Effectiveness of Interventions for Changing More Than One Behavior at a Time to Manage Chronic Conditions: A Systematic Review and Meta-analysis

BACKGROUND

Health behaviors play a significant role in chronic disease management. Rather than being independent of one another, health behaviors often co-occur, suggesting that targeting more than one health behavior in an intervention has the potential to be more effective in promoting better health outcomes.

PURPOSE

We aimed to conduct a systematic review and meta-analysis of randomized trials of interventions that target more than one behavior to examine the effectiveness of multiple health behavior change interventions in patients with chronic conditions.

METHODS

Five electronic databases (Web of Science, PubMed, CINAHL, EMBASE, and Cochrane) were systematically searched in November 2023, and studies included in previous reviews were also consulted. We included randomized trials of interventions aiming to change more than one health behavior in individuals with chronic conditions. Two independent reviewers screened and extracted data, and used Cochrane's Risk of Bias 2 tool. Meta-analyses were conducted to estimate the effects of interventions on change in health behaviors. Results were presented as Cohen's d for continuous data, and risk ratio for dichotomous data.

RESULTS

Sixty-one studies were included spanning a range of chronic diseases: cardiovascular (k = 25), type 2 diabetes (k = 15), hypertension (k = 10), cancer (k = 7), one or more chronic conditions (k = 3), and multiple conditions (k = 1). Most interventions aimed to change more than one behavior simultaneously (rather than in sequence) and most targeted three particular behaviors at once: "physical activity, diet and smoking" (k = 20). Meta-analysis of 43 eligible studies showed for continuous data (k = 29) a small to substantial positive effect on behavior change for all health behaviors (d = 0.081-2.003) except for smoking (d = -0.019). For dichotomous data (k = 23) all analyses showed positive effects of targeting more than one behavior on all behaviors (RR = 1.026-2.247).

CONCLUSIONS

Targeting more than one behavior at a time is effective in chronic disease management and more research should be directed into developing the science of multiple behavior change.

A Meta-Analysis of eHealth Interventions on Ischaemic Heart Disease Health Outcomes

Background

Electronic Health (eHealth) interventions as a secondary prevention tool to empower patients' health in decision-making and behaviour.

Objective

With the growing body of evidence supporting the use of eHealth interventions, the intention is to conduct a meta-analysis on various health outcomes of eHealth interventions among ischaemic heart disease (IHD) patients.

Methods

Based on PRISMA guidelines, eligible studies were searched through databases of Web of Science, Scopus, PubMed, EBSCOHost, and SAGE (PROSPERO registration CRD42021290091). Inclusion criteria were English language and randomised controlled trials published between 2011 to 2021 exploring health outcomes that empower IHD patients with eHealth interventions. RevMan 5.4 was utilised for meta-analysis, sensitivity analysis, and risk of bias (RoB) assessment while GRADE software for generating findings of physical health outcomes. Non-physical health outcomes were analysed using SWiM (synthesis without meta-analysis) method.

Results

This review included 10 studies, whereby, six studies with 895 participants' data were pooled for physical health outcomes. Overall, the RoB varied significantly across domains, with the majority was low risks, a substantial proportion of high risks and a sizeable proportion of unclear. With GRADE evidence of moderate to high quality, eHealth interventions improved low density lipoprotien (LDL) levels in IHD patients when compared to usual care after 12 months of interventions (SMD -0.26, 95% CI [-0.45, -0.06], I² = 0%, p = 0.01). Significance appraisal in each domain of the non-physical health outcomes found significant findings for medication adherence, physical activity and dietary behaviour, while half of the non-significant findings were found for other behavioural outcomes, psychological and quality of life.

Conclusions

Electronic Health interventions are found effective at lowering LDL cholesterol in long-term but benefits remain inconclusive for other physical and non-physical health outcomes for IHD patients. Integrating sustainable patient empowerment strategies with the advancement of eHealth interventions by utilising appropriate frameworks is recommended for future research.

Reporting dose in complex self-management support interventions for long-term conditions: is it defined by researchers and received by participants? A systematic review

BACKGROUND

The minimum clinically effective dose, and whether this is received in randomised controlled trials (RCTs) of complex self-management interventions in long-term conditions (LTCs), can be unclear. The Template for Intervention Description and Replication (TIDieR) checklist states that dose should be clearly reported to ensure validity and reliable implementation.

