Sustainable Lifestyle Changes Research Articles

Health And Wellness Coaching Improves Body Composition and Quality Of Life With No Diet Prescription

Global obesity rates have reached epidemic proportions. However, it is estimated that 95% of the dieters find difficulty in maintaining weight loss and return to gain it for up to 2 years. The desire for long lasting behavioral and weight changes motivated health professionals to seek for new approaches to stop the obesity growing rates. Health and wellness coaching (HWC) comes up as a behavioral change approach, based on a client-centered process, without a diet prescription, and seems to be more likely to promote long lasting changes. The subject of this study had previously tried different diets, all of which failed to achieve lasting weight loss. PURPOSE:the aim of this case report is to present and evaluate HWC in promoting sustainable lifestyle changes especially in body composition, eating pattern and self-assessment of quality of life. METHODS: body composition, quality of life (WHOQOL-bref) and nutritional intake were assessed at baseline (P1), after 12 weeks of HWC (P2) and 14 weeks after the end of the intervention (P3). 12 HWC sessions were completed, which were held weekly (1 hour each), and 36 physical activity sessions, which were held 3 times a week (1 hour each). No diet was prescribed during the whole process. RESULTS: In P3, HWC and physical activity sessions were associated with reductions in body weight (-5.1 kg), fat mass (-5.2 kg), BMI [from 29.6 (P1) to 27.8 kg/m2 (P3)], and waist circumference (-7.1cm). From P1 to P3, we also observed maintenance of the fat free mass (54,1 kg), a decrease in total energy intake (-300 kcal/day) and fat intake (-44%). Great improvement in all aspects of self-rated quality of life was also shown. This outcomes emphazise the effectiveness of HWC in promoting behavioral changes with high impact in health parameters and quality of life. CONCLUSIONS: HWC was effective once the new eating pattern and weight loss achieved during the process were maintained in the medium term after the end of the sessions.

A Novel Algorithm for Determining the Contextual Characteristics of Movement Behaviors by Combining Accelerometer Features and Wireless Beacons: Development and Implementation.

BackgroundUnfortunately, global efforts to promote “how much” physical activity people should be undertaking have been largely unsuccessful. Given the difficulty of achieving a sustained lifestyle behavior change, many scientists are reexamining their approaches. One such approach is to focus on understanding the context of the lifestyle behavior (ie, where, when, and with whom) with a view to identifying promising intervention targets.ObjectiveThe aim of this study was to develop and implement an innovative algorithm to determine “where” physical activity occurs using proximity sensors coupled with a widely used physical activity monitor.MethodsA total of 19 Bluetooth beacons were placed in fixed locations within a multilevel, mixed-use building. In addition, 4 receiver-mode sensors were fitted to the wrists of a roving technician who moved throughout the building. The experiment was divided into 4 trials with different walking speeds and dwelling times. The data were analyzed using an original and innovative algorithm based on graph generation and Bayesian filters.ResultsLinear regression models revealed significant correlations between beacon-derived location and ground-truth tracking time, with intraclass correlations suggesting a high goodness of fit (R2=.9780). The algorithm reliably predicted indoor location, and the robustness of the algorithm improved with a longer dwelling time (>100 s; error <10%, R2=.9775). Increased error was observed for transitions between areas due to the device sampling rate, currently limited to 0.1 Hz by the manufacturer.ConclusionsThis study shows that our algorithm can accurately predict the location of an individual within an indoor environment. This novel implementation of “context sensing” will facilitate a wealth of new research questions on promoting healthy behavior change, the optimization of patient care, and efficient health care planning (eg, patient-clinician flow, patient-clinician interaction).

The Coaching on Lifestyle (CooL) Intervention for Overweight and Obesity: A Longitudinal Study into Participants’ Lifestyle Changes

Combined lifestyle interventions (CLIs) can be effective in reducing weight and improving lifestyle-related behaviours but it is unclear how CLIs can best be implemented in practice in order to achieve sustained lifestyle changes. The Coaching on Lifestyle programme (CooL) is a CLI in the Netherlands, in which professional lifestyle coaches counsel adults and children (and/or their parents) who are obese or at high risk of obesity to achieve a sustained healthier lifestyle. The CooL intervention consists of group and individual sessions addressing the topics of physical activity, dietary behaviours, sleep and stress. Our longitudinal one-group pre-post study aimed to identify lifestyle changes among participants (adults, children and their parents) at 8 and 18 months after initiation. We assessed constructs ranging from motivation and behaviour-specific cognitions to behaviours and health outcomes. Positive and sustained changes among adults were found regarding perceived autonomy, motivation, perceived barriers, lifestyle behaviours, quality of life and weight. Among children and their parents, few improvements were found regarding behaviours and quality of life. CooL has been successful in coaching adult participants towards sustained behavioural change during the intervention period. Mixed results and smaller effect sizes were found for children and their parents.

