Evidence-based Behavioral Medicine Research Articles

Common paraverbal errors during hypnosis intervention training

ABSTRACT There is growing literature to support the use of hypnosis as an evidence-based behavioral medicine intervention to manage a wide variety of symptoms and side effects associated with cancer and its treatment (e.g., pain, nausea, fatigue). However, formal training in hypnosis is often lacking among cancer care providers. The purpose of this study is to identify common paraverbal errors among hypnosis trainees in order to inform future training efforts. In a sample of 196 hypnosis trainees, paraverbal errors (i.e., tone, pacing, and phrasing) were tracked across hypnotic intervention components. Results revealed that trainees had most difficulty with hypnotic tone, particularly during the Induction, Deepening, and Alerting components. Individual trainee characteristics were unrelated to paraverbal errors.

Increasing the public health impact of evidence-based interventions in behavioral medicine: new approaches and future directions.

The dissemination and implementation of evidence-based behavioral medicine interventions into real world practice has been limited. The purpose of this paper is to discuss specific limitations of current behavioral medicine research within the context of the RE-AIM framework, and potential opportunities to increase public health impact by applying novel intervention designs and data collection approaches. The MOST framework has recently emerged as an alternative approach to development and evaluation that aims to optimize multicomponent behavioral and bio-behavioral interventions. SMART designs, imbedded within the MOST framework, are an approach to optimize adaptive interventions. In addition to innovative design strategies, novel data collection approaches that have the potential to improve the public-health dissemination include mHealth approaches and considering environment as a potential data source. Finally, becoming involved in advocacy via policy related work may help to improve the impact of evidence-based behavioral interventions. Innovative methods, if increasingly implemented, may have the ability to increase the public health impact of evidence-based behavioral interventions to prevent disease.

Multiple health behavior change: a synopsis and comment on “A review of multiple health behavior change interventions for primary prevention”

The ninth column on Evidence-Based Behavioral Medicine is a synthesis of a recent systematic meta-review of multiple health behavior change (MHBC) interventions published by Prochaska and Prochaska in the American Journal of Lifestyle Medicine (Am J Life Med 5:208–221, 2011). Health risk behaviors are highly prevalent and increase the risk of developing and exacerbating chronic disease. The purpose of the meta-review was to examine the efficacy of MHBC interventions in a variety of populations and settings. The available literature was synthesized into three health behavior domains including energy-balance behaviors (physical activity and nutrition), addictive behaviors, and disease-related prevention. Twelve systematic reviews were identified that summarized more than 150 randomized clinical trials. Findings suggest that: (1) Physical activity and nutrition interventions are effective in producing weight loss among adults and female youth, (2) treating two addictive behaviors produces a higher long-term abstinence rate than treating a single behavior, and (3) although preventive interventions for cardiovascular disease and cancer significantly reduce health risk behaviors, reductions in disease incidence are yet to be demonstrated.

The impact of team science collaborations in health care: a synopsis and comment on "Interprofessional collaboration: effects of practice-based interventions on professional practice and healthcare outcomes".

The eighth column on evidence-based behavioral medicine is a synthesis of the study of Zwarenstein et al. (1). which examines the effects of practice-based interventions to improve interprofessional collaboration. Poor interprofessional collaboration may have deleterious effects on quality of care. The purpose of the systematic review was to investigate whether interventions aimed at improving interprofessional collaboration affect patient satisfaction and/or the effectiveness and efficiency of care. Five randomized controlled trials were reviewed, examining studies that differed across setting, interventions, and outcomes. Of the five studies reviewed, three showed improvements in patient care, one found no effect, and one had mixed findings. Findings indicate that interventions aimed at improving interprofessional care may improve outcomes, but interpretation of these findings is limited due to the small sample size and heterogeneity across studies reviewed.

Developing a patient-centered medical home: synopsis and comment on “Patient preferences for shared decisions: a systematic review”

The seventh column on Evidence-Based Behavioral Medicine synopsizes a systematic review by Chewning and colleagues (Pat Educ Couns 86:9-18, 2012) on patient preferences for shared decision-making regarding treatment and screening. A total of 115 studies were included in the final analyses. In 63% of studies, a majority of patients preferred sharing decisions with their primary care physician, as opposed to delegating health decisions to their provider. A time trend appeared such that in studies published more recently, a greater percentage of patients, particularly cancer patients, preferred sharing decisions. Further research should seek to better understand how the decision making of specific patient populations is influenced by life course changes and secular trends. Longitudinal studies can help to elucidate how patient decision-making preferences evolve over the course of illness and health status changes in different medical conditions.

