Health-related Behavior Change Research Articles

Psychological, behavioral and social effects of disclosing Alzheimer's disease biomarkers to research participants: a systematic review.

BackgroundCurrent Alzheimer’s disease (AD) research initiatives focus on cognitively healthy individuals with biomarkers that are associated with the development of AD. It is unclear whether biomarker results should be returned to research participants and what the psychological, behavioral and social effects of disclosure are. This systematic review therefore examines the psychological, behavioral and social effects of disclosing genetic and nongenetic AD-related biomarkers to cognitively healthy research participants.MethodsWe performed a systematic literature search in eight scientific databases. Three independent reviewers screened the identified records and selected relevant articles. Results extracted from the included articles were aggregated and presented per effect group.ResultsFourteen studies met the inclusion criteria and were included in the data synthesis. None of the identified studies examined the effects of disclosing nongenetic biomarkers. All studies but one concerned the disclosure of APOE genotype and were conducted in the USA. Study populations consisted largely of cognitively healthy first-degree relatives of AD patients. In this group, disclosure of an increased risk was not associated with anxiety, depression or changes in perceived risk in relation to family history. Disclosure of an increased risk did lead to an increase in specific test-related distress levels, health-related behavior changes and long-term care insurance uptake and possibly diminished memory functioning.ConclusionIn cognitively healthy research participants with a first-degree relative with AD, disclosure of APOE ε4-positivity does not lead to elevated anxiety and depression levels, but does increase test-related distress and results in behavior changes concerning insurance and health. We did not find studies reporting the effects of disclosing nongenetic biomarkers and only one study included people without a family history of AD. Empirical studies on the effects of disclosing nongenetic biomarkers and of disclosure to persons without a family history of AD are urgently needed.Trial registrationPROSPERO international prospective register for systematic reviews CRD42016035388. Registered 19 February 2016.Electronic supplementary materialThe online version of this article (doi:10.1186/s13195-016-0212-z) contains supplementary material, which is available to authorized users.

Can Mobile Phone Apps Influence People's Health Behavior Change? An Evidence Review.

BackgroundGlobally, mobile phones have achieved wide reach at an unprecedented rate, and mobile phone apps have become increasingly prevalent among users. The number of health-related apps that were published on the two leading platforms (iOS and Android) reached more than 100,000 in 2014. However, there is a lack of synthesized evidence regarding the effectiveness of mobile phone apps in changing people’s health-related behaviors.ObjectiveThe aim was to examine the effectiveness of mobile phone apps in achieving health-related behavior change in a broader range of interventions and the quality of the reported studies.MethodsWe conducted a comprehensive bibliographic search of articles on health behavior change using mobile phone apps in peer-reviewed journals published between January 1, 2010 and June 1, 2015. Databases searched included Medline, PreMedline, PsycINFO, Embase, Health Technology Assessment, Education Resource Information Center (ERIC), and Cumulative Index to Nursing and Allied Health Literature (CINAHL). Articles published in the Journal of Medical Internet Research during that same period were hand-searched on the journal’s website. Behavior change mechanisms were coded and analyzed. The quality of each included study was assessed by the Cochrane Risk of Bias Assessment Tool.ResultsA total of 23 articles met the inclusion criteria, arranged under 11 themes according to their target behaviors. All studies were conducted in high-income countries. Of these, 17 studies reported statistically significant effects in the direction of targeted behavior change; 19 studies included in this analysis had a 65% or greater retention rate in the intervention group (range 60%-100%); 6 studies reported using behavior change theories with the theory of planned behavior being the most commonly used (in 3 studies). Self-monitoring was the most common behavior change technique applied (in 12 studies). The studies suggest that some features improve the effectiveness of apps, such as less time consumption, user-friendly design, real-time feedback, individualized elements, detailed information, and health professional involvement. All studies were assessed as having some risk of bias.ConclusionsOur results provide a snapshot of the current evidence of effectiveness for a range of health-related apps. Large sample, high-quality, adequately powered, randomized controlled trials are required. In light of the bias evident in the included studies, better reporting of health-related app interventions is also required. The widespread adoption of mobile phones highlights a significant opportunity to impact health behaviors globally, particularly in low- and middle-income countries.

