Increasing the frequency of physical activity very brief advice for cancer patients. Development of an intervention using the behaviour change wheel

Preoperative decreased physical activity is associated with greater postoperative pain: the mediating role of preoperative sleep disturbance

PURPOSE

Engagement in physical activity (PA) is often associated with better sleep quality and less pain severity among patients diagnosed with breast cancer. However, less research has focused on whether patients' PA prior to breast surgery, including their perceived decrease in PA level, is associated with worse preoperative sleep quality, and subsequently, greater postoperative pain. This longitudinal study investigated whether patients' preoperative PA was associated with their postoperative pain. We also explored whether preoperative sleep disturbance partially mediated the relationship between preoperative PA and postoperative pain.

METHODS

Prior to breast surgery, patients self-reported both their overall level of PA and whether they perceived a decrease in their PA since the diagnosis/onset of treatment for cancer. Patients also completed a measure of preoperative sleep disturbance. Two weeks after surgery, patients completed a measure of postoperative surgical-area pain severity.

RESULTS

Our results showed that preoperatively perceiving a decrease in PA level was significantly associated with greater preoperative sleep disturbance and postoperative pain. A mediation analysis revealed that the association between preoperative decreased PA and postoperative pain was partially mediated by preoperative sleep disturbance. Notably, patients' overall preoperative level of PA was not related to preoperative sleep disturbance or postoperative pain.

CONCLUSION

These findings suggest that maintaining, or even increasing, PA after diagnosis/treatment may be more important than the absolute amount of PA that women engage in during the preoperative period. Potentially, some patients with breast cancer may benefit from a preoperative intervention focused on both maintaining PA and bolstering sleep quality.

Pairing automated exercise coaching with patient-reported symptom monitoring: A way to nudge exercise uptake during cancer treatment?

INTRODUCTION

Symptoms during cancer treatment cause burden, diminished physical functioning, and poor quality of life. Exercise is recommended during treatment to mitigate symptoms; however, interventions are difficult to translate into clinical care due to the lack of patient uptake and clinical implementation barriers. We evaluated the uptake, acceptability, and impact of an automated ePRO exercise module triggered by three patient-reported symptoms: nausea/vomiting, fatigue, and anxiety, during chemotherapy.

METHODS

We conducted a secondary analysis of an exercise module intervention imbedded in the cancer symptom monitoring and management platform, Symptom Care at Home (SCH). Utilizing behavioral economics principles, the exercise module was triggered when any of the three symptoms were reported. Once triggered, participants were coached on exercise benefits for symptom reduction and then offered the opportunity to set weekly exercise goals plus tracking of the goal outcomes and receive further encouragement. We examined uptake, exercise goal setting and attainment, and symptom impact.

RESULTS

Of 180 SCH participants receiving the SCH intervention, 170 (94.4%) triggered the exercise module and 102 of the 170 (60%) accepted the module, setting goals on average for 6.3 weeks. Of 102 participants, 82 (80.4%) achieved one or more exercise goals, exercising on average 79.8 min/week. Participants who achieved a higher proportion of goals had statistically significant lower overall symptom severity and lower severity of the triggered symptom.

CONCLUSION

An automated mHealth exercise coaching intervention, aimed to nudge those receiving chemotherapy to initiate an exercise routine had significant uptake, is acceptable and may reduce symptom severity.

TRIAL REGISTRATION

NCT01973946.

Barriers and facilitators to giving prehabilitation advice by clinical nurse specialists and advanced nurse practitioners in oncology patients

PURPOSE

This is the second article in this series on the knowledge, attitudes and beliefs of clinical nurse specialists (CNSs) and ANPs (advanced nurse practitioners) regarding prehabilitation advice in oncology patients, exploring the barriers and facilitators to giving prehabilitation advice by CNSs and ANPs in oncology patients.

METHODS

A Cross-sectional online questionnaire opens for 3 months to establish the knowledge, attitudes and beliefs of ANPs and CNSs to prehabilitation disseminated through professional organisations and social media.