OBJECTIVES

To identify whether the expected minimum clinically effective dose, and the dose participants received is reported within research articles and if reporting has improved since the TIDieR checklist was published.

METHODS

Four databases were systematically searched (MEDLINE, PsycINFO, AMED and CINAHL) to identify published reports between 2008 and 2022 for RCTs investigating complex self-management interventions in LTCs. Data on reporting of dose were extracted and synthesised from the eligible articles.

RESULTS

94 articles covering various LTCs including diabetes, stroke and arthritis were included. Most complex interventions involved behaviour change combined with education and/or exercise. The maximum dose was usually reported (n=90; 97.8%), but the expected minimum clinically effective dose and the dose received were reported in only 28 (30.4%) and 62 (67.4%) articles, respectively. Reporting of the expected minimum clinically effective dose and the dose participants received did not improve following the publication of the TIDieR checklist in 2014.

CONCLUSIONS

Interpreting results and implementing effective complex self-management interventions is difficult when researchers' reporting of dose is not in line with guidelines. If trial findings indicate benefit from the intervention, clear reporting of dose ensures reliable implementation to standard care. If the results are non-significant, detailed reporting enables better interpretation of results, that is, differentiating between poor implementation and lack of effectiveness. This ensures quality of interventions and validity and generalisability of trial findings. Therefore, wider adoption of reporting the TIDieR checklist dose aspects is strongly recommended. Alternatively, customised guidelines for reporting dose in complex self-management interventions could be developed.

PROSPERO REGISTRATION NUMBER

CRD42020180988.

Making Specific Plan Improves Physical Activity and Healthy Eating for Community-Dwelling Patients With Chronic Conditions: A Systematic Review and Meta-Analysis

Background

Implementation intention formed by making a specific action plan has been proved effective in improving physical activity (PA) and dietary behavior (DB) for the general, healthy population, but there has been no meta-analysis of their effectiveness for patients with chronic conditions. This research aims to analyze several explanatory factors and overall effect of implementation intention on behavioral and health-related outcomes among community-dwelling patients.

Methods

We searched CIHNAL (EBSCO), PUBMED, Web of Science, Science Direct, SAGE Online, Springer Link, Taylor & Francis, Scopus, Wiley Online Library, CNKI, and five other databases for eligible studies. Random-effects meta-analysis was conducted to estimate effect sizes of implementation intention on outcomes, including PA, DB, weight, and body mass index. And the eligible studies were assessed by the Cochrane Collaboration's tool for risk of bias assessment. Sensitivity analysis adopted sequential algorithm and the p-curve analysis method.

Results

A total of 54 studies were identified. Significant small effect sizes of the intervention were found for PA [standard mean difference (SMD) 0.24, 95% confidence interval (CI) (0.10, 0.39)] and for the DB outcome [SMD -0.25, 95% CI (-0.34, -0.15)]. In moderation analysis, the intervention was more effective in improving PA for men (p < 0.001), older adults (p = 0.006), and obese/overweight patients with complications (p = 0.048) and when the intervention was delivered by a healthcare provider (p = 0.01).

Conclusion

Implementation intentions are effective in improving PA and DB for community dwelling patients with chronic conditions. The review provides evidence to support the future application of implementation intention intervention. Besides, the findings from this review offer different directions to enhance the effectiveness of this brief and potential intervention in improving patients' PA and DB.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=160491.

Telehealth delivery of motivational interviewing for diabetes management: A systematic review of randomized controlled trials

OBJECTIVES

The objective of this systematic review was to explore and report the evidence and gaps in the literature for randomized controlled trials (RCTs) studying the effects of motivational interviewing (MI)-based telehealth interventions on outcomes among persons with diabetes (PWD) or prediabetes.

METHODS

Following a modified Cochrane approach, we searched Pubmed, CENTRAL, CINAHL, PsycINFO, and Clinicaltrials.gov. Included studies were RCTs published in English before March 25, 2021 evaluating MI-based telehealth on outcomes for adults with diabetes or prediabetes.

