Facilitate Health Behavior Change Research Articles

14 Years of Self-Tracking Technology for mHealth—Literature Review: Lessons Learned and the PAST SELF Framework

In today’s connected society, many people rely on mHealth and self-tracking (ST) technology to help them adopt healthier habits with a focus on breaking their sedentary lifestyle and staying fit. However, there is scarce evidence of such technological interventions’ effectiveness, and there are no standardized methods to evaluate their impact on people’s physical activity and health. This work aims to help ST practitioners and researchers by empowering them with systematic guidelines and a framework for designing and evaluating technological interventions to facilitate health behavior change and user engagement, focusing on increasing physical activity and decreasing sedentariness. To this end, we conduct a literature review of 129 papers between 2008 and 2022, which identifies the core ST design principles and their efficacy, as well as the most comprehensive list to date of user engagement evaluation metrics for ST. Based on the review’s findings, we propose PAST SELF, a framework to guide the design and evaluation of ST technology that has potential applications in industrial and scientific settings. Finally, to facilitate researchers and practitioners, we complement this article with an open corpus and an online, adaptive exploration tool for the PAST SELF data.

Differences between complete and incomplete couples in physical health research: Implications for methods and generalizability

RationaleCouples-based interventions to facilitate health behavior change and improve disease outcomes are gaining attention from researchers. Dyadic research, however, poses unique methodological challenges that have raised questions about research samples and the generalizability of findings. ObjectiveThe current study examined whether couples in which both partners participated (i.e., complete couples) in a couples’ health research study systematically differed from those in which only one partner participated (i.e., incomplete couples). MethodsBetween January 2014 and November 2015, an online survey was advertised on Facebook to people who were both engaged to be married and living in the Denver, Colorado metropolitan area. When the first member of a couple completed the survey (initially recruited participant), they provided their partner's email address, which prompted the research staff to invite the second partner to complete the same online survey. Constructs assessed included demographics, health behaviors, general health status, and relationship quality. Participants answered questions about themself and their partner. Approximately one-third of the partners of initially recruited participants also participated. Data from initial participants in complete couples (N = 265) were compared to data from initial participants in incomplete couples (N = 509). ResultsChi-square tests and independent samples t-tests indicated participants in incomplete couples had significantly lower relationship quality, worse health behaviors, and poorer health status compared to those in complete couples. Reports on partner health behaviors also differed in the same direction between the two groups. Participants in complete couples were more likely to be White, less likely to have children, and had more education than in incomplete couples. ConclusionsFindings suggest that studies requiring both members of a couple may recruit samples that are less diverse with fewer health concerns than research that only requires individual participation if their partner refused participation. Implications and recommendations for future couples-based health research are discussed.

Introducing a Physical Therapist-Led Acceptance and Commitment Therapy Training for Pain: A Clinical Perspective

Purpose: Mounting evidence supports the use of cognitive and behavioral techniques as part of physical therapist practice. These methods are used within a physical therapist’s multimodal treatment approach for the management of pain and to facilitate health behavior change. There is a multitude of evidence-based cognitive behavioral techniques to choose from including newer approaches based on Acceptance and Commitment Therapy. Yet few studies have examined physical therapists’ perceptions to learning and implementing ACT into clinical practice. The purpose of this manuscript is to present a clinical perspective of physical therapists learning about and incorporating Acceptance and Commitment Therapy in clinical practice. Methods: An 8-week online physical therapist-led ACT for chronic pain training was completed by 65 physical therapists. A post-training evaluation was developed and then scored by 46 participants. The evaluation included 15-questions with regard to the self-reported perceptions of learning foundational ACT skills necessary to implement into physical therapy practice, a deeper understanding of psychological factors involved in musculoskeletal pain, confidence in managing musculoskeletal pain, utility in physical therapist practice, and the recognition of a new or different approach to treating musculoskeletal pain. Results: Participants’ self-reported perceptions were highly positive with 73% reporting the training furthered their understanding of psychological factors in chronic musculoskeletal pain and 100% reported learning the foundational ACT skills necessary to implement it into physical therapy practice. In addition, 7 sub-themes regarding the ACT training emerged from a qualitative content analysis and included the following: 1) The training filled a knowledge gap in understanding of how to assess and treat psychological factors related to pain, 2) A mixture of prerecorded video training, reading, experiential exercises, and self-reflection via the ACTPTE were critical to reinforce learning, 3) Coaching and supervision calls were a useful part of the training and helped to translate course knowledge and implement into clinical practice, 4) Having an opportunity to practice in a group setting with like-minded peers was a critical component of confidence building, 5) Ongoing communication, networking, and mentorship via the online forum and coaching calls allowed participants to complete the course material on-time, stay connected, and share stories and experiences about implementing the material in practice, 6) The ACT stance of not changing pain or related psychological content (example: not changing thoughts, pain related beliefs, reconceptualizing pain) may run counter to other psychologically-informed approaches found in physical therapy practice and took some time for practitioners to process and integrate, 7) Some practitioners expressed that ACT helped them cope with work-related stress and burnout and to drop the struggle of fixing or curing every patient with pain. Conclusions: ACT delivered via an online training was acceptable to physical therapists and supervision calls were necessary for confidence building and implementation into practice. The ACT model was perceived as adaptable to the practice of physical therapy as well as the complex clinical and psychosocial presentation of many chronic pain conditions. Future investigations should explore brief training interventions, treatment fidelity, long-term outcomes, the development and validation of a scale to measure knowledge, concepts and skills conceptualizing psychological flexibility within physical therapist practice.

