Re-Thinking Health Behaviour Change Models From an Integrated Perspective

Scientific evidence indicates that theory-based health interventions are more effective in promoting health behavior change (BC) and in maintaining health changes over time. Previous work identified more than 80 BC theories; however, there is little guidance on how to best choose between them. More than creating new theories, an essential challenge now is to integrate these theories to reach a more complete understanding of the BC process. The chapter is an effort to integrate some of the most central theories in this field, aiming to reach an integrated framework by 1) identifying and merging similarities between theories, reducing conceptual complexity, and by 2) building from dissimilarities as key aspects to overcome limitations. This framework is a practical visual tool that intends to support researchers and practitioners working in the field, guiding on the crucial constructs to address in interventions to promote health BC. This framework also integrates the ACP model as an approach that offers valuable insights to support communication in health interventions.

The Digital Lifeworld and Salutogenesis

In this chapter, the authors explore salutogenesis in the context of the ‘digital world’, concerning both high- and low-resource countries. The digital world is rapidly developing and can transcend physical and financial barriers of health care and health promotion. The digital world also has many challenges, especially for equity. On the one hand, digitalization carries the risk of excluding many people – also healthcare workers – because they cannot access the digital world or do not have the technical skills to understand it (make sense of it). On the other hand, the digital world offers both new generalized resistance resources (GRRs) and specific resistance resources (SRRs) to improve population health and promote healthy lifestyles and health literacy. The authors nicely illustrate how the sense of coherence (SOC) helps people find a balance in the digital world’s stress-rich environment. Important steps forward in this field include work to strengthen the evidence base and to document the preconditions for a digital world that supports decision making in health care, health behaviour change (e.g. quitting smoking) and – above all – supports empowerment and social justice.

Participatory design of a digital platform for cardiovascular disease self-management: mutual learning through an iterative development process (Preprint)

BACKGROUND People living with cardiovascular disease (CVD) require flexible self-management support for health behaviour change for CVD secondary prevention. Digital health interventions can assist with these complex self-management activities. Many stakeholder groups can be involved in digital health design, including people living with CVD (users), researchers, healthcare professionals and technology developers. However, decision-making and aligning views can be difficult to negotiate within interdisciplinary teams, so the use of appropriate methodological strategies is vital. OBJECTIVE The aim of this paper was to design and develop Salvio, and to reflect on the methodological considerations that were the driving forces of this participatory design process. METHODS A triangulation of research methods was used for this iterative development process. Participatory design approaches used included guided group discussions, activity-based workshops, and think-aloud tasks. Data collection was supported by self-efficacy theory to encourage user contributions. Over a 12-month period, participants met at various time points to collectively design and develop Salvio. Workshops were 2-3 hours in length and were facilitated in small groups of 4-6 participants per session. All sessions were audio-recorded, central parts of workshop conversations were transcribed, and qualitative content analysis of data was undertaken. RESULTS Users (n=8) worked collaboratively with researchers (n=6) and technology developers (n=7). Findings indicated that it was critical to include an interdisciplinary team with a wide range of expertise, to build a meaningful and flexible digital platform. Effective methodological strategies were essential for genuine participation and continuous conflict resolution. Our research highlighted key elements that added to the success of this co-design process including i) the creation of a collaborative space where all voices were acknowledged and considered and ii) the effective translation of information during decision-making stages. CONCLUSIONS Future research is needed to expand and evaluate participatory design tools and techniques which challenge the power relations between users and other stakeholders. By exploring methods that create space for mutual learning and resolving conflict through systematic decision-making, complex digital platforms for health behaviour change can be successfully developed with diverse groups. It is clear that flexible digital platforms may be valuable to users, but further research will also be required for the successful implementation and knowledge translation of these contemporary developments.

Multiple health behaviour change primary care intervention for smoking cessation, physical activity and healthy diet in adults 45 to 75 years old (EIRA study): a hybrid effectiveness-implementation cluster randomised trial