A Qualitative Study of How Health Coaches Support Patients in Making Health-Related Decisions and Behavioral Changes.

Although health coaches are a growing resource for supporting patients in making health decisions, we know very little about the experience of health. We undertook a qualitative study of how health coaches support patients in making decisions and implementing changes to improve their health. We conducted 6 focus groups (3 in Spanish and 3 in English) with 25 patients and 5 friends or family members, followed by individual interviews with 42 patients, 17 family members, 17 health coaches, and 20 clinicians. Audio recordings were transcribed and analyzed by at least 2 members of the study team in ATLAS.ti using principles of grounded theory to identify themes and the relationship between them. We identified 7 major themes that were related to each other in the final conceptual model. Similarities between health coaches and patients and the time health coaches spent with patients helped establish the health coach-patient relationship. The coach-patient relationship allowed for, and was further strengthened by, 4 themes of key coaching activities: education, personal support, practical support, and acting as a bridge between patients and clinicians. We identified a conceptual model that supports the development of a strong relationship, which in turn provides the basis for effective coaching. These results can be used to design health coach training curricula and to support health coaches in practice.

Measuring Concurrency Attitudes: Development and Validation of a Vignette-Based Scale.

BackgroundConcurrent sexual partnerships (partnerships that overlap in time) may contribute to higher rates of HIV transmission in African Americans. Attitudes toward a behavior constitute an important component of most models of health-related behavior and behavioral change. We have developed a scale, employing realistic vignettes that appear to reliably measure attitudes about concurrency in young African American adults.MethodsVignette-based items to assess attitudes about concurrency were developed following focus groups and cognitive testing of items adapted from existing scales assessing psychosocial constructs surrounding related sexual behaviors. The new items were included in a telephone survey of African American adults (18–34 years old) in Eastern North Carolina immediately before and after a radio campaign designed to discourage concurrency. We performed an exploratory factor analysis on each sample (pre- and post-campaign) to cross-validate results. We retained factors with a primary loading of ≥0.50 and no secondary loading >0.30. Cronbach’s coefficient alpha was used to evaluate internal reliability. Associations in the predicted direction between the mean responses to items on the final factor and known correlates of concurrency validated the scale.ResultsFactor analysis in a random pre-campaign subsample yielded a one-factor 6-item scale with acceptable internal consistency (Cronbach’s α = 0.79). As expected, the attitude factor was positively associated with participation in concurrent partnerships, whether assessed by self-report (r = 0.298, p<0.0001) or deduced from dates of recent sexual partnerships (r = 0.298, p<0.0001). The factor was also positively associated with alcohol (r = 0.216, p<0.0001) and drug use (r = 0.225, p<0.0001) and negatively associated with increasing age (r = -0.088, p- = 0.02) and female gender (r = -0.232, p<0.0001). Factor analyses repeated in the second random pre-campaign subsample and post-campaign sample confirmed these results.ConclusionA vignette-based scale may be an effective measure of key attitudes related to concurrency and potentially a useful tool to evaluate interventions addressing this network pattern.

Coming of age, becoming obese: a cross-sectional analysis of obesity among adolescents and young adults in Malaysia.

