Support Behavior Change Research Articles

Midstream Players Determine Population-Level Behavior Change: Social Marketing Research to Increase Demand for Lead-Free Components in Pitcher Pumps in Madagascar.

Lead (Pb) exposure through water contamination is an important issue at the intersection of public health and water, sanitation, and hygiene (WASH). Behavior-change programs designed to address this pressing problem rarely take a behavioral-science-informed approach, nor do they consider the role of intermediate players who often influence and support behavior change. Social marketing segments the population and focuses on the consumer/user throughout program development and implementation. To illustrate the social marketing process, this cross-sectional, qualitative design study investigates the use of Pb in the construction and maintenance of household pitcher pumps for potable water in Madagascar. A sample of 18 technicians were interviewed on their current practices, motivators, barriers, and communication channels for knowledge exchange. The results reveal the importance of peers, those considered experts or “market mavens”, and the need for information on the dangers of Pb as an outdated practice for any future intervention. This study advances the notion of a design shift within engineering WASH projects, whereby social/behavioral approaches are used to consider the needs, concerns, and current behaviors of the consumer. We also advocate for engaging intermediate players who often influence behavior change in the rollout of an engineering innovation.

Using Theories of Behavior Change to Develop Interventions for Healthy Aging.

Healthy aging requires people to adopt and maintain beneficial behaviors in all stages of the life span. Supporting behavior change, including via the motivation to make and maintain those changes, is therefore important for the promotion of healthy aging. The aim of this overview is to introduce theoretical frameworks from the psychology of motivation that lend themselves to the development of effective interventions promoting behavior change conducive to healthy aging. We discuss theoretical frameworks referring to the determinants, properties, and functionality of goals aimed at behavior change, and consider the implications of the various theories for designing interventions to support healthy aging. We first consider theories that focus on beliefs and attitudes as determinants of goals, then we address theories that focus on the structure and content as important properties of goals, and, finally, we examine theories drawing on conscious and nonconscious processes underlying the functionality of these goals. We will present if-then planning and mental contrasting, as well as nudging and boosting, that is, novel strategies of behavior change that support the creation of scalable interventions for healthy aging across the life span. Against this background, new perspectives emerge for modern, state-of-the-art, and individually tailored interventions with the aim of enhancing older people's healthy living.

Leveraging Emergent Social Networks to Reduce Sedentary Behavior in Low-Income Parents With Preschool-Aged Children.

This study tested the hypothesis that parents participating in a pediatric obesity intervention who formed social network ties with a parent in the intervention arm would engage in more daily physical activity and less sedentary behavior (after controlling for participant covariates). Data were collected at baseline, 12 months, and 36 months from 610 low-income parent-child pairs participating in an obesity prevention intervention for 3- to 5-year-old children. A network survey was used to identify social network ties among parents and accelerometers were used to measure parental physical activity and sedentary time. Longitudinal regression analyses tested effects of social network ties on parents' physical activity and sedentary behavior. Compared with parents without a social network tie, having a tie with an intervention group participant was associated with a clinically meaningful 11.04 min/day decrease in parental sedentary behavior that approached statistical significance (95% confidence interval [Cl] = [-22.71, 0.63], p = .06). Social network ties among parents in a pediatric obesity prevention intervention were not clearly associated with reduced sedentary behavior among those parents at the traditional level of p = .05. The large effect size (over 77min per week improvement) suggests there might be potential importance of promoting new social networks in community-based health promotion interventions to elicit and support behavior change, but further examination is needed.

Factors associated with engagement and adherence to a low-energy diet to promote 10% weight loss in patients with clinically significant non-alcoholic fatty liver disease

ObjectiveClinical guidelines recommend weight loss to manage non-alcoholic fatty liver disease (NAFLD). However, the majority of patients find weight loss a significant challenge. We identified factors associated with engagement and...