Abstract P289: Social Determinants of Long Term Maintenance of Physical Activity: The Jackson Heart Study

Background: Data showing long term efficacy and sustained active lifestyle change are scant. Identifying social determinants for maintaining an active lifestyle overtime may help pinpoint barriers/facilitators for sustaining an active lifestyle change. Methods: We evaluated the associations between social determinants of health (SDH) and changes in physical activity (PA). The analysis dataset included 3,741 participants in the Jackson Heart Study (JHS) who completed the PA questionnaire at exams 1 and 3, approximately 8 years apart. Participants were classified into 3 PA groups-poor (0 minutes/week moderate/vigorous activity), intermediate (some moderate/vigorous activity), or ideal (≥75 minutes/week vigorous or ≥150 minutes/week moderate or ≥150 minutes/week combined moderate/vigorous activity). SDH evaluated were individual level socioeconomic status (SES), social support, perceived stress and neighborhood characteristics. Other covariates included age, sex and body mass index (BMI). Unadjusted analyses followed by multivariable logistic regression analyses with backward selection were performed to explore the most significant SDH associated with changes in PA. Results: Twenty-eight percent (28%) participants had poor PA at both exams; 35.5% had at least intermediate PA at both exams; 19.2% changed from poor to intermediate/ideal PA and 17.8% changed from intermediate/ideal to poor PA overtime. In unadjusted analyses, among participants with intermediate/ideal PA at exam 1, younger age, higher levels of SES and greater social support; as well as higher neighborhood SES, greater social cohesion, fewer neighborhood problems and violence were positively associated with maintaining intermediate/ideal PA at exam 3. Among those with poor PA at exam 1, the same factors other than social cohesion were associated with improved PA to moderate/ideal level at exam 3. Sex, perceived stress, number of PA facilities in the neighborhood or being overweight/obese at either exam was not associated with changes in physical activity levels. Exploratory multivariable logistic regression with backward selection suggested that all three individual SES indicators were important factors for maintaining moderate/ideal PA levels at exam 3; and younger age, higher education, and higher neighborhood SES were important factors for improving PA levels from poor to intermediate/ideal. Conclusions: Individual SES indicators were significantly associated with maintaining an intermediate/ideal PA overtime; whereas younger age, higher educational attainment and higher neighborhood SES were significantly associated with changes in PA from poor to intermediate/ideal. Targeting individual education and environmental factors (e.g., neighborhood problems, violence) associated with neighborhood SES may provide most benefit both in initiating and maintaining an active lifestyle.

Health Promotion Challenges in Healthy Lifestyles: Can We Transfer Lessons Learned Across Contexts?

This article argues that multi-level and contextual approach, including evidence-informed approach with needs assessment, is needed for sustainable lifestyle change. Examples are given of older and newer whole of community approaches with health in all policies approach as well as on targeting those at increased risk of diabetes type 2. At their best, these approaches empower local people and creates ustainable community structures and policies for healthy life. The commentary further argues that this kind of needs-based and tailored interventions can be transferred across contexts and cultures. To enable this, we need to pay attention to the intervention context as well intervention process characteristics instead of focusing on the contents of the intervention.

Promoting Physical Activity Using the Internet: Is It Feasible and Acceptable for Patients With Chronic Obstructive Pulmonary Disease and Bronchiectasis?