Developing Educational Materials to Support Older Adults With Hypertension Management

A comprehensive approach to hypertension management requires medication adherence as well as more general health behavior changes. Our primary objective is to provide evidence-based and tailored education about hypertension, medications, and health self-management strategies with consideration for different stages of behavior change, health literacy, education, disease knowledge, and experience. To facilitate health behavior change, enable information seeking, and increase engagement, the educational materials provide different layers of information, including tips and information in the MEDSReM app, as well as more detailed educational content on the web portal. We will present examples of the materials in different formats to show how they are tailored to ease comprehension, support adherence, and influence behavior change. These educational materials will have broad utility outside of the MEDSReM system, and will also serve as the education-only comparison condition for the randomized controlled trial.

Motivation for Physical Activity in Adults With Multiple Sclerosis: A Self-determination Theory-Based Approach.

Despite the benefits of regular physical activity (PA), most adults with multiple sclerosis (MS) are insufficiently active. Identifying the motivational correlates of PA is necessary to facilitate health behavior change. The extent to which the constructs of psychological need satisfaction and motivational regulations associate with self-determined PA in adults with the disease was examined. Individuals with MS were provided a link to a web-based survey. There were 290 respondents: 242 women and 48 men aged 22 to 71 (mean ± SD, 49.50 ± 12.05) years with primarily mild to moderate mobility impairment who completed the Psychological Need Satisfaction in Exercise scale, the Behavioral Regulation in Exercise Questionnaire, and the International Physical Activity Questionnaire. Path analysis revealed that PA was best predicted by integrated regulation, competence, and mobility, explaining 28% of the variance in PA behavior. All 3 need satisfaction variables (relatedness, competence, and autonomy) and mobility impairment accounted for 43% of the variance in integrated regulation. Increasing satisfaction of the need for relatedness, competence, and autonomy can lead to more integrated and internally motivated PA engagement in adults with MS.

Lifestyle as a Risk Factor for Atrial Fibrillation.

The growing burden of atrial fibrillation health care resource utlization has created an urgent need to develop preventative strategies and opportunities to improve outcomes in the prevalent population. Modifiable risk factors contribute to both disease development and progression. In the prevalent atrial fibrillation population, modifying cardiovascular risk factors has decreased disease burden and progression. However, further research is required to determine the role of comprehensive cardiovascular risk factor modification programs in primary prevention. An understanding of strategies required to facilitate health behavior change is crucial to the effective implementation of cardiovascular risk factor management programs.