Behavior-change Support Technology that Brings About Positive Mental Changes

Behavior-change Support Technology that Brings About Positive Mental Changes

Learning about Moss: Forming Communities of Inquiry

The term community, when applied to socially engaged projects, often encompasses a range of different motivations for people to come together. It rarely describes a harmonious group, but instead an ever-changing set of individuals, with different interests and reasons for taking part. Looking at the participatory design of a moss wall around the community garden at R-urban, in London, the paper will explore how different understandings of the term community came together through meetings, events and workshops, as a designed process of engagement. The site of the project, defined a community of location, made up of residents. The community garden wall was designed in response to the poor air quality within the area, collaborating with a community of concern, made up of activists and academics. The wall was tested through construction workshops, attracting volunteers interested in learning about DIY as well as air quality, building a diverse community of practice. These different communities came together to learn about the wall through experimental prototypes, as a community of enquiry. The paper will reflect on the success and failures of different engagement strategies to target specific groups, exploring unexpected moments of engagement and the challenges of apathy and misunderstanding. It will explore how these events enabled people to move between different understandings of the term community, through the engagement in design and the legacy of the objects produced. This has the potential to develop a longer-term collective concern for such a project and this community can in turn support behaviour change, informing an individual’s urban mobility.

User Centered Virtual Coaching for Older Adults at Home Using SMART Goal Plans and I-Change Model.

Preventive care and telemedicine are expected to play an important role in reducing the impact of an increasingly aging global population while increasing the number of healthy years. Virtual coaching is a promising research area to support this process. This paper presents a user-centered virtual coach for older adults at home to promote active and healthy aging and independent living. It supports behavior change processes for improving on cognitive, physical, social interaction and nutrition areas using specific, measurable, achievable, relevant, and time-limited (SMART) goal plans, following the I-Change behavioral change model. Older adults select and personalize which goal plans to join from a catalog designed by domain experts. Intervention delivery adapts to user preferences and minimizes intrusiveness in the user’s daily living using a combination of a deterministic algorithm and incremental machine learning model. The home becomes an augmented reality environment, using a combination of projectors, cameras, microphones and support sensors, where common objects are used for projection and sensed. Older adults interact with this virtual coach in their home in a natural way using speech and body gestures on projected user interfaces with common objects at home. This paper presents the concept from the older adult and the caregiver perspectives. Then, it focuses on the older adult view, describing the tools and processes available to foster a positive behavior change process, including a discussion about the limitations of the current implementation.

Behavioral Framework of Immersive Technologies (BehaveFIT): How and Why Virtual Reality can Support Behavioral Change Processes

The design and evaluation of assisting technologies to support behavior change processes have become an essential topic within the field of human-computer interaction research in general and the field of immersive intervention technologies in particular. The mechanisms and success of behavior change techniques and interventions are broadly investigated in the field of psychology. However, it is not always easy to adapt these psychological findings to the context of immersive technologies. The lack of theoretical foundation also leads to a lack of explanation as to why and how immersive interventions support behavior change processes. The Behavioral Framework for immersive Technologies (BehaveFIT) addresses this lack by 1) presenting an intelligible categorization and condensation of psychological barriers and immersive features, by 2) suggesting a mapping that shows why and how immersive technologies can help to overcome barriers and finally by 3) proposing a generic prediction path that enables a structured, theory-based approach to the development and evaluation of immersive interventions. These three steps explain how BehaveFIT can be used, and include guiding questions for each step. Further, two use cases illustrate the usage of BehaveFIT. Thus, the present paper contributes to guidance for immersive intervention design and evaluation, showing that immersive interventions support behavior change processes and explain and predict 'why' and 'how' immersive interventions can bridge the intention-behavior-gap.

Multicultural Adaptation of Mighty Girls for Widespread Dissemination: Pilot Study, App Development and Usability Testing, and Gauging Parent Support With Focus Groups.