BackgroundMalaysians have become increasingly obese over recent years. The transition from adolescence to early adulthood is recognized as critical for the development of eating and activity habits. However, little obesity-related research focuses on this life stage. Drawing on data from a health and demographic surveillance site in Malaysia, this article describes obesity and overweight amongst adolescents and young adults in a multi-ethnic population.MethodsData were collected at the South East Asia Community Observatory (SEACO) in Segamat District, Johor. In this dynamic cohort of approximately 40,000 people, 5,475 were aged 16–35 in 2013–2014. The population consists of Malay, Chinese, Indian and Indigenous (Orang Asli) families in proportions that reflect the national ethnic diversity. Data were collected through health profiles (Body Mass Index [BMI] measurements in homes) and self-report questionnaires.ResultsAge and ethnicity were associated with overweight (BMI 25.0–29.9Kg/m2) and obesity (BMI ≥ 30Kg/m2). The prevalence of overweight was 12.8 % at ages 16–20 and 28.4 % at ages 31–35; obesity was 7.9 % and 20.9 % at the same age groups. The main ethnic groups also showed varied patterns of obesity and overweight at the different age groups with Chinese at lowest and Orang Asli at highest risk. Level of education, employment status, physical activity and frequency of eating out were poorly predictive of overweight and obesity.ConclusionThe pattern of overweight and obesity in the 16–35 age group further highlights this as a significant period for changes in health-related behaviours. Further longitudinal research is however needed to confirm the observed pattern and investigate causal factors.

Using health psychology to help patients: theories of behaviour change.

Behaviour change theories and related research evidence highlight the complexity of making and sticking to health-related behaviour changes. These theories make explicit factors that influence behaviour change, such as health beliefs, past behaviour, intention, social influences, perceived control and the context of the behaviour. Nurses can use this information to understand why a particular patient may find making recommended health behaviour changes difficult and to determine factors that may help them. This article outlines five well-established theories of behaviour change: the health belief model, the theory of planned behaviour, the stages of change model, self-determination theory, and temporal self-regulation theory. The evidence for interventions that are informed by these theories is then explored and appraised. The extent and quality of evidence varies depending on the type of behaviour and patients targeted, but evidence from randomised controlled trials indicates that interventions informed by theory can result in behaviour change.

Effect of personalized nutrition on health-related behaviour change: evidence from the Food4Me European randomized controlled trial.

Optimal nutritional choices are linked with better health, but many current interventions to improve diet have limited effect. We tested the hypothesis that providing personalized nutrition (PN) advice based on information on individual diet and lifestyle, phenotype and/or genotype would promote larger, more appropriate, and sustained changes in dietary behaviour. : Adults from seven European countries were recruited to an internet-delivered intervention (Food4Me) and randomized to: (i) conventional dietary advice (control) or to PN advice based on: (ii) individual baseline diet; (iii) individual baseline diet plus phenotype (anthropometry and blood biomarkers); or (iv) individual baseline diet plus phenotype plus genotype (five diet-responsive genetic variants). Outcomes were dietary intake, anthropometry and blood biomarkers measured at baseline and after 3 and 6 months' intervention. At baseline, mean age of participants was 39.8 years (range 18-79), 59% of participants were female and mean body mass index (BMI) was 25.5 kg/m 2 . From the enrolled participants, 1269 completed the study. Following a 6-month intervention, participants randomized to PN consumed less red meat [-5.48 g, (95% confidence interval:-10.8,-0.09), P = 0.046], salt [-0.65 g, (-1.1,-0.25), P = 0.002] and saturated fat [-1.14 % of energy, (-1.6,-0.67), P < 0.0001], increased folate [29.6 µg, (0.21,59.0), P = 0.048] intake and had higher Healthy Eating Index scores [1.27, (0.30, 2.25), P = 0.010) than those randomized to the control arm. There was no evidence that including phenotypic and phenotypic plus genotypic information enhanced the effectiveness of the PN advice. Among European adults, PN advice via internet-delivered intervention produced larger and more appropriate changes in dietary behaviour than a conventional approach.

