Facilitators and barriers to smoking cessation among minority men using the behavioral-ecological model and Behavior Change Wheel: A concept mapping study

Development of a Health Behavioral Digital Intervention for Patients With Hypertension Based on an Intelligent Health Promotion System and WeChat: Randomized Controlled Trial

BACKGROUND

The effectiveness of timely medication, physical activity (PA), a healthy diet, and blood pressure (BP) monitoring for promoting health outcomes and behavioral changes among patients with hypertension is supported by a substantial amount of literature, with "adherence" playing a pivotal role. Nevertheless, there is a lack of consistent evidence regarding whether digital interventions can improve adherence to healthy behaviors among individuals with hypertension.

OBJECTIVE

The aim was to develop a health behavioral digital intervention for hypertensive patients (HBDIHP) based on an intelligent health promotion system and WeChat following the behavior change wheel (BCW) theory and digital micro-intervention care (DMIC) model and assess its efficacy in controlling BP and improving healthy behavior adherence.

METHODS

A 2-arm, randomized trial design was used. We randomly assigned 68 individuals aged >60 years with hypertension in a 1:1 ratio to either the control or experimental group. The digital intervention was established through the following steps: (1) developing digital health education materials focused on adherence to exercise prescriptions, Dietary Approaches to Stop Hypertension (DASH), prescribed medication, and monitoring of BP; (2) using the BCW theory to select behavior change techniques; (3) constructing the intervention's logic following the guidelines of the DMIC model; (4) creating an intervention manual including the aforementioned elements. Prior to the experiment, participants underwent physical examinations at the community health service center's intelligent health cabin and received intelligent personalized health recommendations. The experimental group underwent a 12-week behavior intervention via WeChat, while the control group received routine health education and a self-management manual. The primary outcomes included BP and adherence indicators. Data analysis was performed using SPSS, with independent sample t tests, chi-square tests, paired t tests, and McNemar tests. A P value <.05 was considered statistically significant.

RESULTS

The final analysis included 54 participants with a mean age of 67.24 (SD 4.19) years (n=23 experimental group, n=31 control group). The experimental group had improvements in systolic BP (-7.36 mm Hg, P=.002), exercise time (856.35 metabolic equivalent [MET]-min/week, P<.001), medication adherence (0.56, P=.001), BP monitoring frequency (P=.02), and learning performance (3.23, P<.001). Both groups experienced weight reduction (experimental: 1.2 kg, P=.002; control: 1.11 kg, P=.009) after the intervention. The diet types and quantities for both groups (P<.001) as well as the subendocardial viability ratio (0.16, P=.01) showed significant improvement. However, there were no statistically significant changes in other health outcomes.

CONCLUSIONS

The observations suggest our program may have enhanced specific health outcomes and adherence to health behaviors in older adults with hypertension. However, a longer-term, larger-scale trial is necessary to validate the effectiveness.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2200062643; https://www.chictr.org.cn/showprojEN.html?proj=172782.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/46883.

Factors associated with attempting and succeeding in smoking cessation following a National Tobacco Control Plan: Analysis of two nationwide surveys (2010 and 2017)

INTRODUCTION

Lower rates of smoking cessation among disadvantaged groups contribute to widening health-disparities. With this recognition, in 2010 free-of-charge/subsidized smoking cessation services became available to all Israeli residents through the not-for-profit health plans.

METHODS

Based on two cross-sectional National Social Surveys, data on adult ever-smokers were used (n = 2,998 in 2010 and 2,859 in 2017). The outcome variable comprised three categories: no quit attempt, unsuccessful quit attempt and successful quit attempt. Changes over-time and demographic, socioeconomic, health- and smoking-related factors associated with quitting attempts and success were tested in the pooled sample, using multivariable multinomial logistic regression models.