RESULTS

The questionnaire gained (n = 415) responses. Prehabilitation advice was routinely given by 89% (n = 371) of respondents. Many (60%) identified a lack of guidance and referral processes as a barrier to giving prehabilitation advice; this corresponded between respondents' confidence to give prehabilitation advice and subsequent referrals (< 0.001). Other factors included time (61%), a lack of patient interest (44%) and limited relevance to patients (35%).

CONCLUSION

The implementation of standardised nurse prehabilitation advice resources would enable CNSs and ANPs to provide personalised prehabilitation advice in their consultations.

A strategy to implement the American College of Sports Medicine's Exercise is Medicine® (EIM) initiative in a community oncology clinic

PURPOSE

Despite proven benefits, few cancer patients exercise during chemotherapy. The American College of Sports Medicine's Exercise is Medicine® (EIM) initiative describes a model to integrate exercise into oncology care, based upon assessing patients' ability to exercise safely, advising on exercise benefits, and referring patients to exercise. We developed and tested a strategy to implement EIM in a community-based oncology clinic, to assess-advise-refer 20 patients undergoing chemotherapy to a 3-month online exercise class, and measured implementation outcomes.

METHODS

Using a community-based provider participation in research (CBPPR) model, researchers and staff co-designed and tested a 4-level implementation strategy, with a goal of assessing-advising-referring 20 cancer patients to exercise. Surveys and interviews were conducted with 12 (100%) staff at baseline and post-implementation on acceptability/appropriateness/feasibility, perceptions of individual implementation roles, and organizational strengths/conditions. Data were analyzed using correlations, t-tests, and content analysis.

RESULTS

The proposed strategy was revised in collaboration with staff who requested assistance for recruitment and data collection. EIM was successfully implemented with 41 (92%) patients assessed, 37 (90%) advised, and 22 (60%) referred to exercise classes. Barriers to implementation were staff shortages and time constraints; facilitators included research team supports. Staff's perceived organizational strengths were positively correlated with exercise promotion acceptability, appropriateness, and feasibility. There were no statistically significant changes in implementation outcomes (acceptability/appropriateness/feasibility) post-implementation.

CONCLUSIONS

Using a collaborative model, EIM was successfully implemented in a community oncology clinic; however, the clinic required significant support from the research team. Adaptations to the EIM process may be required to improve implementation outcomes.

A qualitative study assessing the barriers and facilitators to physical activity in adults with hearing loss

OBJECTIVES

Growing epidemiological evidence has shown hearing loss is associated with physical inactivity. Currently, there is a dearth in evidence investigating why this occurs. This study aimed to investigate the barriers and facilitators to physical activity in middle-aged and older adults with hearing loss.

DESIGN

Individual semi-structured qualitative interviews.

METHODS

A phenomenological approach was taken. Ten adults (≥40 years) were interviewed via videoconferencing. The interview schedule was underpinned by the capability, opportunity, motivation and behaviour (COM-B) model. Reflexive thematic analysis was used to generate themes, which were subsequently mapped onto the COM-B model and behaviour change wheel.

RESULTS

Nine hearing loss specific themes were generated, which included the following barriers to physical activity: mental fatigue, interaction with the environment (acoustically challenging environments, difficulties with hearing aids when physically active) and social interactions (perceived stigma). Environmental modifications (digital capabilities of hearing aids), social support (hearing loss-only groups) and hearing loss self-efficacy were reported to facilitate physical activity.

CONCLUSIONS

Middle-aged and older adults with hearing loss experience hearing-specific barriers to physical activity, which has a deleterious impact on their overall health and well-being. Interventions and public health programmes need to be tailored to account for these additional barriers. Further research is necessary to test potential behaviour change techniques.

