Evidence-based Behavioral Strategies Research Articles

Leveraging Behavioural Insights to Create Healthier Online Environment for Children

Abstract Issue/Problem The proliferation of digital marketing poses a significant threat to children’s health and well-being, necessitating innovative solutions grounded in cross-disciplinary systems approach. Description of the problem Children’s exposure to harmful digital marketing is pervasive, influencing their preferences, behaviours, and health outcomes. Traditional regulatory approaches often fall short in addressing the dynamic nature of online advertising, exacerbating the challenge. Without effective interventions, children remain vulnerable to the detrimental effects of marketing for unhealthy products and services, undermining public health efforts. Results Integrating behavioural sciences with public health suggests promising avenues for addressing the complexities of harmful digital marketing to children. The WHO KidAd app is a ground-breaking tool designed for objective monitoring of digital marketing. Coupled with evidence-based behavioural strategies such as nudges, choice architecture, and social norms, policymakers can influence decision-making in favour of healthier choices, thereby reducing the impact of harmful marketing. By understanding the decision-making processes and behavioural patterns involved, policymakers can design targeted interventions to mitigate exposure and protect children. Lessons Learned The application of behavioural sciences in public health policy-making yields valuable lessons. Firstly, personalized and contextually relevant interventions resonate more effectively with target audiences, enhancing their efficacy. Secondly, leveraging behavioural insights allows for the design of interventions that complement existing regulatory frameworks, filling gaps in enforcement and compliance. Thirdly, interdisciplinary collaboration between public health experts, policymakers, and behavioural scientists is essential for developing evidence-based strategies tailored to the digital landscape’s evolving challenges. [Grant: APVV-22-0587] Speakers/Panelists Amandine Garde Law & Non-Communicable Diseases Unit, Liverpool, UK

The Needle Anxiety Program: A Patient-Centered Initiative for Individuals With Developmental Disabilities.

Objective To describe the development process of a patient-centered initiative focused on improving primary care health outcomes of patients with intellectual and developmental disabilities (IDD) and needle-related anxiety usingevidence-based practices andnovel approaches that canbe implemented in outpatient settings. The overall outcome of the program isto increase vaccine uptake andaccessibilityin the IDD population as well as improve needle-related procedures in primary care settings to be more humane and effective. Methods The development process occurred in the context of a large healthcare system serving a diverse patient population in the U.S. and was led by an expert committee made of an multidisciplinary team of physicians, psychologists, ambulatory and clinic nurses,pharmacists, and anesthesiologistscommitted to promoting quality healthcare for the IDD population. Committee members were recruited within the healthcare system based on their relevant expertise. The methodology included an iterative and collaborative process that took place over three development phases: ideation and design, literature review and synthesis, and expert engagement.The ideation and design phase included a series of planning meetings among the expert committee, in which committee members identified preliminary concerns based on their expertise in the field and background knowledge on the current procedures related to improving routine care for individuals with IDD and/or needle-related anxiety.The literature review and synthesis phase led to the development of an annotated bibliography of research and clinical guidelines that synthesized findingson needle anxiety in clinical care.The expert engagement phase included all Committee members meeting for a final discussion to establish a tiered approach to utilizing evidence-based strategies that could be implemented across clinics within the healthcare system. Results The multidisciplinary team of experts developed a three-tier system, deployed sequentially as needed. The first tier focuses on training nurses in evidence-based behavioral modification strategies to implement as standard of care. The second tier uses the addition of a distraction device and topical analgesic to reduce anxiety in patients with slightly elevated procedural anxiety. The third tier involves a novel minimal sedation protocol using intranasal midazolam for patients with needle phobia that can be administered in an outpatient setting. Conclusion The Needle Anxiety Program eases the administration of needle-related medical procedures in the primary care setting for patients with IDD and needle-related anxiety. The use of evidence-based practices and a novel minimal sedation protocol for individuals with needle phobia assists in the completion of routine healthcare procedures, such as vaccinations and phlebotomy, in a patient-preferred setting. The purpose of delineating needle-related processes and procedures through the Needle Anxiety Program is to reduce health disparities for patients with IDD and promote uptake of the Needle Anxiety Program in similar healthcare settings.