Factors and predictors of cognitive impairment in the elderly

The sixth column on Evidence-Based Behavioral Medicine is focused on Plassman et al.'s (Ann Internal Med 153:182-193, 2010) systematic review on factors associated with risk for and prevention of cognitive decline among the elderly. A total of 250 studies were included in the final analyses. Cognitive training was most consistently and negatively associated with cognitive decline. Evidence was largely consistent across observational and randomized controlled trial (RCT) studies. Other factors, such as physical activity, some healthy nutritional patterns, and not smoking might also be protective against cognitive decline, but the available evidence is not adequate to draw conclusions about the strength of these relationships. Future research addressing these limitations should include well-designed RCTs that attempt to replicate the finding that cognitive training is protective, and well as high-quality observational and interventional studies that examine the impact of health behaviors on cognitive decline.

Meeting them where they are: Using the Internet to deliver behavioral medicine interventions for pain

Pharmacological and interventional pain medicine treatments are emphasized in the routine treatment of chronic pain despite strong evidence for the efficacy and safety of behavioral approaches. Most medical professionals have not incorporated behavioral pain treatments into their practices. Internet-based interventions have the potential to increase clinical use of these treatments. We discuss the strengths and weaknesses of current Internet-based behavioral pain management interventions, focusing on three broad intervention categories: therapist-guided interventions, unguided (automated) interventions, and pain-relevant applications for mobile platforms. Examples of each category are discussed, revealing a high degree of variation in approaches, user interfaces, and components as well as variability in the degree to which these interventions have been subjected to empirical testing. Finally, we highlight key issues for research and clinical implementation, with the goal of advancing this field so that it can meet its potential to increase access to evidence-based behavioral medicine treatments for chronic pain.

The future of pain research, education, and treatment: a summary of the IOM report “Relieving pain in America: a blueprint for transforming prevention, care, education, and research”

The fifth column on Evidence-Based Behavioral Medicine is focused on the Institute of Medicine's (IOM) report entitled "Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research." The IOM has reported that chronic pain affects 116 million American adults, which is greater than the total of heart disease, cancer, and diabetes combined. It is recommended that data collection takes place at regular intervals using standardized questions, survey protocols, and electronic medical records with the aim of the identifying the following: subpopulations at risk; characteristics of acute and chronic pain; health consequences of pain, including death, disease, and disability; and longitudinal trends of pain. In addition, health education programs should be redesigned to include information about self-management, actions to prevent injuries at the individual and community level, advocacy for pain treatment, and support for improved prevention and control policies. Through teamwork between various professions, from physicians, nurses, and psychologists to physical therapists, pharmacists, and policy makers, advancements in pain awareness, education, research, and treatment should begin to materialize.

Behavioral medicine translation in the Veterans Health Administration: editorial to the special section on the Department of Veterans Affairs

The Veterans Health Administration (VHA) within the Department of Veterans Affairs (VA) is a national leader in the systematic translation of basic and clinical science to clinical practice, rapidly advancing the quality of health care for Veterans. The VHA is the nation’s largest fully integrated health care system and this organization makes the translation of evidence-based behavioral medicine possible on a national scale [1]. An early adopter of behavioral medicine almost from its inception in the 1970s, the VHA supported clinical practice and research targeting health risk factor reduction interventions for tobacco and obesity, psychological factors associated with cancer, and on integrated medical and behavioral treatment of pain [2]. In 1995, the VHA established a national office to support many of its behavioral medicine programs through the National Center for Health Promotion and Disease Prevention (NCP), within the VHA Office of Patient Care Services [3]. More recently, responding to VA Secretary Erik K. Shinseki’s transformational initiatives for the twenty-first century in 2009, the VHA expanded its capacity to provide Veterans with behavioral medicine services establishing the position of Chief Consultant for Preventive Medicine and hiring two additional behavioral medicine professionals for each of its 153 medical centers—a behavioral health specialist and a health behavioral coordinator [3, 4].

Quality care process in the VA: a synopsis and comment on "Comparison of the quality of medical care in veterans affairs and non-veterans affairs settings".

The fourth column on Evidence-Based Behavioral Medicine presents a synopsis of the systematic review by Trivedi et al. (2011) comparing the quality of medical care in veterans affairs (VA) and non-VA settings. Thirty-six studies were included in the synthesis. Each article was given a grade of A, B, or C based on the six elements of high-quality studies. Most studies assessing adherence to recommended processes of care showed that the VA performed better that non-VA sites. Similar rates were found for both groups in studies that assessed risk-adjusted mortality. This implies that a greater adherence to evidence-based processes (e.g., preventive care, medication prescription, and referral) did not result in decreased morbidity and mortality. It is established that engaging in evidence-based practices and processes improves short-term intermediate endpoints (e.g., patient satisfaction). Future research is needed to test whether short-term benefits of evidence-based care processes connect to mortality outcomes.