BackgroundTaking evidence-based interventions to scale is a challenge for prevention science. Mighty Girls is an evidence-based sexual health intervention program that combines classroom sessions with novel, cutting-edge technology (digital puppetry). The program was developed for 7th grade Latinas, but US school and community demographics rarely allow interventions targeting a single ethnic group. Additionally, digital puppetry is costly to scale up, and parent disapproval often prevents successful dissemination of adolescent sexual health programs. Intervening steps along the scaling-up pathway are needed to adapt the program prior to scaling up for dissemination.ObjectiveThe aims of this study were to create a multicultural adaptation of the Mighty Girls program using a mobile app that is less costly to disseminate and is acceptable to parents of 7th grade girls.MethodsThis study used a three-phase process to adapt Mighty Girls into Mighty Teens. All phases used purposive (nonprobability) sampling of low-income, multicultural, urban metropolitan groups (7th grade girls and their parents) within central Florida. Phase 1 involved two videotaped implementations of a multicultural adaptation of the classroom sessions, one involving focus groups (N=14) and the other serving as a single-group pretest-posttest pilot study (N=23). Phase 2 involved development of a narrative cell phone app prototype, which was subjected to usability testing (N=25). App usability and engagement were assessed qualitatively (observation, focus group, open-ended questions) and quantitatively. Phase 3 used focus groups to assess parent support for the program (N=6). Qualitative data were analyzed using descriptive content analysis. Quantitative data were analyzed using descriptive statistics and paired t tests.ResultsQualitative findings supported classroom sessions being multicultural, and identified simple changes to improve engagement and learning. Quantitative findings from the second classroom session implementation pilot study indicated a significant pre-post difference in intention to delay sexual intercourse (P=.04). App usability and appeal were supported by a System Usability Scale score of 76 (exceeding 68 per the industry standard) and 83% (20/24) of participants agreeing they would recommend the app to friends. Parents (mothers) expressed only positive regard for program goals, and classroom session and app activities.ConclusionsThis study adapted Mighty Girls into an engaging, easier-to-disseminate, multicultural program, termed Mighty Teens, that uses a narrative-generating app to support behavior change, and is likely to be accepted by parents of 7th grade girls. This study also provides evidence of the preliminary effectiveness of Mighty Teens classroom sessions. The sampling method and sample size were appropriate for adaptation, but research involving a more representative US sample is needed to confirm multicultural fit, parent receptivity, and program effectiveness. Study implications include integrating app use throughout the classroom sessions to build narrative-generating skills across the program and increasing the number of narratives produced, which should in turn increase the program’s behavior change potency.

Intelligent Cognitive Assistants for Attitude and Behavior Change Support in Mental Health: State-of-the-Art Technical Review

Intelligent cognitive assistant (ICA) technology is used in various domains to emulate human behavior expressed through synchronous communication, especially written conversation. Due to their ability to use individually tailored natural language, they present a powerful vessel to support attitude and behavior change. Behavior change support systems are emerging as a crucial tool in digital mental health services, and ICAs exceed in effective support, especially for stress, anxiety and depression (SAD), where ICAs guide people’s thought processes and actions by analyzing their affective and cognitive phenomena. Currently, there is no comprehensive review of such ICAs from a technical standpoint, and existing work is conducted exclusively from a psychological or medical perspective. This technical state-of-the-art review tried to discern and systematize current technological approaches and trends as well as detail the highly interdisciplinary landscape of intersections between ICAs, attitude and behavior change, and mental health, focusing on text-based ICAs for SAD. Ten papers with systems, fitting our criteria, were selected. The systems varied significantly in their approaches, with the most successful opting for comprehensive user models, classification-based assessment, personalized intervention, and dialogue tree conversational models.

Development of a European competency framework for health and other professionals to support behaviour change in persons self-managing chronic disease

BackgroundHealthcare and other professionals are expected to support behaviour change in people living with chronic disease. However, effective behaviour change interventions are largely absent in routine encounters. The Train4Health project, a European strategic partnership for higher education, sought to address this problem. The primary aim of this study, which is part of an early work package, was to develop an interprofessional competency framework for health and other professions to support behaviour change for the self-management of chronic disease at a European level. A secondary aim was to derive a set of behaviour change techniques (BCTs) from an established taxonomy to link with framework competencies.MethodsThe study comprised two interlinked parts. Part 1 involved a two-round e-Delphi study with an interprofessional panel of 48 experts across 12 European countries to develop the behaviour change competency framework. Preparatory work included drafting a list of competency statements based on seven existing frameworks.Part 2 involved an expert panel of six behavioural psychologists deriving a set of BCTs to link with framework competencies. Their feedback was based on preparatory work, which focused on seven high priority chronic diseases for self-management, identified through European projects on self-management and identifying five relevant target behaviours from key clinical guidelines. A literature search yielded 29 effective BCTs for the target behaviours in the selected chronic diseases.ResultsTwenty-seven competency statements, were presented in Round 1 to the Delphi panel. Consensus was achieved for all statements. Based on comments, two statements were removed, one was added, and 14 were modified. All 15 statements subjected to Round 2 were consensus-approved, yielding a total of 12 foundational competencies for behaviour change in self-management of chronic disease and 14 behaviour change competencies. Four behaviour change competencies related to BCTs. Behavioural psychologists’ feedback led to a core set of 21 BCTs deemed applicable to the five target behaviours across the seven chronic diseases.ConclusionsA behaviour change competency framework comprising 26 statements for European health and other professionals to support self-management of chronic disease was developed, linked with a core set of 21 BCTs from an established taxonomy.