Interventions to Reduce Repeat Presentations to Hospital Emergency Departments for Mental Health Concerns: A Scoping Review of the Literature.

The number of readmissions to the emergency department (ED) for mental health services each year is significant, which increases healthcare costs and negatively affects the morale and quality of life of patients and their families. This scoping review aimed to establish a better understanding of interventions that have been implemented to reduce psychiatric patient readmission and ED use within the ED, to identify areas for improvement, and therefore to assist in the development of more effective actions in the future. The scoping review was conducted on several bibliographic databases to identify relevant studies. Two researchers independently screened and reviewed titles, abstracts, and full-text articles that met the inclusion criteria. Using Covidence software, 26 out of 6951 studies were eligible for inclusion in this scoping review based on the PRISMA checklist. Data were extracted, collated, summarized, presented, and discussed. This review identified 26 studies which examined interventions aimed to reduce ED visits, such as the High Alert Program (HAP), the Patient-Centered Medical Home (PCMH), the Primary Behavioral Health Care Integration (PBHCI), and the Collaborative Care (CC) Program, etc. Twenty-three of the studies were conducted in North America, while the rest were conducted in Europe and Australia. A total of 16 studies examined interventions directed to any mental health conditions, while the rest addressed specific health conditions, such as substance use disorders, schizophrenia, anxiety, depression. Interventions involved comprehensive and multidisciplinary services, incorporation of evidence-based behavioral and pharmacological strategies, and emphasized the case management that was found to be effective. Additionally, there was a marked consideration for diverse mental health groups, such as those with substance use disorder and of young age. Most interventions showed a positive effect on reducing psychiatric ED visits. Various initiatives have been implemented worldwide to reduce the number of emergency department visits and the associated burden on healthcare systems. This review highlights the greater need for developing more accessible interventions, as well as setting up a comprehensive community health care system aiming to reduce frequent ED presentations.

Food Selectivity in Children with Autism: Guidelines for Assessment and Clinical Interventions

Autisms Spectrum Disorders (ASD) are characterized by core symptoms (social communication and restricted and repetitive behaviors) and related comorbidities, including sensory anomalies, feeding issues, and challenging behaviors. Children with ASD experience significantly more feeding problems than their peers. In fact, parents and clinicians have to manage daily the burden of various dysfunctional behaviors of children at mealtimes (food refusal, limited variety of food, single food intake, or liquid diet). These dysfunctional behaviors at mealtime depend on different factors that are either medical/sensorial or behavioral. Consequently, a correct assessment is necessary in order to program an effective clinical intervention. The aim of this study is to provide clinicians with a guideline regarding food selectivity concerning possible explanations of the phenomenon, along with a direct/indirect assessment gathering detailed and useful information about target feeding behaviors. Finally, a description of evidence-based sensorial and behavioral strategies useful also for parent-mediated intervention is reported addressing food selectivity in children with ASD.

Effects of an Agricultural Entrepreneurial Training Program with 40 Military Veteran Beginning Farmers

Military veterans returning from war face challenges when re-entering civilian life. Our aim was to evaluate how effective an agricultural entrepreneurial training program (The Farm and Education Treatment Program) was to equip 90 returning military veterans to become self-employed in food and agriculture and secondarily to support health. While there are several agricultural entrepreneurial training programs available, there are few with the breadth, depth, and empirical outcomes of the present study. Our method used eight measures to assess pretest-posttest differences associated with becoming successfully employed in production agriculture. We assessed pretest-posttest changes before and after returning military veteran beginning farmers participated in our year-long, 188-200-hour Farm and Education Treatment Program. Our program trained two cohorts per year each with 15 participants over three years for a total of 90 participants. Especially during COVID-19 with virtual rather than in-person training, our drop-out rate was high. By the end of the three-year program, 40 military veteran beginning farmers completed the program and provided usable pretest-posttest data for a 44% response rate. Almost 88% (n =35/40) of participants were self-employed in agriculture either full-time (60%) or part-time (28%). When they began, two were full-time farmers/ranchers, one was in agricultural business, and one was a part-time farmer/rancher. Our participants’ greatest statistically significant improvements were on the Skills Assessment measure with Farming Skill Level, Crop Skill Level, and Livestock Skill Level subscales, on the Entrepreneurial Self Efficacy Marketing, Innovation, Financial Control, and Total subscales, and on the Independent Living and Working levels. These measures linked well with the overall program goal, intervention, and outcomes because the bulk of the program addressed these variables. There was no change in physical or psychological domains. We concluded that face-to-face, in-person teaching of the program was much preferred and more effective than virtual, remote teaching during COVID-19. Also eight measures with 671 items are far too many. Future researchers are encouraged to expand the training with practical, evidence-based behavioral health strategies that participants can use to improve their behavioral health and quality of life.

