What more can we learn from early learning theory? The contemporary relevance for behaviour change interventions

Changing healthcare professionals' non-reflective processes to improve the quality of care

RATIONALE

Translating research evidence into clinical practice to improve care involves healthcare professionals adopting new behaviours and changing or stopping their existing behaviours. However, changing healthcare professional behaviour can be difficult, particularly when it involves changing repetitive, ingrained ways of providing care. There is an increasing focus on understanding healthcare professional behaviour in terms of non-reflective processes, such as habits and routines, in addition to the more often studied deliberative processes. Theories of habit and routine provide two complementary lenses for understanding healthcare professional behaviour, although to date, each perspective has only been applied in isolation.

OBJECTIVES

To combine theories of habit and routine to generate a broader understanding of healthcare professional behaviour and how it might be changed.

METHODS

Sixteen experts met for a two-day multidisciplinary workshop on how to advance implementation science by developing greater understanding of non-reflective processes.

RESULTS

From a psychological perspective 'habit' is understood as a process that maintains ingrained behaviour through a learned link between contextual cues and behaviours that have become associated with those cues. Theories of habit are useful for understanding the individual's role in developing and maintaining specific ways of working. Theories of routine add to this perspective by describing how clinical practices are formed, adapted, reinforced and discontinued in and through interactions with colleagues, systems and organisational procedures. We suggest a selection of theory-based strategies to advance understanding of healthcare professionals' habits and routines and how to change them.

CONCLUSION

Combining theories of habit and routines has the potential to advance implementation science by providing a fuller understanding of the range of factors, operating at multiple levels of analysis, which can impact on the behaviours of healthcare professionals, and so quality of care provision.

Behavioral Intervention Components Associated With Cost-effectiveness: A Comparison of Six Domains

Background

To help implement behavior change interventions (BCIs) it is important to be able to characterize their key components and determine their effectiveness.

Purpose

This study assessed and compared the components of BCIs in terms of intervention functions identified using the Behaviour Change Wheel Framework (BCW) and in terms of their specific behavior change techniques (BCTs) identified using the BCT TaxonomyV1, across six behavioral domains and the association of these with cost-effectiveness.

Methods

BCIs in 251 studies targeting smoking, diet, exercise, sexual health, alcohol and multiple health behaviors, were specified in terms of their intervention functions and their BCTs, grouped into 16 categories. Associations with cost-effectiveness measured in terms of incremental cost-effectiveness ratio (ICER) upper and lower estimates were determined using regression analysis.

Results

The most prevalent functions were increasing knowledge through education (72.1%) and imparting skills through training (74.9%). The most prevalent BCT groupings were shaping knowledge (86.5%), changing behavioral antecedents (53.0%), supporting self-regulation (47.7%), and providing social support (44.6%). Intervention functions associated with better cost-effectiveness were those based on training (β_low = −15044.3; p = .002), persuasion (β_low = −19384.9; p = .001; β_upp = −25947.6; p < .001) and restriction (β_upp = −32286.1; p = .019), and with lower cost-effectiveness were those based on environmental restructuring (β = 15023.9_low; p = .033). BCT groupings associated with better cost-effectiveness were goals and planning (β_low = −8537.3; p = .019 and β_upp = −12416.9; p = .037) and comparison of behavior (β_low = −13561.9, p = .047 and β_upp = −30650.2; p = .006). Those associated with lower cost-effectiveness were natural consequences (β_low = 7729.4; p = .033) and reward and threat (β_low = 20106.7; p = .004).

Conclusions

BCIs that focused on training, persuasion and restriction may be more cost-effective, as may those that encourage goal setting and comparison of behaviors with others.