Background This study aimed to evaluate the effectiveness of a) a Multiple Health Behaviour Change (MHBC) intervention on reducing smoking, increasing physical activity and adherence to a Mediterranean dietary pattern in people aged 45–75 years compared to usual care; and b) an implementation strategy. Methods A cluster randomised effectiveness-implementation hybrid trial-type 2 with two parallel groups was conducted in 25 Spanish Primary Health Care (PHC) centres (3062 participants): 12 centres (1481 participants) were randomised to the intervention and 13 (1581 participants) to the control group (usual care). The intervention was based on the Transtheoretical Model and focused on all target behaviours using individual, group and community approaches. PHC professionals made it during routine care. The implementation strategy was based on the Consolidated Framework for Implementation Research (CFIR). Data were analysed using generalised linear mixed models, accounting for clustering. A mixed-methods data analysis was used to evaluate implementation outcomes (adoption, acceptability, appropriateness, feasibility and fidelity) and determinants of implementation success. Results 14.5% of participants in the intervention group and 8.9% in the usual care group showed a positive change in two or all the target behaviours. Intervention was more effective in promoting dietary behaviour change (31.9% vs 21.4%). The overall adoption rate by professionals was 48.7%. Early and final appropriateness were perceived by professionals as moderate. Early acceptability was high, whereas final acceptability was only moderate. Initial and final acceptability as perceived by the participants was high, and appropriateness moderate. Consent and recruitment rates were 82.0% and 65.5%, respectively, intervention uptake was 89.5% and completion rate 74.7%. The global value of the percentage of approaches with fidelity ≥50% was 16.7%. Eight CFIR constructs distinguished between high and low implementation, five corresponding to the Inner Setting domain. Conclusions Compared to usual care, the EIRA intervention was more effective in promoting MHBC and dietary behaviour change. Implementation outcomes were satisfactory except for the fidelity to the planned intervention, which was low. The organisational and structural contexts of the centres proved to be significant determinants of implementation effectiveness. Trial registration ClinicalTrials.gov, NCT03136211. Registered 2 May 2017, “retrospectively registered”.

Associations between Behaviour Change Techniques and engagement with mobile health apps: Systematic review protocol (Preprint)

BACKGROUND The use of digitally-enabled care and the emphasis on self-management of health is growing. Mobile health apps provide a promising means of supporting health behaviour change; however, engagement with them is often poor and evidence of their impact on health outcomes is lacking. As engagement is a key prerequisite to health behaviour change, it is essential to understand how engagement with mobile health apps and their target health behaviours can be better supported. Despite an increasing recognition of the importance of engagement in the literature, there is still a lack of understanding of how different components of engagement are associated with specific techniques that aim to change behaviours. OBJECTIVE The purpose of this systematic review protocol is to provide a synthesis of the associations between various Behaviour Change Techniques (BCTs)and the different components of engagement (and their outcome measures) with mobile health apps. METHODS The review protocol was structured using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) and the Population, Intervention, Comparator, and Outcome (PICO) frameworks. Six databases will be systematically searched: PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), APA PsycInfo, ScienceDirect, and Web of Science. Title and abstract screening, full-text review, and data extraction will be conducted by two independent reviewers. Data will be extracted into a predetermined form, and any disagreements in screening or data extraction will be discussed, with a third reviewer consulted if consensus cannot be reached. Risk of bias will be assessed using the Cochrane Collaboration Risk of Bias 2 and ROBINS-I tools and descriptive and thematic analyses will be used to summarise the relationships between BCTs and the different components of engagement. RESULTS The systematic review has not been started. It is expected to be completed and submitted for publication by January 2022. CONCLUSIONS This systematic review will summarize the associations between different BCTs and various components and measures of engagement with mobile health apps. This will identify areas where further research is needed to examine BCTs that could potentially support effective engagement and help to inform the design and evaluation of future mobile health apps. CLINICALTRIAL PROSPERO (reference number TBD)

Co-design of a digital dietary intervention for adults at risk of type 2 diabetes

Background Co-design has the potential to create interventions that lead to sustainable health behaviour change. Evidence suggests application of co-design in various health domains has been growing; however, few public-facing digital interventions have been co-designed to specifically address the needs of adults at risk of Type 2 diabetes (T2D). This study aims to: (1) co-design, with key stakeholders, a digital dietary intervention to promote health behaviour change among adults at risk of T2D, and (2) evaluate the co-design process involved in developing the intervention prototype. Methods The co-design study was based on a partnership between nutrition researchers and designers experienced in co-design for health. Potential end-users (patients and health professionals) were recruited from an earlier stage of the study. Three online workshops were conducted to develop and review prototypes of an app for people at risk of T2D. Themes were inductively defined and aligned with persuasive design (PD) principles used to inform ideal app features and characteristics. Results Participants were predominantly female (range 58–100%), aged 38 to 63 years (median age = 59 years), consisting of a total of 20 end-users and four experts. Participants expressed the need for information from credible sources and to provide effective strategies to overcome social and environmental influences on eating behaviours. Preferred app features included tailoring to the individual’s unique characteristics, ability to track and monitor dietary behaviour, and tools to facilitate controlled social connectivity. Relevant persuasive design principles included social support, reduction (reducing effort needed to reach target behaviour), tunnelling (guiding users through a process that leads to target behaviour), praise, rewards, and self-monitoring. The most preferred prototype was the Choices concept, which focusses on the users’ journey of health behaviour change and recognises progress, successes, and failures in a supportive and encouraging manner. The workshops were rated successful, and feedback was positive. Conclusions The study’s co-design methods were successful in developing a functionally appealing and relevant digital health promotion intervention. Continuous engagement with stakeholders such as designers and end-users is needed to further develop a working prototype for testing.