RESULTS

A total of 21 retained articles captured results for 6436 PWD. Among the most commonly investigated outcomes, 60% of articles documented A1C reductions (ranging from<1% to>3%), 56% documented systolic blood pressure reductions, 57% documented diabetes self-efficacy/empowerment improvements, and 40% documented physical activity improvements. Conversely, diastolic blood pressure, lipid panels, body mass index, depressive symptoms, and quality of life were frequently measured outcomes, where MI-based telehealth yielded minor effects (<30% of articles demonstrating improvements).

CONCLUSIONS

MI-based telehealth seems most effective for improving A1C, systolic blood pressure, diabetes self-efficacy, and physical activity behaviors. Variability in outcome assessment and intervention heterogeneity were key challenges impeding comparisons across retained articles.

PRACTICE IMPLICATIONS

MI-based telehealth interventions demonstrate promising results for improving outcomes in PWD.

Sex Differences in Metabolic and Behavioral Responses to Exercise but Not Exogenous Osteocalcin Treatment in Mice Fed a High Fat Diet

Background

Exercise helps improve glucose handling in diabetes and has been shown to improve mood and cognition in other conditions. Osteocalcin, a protein produced by bone osteoblasts, was reported to have endocrine actions to improve both metabolism and also improve age-related cognitive deficits in mice.

Methods

This study was designed to compare the effects of daily treadmill running exercise with injection of osteocalcin in high fat diet (HFD) induced diabetes in male and female C57BL/6J mice. Following established glucose intolerance and treatment for 8 weeks, mice were assessed for anxiety on an elevated plus maze, motivation by tail suspension test and cognition and memory in a puzzle box. Endogenous osteocalcin was measured by ELISA.

Results

Mice on HFD had high weight gain, glucose intolerance and increased white fat. Exercise increased circulating osteocalcin levels in female mice but decreased them in male mice. Exercise also decreased weight gain and improved glucose tolerance in female but not male mice; however, treatment with osteocalcin made no metabolic improvements in either males or females. HFD induced anxiety only in female mice and this was not improved by osteocalcin. Exercise induced anxiety only in male mice. HFD also increased depressive-like behavior in both sexes, and this was improved by either exercise or osteocalcin treatment. Cognitive deficits were seen in both male and female mice on HFD. Exercise improved cognitive performance in female but not male mice, while osteocalcin treatment improved cognitive performance in both sexes.

Conclusion

There were sex differences in the effects of exercise on endogenous osteocalcin regulation that correlated with improvements in cognitive but not metabolic outcomes. Exogenous osteocalcin did not improve metabolism but was effective in improving HFD-induced cognitive deficits. Sex is an important variable in hormonal and cognitive responses to exercise in diabetes.

Evaluation of Combinations of Nudging, Pricing, and Labeling Strategies to Improve Diet Quality: A Virtual Grocery Store Experiment Employing a Multiphase Optimization Strategy

BACKGROUND

Several intervention strategies have been shown to improve diet quality. However, there is limited evidence on the increase in effectiveness that may be achieved through select combinations of these strategies.

PURPOSE

This study aimed to identify an effective multicomponent intervention to improve diet quality of a grocery basket by applying a Multiphase Optimization Strategy framework and testing various combinations of four promising strategies using a fully functional web-based grocery store: (i) front-of-pack food labels and real-time feedback of the healthiness of the shoppers' grocery basket, (ii) a tax, (iii) ordering products by a nutritional quality score, and (iv) healthier substitute offers.

METHODS

We conducted a hypothetical shopping study (N = 756) with a randomized full factorial design (16 conditions) to estimate main and interaction effects of the four interventions.

RESULTS

The "food labels & real-time feedback" and "ordering" strategies had significantly positive main effects on overall diet quality of the shopping basket (both at p < .001). We found no effects on diet quality for the "tax" and "healthier substitute offers." None of the two-way interaction effects for different strategies on overall diet quality and nutrients were significant.

CONCLUSIONS

Having "food labels & real-time feedback" and "ordering" simultaneously seemed to be more effective at improving diet quality, compared to having only one of these interventions. These results suggest that a combination of food labels with real-time feedback and ordering interventions can be part of a promising multicomponent strategy to improve diet quality in online shopping platforms.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04632212.