Encouraging Gamblers to Think Critically Using Generalised Analytical Priming is Ineffective at Reducing Gambling Biases

Gambling has been associated with an array of fallacious beliefs that foster risky gambling decisions. Research into other belief systems suggests that the endorsement of non-evidence based beliefs, such as the paranormal or conspiracy theories, can be reduced when people think more analytically. The purpose of this study was to explore whether an intervention designed to elicit analytical thinking was effective in altering the gambling beliefs and simulated gambling behaviour of 178 regular electronic gaming machine (EGM) gamblers (102 males, 76 female). Participants were randomly allocated to complete either an analytic or a neutral priming task, followed by completion of belief measures (erroneous and protective) and play on a simulated EGM game. Results failed to show that priming for analytical thinking changed betting on an EGM; including features of bet size, bet change, persistence and theoretical losses. Contrary to expectations, results suggest that priming analytical thinking using generalised interventions does not appear to be effective in altering peoples' simulated gambling involvement or gambling beliefs. In fact, priming people to think more critically might be counterproductive by contributing to greater positive expectations about gambling outcomes. The results further suggested that the number of times a player alters their bet is a good indicator of theoretical gambling losses and is associated with irrational gambling cognitions. Interventions designed to promote safer thinking in gamblers should be implemented with care, as results from our study suggest that encouraging critical thinking in at-risk or problem gamblers may not be effective in reducing risky gambling.

Beliefs About Gambling Mediate the Effect of Cognitive Style on Gambling Problems

Problem gambling is often accompanied by a range of irrational cognitions that promote excessive gambling. The cognitive basis for these beliefs has been largely overlooked in the gambling literature. Dual process theory suggests there are two parallel cognitive processing systems, an intuitive and an analytic system, and that there are potential individual differences in preference for one or the other cognitive style. The current study explored whether people's cognitive styles are an important factor in the development of specific beliefs about gambling that in-turn contribute to gambling problems. The sample consisted of 1168 regular gamblers (539 female, ranging from 18 to 78 years of age; M = 35.47, SD = 10.78) recruited via Mechanical Turk. Participants completed a survey assessing cognitive style, problem gambling severity, and measures of protective and erroneous beliefs. In a path model, greater analytical thinking and lower intuitive thinking was associated with fewer erroneous gambling beliefs, which in turn were related to fewer gambling problems. A second model showed that protective beliefs also mediated the relationship between cognitive style and gambling, demonstrating that greater analytical thinking and lower intuitive thinking was associated with protective beliefs that similarly reduced problem gambling severity. Results suggest that a person's cognitive style influences peoples gambling by contributing to the endorsement of irrational or unsafe beliefs about gambling. Encouraging people to think more analytically may be useful in reducing erroneous beliefs about gambling that promote problematic gambling behaviour.

Gamble with Your Head and Not Your Heart: A Conceptual Model for How Thinking-Style Promotes Irrational Gambling Beliefs

Dual process theory suggests that people use two processing systems to filter information and form judgments that direct a course of action: an intuitive and an analytic system. While the intuitive system is necessary for efficient and effective daily functioning, reliance on fast, intuitive thinking when gambling is likely to result in biased or flawed decision-making. Those who gamble tend to endorse an array of fallacious or irrational beliefs that contribute to risky decision-making and excessive gambling. This paper argues that gambling beliefs may be developed and reinforced through underlying cognitive mechanisms described by dual process theory. More specifically, gamblers tend to apply assumptions and theories developed based on their understanding of the natural world to artificial gambling contexts where such rules do not apply. As a result, gamblers develop biased interpretations and understandings for how gambling works, which tend to align with personal schemas, experiences and gambling motivations. These beliefs are used in future gambling contexts to inform decision-making. Gamblers are often unlikely or unwilling to reflect on the veracity of beliefs as they are often used to justify gambling behaviours. Educating gamblers on how they make decisions and encouraging them to think more analytically may help to reduce the strength with which erroneous beliefs about gambling are endorsed, resulting in safer gambling decisions.