Establishing Innovative Complex Services: Learning from the Active Together Cancer Prehabilitation and Rehabilitation Service

Prehabilitation and rehabilitation will be essential services in an ageing population to support patients with cancer to live well through their life spans. Active Together is a novel evidence-based service embedded within existing healthcare pathways in an innovative collaboration between health, academic, and charity organisations. Designed to improve outcomes for cancer patients and reduce the demand on healthcare resources, it offers physical, nutritional, and psychological prehabilitation and rehabilitation support to patients undergoing cancer treatment. The service is underpinned by behaviour change theories and an individualised and personalised approach to care, addressing the health inequalities that might come about through age, poverty, ethnicity, or culture. Meeting the challenge of delivering high-quality services across multiple stakeholders, while addressing the complexity of patient need, has required skilled leadership, flexibility, and innovation. To support patients equally, regardless of geography or demographics, future services will need to be scaled regionally and be available in locations amenable to the populations they serve. To deliver these services across wide geographic regions, involving multiple providers and complex patient pathways, will require a systems approach. This means embracing and addressing the complexity of the contexts within which these services are delivered, to ensure efficient, high-quality provision of care, while supporting staff well-being and meeting the needs of patients.

Physical Activity Levels in People with Cancer Undergoing Chemotherapy: A Systematic Review

OBJECTIVES

Physical activity (PA) has been shown to improve chemotherapy side effects, survival rates and treatment adherence in people with cancer. This review aimed to identify whether people undergoing chemotherapy in different exercise interventions meet PA guidelines during chemotherapy.

DATA SOURCES

Databases searched were CINAHL complete, PubMed, Cochrane Library, EMBASE, AMED, Joanna Briggs Institute, OVID MEDLINE, and Google Scholar. Eligibility and risk-of-bias were reviewed by two authors. PROSPERO registration: CRD42018093839.

CONCLUSION

Thirty-three studies were eligible (14 randomized controlled trials, six pre-post, and 13 cross-sectional studies), which included 2,722 people with cancer undergoing chemotherapy. Studies (n = 11/13) found PA interventions successfully increased or maintained PA participation levels, whereas PA declined without intervention. This review has identified that due to limited evidence it is not possible to determine the most appropriate intervention to improve PA for people undergoing chemotherapy. Despite the well-documented benefits of PA, most people undergoing chemotherapy do not achieve the PA guidelines. Clinicians should be aware that during treatment, participants may not meet PA guidelines even if they participate in an intervention. However, interventions may prevent PA levels from declining. Further research is required to determine the most effective approaches to increase PA levels while undergoing chemotherapy.

IMPLICATIONS FOR NURSING PRACTICE

Nurses are well placed to have conversations with patients undergoing chemotherapy regarding PA levels. PA should be considered as part of a treatment regimen. Tailored advice must be provided aiming to improve health outcomes. Referral to an exercise professional is best practice to improve the uptake of PA.

Physical activity counseling during and following stem cell transplantation - patients' versus advisors' perspectives

BACKGROUND

People receiving hematopoietic stem cell transplantation (HSCT) endure long phases of therapy and immobility, which diminish their physical activity (PA) level leading to physical deconditioning. One of the reasons is a lack of clarity on the part of those who work in oncology clinical settings of their role in assessing, advising, and referring patients to exercise. Therefore, our study investigates reported physical activity counseling behavior of health care professionals (HCPs) and the patient perspective on this topic.

METHODS

Physicians (N = 52), nurses (N = 52) physical therapists (N = 26), and patients receiving HSCT (N = 62) participated in a nationwide cross-sectional online-survey. Patients' preferred source of information concerning PA was determined. We examined HCPs self-assessed PA counseling behavior and patients' PA recall by assessing the use of the 5As (Ask, Advice, Agree, Assist, Arrange). Analysis of survey responses was descriptive. Univariate multinomial logistic regression examined whether sociodemographic factors and patient characteristics influence the response behavior.