A biobehavioral intervention to enhance recovery following hematopoietic cell transplantation: Protocol for a feasibility and acceptability randomized control trial

BackgroundInsomnia, fatigue, and depression are among the most persistent and distressing concerns for hematologic cancer patients recovering from hematopoietic cell transplantation (HCT). This study will evaluate a novel behavioral intervention, Restoring Sleep and Energy after Transplant (ReSET), designed to alleviate insomnia, fatigue, and depression by improving rest-activity patterns. Evidence-based behavioral strategies to improve nighttime sleep and increase non-sedentary daytime activity will be combined to optimize 24-h rest-activity patterns. MethodsThe protocol herein evaluates the feasibility and acceptability of ReSET by conducting a pilot randomized controlled trial to compare the intervention with usual care. Adults undergoing HCT will be randomly assigned to ReSET or usual care. The ReSET arm will receive 3 face-to-face sessions and telephone coaching delivered in an individual format tailored to each patient. Patient-reported insomnia, fatigue, and depression will be the primary outcome measures. Actigraphy will be used to objectively quantify rest-activity patterns. Semi-structured interviews will evaluate participant satisfaction with ReSET. The goals are to determine: (1) participant satisfaction with and acceptability of the behavioral techniques; (2) facilitator fidelity and participant uptake of key intervention components; (3) ability to recruit, retain, and collect complete data from participants; (4) participant willingness to be randomized and acceptability of the control condition; and (5) validity and acceptability of the assessment strategy. ConclusionThe overarching goal is to optimize recovery following HCT with a brief, non-invasive intervention that can be implemented as a part of routine clinical care.

Evidence-Based Behavioral Strategies in Smartphone Apps for Children's Sleep: Content Analysis.

BackgroundEmpirically supported treatments for pediatric sleep problems exist, but many families turn to other sources for help with their children’s sleep, such as smartphone apps. Sleep apps are easy for families to access, but little evidence exists regarding the validity of the services and information provided in the developer descriptions of the apps.ObjectiveThe goal of this study was to examine the features and claims of developer descriptions of sleep apps for children.MethodsA search of the Apple iTunes store and Google Play was conducted using the terms “kids sleep,” “child sleep,” and “baby sleep.” Data on the type of app, price, user rating, and number of users were collected. Apps were analyzed in comparison with evidence-based behavioral strategies and were thematically coded on the basis of claims provided in developer descriptions.ResultsA total of 83 app descriptions were examined, of which only 2 (2.4%) offered sleep improvement strategies. The majority were sound and light apps (78%) and 19% were bedtime games or stories. Only 18 of 83 (21.6%) apps were identified as containing empirically supported behavioral sleep strategies. Despite this, many apps asserted claims that they will help children “fall asleep instantly,” “cry less and sleep better,” or improve child development.ConclusionsA large variety of sleep apps exist for use among children, but few include evidence-based behavioral strategies according to the developer descriptions of the apps. Addressing sleep difficulties in children is important to promote physical, cognitive, and emotional development. Collaboration between sleep researchers and technology developers may be beneficial for creating evidence-supported apps to help with children’s sleep in the future.