Clustering of health behaviours in Canadians: A multiple behaviour analysis of data from the Canadian Longitudinal Study on Aging

Health risk behaviours such as physical inactivity, unhealthy eating, smoking tobacco, and alcohol use are each leading risk factors for non-communicable chronic disease and each play a central role in limiting health and life satisfaction. However, much less is known about how co-occurring behaviours are associated with health outcomes. Understanding which behaviours tend to co-occur (i.e., cluster together), and how such clusters are associated with physical and mental health, life satisfaction, and health care utilization may provide novel opportunities to leverage this co-occurrence to develop and evaluate interventions to promote multiple health behaviour change. Using cross-sectional baseline data (N=40,268) from the Canadian Longitudinal Study of Aging, we performed a pre-defined set of analyses to examine the co-occurrence of health behaviours. We used agglomerative hierarchical cluster analysis to cluster individuals based on their behavioural tendencies and multinomial logistic regression to examine how these clusters are associated with demographic characteristics, healthcare utilization, and general health and life satisfaction, and assess whether sex and age moderate these relationships. Seven clusters were identified with clusters differentiated by six of the seven health behaviours included in the analysis. Variability between clusters was observed in frequencies of weekly walking, strenuous exercise, and alcohol consumption. Sociodemographic characteristics varied across several clusters while self-reported physical/mental health showed less variation across clusters. The seven identified clusters of health behaviours allow for contrasts to be made with comparable analyses in other countries and will help inform the development of future health behaviour change interventions tailored to sub-populations and their sociodemographic profiles.

Development of a Maternal and Child mHealth Intervention with Aboriginal and Torres Strait Islander Mothers: A Co-Design Approach (Preprint)

BACKGROUND Despite their growing popularity, there are very few mobile health (mHealth) interventions for Aboriginal and Torres Strait Islander people that are culturally safe and evidence-based. A co-design approach is considered a suitable methodology for developing health interventions with Aboriginal and Torres Strait Islander people. OBJECTIVE The aim of this study was to co-design a mHealth intervention to improve health knowledge, health behaviours, and access to health services for women caring for young Aboriginal and Torres Strait Islander children. METHODS Aboriginal researchers led engagement and recruitment with health services and participants in three Aboriginal communities in New South Wales Australia. Focus groups and interviews were facilitated by researchers and an app developer to gather information on three pre-determined themes, 1) design characteristics, 2) content modules, and 3) features and functions. Findings from the co-design led to the development of an intervention prototype. Theories of health behaviour change were used to underpin intervention components. Existing publicly available evidence-based information was used to develop content. Governance was provided by an Aboriginal Advisory group RESULTS Thirty-one mothers and 11 health professionals participated in eight co-design focus groups and 12 interviews from June to September 2019. Six design characteristics identified as important were: (1) Credibility, (2) Aboriginal and Torres Strait Islander designs and cultural safety, (3) Family centredness, (4) Supportive, (5) Simple to use, and (6) Confidential. Content modules include six modules for women’s health: (1) Smoke free families, (2) Safe drinking, (3) Feeling Good, (4) Women’s Business, (5) Eating, (6) Exercise; and six modules for children’s health: (1) Breathing Well, (2) Sleeping, (3) Milestones, (4) Feeding and Eating, (5) Vaccinations and Medicine, and (6) Ears, Eyes and Teeth. Six technology features and functions were also identified: (1) Content feed, (2) Social connection, (3) Reminders, (4) Rewards, (5) Communication with health professionals, and (6) Use of videos. CONCLUSIONS An mHealth intervention including app, Facebook page, and text message modalities was developed based on the co-design findings. The intervention incorporates health behaviour change theory, evidence-based information and the preferences of Aboriginal and Torres Strait Islander women and health professionals. A pilot study is now needed to assess the acceptability and feasibility of the intervention.