Older people with chronic lung diseases and with low physical activity participation rates are at higher risk of morbidity and mortality. This study assessed the feasibility and acceptability of a purpose-designed Internet-based program (ActivOnline) to monitor and encourage exercise and physical activity. Twelve participants with chronic obstructive pulmonary disease or bronchiectasis were recruited (54-84 years). Primary outcome measures were feasibility measured by frequency of program access, and acceptability measured by semistructured interview, system usability scores, and participant perception of benefit. The results suggest regular participation in physical activity and exercise during the 8-week study period and high usability scores (mean = 90% ± 9%). Major themes were the importance of regular exercise and how sustained lifestyle changes were essential to be physically active, regular contact with clinicians assisted with motivation, and aspects of ActivOnline facilitated individual behavior change and confidence to continue exercising. Most participants (82%) reported a benefit from using ActivOnline, and 55% wished to remain on the program indefinitely.

Sustainable Lifestyle Change-Participatory Design of Support Together with Persons with Obesity in the Third Age.

Sustainable lifestyle changes due to obesity are difficult to achieve regardless methods used. We need to know more about the lived experience of obesity and older persons’ needs for support to make a sustainable change. This paper focuses on the need-finding process in designing support for a sustainable lifestyle change. Multistage focus group interviews were conducted with persons aged 61–72 living in Northern Sweden. A participatory and appreciative reflection and action (PAAR) approach was used in the group-sessions. Probes were used to increase reflections and achieve a deeper knowledge about the participants’ needs of support. Data were analysed using qualitative thematic content analysis. Our findings revealed that to be able to succeed with a lifestyle change a focus has to be on a converted way of thinking, managing vulnerability, and achieving an emotional balance. To achieve a sustainable lifestyle change due to obesity in the third age the focus has to be on a health identity instead of a weight identity. Personalised support with enjoyable physical activities should be designed and developed. Strategies for emotional balance based on autonomy and self-empowerment must be included. This knowledge is important when designing support for sustainable change.

The House Is Crashing down on Me: Integrating Mindfulness, Breath Training, and Heart Rate Variability Biofeedback for an Anxiety Disorder in a 71-Year-Old Caregiver

Caregiver stress is a growing problem with an aging population, and many spouses are cast in the caregiver role for extended periods. Preexisting anxiety disorders commonly recur in the face of caregiver stress. This article narrates the case of a 71-year-old retired professional woman serving as caregiver for a husband with dementia. The stress of the caregiver role served to trigger a recurrence of a previously treated anxiety disorder. The case narrative illustrates the value of mindfulness, breath training, and heart rate variability biofeedback for the anxiety disorder, as well as an effort to instill sustainable self-regulation skills and lifestyle changes for greater resilience in this long-term situation. Some of the lifestyle-oriented interventions are summarized only briefly in this article.

Adaptation processes in the context of climate change: a social and environmental psychology perspective

An informed multidisciplinary understanding of the ways in which people experience, appraise, adapt, and respond to global climate change is a prerequisite to effectively managing the transition to a sustainable economy. In this paper, we argue that climate science has to date failed to fully appreciate the contribution that social and environmental psychology can make to such an understanding. We draw on findings from two large national Australian surveys to demonstrate how this perspective can contribute to knowledge, understanding, and policy formulation. Central to this perspective are processes of psychological adaptation, that is, processes through which individuals orient towards, make sense of, and ultimately come to terms with, the threat and reality of climate change. Such adaptive processes are shown to mediate relationships between environmental experiences and behavior, and hence provide the foundation for environmentally-friendly lifestyles. Rather than assuming that external sanctions and incentives are sufficient to engender sustainable lifestyle changes, a social and environmental psychology approach recognises and explores the complexities of the transactions that occur between individuals’ internal and external environments, emphasizes the importance of intrinsic motivation and self-determination, and suggests the need for initiatives that promote behaviors that are both environmentally and psychologically significant.

A Systematic and Integrated Review of Mobile-Based Technology to Promote Active Lifestyles in People With Type 2 Diabetes.

