Using the question-behavior effect to change multiple health behaviors: An exploratory randomized controlled trial

Does Keeping a Sleep Diary Alter the Perception of Sleep Quality? Testing Measurement Reactivity in Healthy Adults

Measurement reactivity, where the act of measuring a behavior changes that behavior, has been documented across various health outcomes. However, its effects on sleep remain understudied, despite the widespread use of sleep diaries in clinical and research settings. In this randomized experiment, 190 healthy young adults (aged 18-40 years; 63% female) were assigned to complete either a sleep diary (Consensus Sleep Diary) or a physical activity diary (Physical Activity Scale) for seven days. All participants completed the Pittsburgh Sleep Quality Index (PSQI) and the International Physical Activity Questionnaire (IPAQ) before and after the diary period. Daily diary completion rates were high (97.3%). Linear mixed-effects models revealed no significant main effects of time (pre vs. post) or condition (sleep vs. physical activity diary), and no significant interaction between time and condition for either PSQI or IPAQ scores. These results suggest stability in sleep quality and physical activity measures, with no evidence of measurement reactivity. An exploratory analysis comparing "good" and "poor" sleepers (based on baseline PSQI scores) found a significant effect of sleep quality group and a time × group interaction on PSQI scores. In this adequately powered short-term study of young adults, we found no evidence of measurement reactivity to daily sleep diaries. These findings suggest that in healthy individuals, completing a week of sleep diaries is unlikely to impact PSQI scores substantially. We discuss our results in terms of the direct controllability of sleep quality, which might make it less susceptible to measurement reactivity relative to other health outcomes.

Research participation effects and where to find them: a systematic review of studies on alcohol

OBJECTIVES

The term 'research participation effects' (RPEs) is intended to capture features and artifacts of study design that may affect measured outcomes in ways that introduce bias into research findings, impacting inference and outcome validity. This systematic review aims to identify which RPEs have been studied in the context of alcohol research and provide an overview of estimates of RPEs on self-reported alcohol consumption.

STUDY DESIGN AND SETTING

This systematic review summarizes the available evidence on RPEs in alcohol research.

RESULTS

Twenty-seven reports were included in the review. The reports included randomized controlled trials (RCTs), studies-within-a-trial, between-subjects experiments, and qualitative investigations. A range of RPEs were addressed as follows: assessment reactivity (N = 15), being randomized to a waiting list control group (N = 3), the impact of obtaining informed consent (N = 2), experimentally induced social desirability (N = 3), and the Hawthorne effect, either specifically by name (N = 2, one quantitative, one qualitative) or described as general RPE presence (N = 2). The literature provided proportionally stronger evidence in favor of assessment reactivity and waiting list designs affecting alcohol outcomes, contrary to obtaining informed consent or inducing social desirability.

CONCLUSION

Variation in study quality, terminology, and outcome measures hinder comprehensive understanding and discussion of RPEs at present. Improved knowledge of RPEs and their potential long-term consequences in alcohol research, including a unified lexicon, would enhance trial design and improve the certainty of evidence in alcohol research.

HabitWalk: A micro-randomized trial to understand and promote habit formation in physical activity

Habit is a key psychological determinant for physical activity behavior change and maintenance. This study aims to deepen the understanding of habit formation in physical activity and identify promotion strategies. We examined the habit formation trajectory and its relationships with cue-behavior repetition (a cue-triggered 15-minute brisk walk) and unconditional physical activity (daily steps). We also tested whether the behavior change techniques (BCTs) 'commitment' and 'prompts and cues' promote habit, cue-behavior repetition, and daily steps within persons. This micro-randomized trial included a 7-day preparatory and a 105-day experimental phase delivered via the HabitWalk app. Participants (N = 24) had a 50% probability of receiving each BCT daily, leading to four conditions. Habit strength was assessed daily using the Self-Report Behavioral Automaticity Index, while cue-behavior repetition and steps were measured via an activity tracker. Person-specific growth functions indicated that habit strength trajectories were highly idiosyncratic. Multilevel models indicated a positive effect of cue-behavior repetition on habit strength, but not vice versa. The effect of habit strength on daily steps varied by the operationalization of cue-behavior repetition. Tentative findings suggest that commitment and prompts and cues are effective habit-promotion strategies when delivered together.