RESULTS

Physicians and PA specialists were patients' preferred source of information regarding PA. A large discrepancy between HCPs' perception and the degree to which HSCT patients recall advice became apparent; profound counseling steps like making referrals were less often recalled in our patient sample. Inactive patients reported to receive less basic PA counseling by physicians.

CONCLUSION

Future research should identify the requirements to increase patients' recall concerning PA counseling in the setting of HSCT. Important messages about PA need to be made more salient to those who are less active and less engaged.

Piloting HealthScore: Feasibility and acceptability of a clinically integrated health coaching program for people living with cancer

BACKGROUND

Cancer supportive care interventions often have limited generalizability, goal misalignment, and high costs. We developed and piloted a health coaching intervention, UNC HealthScore, in patients undergoing cancer treatment (ClinicalTrials.gov identifier NCT04923997). We present feasibility, acceptability, and preliminary outcome data.

METHODS

HealthScore is a six-month, theory-based, multicomponent intervention delivered through participant-driven coaching sessions. For the pilot study, participants were provided a Fitbit, responded to weekly symptom and physical function digital surveys, and met with a health coach weekly to develop and monitor goals. Coaching notes were discussed in weekly interdisciplinary team meetings and provided back to the treating oncology team. Symptom alerts were monitored and triaged through a study resource nurse to relevant supportive care services. Feasibility was determined based on intervention enrollment and completion. Acceptability was based on satisfaction with coaching and Fitbit-wearing and was informed by semistructured exit interviews. Outcomes evaluated for signs of improvement included several PROMIS (Patient-Reported Outcomes Measurement Information System) measures, including the primary intervention target, physical function.

RESULTS

From May 2020 to March 2022, 50 participants completed the single-arm pilot. Feasibility was high: 66% enrolled and 71% completed the full intervention. Participants reported an average of 4.8 and 4.7 (out of 5) on the acceptability of coaching calls and using the Fitbit, respectively. Physical function scores rose 3.1 points (SE = 1.1) from baseline to 3 months, and 4.3 (SE = 1.0) from baseline to 6 months, above established minimal clinically important difference (MCID). Improvements above MCID were also evident in anxiety and depression, and smaller improvements were demonstrated for emotional support, social isolation, cognitive function, symptom burden, and self-efficacy.

DISCUSSION

HealthScore shows feasibility, acceptability, and promising preliminary outcomes. Randomized studies are underway to determine the efficacy of preserving physical function in patients with advanced cancer.

Development of a behavioural support intervention for e-bike use in Australia

BACKGROUND

Insufficient physical activity (PA) is a risk factor for the development of many non-communicable diseases. Electric bicycles (e-bikes) offer considerable potential to support people to be physically active, however, no previous e-bike intervention studies have supported e-bike use with behavioural support. The aim of this study was to co-develop theory-based intervention components which can be used to increase physical activity through e-cycling among people who are overweight or obese and physically inactive.

METHODS

We conducted a mixed-methods study using an online survey and virtual co-design workshops. We utilised the Behaviour Change Wheel (BCW) to inform the development of the behavioural support intervention to facilitate day-to-day e-cycling.

RESULTS

One hundred participants completed an online survey and seven participated in the online co-design workshops. The development of the intervention identified five intervention functions (enablement, training, environmental restructuring, education, and persuasion) and 16 behaviour change techniques (BCTs) from 11 BCT groups (goals and planning, feedback and monitoring, social support, shaping knowledge, natural consequences, comparison of behaviour, associations, repetition and substitution, comparison of outcomes, antecedents, and self-belief).

CONCLUSION

To our knowledge, this is the first study to combine co-design and the BCW to develop a comprehensive behavioural support intervention for e-bike use. Theory based intervention options should be considered when providing e-bikes to individuals to help them increase their habitual PA levels.