Complementary Tools to Empower and Sustain Behavior Change

Improving health behaviors is fundamental to preventing and controlling chronic disease. Healthcare providers who have a patient-centered communication style and appropriate behavioral change tools can empower patients to engage in and sustain healthy behaviors. This review highlights motivational interviewing and mindfulness along with other evidence-based strategies for enhancing patient-centered communication and the behavior change process. Motivational interviewing and mindfulness are especially useful for empowering patients to set self-determined, or autonomous, goals for behavior change. This is important because autonomously motivated behavioral change is more sustainable. Additional strategies such as self-monitoring are discussed as useful for supporting the implementation and maintenance of goals. Thus, there is a need for healthcare providers to develop such tools to empower sustained behavior change. The additional support of a new role, a health coach who specializes in facilitating the process of health-related behavior change, may be required to substantially impact public health.

Theoretical domains framework to assess barriers to change for planning health care quality interventions: a systematic literature review.

BackgroundTheoretical domains framework (TDF) provides an integrative model for assessing barriers to behavioral changes in order to suggest interventions for improvement in behavior and ultimately outcomes. However, there are other tools that are used to assess barriers.ObjectiveThe objective of this study is to determine the degree of concordance between domains and constructs identified in two versions of the TDF including original (2005) and refined version (2012) and independent studies of other tools.MethodsWe searched six databases for articles that studied barriers to health-related behavior changes of health care professionals or the general public. We reviewed quantitative papers published in English which included their questionnaires in the article. A table including the TDF domains of both original and refined versions and related constructs was developed to serve as a reference to describe the barriers assessed in the independent studies; descriptive statistics were used to express the results.ResultsOut of 552 papers retrieved, 50 were eligible to review. The barrier domains explored in these articles belonged to two to eleven domains of the refined TDF. Eighteen articles (36%) used constructs outside of the refined version. The spectrum of barrier constructs of the original TDF was broader and could meet the domains studied in 48 studies (96%). Barriers in domains of “environmental context and resources”, “beliefs about consequences”, and “social influences” were the most frequently explored in 42 (84%), 37 (74%), and 33 (66%) of the 50 articles, respectively.ConclusionBoth refined and original TDFs cataloged barriers measured by the other studies that did not use TDF as their framework. However, the original version of TDF explored a broader spectrum of barriers than the refined version. From this perspective, the original version of the TDF seems to be a more comprehensive tool for assessing barriers in practice.

Some current dimensions of the behavioral economics of health-related behavior change

Health-related behaviors such as tobacco, alcohol and other substance use, poor diet and physical inactivity, and risky sexual practices are important targets for research and intervention. Health-related behaviors are especially pertinent targets in the United States, which lags behind most other developed nations on common markers of population health. In this essay we examine the application of behavioral economics, a scientific discipline that represents the intersection of economics and psychology, to the study and promotion of health-related behavior change. More specifically, we review what we consider to be some core dimensions of this discipline when applied to the study health-related behavior change. Behavioral economics (1) provides novel conceptual systems to inform scientific understanding of health behaviors, (2) translates scientific understanding into practical and effective behavior-change interventions, (3) leverages varied aspects of behavior change beyond increases or decreases in frequency, (4) recognizes and exploits trans-disease processes and interventions, and (5) leverages technology in efforts to maximize efficacy, cost effectiveness, and reach. These dimensions are overviewed and their implications for the future of the field discussed.

Identifying content-based and relational techniques to change behaviour in motivational interviewing