Nutrition Intervention in Cardiac Rehabilitation: A REVIEW OF THE LITERATURE AND STRATEGIES FOR THE FUTURE.

Despite guideline consensus that quality of nutrition affects most modifiable cardiovascular disease risk factors, the implementation of dietary interventions varies considerably in cardiac rehabilitation (CR) programs. The purpose of this review is to highlight the current existing literature and provide recommendations on best practices for nutrition interventions and future research that support secondary prevention outcomes. The review examines original investigations, systematic reviews, and guidelines regarding nutrition intervention in CR. Nutrition intervention in CR plays an integral role in the success of patients; however, the literature is limited and standardization of practice is in its infancy. The role of a qualified registered dietician nutritionist, standardization of dietary assessments, individualized and intensive nutrition interventions, and application of specific behavior change techniques are central components in improving diet in CR. This review provides an overview of the evidence-based cardioprotective diets, nutritional interventions and behavioral strategies in CR, and explores areas for best practices and opportunities for innovation in the delivery of nutrition intervention in CR.

Evaluation of Mood Check-in Feature for Participation in Meditation Mobile App Users: Retrospective Longitudinal Analysis.

BackgroundMindfulness meditation smartphone apps may improve mental health but lack evidence-based behavioral strategies to encourage their regular use for attaining mental health benefits. In October 2019, the Calm mindfulness meditation app introduced a mood check-in feature, but its effects on participation in meditation have yet to be tested.ObjectiveThe objective of this study was to investigate how a mood check-in feature impacts meditation behavior in Calm app subscribers.MethodsThis was a retrospective longitudinal analysis of mobile app usage data from a random sample of first-time subscribers to the Calm app (n=2600) who joined in summer 2018 or summer 2019. The mood check-in feature allows users to rate their mood using an emoji after completing a meditation session and displays a monthly calendar of their past mood check-ins. Regression analyses were used to compare the rate of change in meditation behavior before and after the introduction of mood check-ins and to estimate how usage of mood check-ins was associated with individuals’ future meditation behavior (ie, intent-to-treat effects). Additional regression models examined the heterogenous effect of mood check-ins between subscribers who were active or inactive users prior to the introduction to mood check-ins (ie, above or below the median number of weeks with any meditation within their cohort). In order to confirm the specific associations between mood check-ins and meditation engagement, we modeled the direct relationship between the use of mood check-ins in previous weeks and subsequent meditation behavior (ie, treatment on the treated effects).ResultsDuring the first 9 months of their subscription, the 2019 cohort completed an average of 0.482 more sessions per week (95% CI 0.309 to 0.655) than the 2018 cohort; however, across both cohorts, average weekly meditation declined (–0.033 sessions per week, 95% CI –0.035 to –0.031). Controlled for trends in meditation before mood check-ins and aggregate differences between the 2018 and 2019 samples, the time trend in the number of weekly meditation sessions increased by 0.045 sessions among the 2019 cohort after the introduction of mood check-ins (95% CI 0.039 to 0.052). This increase in meditation was most pronounced among the inactive subscribers (0.063 sessions, 95% CI 0.052 to 0.074). When controlled for past-week meditation, use of mood check-ins during the previous week was positively associated with the likelihood of meditating the following week (odds ratio 1.132, 95% CI 1.059 to 1.211); however, these associations were not sustained beyond 1 week.ConclusionsUsing mood check-ins increases meditation participation in Calm app subscribers and may be especially beneficial for inactive subscribers. Mobile apps should consider incorporating mood check-ins to help better engage a wider range of users in app-based meditation, but more research is warranted.