The associations of emotion regulation, self-compassion, and perceived lifestyle discrepancy with breast cancer survivors' healthy lifestyle maintenance

PURPOSE

Unhealthy lifestyle increases the risk of comorbidities, reduced quality of life, and cancer recurrence among breast cancer survivors. It is important to identify emotional and cognitive factors that may affect the maintenance of a healthy lifestyle over time. This study examined the associations of perceived lifestyle discrepancy, self-compassion, and emotional distress with the maintenance of a healthy lifestyle among breast cancer survivors and the mediating role of emotion regulation patterns (cognitive reappraisal and expressive suppression) in these associations.

METHODS

A total of 145 female breast cancer survivors aged 31-77 completed self-reports on healthy lifestyle maintenance, perceived lifestyle discrepancy, self-compassion, emotional distress, and emotion regulation patterns. Structural equation modeling was used to analyze the data.

RESULTS

Mean physical activity and healthy diet maintenance scores were moderate. The structural equation modeling analysis showed good fit indicators (χ2 = 4.21, df = 10, p = .94; χ2/df = 0.42; NFI = .98; TLI = 1.09; CFI = 1.00; RMSEA = .00, 95% CI (.00, .02)). Lower perceived lifestyle discrepancy was directly associated with higher physical activity (β = -.34, p < .01) and healthy diet (β =-.39, p < .01). Cognitive reappraisal was associated with higher physical activity (β = .19, p < .01), and expressive suppression was associated with lower physical activity (β = -.19, p < .01), and both mediated the association between self-compassion and physical activity.

CONCLUSIONS

The mediated associations reported in this study indicate that psychosocial factors, especially self-compassion, perceived lifestyle discrepancy, and emotional regulation patterns, are relevant to healthy lifestyle maintenance among breast cancer survivors, because solely providing healthy lifestyle recommendations does not motivate individuals to adhere to them.

IMPLICATIONS FOR CANCER SURVIVORS

Short-term structured psychosocial interventions designed to reduce perceived health discrepancy and strengthen self-compassion should be implemented and their effect on lifestyle should be further evaluated.

Promoting influenza prevention for older adults using the Health Action Process Approach: A randomized controlled trial

Older adults are at greater risk of complications from seasonal influenza, and promoting uptake and adherence to preventive behaviors is key to attenuating this risk. The current study examined the efficacy of a theory-based telephone-delivered intervention to promote uptake and maintenance of influenza preventive behaviors in a sample of Hong Kong residents 65 years and older. The intervention adopted a three-group randomized controlled design (n = 312) with two intervention conditions, motivational and motivational + volitional, and a measurement-only control condition. The primary outcome variable was self-reported compliance with influenza preventive behaviors, including washing hands, avoiding touching eyes, nose, or mouth, and wearing face masks. Secondary outcomes were theory-based psychological variables. Influenza preventive behaviors in participants in the motivational + volitional intervention group were significantly improved 3 months post-intervention relative to those in the control condition. However, participants in the intervention group demonstrated no difference in behavior at 6 and 12 months post-intervention relative to the participants in the control group. Intervention effects were observed on the theory-based social support, action planning, and coping planning variables. Although short-term benefits of the intervention were observed, effects appeared to be short-lived and future research should investigate more intensive interventions that lead to greater behavioral maintenance.

Activation Versus Change as a Principle Underlying Intervention Strategies to Promote Health Behaviors

BACKGROUND AND PURPOSE

Interventions are effective in promoting health behavior change to the extent that (a) intervention strategies modify targets (i.e., mechanisms of action), and (b) modifying targets leads to changes in behavior. To complement taxonomies that characterize the variety of strategies used in behavioral interventions, we outline a new principle that specifies how strategies modify targets and thereby promote behavior change. We distinguish two dimensions of targets-value (positive vs. negative) and accessibility (activation level)-and show that intervention strategies operate either by altering the value of what people think, feel, or want (target change) or by heightening the accessibility of behavior-related thoughts, feelings, and goals (target activation).

METHODS AND RESULTS

We review strategies designed to promote target activation and find that nudges, cue-reminders, goal priming, the question-behavior effect, and if-then planning are each effective in generating health behavior change, and that their effectiveness accrues from heightened accessibility of relevant targets. We also identify several other strategies that may operate, at least in part, via target activation (e.g., self-monitoring, message framing, anticipated regret inductions, and habits).