Variable Magnitude and Frequency Financial Reinforcement is Effective at Increasing Adults' Free-Living Physical Activity

Financial rewards can increase health behaviors, but little research has quantified the effects of different reinforcement schedules on this process. This analysis compares the average moderate-to-vigorous physical activity (MVPA) associated with six distinct positive reinforcement schedules implemented within a physical activity promotion clinical trial. In this trial, participants (N = 512) wore an accelerometer for 1 year and were prescribed one of two types of MVPA goals: a static 30-min goal or an adaptive goal based on the MVPA produced over the previous 9 days. As participants met goals, they transitioned through a sequence of reinforcement stages, beginning with a continuous-fixed magnitude (CRF-FM), then CRF-variable magnitude (CRF-VM), followed by a series of variable ratio-VM (VR-VM) schedules. The average accumulation of MVPA bouts over the last 24 days of each stage was compared to each other. Average MVPA during stage transitions was also examined. The results indicated that immediate reinforcement resulted in more MVPA relative to a comparison group and that the relative effectiveness of adaptive versus static goals was dependent on the magnitude of daily MVPA goals. Schedule effects were qualitatively different for individuals who frequently met their daily goals (Large Intervention Effect subgroup) versus those who did not (Small Intervention Effect subgroup). For the Large Intervention Effect group, the CRF-VM schedule produced the most MVPA, in particular within the adaptive goal condition, with increases observed immediately upon encountering this schedule. In contrast, the CRF-FM schedule produced small amounts of MVPA. This pattern was reversed for the Small Intervention Effect subgroup, where the most MVPA was associated with the CRF-FM stage. Future interventions should focus on discriminating small versus large intervention effects as quickly as possible so that the optimal reinforcement schedule can be used.

A loyalty scheme to encourage physical activity in office workers: a cluster RCT

Background

Increasing physical activity in the workplace can provide physical and mental health benefits for employees and economic benefits for the employer through reduced absenteeism and increased productivity. However, there is limited evidence on effective behaviour change interventions in workplace settings that led to maintained physical activity. This study aimed to address this gap and contribute to the evidence base for effective and cost-effective workplace interventions.

Objectives

To determine the effectiveness and cost-effectiveness of the Physical Activity Loyalty scheme, a multicomponent intervention based on concepts similar to those that underpin a high-street loyalty card, which was aimed at encouraging habitual physical activity behaviour and maintaining increases in mean number of steps per day.

Design

A cluster randomised controlled trial with an embedded economic evaluation, behavioural economic experiments, mediation analyses and process evaluation.

Setting

Office-based employees from public sector organisations in Belfast and Lisburn city centres in Northern Ireland.

Participants

A total of 853 participants [mean age 43.6 years (standard deviation 9.6 years); 71% of participants were female] were randomly allocated by cluster to either the intervention group or the (waiting list) control group.

Intervention

The 6-month intervention consisted of financial incentives (retail vouchers), feedback and other evidence-based behaviour change techniques. Sensors situated in the vicinity of the workplaces allowed participants to monitor their accumulated minutes of physical activity.

Main outcome measures

The primary outcome was mean number of steps per day recorded using a sealed pedometer (Yamax Digiwalker CW-701; Yamax, Tasley, UK) worn on the waist for 7 consecutive days and at 6 and 12 months post intervention. Secondary outcomes included health, mental well-being, quality of life, work absenteeism and presenteeism, and the use of health-care resources.

Results

The mean number of steps per day were significantly lower for the intervention group than the control group [6990 mean number of steps per day (standard deviation 3078) vs. 7576 mean number of steps per day (standard deviation 3345), respectively], with an adjusted mean difference of –336 steps (95% confidence interval –612 to –60 steps; p = 0.02) at 6 months post baseline, but not significantly lower at 12 months post baseline. There was a small but significant enhancement of mental well-being in the intervention group (difference between groups for the Warwick–Edinburgh Mental Wellbeing Scale of 1.34 points, 95% confidence interval 0.48 to 2.20 points), but not for the other secondary outcomes. An economic evaluation suggested that, overall, the scheme was not cost-effective compared with no intervention. The intervention was £25.85 (95% confidence interval –£29.89 to £81.60) more costly per participant than no intervention and had no effect on quality-adjusted life-years (incremental quality-adjusted life-years –0.0000891, 95% confidence interval –0.008 to 0.008).

Limitations

Significant restructuring of participating organisations during the study resulted in lower than anticipated recruitment and retention rates. Technical issues affected intervention fidelity.