Pharmacy students’ personal health practices and perceptions on lifestyle medicine

ABSTRACT Pharmacists are accessible and positioned to facilitate health behavior change among patients with chronic diseases. The readiness of pharmacy students to practice lifestyle medicine is unclear. Doctor of Pharmacy students were surveyed on personal characteristics, health behaviors, and opinions on lifestyle counselling in September 2016. Ninety-three out of 359 (26%) students participated. A greater percentage of students with body mass index less than 25 kg/m2 responded that substance abuse counselling was highly relevant to their intended practices as compared to students classified as overweight or obese (p <.05). Over two-thirds of students without health care-related work experience indicated that weight management (p < .05) and alcohol abuse counselling (p < .05) were highly relevant to their intended practices. Student-specific factors are associated with perceptions on whether particular lifestyle medicine topics are relevant to their intended practices. Pharmacy programs can use study results to identify curricular areas where lifestyle medicine should be further emphasized.

Live counselor contact in a Facebook intervention predicts smoking cessation outcomes.

Digital smoking cessation interventions frequently use automated delivery of content. Integrating a counselor may improve participant engagement and facilitate health behavior change. We investigated engagement with live counseling compared to automated content in a Facebook intervention and the impact of engagement on smoking cessation outcomes. The Tobacco Status Project is a 90-day smoking cessation intervention for young adults utilizing automated posts and weekly sessions with a live counselor in Facebook groups tailored to readiness to quit (precontemplation, contemplation, preparation). Data came from the treatment group of a randomized trial. Post-level analyses investigated participant engagement (number of comments) by post type (e.g., counselor posts or automated posts based on transtheoretical model of behavior change, clinical practice guidelines, motivational interviewing), stratified by readiness to quit. Participant-level analyses examined whether extent of participant engagement with counselor posts predicted abstinence at 3 months. We analyzed data of N = 251 participants and N = 2,941 posts, 11% of which were live counselor initiated, and together generated 8,403 comments. Post-level analyses found that compared to the most engaging automated content (motivational content for precontemplation and contemplation, informational content for preparation), live counseling generated more engagement among participants in preparation, similar engagement in precontemplation, and less engagement in contemplation. Extent of live counseling participation predicted 3-month verified abstinence (adjusted OR = 1.10, 95% CI [1.02, 1.20]). In digital interventions, counselor contact may be beneficial in addition to automated posts at yielding engagement and abstinence; however, participants engage differently with counseling according to readiness to quit. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Effectiveness of motivational interviewing to improve oral hygiene in orthodontic patients: A randomized controlled trial

Maintaining good oral hygiene in patients wearing fixed appliances is a challenge for orthodontics. Conventional education has been demonstrated to be insufficient for the promotion of good oral habits, while motivational interviewing has the potential to facilitate health behavior change. The present randomized controlled trial with 130 patients aimed to evaluate the effectiveness of a single session of motivational interviewing in enhancing oral hygiene in orthodontic patients compared with conventional education alone. Results revealed an immediate improvement in oral hygiene which remained stable throughout the 6-month follow-up.

Specification of Change Mechanisms in Pregnant Smokers for Malleable Target Identification: A Novel Approach to a Tenacious Public Health Problem.

Maternal smoking during pregnancy (MSDP) continues to be a leading modifiable risk factor for perinatal complications and a range of neurodevelopmental and cardio-metabolic outcomes across the lifespan. Despite 40 years of intervention research less than one in five pregnant smokers who receive an intervention quit by delivery. Within this context, recognition of pregnancy is commonly associated with abrupt suspension or reduction of smoking in the absence of intervention, yet has not been investigated as a volitional target. The goal of this article is to provide the empirical foundation for a novel direction of research aimed at identifying malleable targets for intervention through the specification of behavior change mechanisms specific to pregnant women. To do so, we: (1) summarize progress on MSDP in the United States generated from conventional empirical approaches to health behavior change; (2) discuss the phenomenon of spontaneous change in the absence of intervention among pregnant smokers to illustrate the need for mechanistic specification of behavior change motivated by concern for fetal well-being; (3) summarize component processes in neurobiological models of parental and non-parental social behaviors as a conceptual framework for understanding change mechanisms during pregnancy; (4) discuss the evidence for the malleability of these processes to support their translational relevance for preventive interventions; and (5) propose a roadmap for validating the proposed change mechanism using an experimental medicine approach. A greater understanding of social and interpersonal processes that facilitate health behavior change among expectant mothers and how these processes differ interindividually could yield novel volitional targets for prenatal interventions. More broadly, explicating other-oriented mechanisms of behavior change during pregnancy could serve as a paradigm for understanding how social and interpersonal processes positively influence health behaviors across the lifespan.