CONCLUSIONS

The Activation Vs. Change Principle (AVCP) offers a theoretically grounded and parsimonious means of distinguishing among intervention strategies. By focusing on how strategies modify targets, the AVCP can aid interventionists in deciding which intervention strategies to deploy and how to combine different strategies in behavioral trials. We outline a research agenda that could serve to further enhance the design and delivery of interventions to promote target activation.

"Please help us with important research": A retrospective analysis examining the impact of research invitation and participation on subsequent blood donor behavior

BACKGROUND

As over-communication can negatively impact consumer behavior, it is important to understand the impact of research communication on donors' future donation behavior. The aim of this study was to determine the effect of (i) being invited to participate in research, and (ii) participating in that research, on future donation behavior.

STUDY DESIGN AND METHODS

A retrospective cohort analysis was conducted with 36,418 donors who were invited to participate in one of 17 research projects, and a matched control group of 36,252 non-invited donors. Poisson regression models were used to examine the associations between invitation or participation in the studies and the likelihood of creating an appointment to donate and attending an appointment at 1, 3, and 6 months.

RESULTS

Donors were significantly more likely to create an appointment within 14 days of receiving an invitation compared to controls (RR: 1.91, 95% CI 1.81-2.02), and to return to donate at 1 (RR:1.18, 95% CI 1.13-1.24), 3 (RR:1.10, 95% CI 1.07-1.13) and 6 (RR:1.11, 95% CI 1.09-1.13) months compared to non-invited controls. Donors who participated in the research were more likely to return than control donors at all time points, while donors who were invited but did not participate were also likely to return more at 1 month (RR:1.06, 95% CI 1.00-1.11) and 6 months (RR:1.03, 95% CI 1.00-1.5) than non-invited controls.

DISCUSSION

Our findings suggest that research participation is positively associated with future donor behavior and provides reassurance that contacting donors for research does not negatively impact blood collections.

Tobacco and alcohol consumption and health behaviors among nursing students

Objetive: To evaluate the association between attitudes, health behaviors, and the use of tobacco and alcohol among nursing students. Materials and method: Exploratory, descriptive and cross-sectional study conducted with 182 undergraduate nursing students in the countryside of São Paulo, Brazil. Sociodemographic Information Form, Alcohol Use Disorders Identification Test – C(AUDIT-C), Fagerström Test for Nicotine Dependence (FTND), Attitudes and Health Behaviors Questionnaire (AHBQ), and Patient Health Questionnaire – 2 (PHQ-2) were applied. Results: More than half of the students showed appropriate health behaviors and positive attitudes. Approximately 50% of the participants had consumed alcoholic beverages in the last month. Experimental use of illicit drugs and smoking were also observed. In addition, students who reported excessive alcohol use presented a deficit in self-care. Conclusion: The precariousness in health attitudes and behaviors identified in this study was associated with various patterns of psychoactive substance use. Thus, the results indicate the need for interventions aimed at promoting well-being and a healthy lifestyle in the university environment.

Development of a Questionnaire Measuring Preventive Behaviors at Work

Purpose This study aimed to develop a questionnaire measuring preventive behaviors at work. Methods A three-step design, including qualitative and quantitative methods, was followed: (1) item generation, (2) experts' validation of content, and (3) pretesting. Results For step 1, 49 relevant existing scales were reviewed, and a pool of 172 items was generated. Redundant items were deleted (n = 48), and unclear items were reworded (n = 27). For step 2, 14 experts (five occupational therapists, four researchers, and five workers) assessed the representativeness, relevance, and clarity of each item through content validity indices (CVIs). An average overall CVI of 0.97 was obtained, and 87.5% of the experts stated that the questionnaire was comprehensive. During this step, 63 items were deleted, and 35 were modified. For step 3, the tool was pretested in the clinical settings of four dyads (occupational therapist-worker). The thematic analysis of interview content allowed several changes to be made to the questionnaire, including the addition of information and format changes. Conclusions Overall, this three-step study led to the construction of a 61-item French questionnaire entitled the Échelle de fréquence des comportements préventifs au travail [Frequency Scale of Preventive Behaviors at Work]. In rehabilitation settings, this tool could be useful to support professionals in enabling workers to adopt preventive behaviors, thereby fostering a healthy, sustainable return to work after a disability period. However, further metrological property assessment is required. A validating study using a large pool of workers is ongoing.

