Maintenance Of Health Behavior Change Research Articles

The NIH Science of Behavior Change Program: Looking Toward the Future

The National Institutes of Health established the Science of Behavior Change (SOBC) program to promote basic research on the initiation, personalization, and maintenance of health behavior change. The SOBC Resource and Coordinating Center now leads and supports activities to maximize the creativity, productivity, scientific rigor, and dissemination of the experimental medicine approach and experimental design resources. Here, we highlight those resources, including the Checklist for Investigating Mechanisms in Behavior-change Research (CLIMBR) guidelines introduced in this special section. We describe the ways in which SOBC can be applied across a range of domains and contexts, and end by considering ways to extend SOBC’s perspective and reach, so as to best promote behavior change linked with health, quality of life, and well-being.

Behavior Change Effectiveness Using Nutrition Apps in People With Chronic Diseases: Scoping Review

Cardiovascular disease, cancer, diabetes mellitus, and obesity are common chronic diseases, and their prevalence is reaching an epidemic level worldwide. As the impact of chronic diseases continues to increase, finding strategies to improve care, access to care, and patient empowerment becomes increasingly essential. Health care providers use mobile health (mHealth) to access clinical information, collaborate with care teams, communicate over long distances with patients, and facilitate real-time monitoring and interventions. However, these apps focus on improving general health care concerns, with limited apps focusing on specific chronic diseases and the nutrition involved in the disease state. Hence, available evidence on the effectiveness of mHealth apps toward behavior change to improve chronic disease outcomes is limited. The objective of this scoping review was to provide an overview of behavior change effectiveness using mHealth nutrition interventions in people with chronic diseases (ie, cardiovascular disease, diabetes mellitus, cancer, and obesity). We further evaluated the behavior change techniques and theories or models used for behavior change, if any. A scoping review was conducted through a systematic literature search in the MEDLINE, EBSCO, PubMed, ScienceDirect, and Scopus databases. Studies were excluded from the review if they did not involve an app or nutrition intervention, were written in a language other than English, were duplicates from other database searches, or were literature reviews. Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020 guidelines, the systematic review process included 4 steps: identification of records through the database search, screening of duplicate and excluded records, eligibility assessment of full-text records, and final analysis of included records. In total, 46 studies comprising 256,430 patients were included. There was diversity in the chronic disease state, study design, number of participants, in-app features, behavior change techniques, and behavior models used in the studies. In addition, our review found that less than half (19/46, 41%) of the studies based their nutrition apps on a behavioral theory or its constructs. Of the 46 studies, 11 (24%) measured maintenance of health behavior change, of which 7 (64%) sustained behavior change for approximately 6 to 12 months and 4 (36%) showed a decline in behavior change or discontinued app use. The results suggest that mHealth apps involving nutrition can significantly improve health outcomes in people with chronic diseases. Tailoring nutrition apps to specific populations is recommended for effective behavior change and improvement of health outcomes. In addition, some studies (7/46, 15%) showed sustained health behavior change, and some (4/46, 9%) showed a decline in the use of nutrition apps. These results indicate a need for further investigation on the sustainability of the health behavior change effectiveness of disease-specific nutrition apps.

Interdisciplinary Perspectives on Maintenance of Health Behavior Change

Modifying health behaviors can be difficult, especially for older adults who are challenged by multiple chronic conditions, reduced functional and/or cognitive capacity, and limited social support. Although much attention has been given to the theories, skills, and resources behind initiating and achieving behavior change, less work has focused on maintenance of health behaviors over time. This presentation will showcase pilot research inspired by RCCN’s first workshop, Achieving and Sustaining Behavior Change. Specifically, this pilot brings together an interdisciplinary team of behavioral scientists and health services researchers working at the intersection of intervention science and implementation science to better understand the construct of maintenance and discuss emerging methods for intervention development and evaluation. The presentation will utilize physical activity as an example behavior to demonstrate the value of interdisciplinary research, including recommendations on how some of the six NIA research centers can make unique contributions to understanding health behavior maintenance.

Success in Weight Management Among Patients with Type 2 Diabetes: Do Perceived Autonomy Support, Autonomous Motivation, and Self-Care Competence Play a Role?