The aim was to review studies examining the effectiveness, acceptability, and feasibility of mobile-based technology for promoting active lifestyles in people with type 2 diabetes (T2D). Benefits of leading an active lifestyle following a diagnosis of T2D, including improved glycemic control, have been reported. Studies examining the specific use of mobile-based technologies to promote an active lifestyle in T2D have not previously been reviewed. Research studies examining effectiveness, feasibility or acceptability of mobile-based technology for active lifestyle promotion for T2D management were included (n = 9). The databases searched included PubMed, Medline, ScienceDirect, and ACM Digital Library (January 2005 to October 2015). Studies were categorized as (1) informing, (2) monitoring, (3) provoking, or (4) sustaining behavior change. Technologies used included smartphone or tablet apps, diabetes personal digital assistant, continuous glucose monitor and accelerometer, pedometer, and a website delivered by a smartphone. No articles examined the effectiveness of mobile-based technology in monitoring health behaviors and behavior change. Four of the studies found mobile-based technology to be motivational and supportive for behavior change. The visual reinforcement was identified as motivational. The feasibility and acceptability of using mobile-based technology to provide sustained lifestyle change and the effectiveness of mobile-based technology in monitoring health behaviors and behavior change have not been investigated. No studies examined all 3 of the outcomes or focused decreasing the participants' sedentary behavior. Limited research has examined the feasibility, acceptability, and effectiveness of mobile-based technology to promote active lifestyles and subsequently good diabetes management in people with T2D.

Emotional Intelligence and Public Health Education

Emotional intelligence (EI) is an ability that is crucial to the field of Public Health due to the fact that it encompasses the practitioner’s ability to communicate professionally, show empathy, obtain patient compliance, and promote sustainable lifestyle changes in communities. This study seeks to evaluate a graduate Public Health program in order to determine what cross-competencies might exist between EI and program objectives, what EI development might currently exist, whether EI exists explicitly or indirectly, and what the attitudes of stakeholders are regarding EI and its importance to the field of Public Health. The information gathered makes it possible to formulate recommendations to further incorporate EI-building activities into a Master of Public Health program. Results of the study show a direct correlation between Public Health and EI competencies, which makes it an ideal program in which to integrate further training. Recommendations for future development of EI in the program include the incorporation of training into the existing new student orientation week, the addition of case studies into the courses most naturally related to EI-building, the provision of training seminars for faculty, the inclusion of an advanced seminar for students on a voluntary basis, and the evaluation of the program using both a self-report EI questionnaire and the Mayer–Salovey–Caruso Emotional Intelligence Test at the beginning and end of each term to track program effectiveness in the long term.

Community-based participatory research to improve life quality and clinical outcomes of patients with breast cancer (DianaWeb in Umbria pilot study)

IntroductionBreast cancer (BC) is the most frequent cancer in Europe and the International Agency for Research on Cancer (IARC) has estimated over 460 000 incident cases per year. Survival among...

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...

Perceptions of predictive testing for those at risk of developing a chronic inflammatory disease: a meta-synthesis of qualitative studies

Background: The availability of tests to predict the risk of developing chronic diseases is increasing. The identification of individuals at high risk of disease can trigger early intervention to reduce the risk of disease and its severity. In order for predictive tests to be accepted and used by those at risk, there is a need to understand people’s perceptions of predictive testing. Method: A meta-synthesis of qualitative research that explored patient and public perceptions of predictive testing for chronic inflammatory diseases was conducted. Studies were coded by researchers and patient research partners, and then organised into common themes associated with the acceptability or use of predictive testing. Results: Perceived barriers to predictive testing were identified, including a concern about a lack of confidentiality around the use of risk information; a lack of motivation for change; poor communication of information; and a possible impact on emotional well-being. In order to reduce these barriers, the literature shows that a patient-centred approach is required at each stage of the testing process. This includes the consideration of individual needs, such as accessibility and building motivation for change; readily available and easy to understand pre and post-test information; support for patients on how to deal with the implications of their results; and the development of condition specific lifestyle intervention programmes to facilitate sustainable lifestyle changes. Conclusion: Patients and members of the public had some concerns about predictive testing; however, a number of strategies to reduce barriers and increase acceptability are available. Further research is required to inform the development of a resource that supports the individual to make an informed decision about whether to engage in a predictive test, what test results mean, and how to access post-test support.

Integrating Sustainable Development in Higher Education through Experience-based Learning: Insights from Experts in Team (EiT) for Developing a Combined Theoretical Framework

Universities are understood to play an essential role in the promotion of sustainable development. However, the recognition of sustainable development in higher education poses multiple challenges to the traditional higher education system. This article introduces a course concept called ‘Experts in Teams’ (EiT) as a new platform of learning which makes use of experience-based learning to address sustainable development in an academic context. The article investigates the ways in which these new forms of learning lead to sustainable lifestyle behavioural changes among participants. Based on the results from the case study, the article presents a combined framework for implementing sustainable development as part of a curriculum that not only provides theoretical education about the topic but also furthers a behavioural change among its participants towards more pro-environmental actions.