Promoting positive physical activity behaviors for children and adolescents undergoing acute cancer treatment: Development of the CanMOVE intervention using the Behavior Change Wheel

Background

Increasing participation in physical activity has the potential to improve outcomes for children and adolescents with cancer during treatment and into survivorship. The aim of this study is to outline the theoretical process behind development of CanMOVE, a behavior change intervention designed to increase physical activity for children and adolescents with cancer.

Study design

This study followed a theoretical design process consistent with the Behavior Change Wheel to inform the design of a complex intervention.

Materials and methods

The three stages of the Behavior Change Wheel intervention design process include: (1) understanding physical activity behavior within the pediatric cancer setting, (2) identifying potential intervention functions, and (3) identifying appropriate behavior change and implementation strategies. Qualitative and behavior change literature relevant to the pediatric cancer treatment setting were used to inform each stage.

Results

An individualized and flexible approach to physical activity promotion that considers intrinsic factors specific to the child/adolescent and their environment is required. Fifteen behavioral change strategies were identified to form the intervention components of CanMOVE. Implementation strategies were identified to build motivation, opportunity and capacity toward increasing physical activity behaviors. Key intervention components of CanMOVE include standardized assessment and monitoring (physical activity, physical function, and health-related quality of life), provision of an activity monitor to both child/adolescent and parent, and one-on-one capacity building sessions with a healthcare professional. Capacity building sessions include education, goal setting, an active supervised physical activity session, barrier identification and problem solving, and action planning.

Conclusion

CanMOVE is a novel approach to physical activity promotion in the pediatric cancer treatment setting. The use of a theoretical intervention design process will aid evaluation and replication of CanMOVE when it is assessed for feasibility in a clinical setting. The design process utilized here can be used as a guide for future intervention development.

Use of the behaviour change wheel to improve everyday person-centred conversations on physical activity across healthcare

BACKGROUND

An implementation gap exists between the evidence supporting physical activity in the prevention and management of long-term medical conditions and clinical practice. Person-centred conversations, i.e. focussing on the values, preferences and aspirations of each individual, are required from healthcare professionals. However, many currently lack the capability, opportunity, and motivation to have these conversations. This study uses the Behaviour Change Wheel (BCW) to inform the development of practical and educational resources to help bridge this gap.

METHODS

The BCW provides a theoretical approach to enable the systematic development of behaviour change interventions. Authors followed the described eight-step process, considered results from a scoping review, consulted clinical working groups, tested and developed ideas across clinical pathways, and agreed on solutions to each stage by consensus.

RESULTS

The behavioural diagnosis identified healthcare professionals' initiation of person-centred conversations on physical activity at all appropriate opportunities in routine medical care as a suitable primary target for interventions. Six intervention functions and five policy categories met the APEASE criteria. We mapped 17 Behavioural Change Techniques onto BCW intervention functions to define intervention strategies.

CONCLUSIONS

This study uses the BCW to outline a coherent approach for intervention development to improve healthcare professionals' frequency and quality of conversations on physical activity across clinical practice. Time-sensitive and role-specific resources might help healthcare professionals understand the focus of their intervention. Educational resources aimed at healthcare professionals and patients could have mutual benefit, should fit into existing care pathways and support professional development. A trusted information source with single-point access via the internet is likely to improve accessibility. Future evaluation of resources built and coded using this framework is required to establish the effectiveness of this approach and help improve understanding of what works to change conversations around physical activity in clinical practice.

Identifying barriers and facilitators of hearing protection use in early-career musicians: a basis for designing interventions to promote uptake and sustained use

OBJECTIVE

The current study aimed to: i) determine the patterns of hearing protection device (HPD) use in early-career musicians, ii) identify barriers to and facilitators of HPD use, and iii) use the Behaviour Change Wheel (BCW) to develop an intervention to increase uptake and sustained use of HPDs.

DESIGN

A mixed-methods approach using questionnaires and semi-structured interviews.

STUDY SAMPLE

Eighty early-career musicians (age range = 18-26 years; women n = 39), across all categories of musical instrument.