ABSTRACTBased on self-determination theory (SDT), this study investigated whether the three central SDT variables—perceived autonomy support (from a physician), autonomous motivation and self-care competence—were associated with success in weight management (SWM) among primary care patients with type 2 diabetes when the effect of other important life-context factors was controlled for. Patients participated in a mail survey in 2011. Those who had tried to change their health behavior during the past two years in order to lose weight, either with or without success (n = 1433, mean age 63 years, 50% men), were included in this study. The successors were more autonomously motivated and energetic than the non-successors. Moreover, male gender, younger age, taking oral medication only, and receiving less social support in diabetes care predicted better success. Autonomous motivation predicted SWM; self-care competence also played a role by partly mediating the effect of autonomous motivation on SWM. These results support the idea of SDT that internalizing the value of weight management and its health benefits is necessary for long-term maintenance of health behavior change. Perceived autonomy support was not directly associated with SWM. However, physicians can promote patients' weight management by supporting their autonomous motivation and self-care competence.

Theoretical, Critical, and Practical Reflections on the Long-Term Maintenance of Health Behavior Change.

This commentary is in response to Joseph, Daniel, Thind, Benitez and Pekmezi (2014). They reviewed randomized controlled trials (RCTs) that included long-term follow-up assessments at least 6 months post-intervention. Their main purpose was to understand which theory or model used by researchers could help explain the long-term maintenance of health behaviors once the intervention was withdrawn in trials focused on physical activity, dietary behavior, and excessive alcohol consumption. Results showed that social cognitive theory (SCT) and transtheoretical model (TTM) were used most often and associated with long-term behavior change compared to self-determination theory (SDT), theory of planned behavior (TPB), or the social-ecological model (SEM). SDT showed encouraging findings while the evidence was unclear for the TPB and the SEM. Here it is argued that scientists should continually reflect on the utility of theory over time and the efforts by Joseph and colleagues should be commended. It is also useful to distinguish theories, which are more specified and offer more generalized statements, than models. Models, such as the TPB and SEM, have incorporated elements of other theories but are typically viewed as tools to characterize behavior. For instance, in 10 studies reviewed by Joseph and colleagues the SCT and TTM were used in an integrative manner. An example of an integrated model is presented that incorporates elements of SDT, TPB, and SCT in an effort to highlight how integrating elements from multiple theories may be useful.

Design, Development, and Formative Evaluation of a Smartphone Application for Recording and Monitoring Physical Activity Levels

Limited research exists addressing the development of health-related smartphone apps, a new and potentially effective health promotion delivery strategy. This article describes the development and formative evaluation of a smartphone app associated with a physical activity promotion website. A combination of qualitative and quantitative techniques (performance measures, direct observation, and subjective participant preferences) were implemented during two usability testing sessions (pre- and postmodification) while participants were completing tasks using the app. Design improvements to the app resulted in a reduction in the problems experienced and a decrease in the time taken to complete tasks. Four usability themes emerged from the data: design, feedback, navigation, and terminology. This study demonstrates the relevance of usability testing to the design and modification of a smartphone app related to a health promotion website. This study resulted in an app with much higher usability, which might increase usage and maintenance of health behavior change in the long term. This study demonstrates the need for formative evaluation in health-related smartphone apps. Attention should be given to basic design principles as well as feedback, navigation, and terminology in order to ensure utility and ease of use of future smartphone app designs.

Positive Affect and Self-affirmation Are Beneficial, but Do They Facilitate Maintenance of Health-Behavior Change?: A Self-determination Theory Perspective

Positive Affect and Self-affirmation Are Beneficial, but Do They Facilitate Maintenance of Health-Behavior Change?: A Self-determination Theory Perspective

Methodological overview of a self-determination theory-based computerized intervention to promote leisure-time physical activity