How Fitness Trackers Facilitate Health Behavior Change

Fitness trackers have broadened the healthcare ecosystem and made self-tracking everyday physical activities possible. Features like heart rate monitoring can help detect health ailments, yet there is little evidence that suggests tracking health indicators and physical activities leads to long-term health behavior change. This proceeding analyzes areas of Human Factors that could be used to increase long-term user engagement. Feedback, information display, and specific design principles and case studies are discussed.

A mindful eating intervention: A theory-guided randomized anti-obesity feasibility study with adolescent Latino females

While pediatric anti-obesity lifestyle interventions have received considerable attention, few show sustained impact on body mass index (BMI). Using the Information-Motivation-Behavioral Skills Theory as a framework, we examined the effects of a satiety-focused mindful eating intervention (MEI) on BMI, weight and mindful awareness. MethodDesign and Setting: Utilizing a two-group, repeated measures design, 37 adolescent females with a BMI >90th percentile, recruited from a public high school in a Latino community in the Southwestern United States, were randomized 2:1, one third to the group receiving a 6-week MEI and two thirds to the comparison group (CG) receiving the usual care (nutrition and exercise information). Intervention: During six weekly 90-min after school MEI group sessions, the behavioral skills of slow intentional eating were practiced with foci on satiety cues and triggers to overeat. Outcomes: Feasibility and acceptability were measured as participant retention (goal ≥55%) and evaluative comments from those in the MEI group, respectively. BMI and mindful awareness were measured on site at baseline, immediately post intervention, and at 4-week follow-up (week 10). ResultsFifty-seven and 65% of those in the MEI and CG were retained throughout the study, respectively. MEI participants showed significantly lowered BMI compared with CG participants, whose weight increased (p<0.001). At six weeks, the MEI group BMI decreased by 1.1kg/m2 (BMI continued to decline to 1.4kg/m2 by week 10); while CG BMI increased by 0.7kg/m2 (consistent with BMI >90th percentile standard growth projections). ConclusionsInitial and sustained decline of BMI in the MEI group supports further study of this theory-guided approach, and the value of practicing satiety-focused mindful eating behavioral skills to facilitate health behavior change.

Telephone coaching to enhance a physiotherapist-prescribed home-based physical activity program for knee osteoarthritis: A randomised clinical trial