English

This article explores the strengths approach in therapeutic recreation practice, as articulated through the Flourishing through Leisure Model: An Ecological Extension of the Leisure and Well-Being Model (Anderson & Heyne, 2012a, 2012b), and examines the Upward Spiral Theory of Lifestyle Change (Fredrickson, 2015) as an explanatory framework for why and how leisure can drive sustained positive lifestyle change. Overviews are provided of the strengths approach and the Flourishing through Leisure Model, emphasizing the central role leisure plays in strengths-based therapeutic recreation practice. The broaden-and-build theory (Fredrickson, 2013b) is explained as it is the basis for the Upward Spiral Theory of Lifestyle Change. The Upward Spiral theory is described in detail in the contexts of the neuroscience of enjoyment, passion (obsessive and harmonious), and prioritizing positivity. Practical applications of the Upward Spiral Theory of Lifestyle Change to strengths-based therapeutic recreation practice are drawn, as well as recommendations for future research.

A pragmatic and scalable strategy using mobile technology to promote sustained lifestyle changes to prevent type 2 diabetes in India—Outcome of screening

AimsWe describe a two-step screening approach using non-invasive risk assessment and glycated hemoglobin (HbA1c) to identify participants for a diabetes prevention trial. MethodsA total of 6030 non-diabetic persons of 35–55 years were screened using risk assessment for diabetes. Those with three or more risk factors were screened using point of care HbA1c test. For this study, participants in HbA1c categories of 6.0% (42.1mmol/mol)–6.4% (46.4mmol/mol) were selected and their characteristics were analyzed. ResultsAmong 6030 persons, 2835 (47%) had three or more risk factors for diabetes. Among those screened with HbA1c, 43.2% (1225) had HbA1c values of <6.0% (42.1mmol/mol), 46.8% (1327) had HbA1c values between 6.0% (42.1mmol/mol) and ≤6.4% (46.4mmol/mol) and 10% (283) had undiagnosed diabetes with ≥6.5% (47.5mmol/mol). Positive family history was present in 53.2%, 81.7% were obese and 14.8% were overweight. ConclusionsOpportunistic screening using a two-step approach: diabetes risk profile and HbA1c measurement detected a large percentage of individuals with prediabetes. Prediabetic persons recruited to the trial had higher percentage of obesity and presence of positive family history than those who had lower HbA1c values. Outcomes from this trial will enable comparisons with the previous prevention studies that used blood glucose levels as the screening criteria.

Using new technologies to promote weight management: a randomised controlled trial study protocol.

BackgroundOver the last three decades, overweight and obesity and the associated health consequences have become global public health priorities. Methods that have been tried to address this problem have not had the desired impact, suggesting that other approaches need to be considered. One of the lessons learned throughout these attempts is that permanent weight loss requires sustained dietary and lifestyle changes, yet adherence to weight management programs has often been noted as one of the biggest challenges. This trial aims to address this issue by examining whether social media, as a potential health promotion tool, will improve adherence to a weight management program. To test the effectiveness of this measure, the designated program will be delivered via the popular social networking site Facebook, and compared to a standard delivery method that provides exactly the same content but which is communicated through a pamphlet. The trial will be conducted over a period of twelve weeks, with a twelve week follow-up. Although weight loss is expected, this study will specifically investigate the effectiveness of social media as a program delivery method. The program utilised will be one that has already been proven to achieve weight loss, namely The CSIRO Total Wellbeing Diet.Methods/designThis project will be conducted as a 3-arm randomised controlled trial. One hundred and twenty participants will be recruited from the Perth community, and will be randomly assigned to one of the following three groups: the Facebook group, the pamphlet group, or a control group. The Facebook Group will receive the weight management program delivered via a closed group in Facebook, the Pamphlet Group will be given the same weight management program presented in a booklet, and the Control Group will follow the Australian Dietary Guidelines and the National Physical Activity Guidelines for Adults as usual care. Change in weight, body composition and waist circumference will be initial indicators of adherence to the program. Secondary outcome measures will be blood glucose, insulin, blood pressure, arterial stiffness, physical activity, eating behaviour, mental well-being (stress, anxiety, and depression), social support, self-control, self-efficacy, Facebook activity, and program evaluation.DiscussionIt is expected that this trial will support the use of social media - a source of social support and information sharing - as a delivery method for weight management programs, enhancing the reduction in weight expected from dietary and physical activity changes. Facebook is a popular, easy to access and cost-effective online platform that can be used to assist the formation of social groups, and could be translated into health promotion practice relatively easily. It is anticipated in the context of the predicted findings that social media will provide an invaluable resource for health professionals and patients alike.Trial registrationAustralian New Zealand Clinical Trials Register (ANZCTR): ACTRN12614000536662. Date registered: 21 May 2014.Electronic supplementary materialThe online version of this article (doi:10.1186/s12889-015-1849-4) contains supplementary material, which is available to authorized users.