Objectives To provide a methodological overview of a computerized intervention to promote leisure-time physical activity (PA) and to apply self-determination theory (SDT) to PA initiation to better understand the psychological mechanisms underlying PA frequency, intensity, and duration in previously-sedentary individuals. Design Based on SDT, two computerized personal trainers were developed for use with sedentary young adults. One personal trainer was designed to be need-supportive, empathic, and structured while the other was designed to be more controlling, evaluative, and judgmental. Method Participants are randomly assigned to work with either the need-supportive or controlling computerized personal trainer. They complete a series of 7 weekly training sessions. In between training sessions, participants complete daily records of PA behaviors and experiences including autonomous self-regulation and perceived competence for PA and PA frequency, intensity, and duration. Potential contributions The design of this intervention and its theoretical basis have important implications for advancing the field of exercise science specifically and health behavior change more broadly. Computerized interventions have the benefit of standardizing intervention content as well as reducing clinical contact burden for practitioners. Daily recording procedures reduce the likelihood of retrospection bias and allow for the modeling of (1) daily fluctuations in PA behavior and (2) the psychological mechanisms believed to be involved in PA behavior (e.g., autonomous self-regulation). Finally, as a broad theory of human motivation, SDT is uniquely positioned to offer explanations for the conditions that are likely to promote both the initiation and maintenance of health behavior change.

Maintenance of physical activity and dietary change following a telephone-delivered intervention.

To examine the maintenance of behavioral changes 6 months following a telephone-delivered physical activity and diet intervention. Patients (n = 434) with Type 2 diabetes or hypertension were recruited from 10 primary care practices in a disadvantaged community; practices were randomized to a telephone-counseling intervention (TC; 5 practices, n = 228) or usual care (UC; 5 practices, n = 206). Validated, self-report measures of physical activity and diet were taken at baseline, 12 months (end-of-intervention), and 18 months (6 months postintervention completion). For physical activity, the significant (p < .001) within-groups improvements from baseline observed at 12 months remained at 18 months, in both the TC (62.2 ± 14.2 minutes/week; 2.2 ± 0.3 sessions/week) and UC (74.7 ± 14.9 minutes/week; 2.1 ± 0.4 sessions/week) groups. For all dietary outcomes, significant (p < .05) between-groups maintenance effects, similar to end-of-intervention outcomes, remained [TC-UC changes from baseline to 18 months (95% CI)]: total fat [-1.33 (-2.16, -0.50)% energy/day], saturated fat [-1.06 (-1.70, -0.43)% energy/day], fiber intake [1.90 (0.72, 3.15) grams/day], and fruit [0.22 (0.05, 0.40) servings/day]), except vegetables [0.59 (-0.01, 1.17) servings/day; p = .05]. Intervention effects across all health behavior outcomes were stronger for the subgroup (n = 145) adhering to the study protocol. Telephone-delivered interventions can promote maintenance of health behavior change. Studies with longer-term follow-up are needed, particularly to determine how intervention duration and intensity might further enhance maintenance.

The Logan Healthy Living Program: A cluster randomized trial of a telephone-delivered physical activity and dietary behavior intervention for primary care patients with type 2 diabetes or hypertension from a socially disadvantaged community — Rationale, design and recruitment

Background Physical activity and dietary behavior changes are important to both the primary prevention and secondary management of the majority of our most prevalent chronic conditions (i.e., cardiovascular disease, hypertension, type 2 diabetes, breast and colon cancer). With over 85% of Australian adults visiting a general practitioner each year, the general practice setting has enormous potential to facilitate wide scale delivery of health behaviour interventions. However, there are also many barriers to delivery in such settings, including lack of time, training, resources and remuneration. Thus there is an important need to evaluate other feasible and effective means of delivering evidence-based physical activity and dietary behaviour programs to patients in primary care, including telephone counseling interventions. Methods Using a cluster randomized design with practice as the unit of randomization, this study evaluated a telephone-delivered intervention for physical activity and dietary change targeting patients with chronic conditions (type 2 diabetes or hypertension) recruited from primary care practices in a socially disadvantaged community in Queensland, Australia. Ten practices were randomly assigned to the telephone intervention or to usual care, and 434 patients were recruited. Patients in intervention practices received a workbook and 18 calls over 12 months. Assessment at baseline, 4-, 12- and 18-months allows for assessment of initial change and maintenance of primary outcomes (physical activity and dietary behavior change) and secondary outcomes (quality of life, cost-effectiveness, support for health behavior change). Conclusions This effectiveness trial adds to the currently limited number of telephone-delivered intervention studies targeting both physical activity and dietary change. It also addresses some of the shortcomings of previous trials by targeting patients from a disadvantaged community, and by including detailed reporting on participant representativeness, intervention implementation and cost-effectiveness, as well as an evaluation of maintenance of health behavior change.