ABSTRACT Motivational interviewing (MI) is a complex intervention comprising multiple techniques aimed at changing health-related motivation and behaviour. However, MI techniques have not been systematically isolated and classified. This study aimed to identify the techniques unique to MI, classify them as content-related or relational, and evaluate the extent to which they overlap with techniques from the behaviour change technique taxonomy version 1 [BCTTv1; Michie, S., Richardson, M., Johnston, M., Abraham, C., Francis, J., Hardeman, W., … Wood, C. E. (2013). The behavior change technique taxonomy (v1) of 93 hierarchically clustered techniques: Building an international consensus for the reporting of behavior change interventions. Annals of Behavioral Medicine, 46, 81–95]. Behaviour change experts (n = 3) content-analysed MI techniques based on Miller and Rollnick’s [(2013). Motivational interviewing: Preparing people for change (3rd ed.). New York: Guildford Press] conceptualisation. Each technique was then coded for independence and uniqueness by independent experts (n = 10). The experts also compared each MI technique to those from the BCTTv1. Experts identified 38 distinct MI techniques with high agreement on clarity, uniqueness, preciseness, and distinctiveness ratings. Of the identified techniques, 16 were classified as relational techniques. The remaining 22 techniques were classified as content based. Sixteen of the MI techniques were identified as having substantial overlap with techniques from the BCTTv1. The isolation and classification of MI techniques will provide researchers with the necessary tools to clearly specify MI interventions and test the main and interactive effects of the techniques on health behaviour. The distinction between relational and content-based techniques within MI is also an important advance, recognising that changes in motivation and behaviour in MI is a function of both intervention content and the interpersonal style in which the content is delivered.

Impact of emergency department visit on disease self-management in adults with depression.

Unexpected health-endangering events that lead to an emergency department visit may be perceived as "wake-up calls" and induce significant changes in health-related behavior ("health shock" effect). This study uses two waves of a survey of 826 adults with depression and finds that having an emergency department visit(s) increased medication adherence by 7.6 percentage points ( p < 0.05) relative to non-emergency department visitors but had no significant effect on counseling attendance (0.02% points, p = 0.380). Emergency department visits may provide an opportune teachable moment to initiate targeted interventions for positive behavioral change in adults with depression.

A Review of the Literature on Remote Monitoring Technology in Incentive-Based Interventions for Health-Related Behavior Change.

Use of technology (e.g., Internet, cell phones) to allow remote implementation of incentives interventions for health-related behavior change is growing. To our knowledge, there has yet to be a systematic review of this literature reported. The present report provides a systematic review of the controlled studies where technology was used to remotely implement financial incentive interventions targeting substance use and other health behaviors published between 2004 and 2015. For inclusion in the review, studies had to use technology to remotely accomplish one of the following two aims alone or in combination: (a) monitor the target behavior, or (b) deliver incentives for achieving the target goal. Studies also had to examine financial incentives (e.g., cash, vouchers) for health-related behavior change, be published in peer-reviewed journals, and include a research design that allowed evaluation of the efficacy of the incentive intervention relative to another condition (e.g., non-contingent incentives, treatment as usual). Of the 39 reports that met inclusion criteria, 18 targeted substance use, 10 targeted medication adherence or home-based health monitoring, and 11 targeted diet, exercise, or weight loss. All 39 (100%) studies used technology to facilitate remote monitoring of the target behavior, and 26 (66.7%) studies also incorporated technology in the remote delivery of incentives. Statistically significant intervention effects were reported in 71% of studies reviewed. Overall, the results offer substantial support for the efficacy of remotely implemented incentive interventions for health-related behavior change, which have the potential to increase the cost-effectiveness and reach of this treatment approach.

The Healthy Children, Strong Families intervention promotes improvements in nutrition, activity and body weight in American Indian families with young children.

American Indian children of pre-school age have disproportionally high obesity rates and consequent risk for related diseases. Healthy Children, Strong Families was a family-based randomized trial assessing the efficacy of an obesity prevention toolkit delivered by a mentor v. mailed delivery that was designed and administered using community-based participatory research approaches. During Year 1, twelve healthy behaviour toolkit lessons were delivered by either a community-based home mentor or monthly mailings. Primary outcomes were child BMI percentile, child BMI Z-score and adult BMI. Secondary outcomes included fruit/vegetable consumption, sugar consumption, television watching, physical activity, adult health-related self-efficacy and perceived health status. During a maintenance year, home-mentored families had access to monthly support groups and all families received monthly newsletters. Family homes in four tribal communities, Wisconsin, USA. Adult and child (2-5-year-olds) dyads (n 150). No significant effect of the mentored v. mailed intervention delivery was found; however, significant improvements were noted in both groups exposed to the toolkit. Obese child participants showed a reduction in BMI percentile at Year 1 that continued through Year 2 (P<0·05); no change in adult BMI was observed. Child fruit/vegetable consumption increased (P=0·006) and mean television watching decreased for children (P=0·05) and adults (P=0·002). Reported adult self-efficacy for health-related behaviour changes (P=0·006) and quality of life increased (P=0·02). Although no effect of delivery method was demonstrated, toolkit exposure positively affected adult and child health. The intervention was well received by community partners; a more comprehensive intervention is currently underway based on these findings.