Conclusions

Overall, assignment to the intervention group resulted in a small but significant decline in the mean pedometer-measured steps per day at 6 months relative to baseline, compared with the waiting list control group. The Physical Activity Loyalty scheme was deemed not to be cost-effective compared with no intervention, primarily because no additional quality-adjusted life-years were gained through the intervention. Research to better understand the mechanisms of physical activity behaviour change maintenance will help the design of future interventions.

Trial registration

Current Controlled Trials ISRCTN17975376.

Funding

This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 7, No. 15. See the NIHR Journals Library website for further project information.

What do cost-effective health behaviour-change interventions contain? A comparison of six domains

OBJECTIVES

To help implement behaviour change interventions (BCIs) in practice it is important to be able to characterize their key components. This study compared broad features of cost-effective BCIs that addressed smoking, diet, physical activity, alcohol and sexual health. It also assessed the association of these with the magnitude of the cost-effectiveness estimates.

METHODS

A content analysis of 79 interventions based on 338 intervention descriptions was conducted, using the Behaviour Change Wheel (BCW) to classify intervention content in terms of intervention functions, and the BCT taxonomy to identify and categorise component Behaviour Change Techniques (BCT). Regression analysis identified the association of these with upper (pessimistic) and lower (optimistic) cost-effectiveness estimates.

RESULTS

The most and least common functions and BCT clusters were education (82.3%) and shaping knowledge (79.7%), and coercion (3.8%) and covert learning (2.5%). Smoking interventions contained the largest ([Formula: see text] = 12) number of BCTs and were most cost-effective. Several other factors were associated with worse (coercionfunction βupper = 36551.24; shaping knowledgeBCT βlower = 2427.78; comparison of outcomesBCT βupper = 9067.32; repetition and substitutionBCT βupper = 7172.47) and better (modellingfunction βlower = -2905.3; environmental restructuringfunction βupper = -8646.28; reward and threatBCT βupper = -5577.59) cost-effectiveness (p<0.05).

DISCUSSION

Cost-effective BCIs rely heavily on education with smoking interventions exhibiting the most comprehensive range of BCTs. Providing an example to aspire to, restructuring the environment and rewarding positive behaviour may be associated with greater cost-effectiveness.

Understanding active school travel through the Behavioural Ecological Model

Active school travel (AST) is an important source of physical activity for children and a conceptual understanding of AST is necessary to inform promotion efforts. The aim of this article is to provide a conceptual analysis of AST. All currently identified AST formulations include intra-individual variables which are often recommended as intervention targets. However, existing literature lacks clarity on precisely how these intra-individual variables might shape specific AST interventions. Moreover, evaluative studies of AST interventions typically fail to specify an underpinning theory or model. To address this limitation, the Behavioural Ecological Model (BEM), not previously addressed in AST, is presented to guide this area of research. Based on specific examples, we draw attention to the role of potential antecedents and potential reinforcers of AST, as well as potential reinforcers of motorised travel. Antecedents and reinforcers may help to explain choices of school travel mode, and to inform and increase intervention options to promote AST. Consistent with the BEM, the provision of more immediate consequences, such as fun and material prizes, is an evidence-based strategy for increasing AST which is likely to be low-cost and easier to deliver than alternative interventions. This approach to the study of AST is expected to contribute to similar analyses in this and other areas of behaviour change research, and to a more useful discussion and treatment of theoretical and conceptual behavioural models.

Effectiveness of physical activity interventions in achieving behaviour change maintenance in young and middle aged adults: A systematic review and meta-analysis

BACKGROUND

Physical activity (PA) interventions are generally effective in supporting short-term behaviour change, but increases are not always maintained. This review examined the effectiveness of PA interventions for behaviour change maintenance in young and middle-aged adults, and investigated which Behaviour Change Techniques (BCTs) and other intervention features were associated with maintenance.

METHODS

Six databases (Medline, EMBASE, PsycINFO, Cochrane Database of Systematic Reviews, CINAHL, Web of Science) were systematically searched. Eligibility criteria were controlled trials investigating the effectiveness of PA interventions with adult (mean age 18-64 years) non-clinical populations using validated measures of PA behaviour at baseline and ≥six months' post-baseline. Results were pooled in meta-analyses using standardised mean differences (SMD) at five time intervals (6-9, 9-15, 15-21, 21-24, >24 months). Moderator analyses investigated the influence of sample and intervention characteristics on PA maintenance at 6-9 months.