Commentary: Psychosocial Functioning of Children and Adolescents Surviving Cancer: The Junior Investigators’ Perspective

In their articles, Patenaude and Kupst (2005) and Kazak (2005) have aptly provided the next generation of pediatric psycho-oncologists with not only a thorough review of how far we have come but also a direction for future research in the field of pediatric psycho-oncology. Patenaude and Kupst highlight that although substantial progress has been made in a relatively short period, we are only beginning to understand what the psychosocial needs of patients and their families are and how to address them. In both articles, the authors comment that as methods of treatment for cancer have improved and as length of survival has increased, the needs of children and families have changed. For instance, Kazak points out that advances in pharmacological treatments for pain management have decreased the need among some patients for traditional cognitive behavioral therapy for pain management. Patenaude and Kupst point out that as length of survival increases, the need for management of late effects—for example, neurocognitive deficits, infertility, cardiotoxicity—is quickly becoming a burgeoning area of study. Other pertinent issues for children with cancer and their families are decision making regarding treatment options, patient–provider communication, end-of-life care, genetic counseling, and the need to reach out to racial and ethnic minority groups. There is also a need to develop innovative psychosocial interventions that can be feasibly disseminated in practice. An area of research that has yet to be explored in psycho-oncology is the concept of “burden” related to treatment and survivorship. As trends in pediatric oncology continue to emphasize outpatient care over inpatient care, home-based support services over clinic support services, and the growing potential for oral versus intravenous chemotherapy, patients and families are likely to experience an increase in their amount of burden, including that of care, psychological well-being, financial management, and compliance and adherence. Additionally, as the survivors of today transition through the stages of life, there will be a need to understand the extent and type of burden subsequent to disease and medical treatment that is placed on the survivors and their family members in regard to securing health insurance, education, employment, and social relationships. Such research has potential for informing health care (acute and follow-up) and for guiding survivors’ longterm planning. Attention to the transition into adulthood will likely need to include a focus on how best to promote optimal health and avert health behaviors that compromise the quality of survival—namely, smoking, poor diet, and physical inactivity. There may be “teachable” moments (e.g., as children end treatment) when the delivery of such health messages may have a more robust effect. Strategies to reach and communicate such messages with this growing cohort of survivors will need to be better developed and implemented. To address these emerging issues, young investigators will need to build on the foundation of extant research in pediatric psycho-oncology and develop new theories, improve methodology to obtain meaningful data, and continue efforts to develop evidence-based interventions. Young investigators in pediatric psycho-oncology will need to ask whether current theoretical frameworks are sufficient to guide research questions and hypotheses. For example, areas of research emphasis in long-term cancer survivorship are shifting to include long-term psychosocial effects, health behaviors, posttreatment surveillance, and health care utilization (Aziz & Rowland, 2003). What are needed are theoretical frameworks that address the trajectory from illness, to treatment, to long-term survivorship. Frameworks that address posttraumatic growth or maintenance of health behavior change may

Promoting the maintenance of health behavior change: Recommendations for the next generation of research and practice.

Promoting the maintenance of health behavior change: Recommendations for the next generation of research and practice.

Promoting the maintenance of health behavior change: Recommendations for the next generation of research and practice.

This article highlights several broad themes that emerged from the series of papers presented at the National Heart, Lung, and Blood Institute conference, "Maintenance of Behavior Change in Cardiorespiratory Risk Reduction," with a view to generating recommendations for the next generation of research and practice. Major recommendations center around the need for (a) new models of population health behavior change and maintenance that integrate individual-level with broader environmental and macro-level policy influences; (b) a fuller model of the maintenance process, which views maintenance more as a journey than as a destination; and (c) more theory-based and interdisciplinary research on the maintenance process and on strategies for assisting special populations and addressing more than one behavioral risk at a time.