Addressing Antibiotic Overuse in the Outpatient Setting: Lessons From Behavioral Economics

Addressing Antibiotic Overuse in the Outpatient Setting: Lessons From Behavioral Economics

Initiation and maintenance of behaviour change to support memory and brain health in older adults: A randomized controlled trial

ABSTRACT The implementation of healthy lifestyle and memory behaviours has the potential to mitigate the impact of age-related memory changes on the lives of older adults. The objective of this study was to examine whether a 10–hour multi-component memory intervention improves the initiation and maintenance of targeted, adaptive behaviour changes. Sixty-seven cognitively-normal, community-dwelling older adults, age 50–91 (72% female) participated in a randomized controlled trial with outcomes assessed at baseline, post-intervention, and six-week follow-up. Participants were allocated to a five-week, in-person, facilitator-led group intervention (n = 34) versus treatment as usual (n = 33). The intervention was associated with significant changes in participant-reported primary outcomes, including increased initiation and maintenance of health-promoting lifestyle behaviours (personal health responsibility, stress management, physical activity, and nutrition) and use of evidence-based behavioural memory strategies in everyday situations. Individualized goals were attained in both the intervention and control conditions. Secondary outcomes replicated prior findings (increased knowledge and improved memory-related confidence, affect, and self-rated ability), but were null with respect to benefits on general health and well-being. Group interventions that target positive adaptation to age-related cognitive decline via behaviour change are a promising avenue to enhance the health and wellness of our aging population. Trial registration ClinicalTrials.gov identifier: NCT02087137.

The Nature and Treatment of Pandemic-Related Psychological Distress.

The COVID-19 crisis has created a “mental health pandemic” throughout the world. Scientific data are not available to fully understand the nature of the resulting mental health impact given the very recent onset of the pandemic, nevertheless, there is a need to act immediately to develop psychotherapeutic strategies that may alleviate pandemic-related distress. The psychological distress, in particular fear and sadness, is a function of the pandemic’s negative impact upon people’s ability to meet their most basic needs (e.g., physical safety, financial security, social connection, participation in meaningful activities). This paper presents evidence-based cognitive behavioral strategies that should prove useful in reducing the emotional suffering associated with the COVID crisis.

Incorporating Health Behavior Theory into mHealth: an Examination of Weight Loss, Dietary, and Physical Activity Interventions

Health behavior interventions are effective for many modifiable lifestyle behaviors. In some cases, remotely-delivered behavioral interventions, particularly those that include some form of contact with a clinician and strong behavioral strategies, have been shown to be as effective as traditional in-person interventions; they are also more flexible, disseminable, and cost-effective. With ubiquitous increases in mobile phone use, opportunities for remote delivery of health interventions (mHealth) have grown exponentially, particularly in the use of behavioral smartphone applications. Despite research suggesting that mHealth interventions can be effective at initiating and maintaining behavior changes, many mHealth interventions are not theoretically-based, and evidence-based behavioral strategies are not often adapted into the mobile format. Thus, there is a need for clear summaries of behavioral change theories and examples of theoretically driven behavioral strategies to unify and improve the field of mHealth. The authors review the existing literature on theories of behavior change, intervention, and systems for evaluating theoretical content. Specifically, the authors briefly summarize both traditional and contemporary theories of behavior change, evidence-based behavioral strategies, and the methods for evaluating the degree to which they are included in existing mHealth behavioral interventions, with an emphasis on weight loss, dietary, and physical activity interventions. Authors also include examples of integration of theory into both research and clinical practice. This research highlights the importance of incorporation of theory into behavior change interventions. The authors suggest specific theoretical considerations for the development of mHealth interventions within collaborative, interdisciplinary environments, and recommend future research areas.

Developing evidence-based behavioural strategies to overcome physiological resistance to weight loss in the general population.

Physiological and behavioural systems are tolerant of excess energy intake and responsive to energy deficits. Weight loss (WL) changes body structure, physiological function and energy balance (EB) behaviours, which resist further WL and promote subsequent weight regain. Measuring and understanding the response of EB systems to energy deficits is important for developing evidence-based behaviour change interventions for longer-term weight management. Currently, behaviour change approaches for longer-term WL show modest effect sizes. Self-regulation of EB behaviours (e.g. goal setting, action plans, self-monitoring, relapse prevention plans) and aspects of motivation are important for WL maintenance. Stress management, emotion regulation and food hedonics may also be important for relapse prevention, but the evidence is less concrete. Although much is known about the effects of WL on physiological and psychological function, little is known about the way these dynamic changes affect human EB behaviours. Key areas of future importance include (i) improved methods for detailed tracking of energy expenditure, balance and by subtraction intake, using digital technologies, (ii) how WL impacts body structure, function and subsequent EB behaviours, (iii) how behaviour change approaches can overcome physiological resistance to WL and (iv) who is likely to maintain WL or relapse. Modelling physiological and psychological moderators and mediators of EB-related behaviours is central to understanding and improving longer-term weight and health outcomes in the general population.