RESULTS

Sixty-two studies were included. PA interventions had a significant effect on behaviour maintenance 6-15 months post-baseline relative to controls. Interventions had a larger effect on maintenance at 6-9 months (SMD = 0.28; 95% CI: 0.20, 0.35; I² = 73%) compared to 9-15 months (SMD = 0.20; 95% CI: 0.13, 0.26; I² = 70%). Beyond 15 months, PA measurements were infrequent with little evidence supporting maintenance. Moderator analyses showed some BCTs and intervention settings moderated PA outcomes at 6-9 months. A multivariable meta-regression model showed interventions using the BCTs 'Prompt self-monitoring of behavioural outcome' (b = 1.46, p < 0.01) and 'Use of follow-up prompts' (b = 0.38, p < 0.01) demonstrated greater effectiveness at promoting PA maintenance at 6-9 months. Interventions implemented in primary care (versus community or workplace/university) settings (b = -0.13, p = 0.10) tended to demonstrate less effectiveness.

CONCLUSIONS

This review provides evidence of some effective BCTs for maintaining behaviour to 15 months. Greater consideration must be given to how future interventions encourage and measure maintenance of changes, and investigate broader psychological, social and environmental influences of PA behaviour.

PROSPERO REGISTRATION

PROSPERO 2015:CRD42015025462.

Evolutionary learning processes as the foundation for behaviour change

We argue that the active ingredients of behaviour change interventions, often called behaviour change methods (BCMs) or techniques (BCTs), can usefully be placed on a dimension of psychological aggregation. We introduce evolutionary learning processes (ELPs) as fundamental building blocks that are on a lower level of psychological aggregation than BCMs/BCTs. A better understanding of ELPs is useful to select the appropriate BCMs/BCTs to target determinants of behaviour, or vice versa, to identify potential determinants targeted by a given BCM/BCT, and to optimally translate them into practical applications. Using these insights during intervention development may increase the likelihood of developing effective interventions - both in terms of behaviour change as well as maintenance of behaviour change.

Can an incentive-based intervention increase physical activity and reduce sitting among adults? the ACHIEVE (Active Choices IncEntiVE) feasibility study

Background

Despite recent interest in the potential of incentivisation as a strategy for motivating healthier behaviors, little remains known about the effectiveness of incentives in promoting physical activity and reducing sedentary behavior, and improving associated health outcomes.

This pre-post-test design study investigated the feasibility, appeal and effects of providing non-financial incentives for promoting increased physical activity, reduced sedentary time, and reduced body mass index (BMI) and blood pressure among inactive middle-aged adults.

Methods

Inactive men (n = 36) and women (n = 46) aged 40–65 years were recruited via a not-for-profit insurance fund and participated in a 4 month pre-post design intervention. Baseline and post-intervention data were collected on self-reported physical activity and sitting time (IPAQ-Long), BMI and blood pressure. Participants were encouraged to increase physical activity to 150 mins/week and reduce sedentary behavior by 150 mins/week in progressive increments. Incentives included clothing, recipe books, store gift vouchers, and a chance to win one of four Apple iPad Mini devices. The incentive component of the intervention was supported by an initial motivational interview and text messaging to encourage participants and provide strategies to increase physical activity and reduce sedentary behaviors.

Results

Only two participants withdrew during the program, demonstrating the feasibility of recruiting and retaining inactive middle-aged participants. While two-thirds of the sample qualified for the easiest physical activity incentive (by demonstrating 100 mins physical activity/week or 100 mins reduced sitting time/week), only one third qualified for the most challenging incentive. Goals to reduce sitting appeared more challenging, with 43% of participants qualifying for the first incentive, but only 20% for the last incentive. More men than women qualified for most incentives. Mean leisure-time physical activity increased by 252 mins/week (leisure-time), with 65% of the sample achieving at least 150 mins/week; and sitting time decreased by 3.1 h/day (both p < 0.001) between baseline and follow-up. BMI, systolic and diastolic (men only) blood pressure all significantly decreased. Most participants (50–85%) reported finding the incentives and other program components helpful/motivating.