Purpose: Physical activity and exercise are recommended by osteoarthritis (OA) clinical and general health guidelines. Amongst people with OA, physical activity levels are low, there is a global under-utilisation of exercise, and benefits are generally not sustained because adherence is typically suboptimal and declines over time. Health coaching, often delivered by telephone, is increasingly used for chronic disease self-management. It aims to improve patient adherence to treatment recommendations and facilitate health behavior change. Aim: To investigate whether telephone coaching improves effectiveness of a physiotherapist-prescribed home-based physical activity and exercise program for knee OA. Methods: Design: Randomised controlled trial. Participants: 168 inactive adults aged ≥50 with knee pain and clinically-diagnosed knee OA were recruited from the community. Eighty-four participants were randomly allocated to Coaching (27M, 57F; age 61.1±6.9 years; mass 89.0±19.5 kgs) and 84 to Control (35M, 49F; 63.4±7.8 years, 87.5±22.0 kgs). Intervention: All participants received 5x30 minute face-to-face consultations with a physiotherapist over 6 months for education, prescription of a home exercise program (4–6 lower limb strengthening exercises, 3 times per week) and physical activity advice. Coaching participants also received 6–12 telephone coaching sessions by clinicians trained in health coaching for physical activity and exercise behaviour change support. Outcomes: Measures were assessed at baseline, 6, 12 and 18 months. Primary outcomes were average knee pain over the past week assessed using an 11-point numeric rating scale (NRS; 0-10) and physical function assessed using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC; 0-68) at 6 months. Secondary outcomes included these measures at 12 and 18 months, NRS walking pain, WOMAC pain score, quality-of-life (AQoL-6D) and physical activity assessed by the Physical Activity Scale for the Elderly (PASE), Active Australia Survey, 7 day activity monitor and perceived change (7-point Likert scale). Exercise adherence was assessed every 3 months. Statistical analysis: The study was powered to detect a minimum clinically important difference (MCID) in NRS pain of 1.8 and in WOMAC function of 6 non-normalized units with standard deviations of 2.2 and 11.6 respectively. Analyses were by intention-to-treat with multiple imputation for missing data. The mean (95% confidence interval) difference in change (baseline minus follow-up) between groups was estimated using a linear mixed model including random effects for physiotherapists and telephone coaches and baseline outcome score as a covariate. Results: 142 (85%), 136 (81%) and 128 (76%) participants completed 6, 12 and 18 month measurements, respectively, with completion rates comparable between groups. Most participants attended all 5 physiotherapy sessions with the mean (SD) being 4.4 (1.2) for coaching and 4.3 (1.4) for control (p>0.05). The mean (SD) number of telephone coaching sessions was 5.4 (2.0). Change in NRS pain (mean difference 0.4 units; 95%CI −0.4 to 1.3) or WOMAC function (1.8; 95%CI −1.9 to 5.5) did not differ between groups at 6 months, with both showing clinically relevant improvements. Most secondary outcomes related to physical activity and exercise behaviour favoured coaching at 6 months (PASE, mean difference −28.3; 95%CI −54.9 to −1.8; Home exercise completion, mean difference 14%, 95%CI 4 to 24; Self-rated exercise adherence on NRS, mean difference 1.7, 95%CI 0.8 to 2.6; Global increase in physical activity, Odds ratio 2.1; 95%CI 1.0 to 4.4) but generally not at 12 or 18 months. There were no between-group differences in most other secondary outcomes. Adverse events were mild (mostly transient increased knee pain), similar between groups and reported by approximately one-third of participants during the intervention, but were infrequent during follow-up. Co-intervention use was also similar across groups. Conclusions: Addition of telephone coaching did not augment pain and function benefits of a physiotherapist-prescribed physical activity and exercise program, although physical activity levels and adherence to home exercise were generally increased in the short-term. Our study provides novel information about the effects of telephone coaching and extends the limited research in telephone coaching for OA.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Food for Thought: The Impact of m-Health Enabled Interventions on Eating Behavior

Mobile apps have great potential to deliver promising health-related interventions to engage consumers and change their behaviors such as healthy eating. Currently, the interventions for promoting healthy eating are either too onerous to keep consumers engaged or too restrictive for consumers to act upon when receiving feedback from healthcare professionals. In addition, while social media allows individuals to receive information from many sources, it is unclear how the effect from peer engagement interacts with professional support in the context of such interventions. This study proposes and evaluates three mobile-enabled interventions to address these challenges: a mobile-based visual diary, image-based dietitian support, and peer engagement. We examined their effects on user engagement and food choices via a 4-month randomized field experiment. We show strong positive impact of the mobile-based visual diary and dietitian support on improving customer engagement. Specifically, the mobile-based visual diary and dietitian support each increases the log-odds ratio of user engagement by 43.8% and 50.7%, respectively. Mediation analysis further reveals that while the use of a mobile app increases user engagement through improved self-efficacy, the influence mechanism of dietitian support is through improved intention and enhanced transition from intention to behavior. We also identify some negative effects of peer engagements, as the log-odds ratio of customer engagement is decreased by 33.8%. This negative effect may serve to caution researchers and developers against incorporating social engagement features into their mHealth apps without adequate consideration. The effectiveness of the mobile app varies across customers, both by ethnicity and age. Young, white customers tended to benefit the most from the mobile-based interventions presented in our study. We also find that the mobile-based visual diary had a significant positive impact on fruit and vegetable consumption as well as the control of portion sizes, increasing their scores by 0.30 and 0.37, respectively; in addition, users’ overall scores for healthy eating can also be improved by providing dietitian support, albeit with smaller effect sizes. These results provide quantitative evidence that highlight the promise of mobile apps for delivering advanced interventions to engage users and facilitate health behavior change.

How to Design Tobacco Prevention and Control Games for Youth and Adolescents: A Qualitative Analysis of Expert Interviews.