Why is changing health-related behaviour so difficult?

ObjectiveTo demonstrate that six common errors made in attempts to change behaviour have prevented the implementation of the scientific evidence base derived from psychology and sociology; to suggest a new approach which incorporates recent developments in the behavioural sciences. Study designThe role of health behaviours in the origin of the current epidemic of non-communicable disease is observed to have driven attempts to change behaviour. It is noted that most efforts to change health behaviours have had limited success. This paper suggests that in policy-making, discussions about behaviour change are subject to six common errors and that these errors have made the business of health-related behaviour change much more difficult than it needs to be. MethodsOverview of policy and practice attempts to change health-related behaviour. ResultsThe reasons why knowledge and learning about behaviour have made so little progress in alcohol, dietary and physical inactivity-related disease prevention are considered, and an alternative way of thinking about the behaviours involved is suggested. This model harnesses recent developments in the behavioural sciences. ConclusionIt is important to understand the conditions preceding behaviour psychologically and sociologically and to combine psychological ideas about the automatic and reflective systems with sociological ideas about social practice.

Integrative health coaching: a behavior skills approach that improves HbA1c and pharmacy claims-derived medication adherence

ObjectiveMedication adherence requires underlying behavior skills and a supporting mindset that may not be addressed with education or reminders. Founded in the study of internal motivation and health psychology, integrative...

Hypertension Health Promotion via Text Messaging at a Community Health Center in South Africa: A Mixed Methods Study.

BackgroundThe use of mobile phones to deliver health care (mHealth) is increasing in popularity due to the high prevalence of mobile phone penetration. This is seen in developing countries, where mHealth may be particularly useful in overcoming traditional access barriers. Non-communicable diseases may be particularly amenable to mHealth interventions, and hypertension is one with an escalating burden in the developing world.ObjectiveThe objective of this study was to test whether the dissemination of health information via a short message service (SMS) led to improvements in health knowledge and self-reported health-related behaviors.MethodsA mixed methods study was carried out among a cohort of 223 hypertension clinic patients, in a resource-poor setting in Cape Town, South Africa, in 2012. Hypertensive outpatients were recruited at the clinic and administered a baseline questionnaire to establish existing knowledge of hypertension. Participants were then randomly assigned to intervention or control groups. The intervention group received 90 SMSes over a period of 17 weeks. Thereafter, the baseline questionnaire was readministered to both groups to gauge if any improvements in health knowledge had occurred. Those who received SMSes were asked additional questions about health-related behavior changes. A focus group was then conducted to obtain in-depth feedback about participants’ experience with, and response to, the SMS campaign.ResultsNo statistically significant changes in overall health knowledge were observed between the control and intervention groups. The intervention group had positive increases in self-reported behavior changes. These were reaffirmed by the focus groups, which also revealed a strong preference for the SMS campaign and the belief that the SMSes acted as a reminder to change, as opposed to providing new information.ConclusionsAlthough the content of the SMSes was not new, and did not improve health knowledge, SMSes were effective in motivating positive self-reported behavior change among hypertensive patients.Trial RegistrationPan African Clinical Trials Registry Number: PACTR201412000968462. Registered 18 December 2014 (Archived by WebCite at http://www.webcitation.org/6fhtyLRcO).