RESULTS

42.5% percent of participants reported using HPDs at least once a week, 35% less than once a week, and 22.5% reported never using HPDs for music-related activities. Six barriers and four facilitators of HPD use were identified. Barriers include the impact of HPDs on listening to music and performing, and a lack of concern about noise exposure. Barriers/facilitators were mapped onto the Theoretical Domains Framework. Following the systematic process of the BCW, our proposed intervention strategies are based on 'Environmental Restructuring', such as providing prompts to increase awareness of noisy settings, and 'Persuasion/Modelling', such as providing credible role models.

CONCLUSIONS

For the first time, the present study demonstrates the use of the BCW for designing interventions in the context of hearing conservation.

The barriers and facilitators to physical activity in people with a musculoskeletal condition: A rapid review of reviews using the COM-B model to support intervention development

Objectives

The objective of this review of reviews was to identify the potentially modifiable barriers and facilitators to physical activity in people with a musculoskeletal condition to influence intervention development.

Study design

A rapid review of reviews.

Methods

The Cochrane library and PubMed Central were searched for reviews using pre-defined search terms and relevant synonyms for “physical activity”, “barriers” or “facilitators”, and “musculoskeletal condition”. The identified reviews were screened for inclusion by the principal investigator in line with recognised streamlining approaches for a rapid review. Only review papers investigating the barriers and facilitators to physical activity in adults with a musculoskeletal condition were included. A team of seven assessed the included reviews for identification of the barriers and facilitators to physical activity coded using the COM-B model of behaviour.

Results

503 reviews were identified with 12 included for analysis across a mix of conditions and designs (n = 2: qualitative; n = 6: quantitative; n = 4 mixed). A multitude of interrelated factors were identified across the COM-B components. The most prevalent factors included disease symptoms and physical function (physical capability), knowledge of the specific benefits of physical activity and knowing what to do (psychological capability), the accessibility of facilities and individualised programming (physical opportunity), tailored advice from healthcare professionals and peer support (social opportunity), beliefs about the benefits or harms of being active (reflective motivation) and having the self-efficacy to be active and experiencing positive emotions (automatic motivation).

Conclusions

This review of reviews identified the complex nature of physical activity in people living with a musculoskeletal condition. The identified barriers and facilitators should be considered by intervention designers when developing behaviour change interventions for this population group.

Co-design of a school-based physical activity intervention for adolescent females in a disadvantaged community: insights from the Girls Active Project (GAP)

BACKGROUND

Globally, adolescents' physical activity (PA) participation rates are low, particularly among lower socioeconomic groups, with females consistently the least active. The aim of this study was to co-design, with adolescent females, a school-based PA intervention in a single-sex, females-only designated disadvantaged post-primary school in Ireland. This involved using the Behaviour Change Wheel (BCW) and Public and Patient Involvement (PPI). This paper outlines the novel methodological approach taken.

METHODS

The three stages 1) understand the behaviour, 2) identify intervention options, and 3) identify content and implementation options of the BCW guide is described. A student PPI Youth Advisory Group (YAG) (n = 8, aged 15-17) was established. Mixed-methods were used with students (n = 287, aged 12-18) and teachers (n = 7) to capture current self-reported PA levels and to identify factors influencing adolescent females' PA behaviour in their school setting. The intervention options, content and implementation options were identified through discussion groups with the YAG. The Template for Intervention Description and Replication (TIDieR) checklist was used to specify details of the intervention.

RESULTS

Just 1.4% of the students in this sample reported meeting the recommended PA guidelines. Students identified having more 'time' as the strongest predictor to becoming more active in school (Mean = 4.01, 95% CI 3.91 to 4.12). Social influences, environmental context and resources, behavioural regulation, beliefs about capabilities, goals, and reinforcement emerged from the qualitative data as factors influencing PA behaviour at school. The BCW co-design process resulted in the identification of seven intervention functions, four policy categories and 21 Behaviour Change Techniques. The Girls Active Project (GAP) intervention, a peer-led, after-school PA programme was proposed.