Translating clinical evidence to the community: a synopsis and comment on “Community wide interventions for increasing physical activity”

The third column on Evidence-Based Behavioral Medicine is focused on the Baker et al. Cochrane Review entitled "Community wide interventions for increasing physical activity." We provide a synopsis of the review as well as a comment on the future direction of community-wide physical activity interventions.

The DECISIONS study: synopsis of evidence for shared decision-making and quality patient–provider communication

The second column on Evidence-Based Behavioral Medicine (EBBM) has two goals. First, we describe the importance of patient-provider communication and shared decision-making as integral components in EBBM. Second, we provide a synopsis of the DECISIONS study's findings on patient knowledge and prevalence of decision-making in order to illustrate the role that patient involvement in health care decisions plays in quality health care.

Insights on conducting research in low-resource settings: examples from Vietnam and Uganda

ABSTRACTThis commentary describes key observations and strategies, based on the author's experiences in Vietnam and Uganda, for tailoring evidence-based behavioral medicine research in low-resource settings.

Adaptation and implementation of an evidence-based behavioral medicine program in diverse global settings: The Williams LifeSkills experience

Epidemiological research has documented the health-damaging effects of psychosocial factors like hostility, depression, anxiety, job stress, social isolation and low socioeconomic status. Several studies suggest that behavioral interventions can reduce levels of these psychosocial factors. Herein we describe the translational process whereby the Williams LifeSkills® (WLS(®)) program and products for reducing psychosocial risk factors have been developed and tested in clinical trials in the U.S. and Canada and then adapted for other cultures and tested in clinical trials in other countries around the world. Evidence from published controlled and observational trials of WLS(®) products in the U.S. and elsewhere shows that persons receiving coping skills training using WLS(®) products have consistently reported reduced levels of psychosocial risk factors. In two controlled trials, one for caregivers of a relative with Alzheimer's Disease in the U.S. and one for coronary bypass surgery patients in Singapore, WLS(®) training also produced clinically significant blood pressure reductions. In conclusion, WLS(®) products have been shown in controlled and observational trials to produce reduced levels of both psychosocial and cardiovascular stress indices. Ongoing research has the potential to show that WLS(®) products can be an effective vehicle for the delivery of stress reduction and mental health services in developing countries.

CALM technology-supported intervention: synopsis of evidence for an emerging class of practice tool

CALM technology-supported intervention: synopsis of evidence for an emerging class of practice tool

Online Interventions for Social Marketing Health Behavior Change Campaigns: A Meta-Analysis of Psychological Architectures and Adherence Factors

BackgroundResearchers and practitioners have developed numerous online interventions that encourage people to reduce their drinking, increase their exercise, and better manage their weight. Motivations to develop eHealth interventions may be driven by the Internet’s reach, interactivity, cost-effectiveness, and studies that show online interventions work. However, when designing online interventions suitable for public campaigns, there are few evidence-based guidelines, taxonomies are difficult to apply, many studies lack impact data, and prior meta-analyses are not applicable to large-scale public campaigns targeting voluntary behavioral change.ObjectivesThis meta-analysis assessed online intervention design features in order to inform the development of online campaigns, such as those employed by social marketers, that seek to encourage voluntary health behavior change. A further objective was to increase understanding of the relationships between intervention adherence, study adherence, and behavioral outcomes.MethodsDrawing on systematic review methods, a combination of 84 query terms were used in 5 bibliographic databases with additional gray literature searches. This resulted in 1271 abstracts and papers; 31 met the inclusion criteria. In total, 29 papers describing 30 interventions were included in the primary meta-analysis, with the 2 additional studies qualifying for the adherence analysis. Using a random effects model, the first analysis estimated the overall effect size, including groupings by control conditions and time factors. The second analysis assessed the impacts of psychological design features that were coded with taxonomies from evidence-based behavioral medicine, persuasive technology, and other behavioral influence fields. These separate systems were integrated into a coding framework model called the communication-based influence components model. Finally, the third analysis assessed the relationships between intervention adherence and behavioral outcomes.ResultsThe overall impact of online interventions across all studies was small but statistically significant (standardized mean difference effect size d = 0.19, 95% confidence interval [CI] = 0.11 - 0.28, P < .001, number of interventions k = 30). The largest impact with a moderate level of efficacy was exerted from online interventions when compared with waitlists and placebos (d = 0.28, 95% CI = 0.17 - 0.39, P < .001, k = 18), followed by comparison with lower-tech online interventions (d = 0.16, 95% CI = 0.00 - 0.32, P = .04, k = 8); no significant difference was found when compared with sophisticated print interventions (d = –0.11, 95% CI = –0.34 to 0.12, P = .35, k = 4), though online interventions offer a small effect with the advantage of lower costs and larger reach. Time proved to be a critical factor, with shorter interventions generally achieving larger impacts and greater adherence. For psychological design, most interventions drew from the transtheoretical approach and were goal orientated, deploying numerous influence components aimed at showing users the consequences of their behavior, assisting them in reaching goals, and providing normative pressure. Inconclusive results suggest a relationship between the number of influence components and intervention efficacy. Despite one contradictory correlation, the evidence suggests that study adherence, intervention adherence, and behavioral outcomes are correlated.ConclusionsThese findings demonstrate that online interventions have the capacity to influence voluntary behaviors, such as those routinely targeted by social marketing campaigns. Given the high reach and low cost of online technologies, the stage may be set for increased public health campaigns that blend interpersonal online systems with mass-media outreach. Such a combination of approaches could help individuals achieve personal goals that, at an individual level, help citizens improve the quality of their lives and at a state level, contribute to healthier societies.