Financial Constraints & Collegiate Student Learning: A Behavioral Economics Perspective

Gaps in college completion persist between low- and high-income students. These disparities can be attributed in large part to a lack of college affordability and information asymmetries about the process of accessing financial assistance as well as other campus-based resources and supports. While substantial policy investments have been made to address these inequalities, such as expanded financial aid programs and increased investments in college advising, these programs are not always fully utilized by students who might benefit from them. In this essay, we apply a behavioral economics perspective to examine how financial constraints affect students' navigation of the complex processes–financial, academic, and otherwise–required to succeed in American higher education. We conclude with a discussion of evidence-based behavioral strategies that policy-makers and educators can draw on to proactively mitigate these behavioral obstacles and improve student success.

A pilot randomized controlled trial to improve sleep and fatigue in children with central nervous system tumors hospitalized for high-dose chemotherapy.

To determine whether a sleep intervention compared with standard of care (SOC) was successful in preserving nighttime sleep in children with central nervous system cancers hospitalized for high-dose chemotherapy (HDCT) and autologous stem cell rescue, and to explore associations between sleep and fatigue during treatment. An unblinded, randomized, controlled, multicomponent intervention (NCT00666614) including evidence-based cognitive and behavioral strategies to improve sleep was implemented in 33 children (age 4-12 years) and adolescents (age 13-19 years) during hospitalization. Children wore an actigraph to measure sleep and wake, and reported fatigue scores daily. Parents concurrently kept a sleep diary and reported fatigue scores for their children. The mean age was 9.5 ± 3.9 years, 81.8% were white, and 60.6% were male. Sleep in all children was seriously disturbed throughout the study. Children in the intervention group maintained their longest nighttime sleep across the study, while it declined in children receiving SOC (P = 0.009 for interaction). There were few other differences in sleep between groups. Controlling for age and baseline fatigue, higher nighttime activity score, and lower percent sleep were significantly associated with higher next-day adolescent-reported fatigue (P < 0.05); longest sleep was significantly positively associated with next-day child-reported fatigue (P = 0.018). In this sample of children undergoing HDCT, a multicomponent sleep intervention modestly preserved nighttime sleep duration, although overall sleep was poor in both groups. Sleep is an integral component of health, and may influence outcomes of children receiving HDCT. Further investigation into methods of preserving sleep in children undergoing intensive cancer therapy is warranted.

Goal-directed versus outcome-based financial incentives for weight loss among low-income patients with obesity: rationale and design of the Financial Incentives foR Weight Reduction (FIReWoRk) randomised controlled trial

IntroductionObesity is a major public health challenge and exacerbates economic disparities through employment discrimination and increased personal health expenditures. Financial incentives for weight management may intensify individuals’ utilisation of evidence-based...

CBT Assistant Platform: web/mobile co-design solution for cognitive behavioural therapy

CBT Assistant Platform is a web/mobile co-design mHealth solution to support cognitive behavioural therapy (CBT). CBT Assistant Platform supports the end-to-end CBT treatment process for clients suffering from psychological disorders and are currently undergoing CBT sessions with trained professionals. A therapist can create customized treatments through a web-based application that guide clients in following CBT homework routine, through their smartphone CBT app. Client support app utilizes evidence-based behavioural change strategies intelligently enhanced through the use of wearable devices and on-board mobile sensors. We built the CBT Assistant Platform hoping to improve delivery of CBT in the following key areas: two-way communication between clients and therapists, cutting the time of a therapy session and helping therapists serve more clients, and client’s adherence to the therapy rigor by engaging the client in therapy process and making CBT homework easier and more fun to perform.

