

To investigate relationships between smoking-related behaviours and knowledge of the disease risks of smoking and the causes of smoking harms, using a four-way division of 'component causes': nicotine, other substances found in unburned tobacco, combustion products of tobacco and additives.

DESIGN AND METHODS

The data were collected using an on-line survey in Australia with 1047 participants in three groups; young non-smokers (18 to 25), young smokers (18 to 25) and older smokers (26 and above).

RESULTS

Most participants agreed that cancer and heart disease are major risks of smoking but only a quarter accurately quantified the mortality risk of lifetime daily smoking. Very few (two of 1047) correctly estimated the relative contributions of all four component causes. Post-hoc analyses reinterpreting responses as expressions of relative concern about combustion products and nicotine showed that 29% of participants rated combustion products above nicotine. We delineated six relative concern segments, most of which had distinctive patterns of beliefs and actions. However, higher levels of concern about combustion products were only weakly positively associated with harm reducing beliefs and actions.

DISCUSSION AND CONCLUSIONS

Most smokers do not appear to understand the risks of smoking and their causes well enough to be able to think systematically about the courses of action open to them to reduce their health risk. To facilitate informed decision-making, tobacco control communicators may need to better balance the dual aims of creating fear/negative affect about smoking and imparting knowledge about the health harms and their mechanisms.

Smokers' risk perceptions and misperceptions of cigarettes, e-cigarettes and nicotine replacement therapies

INTRODUCTION AND AIMS

To identify the range and coherence of smokers and recent ex-smokers' general beliefs about the harms associated with smoking and the implications of these beliefs for their assessments of the relative harms and addictiveness of various nicotine containing products.

DESIGN AND METHODS

The study consisted of 18 single participant interviews with current smokers or vapers (13 M, 5 F) and three focus groups (15 M, 14 F) with current smokers/vapers and recent quitters. Both individual interviews and focus groups included semi-structured discussions of how nicotine and cigarette smoke cause disease and addiction, and a structured task involving rating the relative harmfulness and addictiveness of 17 nicotine products against a reference, popular, cigarette.

RESULTS

Most participants were able to give adequate accounts of what makes cigarette smoking harmful and addictive but this general knowledge was not consistently applied to making harmfulness and addictiveness judgements about specific products. Many participants applied simple affect-based heuristics to harmfulness and addictiveness judgments, even when they had apparently demonstrated more sophisticated knowledge earlier. Most used binary safe/dangerous thinking, with addictiveness and harmfulness strongly linked and a decoupling of satisfaction and addictiveness.

DISCUSSION AND CONCLUSIONS

Many smokers appear to have reasonable general knowledge of the risks of smoking but cannot reliably apply this knowledge to practical risk judgements. We need to rethink how we communicate with the public about the risks of smoking, and using other nicotine products, in ways that allow them to make more informed decisions about their smoking.

Factors associated with future intentions to use personal vaporisers among those with some experience of vaping

INTRODUCTION AND AIMS

Personal vaporisers (PV), including e-cigarettes, may be a harm reduction strategy for tobacco control. This study aims to identify factors associated with future intentions to vape among smokers and ex-smokers in Australia and the UK.

DESIGN AND METHODS

Cross-sectional data of smokers and ex-smokers (n = 1199, mean age = 45.3 years, 44.8% male), collected in 2014/2015 and divided into four subgroups: smoking past vapers (SPV), smoking vapers (SV), ex-smoking past vapers (ESPV) and ex-smoking vapers (ESV), from the International Tobacco Control Australia and UK surveys were analysed by using regression models.

RESULTS

Higher vaping satisfaction increased vaping intentions for all groups except ESPV. Perceiving PVs as less harmful predicted intentions to vape for all groups except ESV. The importance of PVs for stopping smoking predicted lower intentions to continue vaping for SV, but higher intentions to initiate vaping for SPV. The importance of PVs for cutting down smoking was a positive predictor only for SPV. Among ex-smokers, importance for maintaining not smoking was a positive predictor for ESPV, but not for ESV. The importance of perceiving vapour being less harmful also depended on vaping status for ex-smokers. The only country interaction was that only in the UK was perceiving PVs as less harmful associated with intention among SPV.

DISCUSSION AND CONCLUSION

Factors influencing intentions vary by smoking and/or vaping status, with greater differences between the ex-smoker subgroups. This is consistent with PVs being seen as a way of managing smoking, rather than something that has intrinsic value, for all except the ex-smoking vapers. [Ma BH, Yong H-H, Borland R, McNeill A, Hitchman SC. Factors associated with future intentions to use personal vaporisers among those with some experience of vaping. Drug Alcohol Rev 2017;00:000-000].

The gap between behavioral risk status and willingness to change behavior among healthcare professionals

Aims:

This study explored behavioral health risk factors among healthcare professionals and investigated the at-risk persons’ satisfaction with their health habits and ongoing change attempts.

Methods:

The study was based on a cross-sectional web-based survey directed at the nurses and physicians ( N = 1233) in Finnish healthcare. Obesity, low physical activity, smoking, and risky alcohol drinking were used as behavioral health risk factors.

Results:

In all, 70% of the participants had at least one behavioral risk factor, and a significant number of at-risk persons were satisfied with their health habits and had no ongoing change process. Good self-rated health and good self-rated work ability were significantly associated with whether a participant had a behavioral health risk factor.

Conclusion:

Overall, unhealthy behaviors and a lack of ongoing change attempts were commonly observed among healthcare professionals. Work in healthcare is demanding, and healthy lifestyles can support coping. Thus, healthy lifestyle programs should also be targeted to healthcare professionals.

Q: Is Addiction a Brain Disease or a Moral Failing? A: Neither

This article uses Marc Lewis' work as a springboard to discuss the socio-political context of the brain disease model of addiction (BDMA). The claim that promotion of the BDMA is the only way the general public can be persuaded to withhold blame and punishment from addicts is critically examined. After a discussion of public understandings of the disease concept of addiction, it is pointed out that it is possible to develop a scientific account of addiction which is neither a disease nor a moral model but which the public could understand. Evidence is reviewed to suggest that public acceptance of the disease concept is largely lip-service and that the claim the BDMA removes stigma among the public and professionals is unsupported by evidence. Further, there is good evidence that biogenetic explanations of mental/behavioural disorders in general have been counterproductive in the attempt to ally stigma. A model of addiction as a disorder of choice may attract special problems in public-facing communications and risks being misunderstood. However, ways of presenting this model to the public are suggested that may avoid such risks. Lastly, the claim that the BDMA is the only way of ensuring access to treatment and of maintaining research funding for addiction is disputed and a way in which these benefits can be retained under a disorder-of-choice model proposed. The article concludes by enthusiastically endorsing Lewis' call for a third stage in the governing image of addiction.