Meta-analysis as the core of evidence-based behavioral medicine: tools and pitfalls of a statistical approach

Meta-analyses have a significant impact on clinical decision-making. In behavioral medicine, they are regularly used to derive clinical practice guidelines. Owing to an increasing complexity of data integration methods used, their interpretation has become a challenge to clinicians and researchers. This review aims to provide an accessible introduction to recent advances in the methodology and reporting style of quantitative reviews within the field of behavioral medicine. Meta-analytical findings are sensitive to the precise methods used. State-of-the-art criteria for reporting of clinical trials and meta-analyses have been put forward. Further adaptations of these criteria result from recent meta-analyses of the placebo effect in clinical trials. There is a need to carefully develop and evaluate methods to deal with patient dropout and missing data. Useful methods to evaluate diagnostic test accuracy and meta-analytically evaluate direct and indirect treatment comparisons have recently been developed. In the interdisciplinary field of behavioral medicine, meta-analyses are applied to evaluate interventions, diagnostic instruments, and procedures, and to derive evidence-based treatment recommendations. Criteria to improve reporting quality and methods to control for potential biases have been adapted to meet the requirements of research in behavioral medicine today.

Behavioral medicine for migraine and medication overuse headache

Primary headaches, including migraine and medication overuse headache (MOH), can be conceptualized as biobehavioral disorders based on the interaction of biological, psychological, and environmental factors. This article reviews empirically supported and efficacious behavioral approaches to the treatment and management of headaches in general, with an emphasis on migraine and MOH from a biopsychosocial perspective. Evidence-based behavioral medicine treatments for migraine and MOH are reviewed, including patient education, cognitive behavioral therapy, and biobehavioral training (biofeedback, relaxation training, and stress management). Information regarding psychological comorbidities and risk factors for progression of migraine and the development of MOH is also reviewed. Strategies are provided for enhancing adherence and motivation, as well as facilitating medical communication.

Practical behavioral trials to advance evidence-based behavioral medicine

There is a well-documented gap between research and practice in many areas of behavioral medicine. This gap is due in part to limitations in the capacity of the research database to address questions that are of central concern to clinicians, administrative decision makers, and policymakers. Thus, there has been a call for "practical clinical trials" that compare clinically viable alternative interventions and assess multiple outcomes important for clinical and policy decisions in diverse patient populations and settings. Such trials offer great potential, and they raise interesting challenges regarding optimal research design and source of funding. We discuss issues related to practical clinical trials in behavioral medicine, propose a need for practical behavioral trials (PBTs), and describe design features that will facilitate clinical and policy decision making. This type of PBT can help to close the gap between research and practice and advance the field of evidence-based behavioral medicine. We discuss potential challenges and objections to PBTs and conclude by providing recommendations for the design, conduct, reporting, and review of practical trials.

Invitation to a dialogue between researchers and clinicians about evidence-based behavioral medicine

Evidence-based behavioral medicine (EBBM) aims to improve the process through which best scientific research evidence can be obtained and translated into best clinical decisions regarding behavioral treatments to improve health. The objective was to examine some legitimate concerns raised by both clinicians and researchers about the evidence-based movement. This article begins with a discussion of clinicians' fears that EBBM devalues clinical judgment and the therapist-patient relationship, will be used to restrict practice, is unnecessary, and is based on research that is irrelevant to clinical decision making. Next we consider researchers' worries that EBBM neglects evidence not based on randomized controlled trials and ignores causal mechanisms. We find that these fears, although understandable, largely reflect misinterpretations of the evidence-based movement. Further, it is suggested that behavioral medicine is in a unique position to enhance the evidence-based movement by encouraging increased attention to treatment mechanisms and to knowledge translation. Clinicians, researchers, and, importantly, the public will benefit from the evidence-based movement by having a health care system that is built on solid grounds of evidence in determining which treatments should constitute the standard of care. A full partnership between clinicians and researchers is called for to generate the practical, rigorous evidence base needed to take behavioral health treatments to the next level of scientific support and implementation.