Nurses back pain beliefs, coping strategies and factors associated with participant activation for self-management of back pain.

To determine the back pain beliefs, coping strategies and factors associated with participant activation for self-management of back pain amongst nurses working in peri-urban district healthcare centres. A descriptive cross-sectional study design. Data were collected between February and March 2020 using a self-administered questionnaire. Descriptive data analysis was done in Stata version 20.0. Back pain beliefs, participant activation and coping strategies were presented using relative frequencies and percentages. Odds ratios at 5% significance level were used to test association of factors for participant activation for self-management of back pain. Majority of the participants had experienced back pain which lasted 3days for half of the participants. Further, pain medication was commonly used to cope with back pain. In addition, age, gender and work-setting were significantly associated with participant activation for self-management of back pain. Participants' coping strategies for back pain were linked to the conveyed back pain beliefs which demonstrate that participants believed in rest and lengthy periods of time off work for back pain. However, participants acknowledged that taking an active role in determining one's health and function is vital. This highlights the importance of self-management support for health behaviour change amongst nurses. The study addressed back pain beliefs, coping strategies and participant activation for self-management of back pain amongst nurses in peri-urban healthcare centres. Majority of the participants experienced back pain which lasted 3days. Pain medication was commonly used to cope with back pain. Age, gender and work-setting were significantly associated with participant activation for self-management of back pain. Although this study was conducted in Zambia, outcomes from this study may be of benefit to nurses in similar settings. Further, the research provides insight to the international body of knowledge on the process and appropriateness of international research in resource-constrained settings.

"Strong Teeth": an early-phase study to assess the feasibility of an oral health intervention delivered by dental teams to parents of young children

BackgroundTooth decay (caries) is a significant health burden in young children. There is strong evidence for the benefits of establishing appropriate home-based oral health behaviours in early childhood. Dental teams are well placed to provide this information and there is clear advice on what oral health information should be given to parents. However, research has shown that there is limited guidance, training and resources on how dental teams should deliver this advice. "Strong Teeth" is a complex oral health intervention, using evidence-based resources and training underpinned by behaviour change psychology, to support behaviour change conversations in dental practice. This early phase evaluation aims to assess the feasibility of this intervention, prior to a full-scale trial.MethodsThe study recruited 15 parents of children aged 0–2-years-old and 21 parents of children aged 3–5 years old, from five NHS dental practices across West Yorkshire. Participant demographics, self-reported brushing behaviours, dietary habits, a dental examination and three objective measures of toothbrushing were collected in a home-setting at baseline, then at 2-weeks and 2-months post-intervention. Recruitment, retention and intervention delivery were analysed as key process outcomes. Brushing habits were compared to national toothbrushing guidelines – the Delivering Better Oral Health toolkit (Public Health England).ResultsStrong Teeth was feasible to deliver in a General Dental Practice setting in 94% of cases. Feasibility of recruitment (37%) exceeded progression criterion, however retention of participants (75%) was below the progression criterion for the 0–2 age group. More than half of children recruited aged 3–5-years had caries experience (52%). Total compliance to toothbrushing guidance at baseline was low (28%) and increased after the intervention (52%), an improvement that was statistically significant. Dietary habits remained largely unchanged. Plaque scores significantly decreased in the 3–5-year-olds and toothbrushing duration increased in all age groups.Conclusion"Strong Teeth" intervention delivery and data collection in the home setting was feasible. There was a positive indication of impact on reported toothbrushing behaviours. Some amendments to study design, particularly relating to the inclusion of the 0–2-year-old group, should be considered before progression to a full trial.Trial registration ISRCTN Register: ISRCTN10709150. Registered retrospectively 24/7/2019.