The Influence of Dissonance Induction and Assessment Reactivity in Improving Adherence to COVID-19 Precautionary Measures: A Cluster Randomised Controlled Trial

Background

During the coronavirus disease 2019 (COVID-19) pandemic, adherence to suggested precautionary measures has been emphasized as important in preventing and curtailing its spread. However, strict adherence to precautionary measures can be demanding.

Methods

This cluster randomised controlled trial done among 1517 undergraduate dental students tested the effectiveness of ‘dissonance induction’ (DI) and ‘assessment reactivity’ (AR) in improving adherence to World Health Organization (WHO) measures as compared to a control group. At baseline, participants in the DI group were tested for their knowledge of precautionary measures, immediately followed by assessment of their adherence to them. This methodology was adapted to systematically reveal the poor adherence of the participants in their self-held cognitions, should there be any. The magnitude of dissonance was measured as the proportion of such dissonant cognitions held by an individual. In the AR group, at baseline, participants were asked about their attitudes alone toward measures. The control group was neither assessed for knowledge and adherence nor for attitudes toward the measures at baseline. Two weeks after the administration of these interventions in the DI and AR groups, the 3 study groups were assessed for adherence.

Results

The follow-up adherence scores in the DI group were found to be significantly higher (15.11 ± 4.1) compared to the AR (13.13 ± 2.01) and control (12.87 ± 2.97) groups as analysed by Kruskal-Wallis analysis of variance (H = 243.5; P < .001). Wilcoxon signed-rank test showed that the adherence scores significantly improved in the DI group from baseline to follow-up (z = -8.84; P < .001). Magnitude of dissonance at baseline was found to be a significant predictor of follow-up adherence scores (R² = 0.255).

Conclusion

This study found that DI is an easy intervention to bring an immediate and significant change in adherence to precautionary measures.

A Quasi-Experimental Analysis of Lethal Means Assessment and Risk for Subsequent Suicide Attempts and Deaths

BACKGROUND

Counseling on access to lethal means is highly recommended for patients with suicide risk, but there are no formal evaluations of its impact in real-world settings.

OBJECTIVE

Evaluate whether lethal means assessment reduces the likelihood of suicide attempt and death outcomes.

DESIGN

Quasi-experimental design using an instrumental variable to overcome confounding due to unmeasured patient characteristics that could influence provider decisions to deliver lethal means assessment.

SETTING

Kaiser Permanente Colorado, an integrated health system serving over 600,000 members, with comprehensive capture of all electronic health records, medical claims, and death information.

PARTICIPANTS

Adult patients who endorsed suicide ideation on the Patient Health Questionnaire-9 (PHQ-9) depression screener administered in behavioral health and primary care settings from 2010 to 2016.

INTERVENTIONS

Provider documentation of lethal means assessment in the text of clinical notes, collected using a validated Natural Language Processing program.

MEASUREMENTS

Main outcome was ICD-9 or ICD-10 codes for self-inflicted injury or suicide death within 180 days of index PHQ-9 event.

RESULTS

We found 33% of patients with suicide ideation reported on the PHQ-9 received lethal means assessment in the 30 days following identification. Lethal means assessment reduced the risk of a suicide attempt or death within 180 days from 3.3 to 0.83% (p = .034, 95% CI = .069-.9).

LIMITATIONS

Unmeasured suicide prevention practices that co-occur with lethal means assessment may contribute to the effects observed.

CONCLUSIONS

Clinicians should expand the use of counseling on access to lethal means, along with co-occurring suicide prevention practices, to all patients who report suicide ideation.

Self-Efficacy for Physical Activity-A Question of Item Framing and Age?

Older adults process and remember positive information relatively better than negative information, compared with younger adults; this is known as the positivity effect. This study examined whether older adults compared with younger adults also respond differently to positively and negatively framed questionnaire items. Participants (N = 275; age = 18-81 years) were randomly assigned to a positively or negatively framed version of a self-efficacy for physical activity questionnaire. Self-efficacy, physical activity intentions, and planned physical activity in the following week were regressed on experimental group and age, controlling for baseline physical activity and covariates. A significant Age × Frame interaction showed that item framing made a difference in planned physical activity for the oldest age group (+350 min compared with the youngest group). This study provides initial support for the positivity effect in item framing on physical activity plans, but not on intentions or self-efficacy. Item framing should be taken into consideration for accurate measurement, but could also be a simple intervention approach.