RESULTS

The pooled sample of the two surveys included 2,611 participants (44.2%) who were successful quitters, 1,941 (32.7%) who reported an unsuccessful quit attempt, and 1,305 (23.1%) smokers who did not attempt to quit. Compared to 2010, ever-smokers in 2017 were less likely to report an unsuccessful quit attempt (adjusted OR = 0.81, 95%CI: 0.70-0.94). The likelihood of successfully quitting was similar in both surveys. Older age and self-reported health problem were associated with higher likelihood of quitting attempt. Meeting living expenses, being overweight/obese, engaging in physical activity and heavy smoking were associated with higher likelihood of successful smoking cessation; while environmental tobacco exposure was associated with 43% lower likelihood of successful cessation. Finally, there was an interaction between education and ethnicity. Higher education level was associated with a greater likelihood both to attempt to quit smoking and to succeed among Jewish participants, while the opposite phenomenon was observed among Arab smokers.

CONCLUSIONS

Despite the availability of subsidized smoking cessation services, social disparities in smoking cessation rates persist. Efforts should focus on proactively reaching subpopulations with low cessation rates, using tailored strategies for successful smoking cessation. Promoting smoke free homes and workplaces should be prioritized.

Perceptions of Barriers and Facilitators to Reducing Exposure to Secondhand Smoke in the Home: A Qualitative Study With Palestinian-Arab Women in Israel

INTRODUCTION

Smoking is a collective and complex problem in the Palestinian-Arab community in Israel, where women and children are particularly vulnerable to exposure to secondhand smoke (SHS), especially in the home.

AIMS AND METHODS

We undertook this study to better understand women's experiences with SHS exposure in the home and to identify pathways for intervention. Using the grounded theory approach, seven focus groups were conducted with 66 women in different localities across Israel. Purposive and snowball sampling techniques were applied to recruit women who have currently or previously been exposed to smoking in the home. Focus groups were audio-recorded and transcribed verbatim, and data were then coded and analyzed using the constant comparison analysis method to identify emergent themes and subthemes.

RESULTS

Three core themes emerged from the discussions. These include women's perceptions of smoking among men and exposure to SHS in the home, the implications of smoking on spousal and social relationships, and the women's experiences in coping with this situation and their suggestions for interventions. We identified additional sub-themes, including the consequences to women's and children's health, as well as the complex interaction between smoking in the home and women's social position, agency, and home ownership.

CONCLUSIONS

Women exposed to SHS in the home experience consequences that affect their health and their spousal and social relationships. They also face several personal and societal challenges in tackling this issue. Culturally tailored interventions targeting both communities and households can raise awareness and impact smoking behaviors in the home.

IMPLICATIONS

The findings of this study demonstrate the far-reaching consequences of SHS exposure in the home among women who are exposed. The findings contribute to our understanding of smoking contingencies among men and smoking behaviors in the home. This study lays the groundwork for future community and household-based research and interventions. We suggest several critical junctures that may increase response to smoking cessation interventions and to reduce smoking in the home, such as at the time of marriage when the home policy is set, and the adverse effects of exposure on children and other family members, especially those with illness.

A conceptual framework of the psychosocial elements that should be assessed in candidates for hematopoietic cell transplant: Social workers' and psychologists' perspectives

Background: The aim of this work was to explicate a conceptual framework of psychosocial elements assessed in candidates for hematopoietic cell transplant (HCT) and to explore differences in the conceptualization based on the use of risk rating scales in clinical practice.Methods: Concept mapping is a mixed methods participatory approach to elicit and organize the ideas of a group of stakeholders and produce a composite conceptual framework. Participants were social workers and psychologists with experience assessing HCT candidates.Results: Participants brainstormed 114 psychosocial elements and conceptualized them into 12 distinct clusters: Transplant Mindset, Support System, Caregiver, Lodging and Transportation, Financial and Legal, Work, Demographic Characteristics, Mental Health, Communication, Educational and Resource Needs, Physical Functioning, and Cognition. Participants who used risk rating scales did not prioritize the importance of the clusters differently than those who did not.Conclusions: The conceptualization converges and diverges with the literature. Divergences are of particular interest since the perspectives of practicing psychosocial professionals have been largely absent from the literature. The conceptual framework can guide psychosocial providers in assessing patients. Assessing the caregiver is a high priority, as is evaluating the patient's mental health and mindset about transplant.