A Smartphone App (TRIANGLE) to Change Cardiometabolic Risk Behaviors in Women Following Gestational Diabetes Mellitus: Intervention Mapping Approach

BackgroundGestational diabetes mellitus (GDM) is the most common complication during pregnancy and is associated with an increased risk for the development of cardiometabolic diseases. Behavioral interventions can reduce this risk, but current solutions insufficiently address the requirements for such a program. The systematic development of a scalable mobile health (mHealth) promotion program for mothers during the first years post-GDM may contribute to solving this problem.ObjectiveThe aim of this project was to systematically plan and develop a theory- and evidence-based mHealth intervention to change cardiometabolic risk behaviors in women during the first 5 years post-GDM that meets women’s expected standards of commercial health apps.MethodsThe intervention mapping steps 1 to 4 structured the systematic planning and development of the mHealth program described in this paper. Steps 1 and 2 led to a theory- and evidence-based logic model of change for cardiometabolic health. Based on this model, the prevention program was designed (step 3) and produced (step 4) in cooperation with industrial partners to ensure a high technological standard of the resulting smartphone app for the iPhone (Apple Inc). Step 4 included a user study with women during the first 5 years post-GDM once a beta version of the app (“TRIANGLE”) was available. The user study comprised 2 test rounds of 1 week (n=5) and 4 weeks (n=6), respectively. The tests included validated questionnaires on user acceptance, user logs, and think-alouds with semistructured interviews.ResultsThe novel TRIANGLE app is among the first self-paced smartphone apps for individual habit change in the 3 lifestyle areas of physical activity, nutrition, and psychosocial well-being. The 3 core features—a challenge system, human coaching, and a library—address 11 behavioral determinants with 39 behavior change methods to support lifestyle changes. Participants in the user study showed a high acceptance, high perceived quality, and high perceived impact of the TRIANGLE app on their health behaviors. Participants tested the app regularly, used it intuitively, and suggested improvements. We then adapted the TRIANGLE app according to the insights from the user study before the full TRIANGLE program production.ConclusionsThe intervention mapping approach was feasible to plan and develop an innovative and scalable smartphone solution for women during the first 5 years post-GDM. The resulting TRIANGLE intervention has the potential to support behavior change for cardiometabolic disease prevention. However, the app needs further refinement and testing in clinical trials. Intervention mapping steps 5 (implementation plan) and 6 (evaluation plan) may support the integration of the TRIANGLE intervention into routine care.Trial RegistrationGerman Clinical Trials Register DRKS00012736; https://www.drks.de/DRKS00012736

Use of motivational interviewing in behavioural interventions among adults with obesity: A systematic review and meta-analysis.

This review aimed to identify whether motivational interviewing (MI) (a counselling approach for supporting behaviour change [BC]) helps to reduce bodyweight and BMI in an adult obesity context. This included evaluating effectiveness of MI interventions within this population and reporting the methodology used, including theoretical underpinnings and identification of BC and MI techniques. Eight databases were searched using controlled vocabulary. Eligible studies included adults with obesity (BMI ≥30 kg/m2 ), author-reported interventions using MI aiming to reduce body weight or BMI, and comparator groups not receiving an MI intervention. Data extraction and quality appraisal tools were used to identify study characteristics, intervention content was coded for techniques, and random-effects meta-analysis were conducted to investigate effects. Meta-analysis of 12 studies indicated no overall pooled effect on bodyweight and BMI outcomes between intervention and control groups (SMD=-0.01 [95%CI -0.13 to 0.12, P=.93]). Findings were limited by multiple sources accounting for risk of bias, and poor reporting of intervention fidelity and content. Intervention and control content descriptions indicated similar techniques, with social support, goal setting (behaviour) and self-monitoring of behaviour occurring most frequently across both. Findings do not contribute additional evidence for MI use in this context, however methodological limitations were identified which must be resolved to better identify the intervention effects on obesity-related outcomes.