CONCLUSIONS

This paper describes how the BCW, a comprehensive, evidence-based, theory-driven framework was used in combination with PPI to co-design a school-based intervention aimed to increase adolescent females' PA levels. This approach could be replicated in other settings to develop targeted behavioural interventions in populations with specific demographic characteristics.

Applying the behaviour change wheel to develop a smartphone application 'stay-active' to increase physical activity in women with gestational diabetes

BACKGROUND

Physical activity (PA) interventions are an important but underutilised component in the management of gestational diabetes mellitus (GDM). The challenge remains how to deliver cost effective PA interventions that have impact on individual behaviour. Digital technologies can support and promote PA remotely at scale. We describe the development of a behaviourally informed smartphone application (Stay-Active) for women attending an NHS GDM clinic. Stay-Active will support an existing motivational interviewing intervention to increase and maintain PA in this population.

METHODS

The behaviour change wheel (BCW) eight step theoretical approach was used to design the application. It provided a systematic approach to understanding the target behaviour, identifying relevant intervention functions, and specifying intervention content. The target behaviour was to increase and maintain PA. To obtain a behavioural diagnosis, qualitative evidence was combined with focus groups on the barriers and facilitators to PA in women with GDM. The findings were mapped onto the Capability Opportunity Motivation-Behaviour (COM-B) model and Theoretical Domains Framework to identify what needs to change for the target behaviour and linked to appropriate intervention functions. Finally, behaviour changes techniques (BCT) and modes of delivery that are most likely to serve the intervention functions were selected. Current evidence, patient focus groups and input from key stakeholders informed Stay-Active's development.

RESULTS

We found that psychological capability, reflective and automatic motivation, social and physical opportunity needed to change to increase PA in women with GDM. The four key intervention functions identified were Enablement, Education, Persuasion and Training. Stay-Active incorporates these four intervention functions delivering ten BCTs including: goal setting, credible source, self-monitoring, action planning, prompts and cues. The final design of Stay-Active delivers these BCTs via an educational resource centre, with goal setting and action planning features, personalised performance feedback and individualised promotional messages.

CONCLUSION

The BCW has enabled the systematic and comprehensive development of Stay-Active to promote PA in women with GDM within an NHS Maternity service. The next phase is to conduct a trial to assess the feasibility and acceptability of a multi-component intervention that combines Stay-Active with PA Motivational Interviewing.

Cost evaluation of an exercise oncology intervention: The exercise in all chemotherapy trial

BACKGROUND

There is strong evidence supporting the efficacy of exercise oncology programs to improve physical and psychosocial outcomes during active treatment. However, there is a paucity of evidence on the effect of exercise on healthcare utilization and cost analyzes of exercise oncology programs.

AIMS

Our objective was to assess the effects of a pragmatic exercise oncology program (ENACT) during active chemotherapy treatment on healthcare utilization and associated costs.

METHODS

We conducted post-hoc analyzes on 160 ENACT participants and 75 comparison participants matched on cancer site, stage, age range, and gender. We obtained complete healthcare utilization histories for each patient (specific to emergency department [ED] visits and hospital admissions) coinciding with their participation in ENACT. A sub-analysis was conducted for advanced stage breast, gastrointestinal, and pancreatic cancer patients.

RESULTS

Healthcare costs for patients who participated in the ENACT exercise oncology intervention were numerically lower than healthcare costs for the comparison group, even after accounting for the cost of the intervention. However, the differences were not statistically significant.

CONCLUSION

Our findings suggest that an exercise oncology program during active chemotherapy treatment are at least cost neutral for all cancer patients, including advanced stage cancers. Additional research is warranted to evaluate the potential for exercise oncology programs to reduce healthcare utilization, particularly in advanced cancer patients.