Asking questions changes health-related behavior: an updated systematic review and meta-analysis

Objectives

The question-behavior effect (QBE) refers to whether asking people questions can result in changes in behavior. Such changes in behavior can lead to bias in trials. This study aims to update a systematic review of randomized controlled trials investigating the QBE, in light of several large preregistered studies being published.

Study Design and Setting

A systematic search for newly published trials covered 2012 to July 2018. Eligible trials randomly allocated participants to measurement vs. non-measurement control conditions or to different forms of measurement. Studies that reported health-related behavior as outcomes were included.

Results

Forty-three studies (33 studies from the original systematic review and 10 new studies) compared measurement vs. no measurement. An overall small effect was found using a random effect model: standardized mean difference = 0.06 (95% CI: 0.02–0.09), n = 104,388. Statistical heterogeneity was substantial (I² = 54%). In an analysis restricted to studies with a low risk of bias, the QBE remained small but significant. There was positive evidence of publication bias.

Conclusion

This update shows a small but significant QBE in trials with health-related outcomes but with considerable unexplained heterogeneity. Future trials with lower risk of bias are needed, with preregistered protocols and greater attention to blinding.

Socioeconomic Status Moderates the Effects of Health Cognitions on Health Behaviors within Participants: Two Multibehavior Studies

Background

Socioeconomic differences in health-related behaviors are a major cause of health inequalities. However, the mechanisms (mediation/moderation) by which socioeconomic status (SES) affects health behavior are a topic of ongoing debate.

Purpose

Current research on SES as moderator of the health cognitions–health behavior relation is inconsistent. Previous studies are limited by diverse operationalizations of SES and health behaviors, demographically narrow samples, and between-person designs addressing within-person processes. This paper presents two studies addressing these shortcomings in a within-person multibehavior framework using hierarchical linear models.

Methods

Two online studies, one cross-sectional and one 4 week longitudinal, assessed 1,005 (Study 1; Amazon MTurk; USA only) and 1,273 participants (Study 2; Prolific; international). Self-reports of multiple SES indicators (education, income, occupation status; ZIP code in Study 1), health cognitions (from the theory of planned behavior), and measures of six health behaviors were taken. Multilevel models with cross-level interactions tested whether the within-person relationships between health cognitions and behaviors differed by between-person SES.

Results

Education significantly moderated intention-behavior and attitude-behavior relationships in both studies, with more educated individuals showing stronger positive relationships. In addition, ZIP-level SES (Study 1) moderated attitude-behavior effects such that these relationships were stronger in participants living in areas with higher SES.

Conclusions

Education appears to be an important resource for the translation of intentions and attitudes into behavior. Other SES indicators showed less consistent effects. This has implications for interventions aiming at increasing intentions to change health behaviors, as some interventions might inadvertently increase health inequalities.

Degree of reasoned action predicts increased intentional control and reduced habitual control over health behaviors

BACKGROUND

Research is needed to understand factors that attenuate the association between habits and health behavior performance.

PURPOSE

We tested whether degree of reasoned action (DRA) moderates both intention-behavior and habit-behavior relations. DRA was defined by how well cognitions predict behavioral intentions, and was measured by the respective within-participants multiple correlation (R).

METHODS

Four studies were undertaken. Two pilot studies established the validity of our measure of DRA. Studies 1 (N = 663) and 2 (N = 1014) were prospective surveys of eight and six health behaviors, respectively. Intentions were measured via standard scales and habits were indexed by measures of frequency of performance × context stability.

RESULTS

In both studies, habits attenuated the predictive validity of intention. However, well-reasoned intentions better predicted health behaviors than poorly reasoned intentions, and habits offered weaker prediction of behavior when intentions were well reasoned. Three-way DRA × intention × habit interactions were also observed. Habits best predicted health behaviors when intentions were weak and poorly reasoned (Study 1), or offered poorest prediction of health behaviors when intentions were both strong and well-reasoned (Study 2).

CONCLUSIONS

Degree of reasoned action predicts increased intentional control and reduced habitual control over multiple health behaviors.