The Index of Self-Regulation: Development and Psychometric Analysis

This paper describes the development and initial psychometric evaluation of a measure of individual self-regulation in the maintenance of health behavior change. Items were developed from inductively generated data to index dimensions of self-regulation in behavioral change (Fleury, 1991). Quantification of Index of Self-Regulation (ISR) content validity was supported through the ratings of 10 experts, following criteria established by Imle and Atwood (1988). The instrument was tested in successive steps with 146 individuals who were participating in an outpatient cardiac rehabilitation program for reliability and validity, including internal consistency reliability and three forms of validity assessment (content validity, criterion-related validity, and construct validity). The three subscales of Stimulus Control, Reconditioning, and Behavioral Monitoring demonstrated internal consistency ranging from .73-.76. Total scale alpha was .87. Initial estimates of criterion-related and construct validity were documented with correlations between ISR subscales and theoretically related criterion measures (.20-.47). With refinement the ISR will provide a basis for tailoring and evaluating clinical interventions designed to enhance motivation in the maintenance of health behavior change.

Health promotion in context: the effects of significant others on health behavior change.

Maintenance of health behavior change over the long-term has been routinely difficult. One of the reasons for this difficulty is that only individuals' attitudes or behavior are changed, without concomitant support from the social environment. The purpose of this study was to explore several of the ways in which significant others--family members, friends, and coworkers--may affect changes in health behavior. Eighty-four participants in a work site health promotion program were the subjects of the study. Self-reports of health behaviors were gathered at baseline and at the end of the 7-week program; in addition, subjects reported the extent to which significant others generally supported health behavior changes, encouraged them to maintain changes they had made, and made changes in their own health behaviors. Results provide support for the general hypothesis that one individual attempting to change health behavior may be positively influenced by significant others during the course of the change process. Family members were particularly helpful, and overall supportiveness was more helpful than others' change in health habits or encouragement. Behaviors most influenced by others were exercise and fat consumption. Suggestions for future theoretical development, research, and intervention are discussed.

Health Promotion in the Workplace: Suggested Directions for Research

Health promotion programming in the workplace is one of the most promising developments in health care during the last decade. In an era when employee health care costs have doubled for most companies in less than ten years, ~ employer-sponsored health promotion programs offer the potential long-term benefits of decreasing health care claims, lowering absenteeism and enhancing worker health, morale and productivity? -~ The first generation of health promotion research studies in worksites focused primarily on cost benefit or cost effectiveness analysis of programs. Bottom line concerns were addressed to determine the monetary impact of these new health ventures. 6-~ While some of the early studies were too small in sample size or too weak methodologically to produce sound data, recent large-scale studies provide support for employer savings as a result of health promotion efforts. 9A~ Although further longitudinal studies of the cost impact of health promotion programs need to be conducted, the purpose of this Research Agenda section is to identify additional directions for the second generation of research studies on health promotion in the workplace. Three areas suggested for emphasis in future research efforts include: 1) factors influencing maintenance of health behavior change over time, 2) characteristics of health strengthening work environments, and 3) considerations in structuring health promotion efforts for an increasingly diverse workforce.

47 THE EFFECTS OF PARENTAL COOPERATION ON MAINTENANCE CF WEIGHT LOSS IN OBESE CHILDREN

Maintenance of health behavior change is one of the most difficult problems in preventive medicine. The present study evaluated the effects of including obese parents as weight loss participants in the treatment of obese 6-12 year old children. Seventy-six families with at least one obese child and parent were randomly assigned to one of three treatment groups: Group I included both the parent and child as weight loss targets; Group II had only the child as the target, and Group III did not specify either as the target. Participants were provided an eight-month behaviorally oriented treatment designed to change both eating and exercise habits, and a two year follow-up. Child results showed highly significant (p<.01) changes from pretreatment to the 8 month follow-up in relative weight across all three groups, with Groups I (17.1%) and II (18.7%) showing superior changes compared to Group III (13.8%). At the two year follow-up, all groups were still significantly less (10%) than at pretreatment, with no differences across groups. However, very different patterns of maintenance emerged, with all the children in Group I who were non-obese at the 8 month point still non-obese (7/7), while 40% of children in Groups II (4/10) and III (2/5) were still non-obese (p<.05). These results clearly show that weight loss can be maintained in obese pre-adolescents, and that active parental involvement is an important component.