The understanding, acceptability, and relevance of personalised multidimensional physical activity feedback among urban adults: evidence from a qualitative feasibility study in Sri Lanka

BackgroundWearable technologies are being used to provide personalised feedback across multiple physical activity dimensions in countries such as the UK, but their feasibility has not been tested in South Asia, where physical inactivity is increasing. This study assessed the understanding, acceptability, and relevance of personalised multidimensional physical activity feedback in urban dwellers in Colombo, Sri Lanka.MethodsA qualitative feasibility study was conducted among 35 adults to assess a community-based approach to provide multidimensional physical activity feedback. Healthy adults, adults at risk of non-communicable diseases and community-based primary healthcare professionals wore a physical activity monitor for 7 days and were then guided through their personalised multidimensional physical activity feedback. One-to-one interviews were conducted, transcribed verbatim and analysed using framework analysis.ResultsFour themes were generated: understanding of personalised physical activity feedback, perceived novelty of the feedback, motivation, and consideration of the multidimensional nature of physical activity. A majority of participants required guidance initially to understand the feedback, following which most were quickly able to interpret the data shown, and were willing to use the feedback as a basis for identifying goals to improve physical activity. Participants perceived the feedback and its delivery as novel because it provided new knowledge about physical activity guidelines and awareness on their own behaviour through graphics. Comparisons of personal performance against recommended physical activity levels and information on sedentary time were the most commonly motivating aspects of the feedback, prompting talk about behaviour change. All three groups showed poor planning on goal achievement, with some noticeable differences between those with and without health risk of non-communicable diseases. Following the feedback, most participants understood that physical activity is composed of several dimensions, while around half could recognise more suitable options to change behaviour. Of the physical activity dimensions, calorie burn received more attention than others.ConclusionsMultidimensional physical activity feedback was considered understandable and acceptable and has the potential to support behaviour change among urban Sri Lankans with or without identified health risk. These findings highlight the feasibility of this technology-enabled approach as a personalised intervention to improve knowledge and motivation for physical activity behaviour.

Impact of COVID-19 on an established physical activity and behaviour change support programme for cancer survivors: An exploratory survey of the Macmillan Move More service for Northern Ireland

PurposeThe recent coronavirus pandemic (COVID-19) has affected the delivery of routine cancer care and supportive services. The Macmillan Move More Northern Ireland (MMNI) programme provides access to physical activity and behavioural change support before, during and after cancer treatment. This evaluation details the impact of the pandemic on the MMNI participants and identifies methods to adapt service delivery.MethodsA multiple-choice and short answer online survey was sent to 730 MMNI participants, to investigate the impact of the initial, national COVID-19 lockdown. Specifically, the survey examined physical activity patterns, the physical/emotional/social impact of restrictions and attitudes towards digitally supported exercise. Free text responses were analysed thematically with findings verified within the research team.Results377 participants completed the survey (52% response rate). 50% of respondents had breast cancer, with 36 other diagnoses registered (82% were female). Participants reported physical activity levels decreased during restrictions, citing isolation; declining health/fitness; lack of access and motivation. The dataset trended towards women and those diagnosed with breast cancer. 71% reported the pandemic impacted their physical (n=119) and/or psychosocial (n=231) wellbeing. Many respondents were availing of digitally supported exercise, whilst half of males did not engage (46%). Finally, 80% of respondents were interested in using a MMNI smart application.ConclusionThe COVID-19 pandemic has affected participant physical activity levels. Supervised classes were the most popular (pre-pandemic), with enforced leisure centre closures prompting this reduction. The pandemic has negatively affected the psychosocial wellbeing (mental health) of participants, compounded by the restrictions imposed on the traditional delivery of MMNI. This impact is felt equally across cancer types. Participants with breast cancer are the most engaged in using digital technology to access exercise. Although underrepresented, men require greater targeting to ensure equality in access to online services.

Environmental Hazards and Behavior Change: User Perspectives on the Usability and Effectiveness of the AirRater Smartphone App.