Development and pilot evaluation of a clinic-based mHealth app referral service to support adult cancer survivors increase their participation in physical activity using publicly available mobile apps

BackgroundParticipation in regular physical activity holds key benefits for cancer survivors, yet few cancer survivors meet physical activity recommendations. This study aimed to develop and pilot test a mHealth app referral service aimed at assisting cancer survivors to increase their physical activity. In particular, the study sought to examine feasibility and acceptability of the service and determine preliminary efficacy for physical activity behaviour change.MethodsA systematic search identified potentially appropriate Apple (iOS) and Android mHealth apps. The apps were audited regarding the type of physical activity encouraged, evidence-based behavioural strategies and other characteristics, to help match apps to users’ preferences and characteristics. A structured service was devised to deliver the apps and counselling, comprising two face-to-face appointments with a mid-week phone or email check-up. The mHealth app referral service was piloted using a pre-post design among 12 cancer survivors. Participants’ feedback regarding the service’s feasibility and acceptability was sought via purpose-designed questionnaire, and analysed using inductive thematic analysis and descriptive statistics. Change in physical activity was assessed using a valid and reliable self-report tool and analysed using paired t-tests. In line with recommendations for pilot studies, confidence intervals and effect sizes were reported to aid interpretation of clinical significance, with an alpha of 0.2 used to denote statistical significance.ResultsOf 374 mHealth apps identified during the systematic search, 54 progressed to the audit (iOS = 27, Android = 27). The apps consistently scored well for aesthetics, engagement and functionality, and inconsistently for gamification, social and behaviour change features. Ten participants completed the pilot evaluation and provided positive feedback regarding the service’s acceptability and feasibility. On average, participants increased their moderate-vigorous physical activity by 236 min per week (d = 0.73; 95% CI = −49 to 522; p = 0.09).ConclusionThis study offered initial evidence that a mHealth app referral service for cancer survivors is feasible and acceptable and may increase physical activity levels. The large increase in physical activity is promising, but should be interpreted with caution given the small sample size and lack of control group. Further research is warranted on a larger scale to investigate generalisability, long-term compliance and application in clinical settings.

Emerging themes in coping with lifetime stress and implication for stress management education.

Background:Adults with adverse childhood experiences and exposure to adverse life events experience a diverse array of physical, mental, and social health problems across their lifespan. Adult exposure to emotional trauma, physical injury, or other adverse life events may result in the development of post-traumatic stress and post-traumatic stress disorder. Understanding individuals’ response to stress and their coping strategies is as important as the stimulus or the causes of the stress for effective stress management interventions.Methods:This is a mixed quantitative and qualitative online survey study which explores the coping strategies to stress in adults with adverse childhood experiences and exposure to adverse life events through analysis of emerging themes from survey questionnaire responses of study participants.Results:Participants who respond to stress through adaptive coping focused either on problem-solving, 17.6% (32 out of 188), or on emotion-focused coping, 45.2% (85 out of 188). Participants engaged in problem-solving mainly through therapy such as counseling and other professional stress management, whereas those who chose emotion-focused coping used diverse strategies including practicing mindfulness, meditation, and yoga; using humor and jokes; seeking higher power or religious pursuits; engaging in physical or breathing exercises; and seeking social support. Participants who practiced maladaptive coping styles constituted 37.2% (70 out of 188) of respondents and resorted to avoidance of the stressful condition, withdrawal from a stressful environment, disengagement from stressful relationships, and use and abuse of drugs and/or alcohol.Conclusion:An understanding of emerging themes in coping strategies calls for collaborative and multidisciplinary approaches in the design, implementation, and execution of health education and promotion programs tailored to meet the diverse needs of priority populations. Stress management educators need to take into account the vulnerabilities of individuals who resort to maladaptive coping and institute evidence-based behavioral and social service intervention strategies, including life skills training, to prevent the consequences of maladaptive coping and to enhance the self-efficacy of individuals to cope more effectively with stress and stressful life events.