Conclusions

Acknowledging the uncontrolled design, the large pre-post changes in behavioral and health-related outcomes suggest that the ACHIEVE incentives-based behavior change program represents a promising approach for promoting physical activity and reducing sitting, and should be tested in a randomized controlled trial.

Trial registration

Australian New Zealand Clinical Trials Registry IDACTRN12616000158460, registered 10/2/16.

Perfectionism and adolescent sleep quality: The mediating role of repetitive negative thinking

This study explores the mediating effects of repetitive negative thinking in the relationship between perfectionism and adolescent sleep quality. A sample of 1664 Chinese adolescents with a mean age of 15.0 years was recruited, and they completed four measures relating to perfectionism, sleep quality, worry, and rumination. The results showed that maladaptive perfectionism was positively correlated with poor sleep quality in adolescents, which was mediated by both worry and rumination. However, adaptive perfectionism was not significantly associated with adolescent sleep quality, and this relationship was suppressed by rumination (but not worry). The implications of these results are also discussed.

5-2-1-0 Activity and Nutrition Challenge for Elementary Students: New, Evidence-Based, Promising

Obesity prevention in youth is a health priority, and teaching healthy habits toward this end is one of a school nurse's many responsibilities. A school nurse developed and implemented a school-wide, 2-week-long Activity and Nutrition Challenge (ANC) using the evidence-based 5-2-1-0 initiative to prevent and fight childhood obesity. Despite minimal promotion, nearly half of the students at two elementary schools participated and earned points by following the guidelines in the ANC. The amount of chocolate milk consumed by students dropped significantly during the ANC, showing that the healthy behavior of choosing beverages without added sugar had been positively impacted. Anecdotal evidence suggested positive changes in other healthy behaviors as well. This ANC was a new way for a school nurse to teach healthy habits to a large group of children in a short period of time, with limited extra work, and with promising results.

Effectiveness and cost-effectiveness of a physical activity loyalty scheme for behaviour change maintenance: a cluster randomised controlled trial

BACKGROUND

Increasing physical activity in the workplace can provide employee physical and mental health benefits, and employer economic benefits through reduced absenteeism and increased productivity. The workplace is an opportune setting to encourage habitual activity. However, there is limited evidence on effective behaviour change interventions that lead to maintained physical activity. This study aims to address this gap and help build the necessary evidence base for effective, and cost-effective, workplace interventions.

METHODS/DESIGN

This cluster randomised control trial will recruit 776 office-based employees from public sector organisations in Belfast and Lisburn city centres, Northern Ireland. Participants will be randomly allocated by cluster to either the Intervention Group or Control Group (waiting list control). The 6-month intervention consists of rewards (retail vouchers, based on similar principles to high street loyalty cards), feedback and other evidence-based behaviour change techniques. Sensors situated in the vicinity of participating workplaces will promote and monitor minutes of physical activity undertaken by participants. Both groups will complete all outcome measures. The primary outcome is steps per day recorded using a pedometer (Yamax Digiwalker CW-701) for 7 consecutive days at baseline, 6, 12 and 18 months. Secondary outcomes include health, mental wellbeing, quality of life, work absenteeism and presenteeism, and use of healthcare resources. Process measures will assess intervention "dose", website usage, and intervention fidelity. An economic evaluation will be conducted from the National Health Service, employer and retailer perspective using both a cost-utility and cost-effectiveness framework. The inclusion of a discrete choice experiment will further generate values for a cost-benefit analysis. Participant focus groups will explore who the intervention worked for and why, and interviews with retailers will elucidate their views on the sustainability of a public health focused loyalty card scheme.

DISCUSSION

The study is designed to maximise the potential for roll-out in similar settings, by engaging the public sector and business community in designing and delivering the intervention. We have developed a sustainable business model using a 'points' based loyalty platform, whereby local businesses 'sponsor' the incentive (retail vouchers) in return for increased footfall to their business.

TRIAL REGISTRATION

ISRCTN17975376 (Registered 19/09/2014).