AirRater is a free smartphone app developed in 2015, supporting individuals to protect their health from environmental hazards. It does this by providing (i) location-specific and near real-time air quality, pollen and temperature information and (ii) personal symptom tracking functionality. This research sought to evaluate user perceptions of AirRater’s usability and effectiveness. We collected demographic data and completed semi-structured interviews with 42 AirRater users, identified emergent themes, and used two frameworks designed to understand and support behavior change—the Behavior Change Wheel (BCW) and the Protective Action Decision Model (PADM)—to interpret results. Of the 42 participants, almost half indicated that experiencing symptoms acted as a prompt for app use. Information provided by the app supported a majority of the 42 participants to make decisions and implement behaviors to protect their health irrespective of their location or context. The majority of participants also indicated that they shared information provided by the app with family, friends and/or colleagues. The evaluation also identified opportunities to improve the app. Several study limitations were identified, which impacts the generalizability of results beyond the populations studied. Despite these limitations, findings facilitated new insights into motivations for behavior change, and contribute to the existing literature investigating the potential for smartphone apps to support health protection from environmental hazards in a changing climate.

'Focus on diet quality': a qualitative study of clinicians' perspectives of use of the Mediterranean dietary pattern for non-alcoholic fatty liver disease.

Practice guidelines for non-alcoholic fatty liver disease (NAFLD) recommend promoting the Mediterranean dietary pattern (MDP) which is cardioprotective and may improve hepatic steatosis. This study aimed to explore multidisciplinary clinicians' perspectives on whether the MDP is recommended in routine management of NAFLD and barriers and facilitators to its implementation in a multi-ethnic setting. Semi-structured individual interviews were conducted with fourteen clinicians (seven doctors, three nurses, three dietitians and one exercise physiologist) routinely managing patients with NAFLD in metropolitan hospital outpatient clinics in Australia. Interviews were audio-recorded, transcribed and analysed using thematic content analysis. Clinicians described that lifestyle modification was their primary treatment for NAFLD and promoting diet was recognised as everyone's role, whereby doctors and nurses raise awareness and dietitians provide individualisation. The MDP was regarded as the most evidence-based diet choice currently and was frequently recommended in routine care. Facilitators to MDP implementation in practice were: improvement in diet quality as a parallel goal to weight loss; in-depth knowledge of the dietary pattern; access to patient education and monitoring resources and; service culture, including an interdisciplinary clinic goal, and knowledge sharing from expert dietitians. Barriers included perceived challenges for patients from diverse cultural and socio-economic backgrounds and limited clinician training, time and resourcing to support behaviour change. Integration of MDP in routine management of NAFLD in specialist clinics was facilitated by a focus on diet quality, knowledge sharing, belief in evidence and an interdisciplinary team. Innovations to service delivery could better support and empower patients to change dietary behaviour long-term.

Text message reminders for adolescents with poorly controlled type 1 diabetes: A randomized controlled trial.

BackgroundAmong adolescents with type 1 diabetes, some experience great difficulties with treatment adherence, putting them at high risk of complications. We assessed the effect of text messaging (Short Messaging Service [SMS]) on glycemic control.MethodsA two-arm open label randomized controlled trial enrolled adolescents with type 1 diabetes aged 12–21 years with baseline HbA1c ≥ 69 mmol/mol (8.5%). The intervention group received daily SMS reminders at self-selected times about insulin injections while the control group received standard of care. The patients allocated to the control group were not aware of the intervention.Results92 patients were randomized, 45 in the SMS arm and 47 in the control arm. After 6 months, median HbA1c level was significantly lower in the intervention arm: 73 mmol/mol (8.8%) in the SMS arm and 83 mmol/mol (9.7%) in the control arm in the intent-to-treat analysis (P = 0.03) but no longer in the per protocol analysis (P = 0.65). When we consider the proportions of patients whose HbA1c level decreased by at least 1% between baseline and 6 months, we find a significant difference among patients whose baseline HbA1c was ≥ 80 mmol/mol (9.5%) (n = 56): 60% in the SMS arm and 30.6% in the control arm had lowered their HbA1c level (P = 0.03) in the intent-to-treat analysis but not in the per-protocol analysis (P = 0.50). Patients in the SMS arm reported high satisfaction with the intervention.ConclusionsWhile there is a trend to lower HbA1c in the intervention group, no firm conclusions can yet be drawn. Further studies are needed to address methodological issues as we believe these interventions can support behavior change among adolescents with poorly controlled type 1 diabetes. ClinicalTrials.gov identifier: NCT02230137.