Selecting an intervention to prevent ketoacidosis at diabetes diagnosis in children using a behavior change framework

OBJECTIVE

The rate of diabetic ketoacidosis (DKA), a preventable, life-threatening complication of diabetes, at the time of diagnosis in children remains unacceptably high worldwide. We describe our initial approach to selecting a national DKA prevention strategy, to be implemented by the Canadian Pediatric Endocrine Group DKA Prevention Working Group, informed by a framework for behavior change interventions.

METHODS

Existing interventions were identified from a systematic review and our own gray literature search. We then characterized interventions using the Behavior Change Wheel, a framework to inform and drive behavior change, and matched interventions to behavioral targets, audiences, and identified barriers and facilitators. Feedback from the CPEG DKA prevention working group was incorporated into the intervention plan.

RESULTS

We identified 27 interventions. Our proposed target behaviors are: (1) prompt recognition of symptoms of diabetes in children; (2) urgent attendance to medical care with a request for an office-based test for diabetes; and (3) rapid confirmation of diagnosis and urgent consultation with pediatric diabetes experts. We initially identified four possible intervention functions including education, training, environment restructuring, and enablement. Feedback from the working group favored education intervention functions including symptom recognition messages targeting parents, caregivers, teachers, and providers and messages about how to make a rapid diagnosis and need for urgent referral targeting providers.

CONCLUSIONS

The Behavior Change Wheel has been used successfully in selecting interventions in other clinical areas. We describe how we used this framework to provide a foundation for developing an intervention to prevent DKA at diabetes diagnosis in children.

Evaluating the impact of culturally specific patient-centric behavioral intervention package versus usual care for tobacco cessation among patients attending noncommunicable disease clinics in North India: A single-blind trial pilot study protocol

Background

In a low and middle-income country (LMIC) like India, non—communicable diseases (NCDs) contribute a major proportion (61.8%) of all causes of death. Out of this, 48% of cardiovascular diseases , 23% of Chronic Respiratory Diseases , and 10% of Cancer deaths are attributable to tobacco use. Tobacco use is a major risk factor for NCDs and thus, the tobacco cessation approach is a high priority intervention to combat complications and death among NCD patients. While several interventions are available for tobacco cessation, in resource constraint countries like India, the effectiveness of low-cost, culturally specific patient-centric tobacco cessation behavioral intervention holds a potential that needs to be evaluated. A newly developed evidence-based tobacco cessation intervention package will be compared with the existing/usual care provided under the National Programme for Prevention and Control of Cancers, Diabetes, Cardiovascular Diseases, and Stroke (NPCDCS) at NCD clinics.

Methods and design

2 arm, parallel-group randomized controlled trial.

Participants

Patients aged ≥30 years suffering from NCD, currently using tobacco, and attending NCD clinics in 2 districts of Punjab, India.

Sample size

A total of 200 participants meeting the selection criteria will be recruited. They will be allocated either to the intervention arm or control (usual care) arm (100 each) using block randomization.

Intervention

For the participants, there will be 4 face-to-face disease-specific cessation counseling sessions, disease-specific pamphlets, short text messages in vernacular language, that is, Punjabi. Follow-ups will be done at the third, sixth, ninth, and 12th months.

Primary outcome

Seven-day abstinence, biochemically verified by plasma cotinine levels.

Secondary outcome

Quit attempts, number of sticks/number of times of smokeless tobacco usage in a day, and stage of behavior change in tobacco users.

Discussion

This multicomponent culturally specific-patient-centric behavioral intervention package for tobacco cessation at NCD clinic settings focusing on the individual, family, and social environment could increase the outreach of cessation services using existing resources, thereby strengthening health systems and enhancing the quality of life of NCD patients.