Integrating mobile technology with routine dietetic practice: the case of myPace for weight management.

The field of Mobile health (mHealth), which includes mobile phone applications (apps), is growing rapidly and has the potential to transform healthcare by increasing its quality and efficiency. The present paper focuses particularly on mobile technology for body weight management, including mobile phone apps for weight loss and the available evidence on their effectiveness. Translation of behaviour change theory into weight management strategies, including integration in mobile technology is also discussed. Moreover, the paper presents and discusses the myPace platform as a case in point. There is little clinical evidence on the effectiveness of currently available mobile phone apps in enabling behaviour change and improving health-related outcomes, including sustained body weight loss. Moreover, it is unclear to what extent these apps have been developed in collaboration with health professionals, such as dietitians, and the extent to which apps draw on and operationalise behaviour change techniques has not been explored. Furthermore, presently weight management apps are not built for use as part of dietetic practice, or indeed healthcare more widely, where face-to-face engagement is fundamental for instituting the building blocks for sustained lifestyle change. myPace is an innovative mobile technology for weight management meant to be embedded into and to enhance dietetic practice. Developed out of systematic, iterative stages of engagement with dietitians and consumers, it is uniquely designed to complement and support the trusted health practitioner-patient relationship. Future mHealth technology would benefit if engagement with health professionals and/or targeted patient groups, and behaviour change theory stood as the basis for technology development. Particularly, integrating technology into routine health care practice, rather than replacing one with the other, could be the way forward.

Health trainers: a service in transition.

Public health has changed significantly over the past century. With the rise in living standards and greater access to health care, the major public health challenges of the early 20th century, including infectious diseases like tuberculosis, have gradually declined.1 However, at the same time, we have seen the rise of new, more intractable public health issues, namely, the growing prevalence of lifestyle-related illness. It is estimated that a staggering two-thirds of all deaths for under 75s could have been avoided through the adoption of healthier lifestyles, such as eating more healthily, and tackling the wider determinants of health or health care interventions, such as earlier diagnosis.2As the challenges to public health evolve, it is essential that how we seek to tackle them also adapts. This is recognised in the White Paper, Choosing Health: Making Healthy Choices Easier, which introduced the health trainer service in 2004. The introduction of the health trainer service marked a transition in public health. Whereas previous initiatives have adopted a topdown approach, health trainers were to be a resource for communities, providing 'clients' with the skills and support necessary to make positive, sustained lifestyle changes. The health trainer service was an integral part of a new approach to tackle health inequalities and avoidable illness. By recruiting health trainers from within local communities, they would be ideally placed to target 'hard to reach' and disadvantaged groups, providing 'support from next door' rather than 'advice from on high'.3The efficacy of the health trainer service is supported by a strong evidence base in the form of the data collection and reporting system (DCRS), the data repository established by the Department of Health. The half-yearly DCRS reports published to date have sought to provide almost a national picture of the health trainer service, demonstrating its considerable success in supporting behaviour change in areas such as healthy eating, physical activity, smoking and alcohol, and increasing mental wellbeing of clients.Over the next three years, the RSPH will work with DCRS on a series of reports looking at the health trainer service. The DCRS report published by RSPH in February 2015 sought to look in greater depth at how the service has developed since it was rolled out in 2006 and to examine the extent to which the service has moved away from the 'original' service model. Unlike previous editions, this report combined the use of both DCRS data and qualitative research, consisting of telephone interviews with service managers and a survey completed by health trainers from 22 services. …