Games for health, including digital videogames and gaming-based approaches, are increasingly being used in health promotion research and practice. Recently published research has shown that videogames have significant potential to promote healthy behaviors among youth and adolescents. Yet, there is a lack of available evidence-based resources to guide practitioners on the integration of games into tobacco prevention and smoking cessation interventions. To address this gap, expert researchers and game developers were interviewed to further define games for health, explore the current research, and provide recommendations for developing, evaluating, and promoting effective anti-tobacco games. Nationally recognized experts on game development, games for health, tobacco, and health behavior were asked to participate. A qualitative analysis of 25 in-depth individual interviews using a constant comparative approach for emerging themes was conducted. Main themes that emerged from the data analysis included the following: (1) the current state of games for health research to facilitate health behavior change, (2) strategies for how to develop and evaluate games for quality and impact, and (3) recommendations for how to effectively design tobacco prevention and smoking cessation educational videogames that engage youth and adolescents. The synthesized findings identified through these expert interviews offer stakeholders strategies for how to incorporate games for health within their current and future work. Specific recommendations are presented for developers and researchers to consider when developing and evaluating videogames for tobacco prevention and smoking cessation targeted at youth and adolescents.

A story of change: The influence of narrative on African-Americans with diabetes

ObjectiveTo understand if narratives can be effective tools for diabetes empowerment, from the perspective of African-American participants in a program that improved diabetes self-efficacy and self-management. MethodsIn-depth interviews and focus groups were conducted with program graduates. Participants were asked to comment on the program's film, storytelling, and role-play, and whether those narratives had contributed to their diabetes behavior change. An iterative process of coding, analyzing, and summarizing transcripts was completed using the framework approach. ResultsAfrican-American adults (n=36) with diabetes reported that narratives positively influenced the diabetes behavior change they had experienced by improving their attitudes/beliefs while increasing their knowledge/skills. The social proliferation of narrative – discussing stories, rehearsing their messages with role-play, and building social support through storytelling – was reported as especially influential. ConclusionUtilizing narratives in group settings may facilitate health behavior change, particularly in minority communities with traditions of storytelling. Theoretical models explaining narrative's effect on behavior change should consider the social context of narratives. Practice implicationsNarratives may be promising tools to promote diabetes empowerment. Interventions using narratives may be more effective if they include group time to discuss and rehearse the stories presented, and if they foster an environment conducive to social support among participants.

Integrating Motivational Interviewing with Brief Strategic Therapy for Heart Patients

Problem statementpsychological distress, obesity and unhealthy lifestyles may contribute to a worse prognosis of cardiac diseases; an important public health challenge is to motivate people and facilitate health behavior change. Research questionspecifically, aim of the current study is to test the mediating effect of motivation in improving lifestyle changes in a long term. Purpose of the studythe MOTIV-HEART (MOTivational strategies for HEART patients) study, a two-arm randomized controlled clinical trial, compares the efficacy of an alternative-integrative brief motivational intervention (MI) with the cardiac rehabilitation programmed treatment - Brief Strategic Therapy (BST) - in order to develop interventions able to improve lifestyle change among heart patients. Research methodinpatients with Coronary Artery Disease (CAD) referred to a single clinical center for cardiac rehabilitation (CR) and weight loss treatment will be randomly allocated into two conditions: a) 3 sessions of BST, b) 3 sessions of BST combined with Motivational Interviewing (MI) techniques. Data are going to be collected at baseline, discharge (1 month after) and after 3, 6, 12 months follow-up. Findingthree kinds of outcomes are going to be relieved: behavioral, psychological and biomedical. Primary outcome is the improvement of patients’ diet and physical activity at 3 months follow-up. Secondary outcomes are (a) the maintenance of healthy lifestyle habits, (b) the reduction of patients’ body mass index (BMI) and specific cardiac parameters levels, (c) the improvement of adequate psychological outcomes. Conclusionobese patients with cardiovascular diseases face numerous difficulties in achieving self-care. Motivational interviewing showed encouraging results in eliciting adoption of high-risk behavioral change, such as initiating an exercise regimen and changing diet. The rationale behind this investigation is that focusing on enhancing motivation would result in better outcomes than those brought about by existing therapy. Study is currently ongoing.