Population-based evaluation of the 'LiveLighter' healthy weight and lifestyle mass media campaign.

The Western Australian (WA) ‘LiveLighter’ (LL) mass media campaign ran during June–August and September–October 2012. The principal campaign ad graphically depicts visceral fat of an overweight individual (‘why’ change message), whereas supporting ads demonstrate simple changes to increase activity and eat healthier (‘how’ to change message). Cross-sectional surveys among population samples aged 25–49 were undertaken pre-campaign (N = 2012) and following the two media waves (N = 2005 and N = 2009) in the intervention (WA) and comparison state (Victoria) to estimate the population impact of LL. Campaign awareness was 54% after the first media wave and overweight adults were more likely to recall LL and perceive it as personally relevant. Recall was also higher among parents, but equal between socio-economic groups. The ‘why’ message about health-harms of overweight rated higher than ‘how’ messages about lifestyle change, on perceived message effectiveness which is predictive of health-related intention and behaviour change. State-by-time interactions showed population-level increases in self-referent thoughts about the health-harms of overweight (P < 0.05) and physical activity intentions (P < 0.05). Endorsement of stereotypes of overweight individuals did not increase after LL aired. LL was associated with some population-level improvements in proximal and intermediate markers of campaign impact. However, sustained campaign activity will be needed to impact behaviour.

Causal pathways linking environmental change with health behaviour change: Natural experimental study of new transport infrastructure and cycling to work

BackgroundMechanisms linking changes to the environment with changes in physical activity are poorly understood. Insights into mechanisms of interventions can help strengthen causal attribution and improve understanding of divergent response patterns. We examined the causal pathways linking exposure to new transport infrastructure with changes in cycling to work. MethodsWe used baseline (2009) and follow-up (2012) data (N=469) from the Commuting and Health in Cambridge natural experimental study (Cambridge, UK). Exposure to new infrastructure in the form of the Cambridgeshire Guided Busway was defined using residential proximity. Mediators studied were changes in perceptions of the route to work, theory of planned behaviour constructs and self-reported use of the new infrastructure. Outcomes were modelled as an increase, decrease or no change in weekly cycle commuting time. We used regression analyses to identify combinations of mediators forming potential pathways between exposure and outcome. We then tested these pathways in a path model and stratified analyses by baseline level of active commuting. ResultsWe identified changes in perceptions of the route to work, and use of the cycle path, as potential mediators. Of these potential mediators, only use of the path significantly explained (85%) the effect of the infrastructure in increasing cycling. Path use also explained a decrease in cycling among more active commuters. ConclusionThe findings strengthen the causal argument that changing the environment led to changes in health-related behaviour via use of the new infrastructure, but also show how some commuters may have spent less time cycling as a result.

Improvement of Oral Environment Indices of Oral Preventive Care Program, and Change in Oral Health-related Behaviors based on Dental Hygiene Process

This study aims to ensure the autonomy of dental hygienists through an oral preventive care program based on the dental hygiene process, and to provide basic data to support systematic and professional oral care. It was intended to determine changes in patients’ oral-related knowledge, awareness, practice, OHB and other various oral hygiene care indices through the dental hygiene process. Data analysis was performed using IBM SPSS Statistics (version 21.0), and statistical significance level was set at p<0.05. Frequency analysis was performed for general characteristics and two-way repeated measures ANOVA was performed to compare changes in the oral health care indices of the dental hygiene process. In addition, paired t-test was performed to compare differences in oral health knowledge, awareness, practice and OHB, and bivariate correlation analysis was performed to determine correlations between them. In the results of this study, it was found that there were significant decreases in S-0HI, PSR Score and BOP, O’ Leary through the dental hygiene process, showing that the oral preventive care program was effective (p<.001). Oral health knowledge, awareness, practice and OHB were also found to be significantly increased, revealing that there were positive changes (p<.001). It is expected that the clinical application of this dental hygiene program would be established as an effective manual to improve the oral environment.