Trial registration

The protocol for the study has been registered with the Clinical Trials Registry in India under the registration number CTRI/2018/01/011643.

#LetsUnlitterUK: A demonstration and evaluation of the Behavior Change Wheel methodology

The Behavior Change Wheel is the most comprehensive and practically useful methodology available for developing behavior change interventions. The current article demonstrates how it can be applied to optimize pro-environmental behaviors and, in so doing, give interventionists access to a rigorous set of theories and techniques for systematically developing pro-environmental interventions. Section 1 describes the development of an intervention to increase people's intentions to post anti-littering messages on social media. Study 2 describes the development and evaluation of an intervention to increase people's actual anti-littering posts. Both evaluations are randomized controlled trials that compare the effectiveness of the developed intervention with interventions less informed by the Wheel. We found interventions completely informed by the Wheel to be more effective than interventions less (or not at all) informed by the Wheel. The discussion explores how the Behavior Change Wheel methodology can be used to design future pro-environment interventions.

An innovation involving self-surveillance and serious gaming to increase smoking quit rate: Protocol for a pilot randomized controlled trial

Smoking is a health hazard. Current smoking cessation measures such as behavioral change counselling by trained professionals, nicotine replacement therapy and medications have limited success. Smoking intensity is assessed using a portable device to measure the smokers’ exhaled breath carbon monoxide (eCO) level. A systematic review suggests the potential of serious gaming to increase smoking quit rate. However, the related studies were unable to explain and determine the effect gamification on smoking cessation.

A handy personalized eCO measurement device linked to a smart-phone applications (app) has been developed (integrated STEADES-2 system). This novel system incorporates app-based video and print learning resources, authentication function and gamification using the eCO data as game element. Trained multidisciplinary healthcare professionals access the STEADES-2 data to monitor smoking status and support smokers via asynchronous virtual coaching. The pilot randomized controlled trial will enroll 20 smokers to use the STEADES-2 system (intervention group) and another 20 to the existing smoking cessation programme (control group) in primary care. The primary feasibility outcomes will include the recruitment response rate, the smokers’ usability of the STEADES-2 system, their self eCO monitoring, frequencies of participation in the serious games and interactions with their virtual coaches. Their smoking literacy, utility and experience of the STEADES-2 system are other outcomes. Smokers in both groups will be compared on their cigarette abstinence as secondary outcome based on eCO levels and urine cotinine test (primary outcomes after 12 weeks).

The results will be disseminated via conferences and publications.

Quitting the quitline: a qualitative study of patient experience of electronic referrals to quitlines

BACKGROUND

The use of electronic referrals (eReferrals) to state quitlines (QLs) for tobacco-using patients is a promising approach for addressing smoking cessation on a large scale. However, QL contact, enrollment, and completion rates are low. The purpose of this study was to examine the eReferral to QL process from the patient's perspective in order to inform strategies for improving QL engagement.

METHODS

We conducted interviews with 55 patients who agreed to an eReferral at a primary care visit to 1 of 8 safety-net community health centers in Cuyahoga County, Ohio (September 2017-August 2018). Interviews were designed to explore the experiences of three subgroups of patients who subsequently: 1) declined participation in the QL; 2) were unreachable by the QL; or 3) were enrolled in or had completed the QL program. Analysis was guided by a phenomenological approach designed to identify emergent themes.

RESULTS

Reasons for QL program non-completion included changing life circumstances and events making cessation unviable; misunderstandings about the QL; discomfort with telephonic counseling; perceived lack of time for counseling; cell phone barriers; and having already quit smoking. We found that some individuals who were no longer engaged with the QL still desired continued support from the QL.

CONCLUSIONS

Participants intentionally and unintentionally disengage from the QL for a wide variety of reasons, several of which are mediated by low socioeconomic status. Integrating QL care with community-based resources that address these mediators could be a promising strategy.