State of the Evidence Regarding Behavior Change Theories and Strategies in Nutrition Counseling to Facilitate Health and Food Behavior Change

Behavior change theories and models, validated within the field of dietetics, offer systematic explanations for nutrition-related behavior change. They are integral to the nutrition care process, guiding nutrition assessment, intervention, and outcome evaluation. The American Dietetic Association Evidence Analysis Library Nutrition Counseling Workgroup conducted a systematic review of peer-reviewed literature related to behavior change theories and strategies used in nutrition counseling. Two hundred fourteen articles were reviewed between July 2007 and March 2008, and 87 studies met the inclusion criteria. The workgroup systematically evaluated these articles and formulated conclusion statements and grades based upon the available evidence. Strong evidence exists to support the use of a combination of behavioral theory and cognitive behavioral theory, the foundation for cognitive behavioral therapy (CBT), in facilitating modification of targeted dietary habits, weight, and cardiovascular and diabetes risk factors. Evidence is particularly strong in patients with type 2 diabetes receiving intensive, intermediate-duration (6 to 12 months) CBT, and long-term (>12 months duration) CBT targeting prevention or delay in onset of type 2 diabetes and hypertension. Few studies have assessed the application of the transtheoretical model on nutrition-related behavior change. Little research was available documenting the effectiveness of nutrition counseling utilizing social cognitive theory. Motivational interviewing was shown to be a highly effective counseling strategy, particularly when combined with CBT. Strong evidence substantiates the effectiveness of self-monitoring and meal replacements and/or structured meal plans. Compelling evidence exists to demonstrate that financial reward strategies are not effective. Goal setting, problem solving, and social support are effective strategies, but additional research is needed in more diverse populations. Routine documentation and evaluation of the effectiveness of behavior change theories and models applied to nutrition care interventions are recommended.

Teaching Behavior Change Concepts and Skills During the Third-Year Medicine Clerkship

Risky health behaviors and social factors are linked to half of all causes of morbidity and mortality in the United States. Physicians report lack of training as one of the barriers to providing behavior change counseling. Formal behavior change curricula are infrequent in medical schools, and where they are available, they are often isolated from clinical experiences or presented through a limited approach. The authors developed the Health Beliefs and Behavior (HBB) course at University of Medicine and Dentistry-New Jersey Medical School (UMDNJ-NJMS) to teach the impact of unhealthy behaviors on health and wellness, to broaden students' understanding of the many factors that affect behavior, and to give medical students tools to facilitate health behavior change in patients. To the authors' knowledge, this is the only comprehensive, clinically integrated course on health behavior change in a U.S. medical school.The authors intercalated the 60-hour HBB course in the four-week, third-year internal medicine clerkship ambulatory block. Thus, students practice learned techniques in both the ambulatory and classroom settings, and they gain insight into health behavior by applying learned health models to patients and engaging in experiential exercises. Course components stress the biopsychosocial and patient-centered approach. The authors measure the impact of the course through student surveys. Third-year medical students at UMDNJ-NJMS who have completed the HBB course report enhanced understanding of the principles of behavior change and improved ability to perform behavior change counseling.

Integrated Theory of Health Behavior Change: background and intervention development.

An essential characteristic of advanced practice nurses is the use of theory in practice. Clinical nurse specialists apply theory in providing or directing patient care, in their work as consultants to staff nurses, and as leaders influencing and facilitating system change. Knowledge of technology and pharmacology has far outpaced knowledge of how to facilitate health behavior change, and new theories are needed to better understand how practitioners can facilitate health behavior change. In this article, the Integrated Theory of Health Behavior Change is described, and an example of its use as foundation to intervention development is presented. The Integrated Theory of Health Behavior Change suggests that health behavior change can be enhanced by fostering knowledge and beliefs, increasing self-regulation skills and abilities, and enhancing social facilitation. Engagement in self-management behaviors is seen as the proximal outcome influencing the long-term distal outcome of improved health status. Person-centered interventions are directed to increasing knowledge and beliefs, self-regulation skills and abilities, and social facilitation. Using a theoretical framework improves clinical nurse specialist practice by focusing assessments, directing the use of best-practice interventions, and improving patient outcomes. Using theory fosters improved communication with other disciplines and enhances the management of complex clinical conditions by providing holistic, comprehensive care.