Effects of eHealth-Based Multiple Health Behavior Change Interventions on Physical Activity, Healthy Diet, and Weight in People With Noncommunicable Diseases: Systematic Review and Meta-analysis

Background

Noncommunicable diseases (NCDs) are associated with the burden of premature deaths and huge medical costs globally. There is an increasing number of studies combining a multiple health behavior change (MHBC) intervention paradigm with eHealth approaches to jointly promote weight-related health behaviors among people with NCD; yet, a comprehensive summary of these studies is lacking.

Objective

This review aims to meta-analyze the effectiveness and systematically summarize the characteristics of the relevant intervention studies for improving the outcomes of physical activity, healthy diet, and weight among people with NCD.

Methods

Following PRISMA guidelines, 4 electronic databases (PsycINFO, PubMed, Scopus, SPORTDiscus) were systematically searched to identify eligible articles based on a series of inclusion and exclusion criteria. Article selection, quality assessment, and data extraction were independently performed by 2 authors. The standardized mean difference (SMD) was calculated to evaluate the effectiveness of interventions for 3 intervention outcomes (physical activity, healthy diet, and weight), and subsequent subgroup analyses were performed for gender, age, intervention duration, channel, and theory. Calculations were conducted, and figures were produced in SPSS 22 and Review Manager 5.3.

Results

Of the 664 original hits generated by the systematic searches, 15 eligible studies with moderate to high quality were included. No potential publication bias was detected using statistical analyses. Studies varied in intervention channel, intensity, and content. The meta-analysis revealed that the eHealth MHBC interventions significantly promoted physical activity (SMD 0.85, 95% CI 0.23 to 1.47, P=.008) and healthy diet (SMD 0.78, 95% CI 0.13 to 1.43, P=.02), but did not contribute to a healthy weight status (SMD –0.13, 95% CI= –0.47 to 0.20, P=.43) among people with NCDs, compared to the control conditions. Results from subgroup analysis indicated that theory-based interventions achieved greater effect than nontheory-based interventions in promoting physical activity, and interventions with traditional approaches (SMS, telephone) were more effective than those with modern internet-based approaches in promoting healthy diet.

Conclusions

The results of this review indicates that eHealth MHBC interventions achieve preliminary success in promoting physical activity and healthy diet behaviors among people with NCD. Future studies could improve the intervention design to achieve better intervention effectiveness.

Trial Registration

PROSPERO International Prospective Register of Systematic Reviews CRD42019118629; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=118629

Dietitians Australia position statement on telehealth

It is the position of Dietitians Australia that clients can receive high‐quality and effective dietetic services such as Medical Nutrition Therapy (MNT) delivered via telehealth. Outcomes of telehealth‐delivered dietetic consultations are comparable to those delivered in‐person, without requiring higher levels of additional training nor compromising quality of service provision. Dietitians Australia recommends that policy makers and healthcare funders broaden the recognition for telehealth‐delivered dietetic consultations as a responsive and cost‐effective alternative or complement to traditional in‐person delivery of dietetic services. The successful implementation of telehealth can help to address health and service inequalities, improve access to effective nutrition services, and support people with chronic disease to optimise their diet‐related health and well‐being, regardless of their location, income or literacy level, thereby addressing current inequities.

Making sense of blood glucose data and self-management in individuals with type 2 diabetes mellitus: A qualitative study

AIMS AND OBJECTIVES

To describe individuals' with type 2 diabetes mellitus sense-making of blood glucose data and other influences impacting self-management behaviour.

BACKGROUND

Type 2 diabetes mellitus prevalence is increasing globally. Adherence to effective diabetes self-management regimens is an ongoing healthcare challenge. Examining individuals' sense-making processes can advance staff knowledge of and improve diabetes self-management behaviour.

DESIGN

A qualitative exploratory design examining how individuals make sense of blood glucose data and symptoms, and the influence on self-management decisions.

METHODS

Sixteen one-on-one interviews with adults diagnosed with type 2 diabetes mellitus using a semi-structured interview guide were conducted from March-May 2018. An inductive-deductive thematic analysis of data using the Sensemaking Framework for Chronic Disease Self-Management was used. The consolidated criteria for reporting qualitative research (COREQ) checklist were used in completing this paper.

RESULTS

Three main themes described participants' type 2 diabetes mellitus sense-making and influences on self-management decisions: classifying blood glucose data, building mental models and making self-management decisions. Participants classified glucose levels based on prior personal experiences. Participants learned about diabetes from classes, personal experience, health information technology and their social network. Seven participants expressed a need for periodic refreshing of diabetes knowledge.

CONCLUSION

Individuals use self-monitored glucose values and/or HbA1C values to evaluate glucose control. When using glucose values, they analyse the context in which the value was obtained through the lens of personal parameters and expectations. Understanding how individuals make sense of glycaemic data and influences on diabetes self-management behaviour with periodic reassessment of this understanding can guide the healthcare team in optimising collaborative individualised care plans.

RELEVANCE TO CLINICAL PRACTICE

Nurses must assess sense-making processes in self-management decisions. Periodic "refresher" diabetes education may be needed for individuals with type 2 diabetes mellitus.

Frequency of Diet and Physical Activity Goal Attainment and Barriers Encountered Among Adults With Type 2 Diabetes During a Telephone Coaching Intervention

IN BRIEF Participants with type 2 diabetes established personalized dietary and physical activity goals as behavioral strategies to reduce cardiovascular risk during a 16-week telephone coaching intervention. People were most likely to attain dietary goals that involved altering the intake of specific foods rather than certain nutrients and were more successful at physical activity goals to increase activity levels rather than to add new types of activity. Barriers to goal success included time management, physical limitations/illness, and social/cultural activities.

Patient-reported outcomes in multimorbidity intervention research: A scoping review

BACKGROUND

Although chronic disease management interventions for persons with multimorbidity are offered in primary healthcare, a strong evidence base supporting such interventions is still lacking. Part of this problem is due to the heterogeneity in the use of outcome measures in multimorbidity intervention research.

OBJECTIVES

This review aims to describe and map outcome measurement in chronic disease management intervention research for people with multimorbidity.

DESIGN

A scoping review of multiple chronic disease management intervention studies published between January 1996 and July 2017.

DATA SOURCES

Search of the academic literature was undertaken in the MEDLINE, CINAHL and PsycINFO electronic databases.

RESULTS

Twenty-two studies were identified, 56 outcomes were reported, grouped into 18 categories and six emergent domains of outcomes: General health, Psychosocial, Disease management, Health-related behaviours, Functional and Health services. Quality of life, health-related behaviors and self-efficacy were the most reported outcome categories, while patient satisfaction, communication with providers and adverse outcomes were rarely reported.

CONCLUSIONS

The mapping and description brought to light the large heterogeneity of outcome categories and measures. The organization proposed in this paper could contribute to improved outcome selection for research, care and policy and lead to the creation of adapted patient-related outcome measures.

Impact of a goal setting and decision support telephone coaching intervention on diet, psychosocial, and decision outcomes among people with type 2 diabetes

OBJECTIVE

Evaluate a 16-week decision support and goal-setting intervention to compare diet quality, decision, and diabetes-related outcomes to a control group.

METHODS

Adults with type 2 diabetes (n=54) were randomly assigned to an intervention or control group. Intervention group participants completed one in-person motivational interviewing and decision support session followed by seven biweekly telephone coaching calls. Participants reported previous goal attempts and set diet- and/or physical activity-related goals during coaching calls. Control group participants received information about local health care resources on the same contact schedule.

RESULTS

There was a significant difference between groups for diabetes empowerment (p=0.045). A significant increase in diet quality, diabetes self-efficacy, and diabetes empowerment, and a significant decrease in diabetes distress and depressive symptoms (all p≤0.05) occurred in the intervention group. Decision confidence to achieve diet-related goals significantly improved from baseline to week 8 but then declined at study end (both p≤0.05).

CONCLUSIONS

Setting specific diet-related goals may promote dietary change, and telephone coaching can improve psychosocial outcomes related to diabetes self-management.

PRACTICE IMPLICATIONS

Informed shared decision making can facilitate progressively challenging yet attainable goals tailored to individuals' lifestyle. Decision coaching may empower patients to improve self-management practices and reduce distress.