Health Professionals' Views on Lifestyle Advice Delivery to Teenage and Young Adult Cancer Patients: A Qualitative Study

BACKGROUND

Many health professionals working with teenage and young adult cancer patients (TYA-HPs) do not provide advice on physical activity, dietary intake, smoking cessation, and alcohol consumption as part of routine cancer care.

OBJECTIVE

The aim of this study was to understand TYA-HPs' perspectives on the provision of health behavior advice and preferences on an intervention to help develop their health promotion skills.

METHODS

In-depth, semistructured interviews were conducted with 26 TYA-HPs (12 nurses, 8 clinicians, and 6 allied health professionals) whose average time working with teenage and young adult (TYA) cancer patients was 8 years. Each interview followed the same semistructured guide, which was based upon constructs of the COM-B model of behavior change (capability, physical opportunity, social opportunity, reflective motivation, and automatic motivation), transcribed verbatim, and analyzed using the Framework analysis.

RESULTS

Overall, TYA-HPs recognized the value and importance of promoting health behaviors but felt that their capability to provide health behavior advice was limited by the availability of, and access to, good-quality evidence linking health behavior to cancer outcomes. The TYA-HPs expressed confusion over professional responsibility to provide choices.

CONCLUSIONS

The TYA-HPs recognize health behavior promotion to be a core part of TYA cancer care but feel ill-equipped to provide such advice to patients.

IMPLICATIONS FOR PRACTICE

Mapped to constructs of the COM-B model of behavior, these findings suggest that TYA-HPs would benefit from cross-multidisciplinary team support for improved access to TYA-specific resources covering key health behaviors and skills-based training on delivering lifestyle advice.

Exercise oncology: an emerging discipline in the cancer care continuum

Exercise is an essential component of healthy living and well-being. While there is a global acceptance of the benefits of exercise for the general population, there exists hesitancy and confusion among health-care professionals, particularly oncologists, as to whether these benefits translate to cancer patients. Patient referrals to accessible, structured exercise programs in this setting are often overlooked by physicians when formulating a cancer management plan. There is however increasing awareness and acceptance of cancer survivorship as a part of the cancer care continuum, identifying multiple factors that contribute to well-being beyond just cancer outcomes. Efforts to optimize cancer survivorship have stimulated further academic interest in the benefits of healthy living and particularly exercise oncology. There is now compelling evidence that exercise, which includes daily activities such as walking, as well as structured programs, improves multiple-cancer outcomes such as fatigue, quality of life and likely survival, and warrants consideration in the multidisciplinary care of cancer patients. International guidelines have been established that recommend counseling cancer patients with regard to healthy lifestyle changes including exercise. However, there still remains a reluctance from oncology physicians to prescribe exercise for these patients, largely due to uncertainty with regard to their patients' ability to tolerate such an intervention, coupled with insufficient understanding of the potential benefits of these programs. There also exist patient barriers and attitudes that must be overcome. Exercise strategies and bespoke programs that are tailored to the unique abilities and goals of the patients will enhance participation. To move the field forward and integrate exercise oncology into standard practice, it is imperative to raise awareness of the benefits of exercise to cancer patients and their health-care providers. This will facilitate the prescription of exercise as part of the multimodal treatment plan with the ultimate aim of promoting an active lifestyle to optimize patient care and well-being.

Addressing Emotional and Psychological Problems Associated With Hearing Loss: Perspective of Consumer and Community Representatives

PURPOSE

Hearing loss causes emotional distress and can contribute to the development of psychological difficulties, yet emotional and psychological issues are not addressed within current audiology services. The purpose of this study was to use focus groups with consumer and community representatives to explore how we might improve the provision of support for clients experiencing emotional and psychological issues in relation to their hearing loss.

PARTICIPANTS

Adults with hearing loss (n = 19) and their significant others (n = 9), as well as 10 hearing health care professionals (n = 4 hearing health care clinicians, n = 4 reception staff, and n = 2 clinical managers), participated in consumer and community engagement focus groups.

METHOD

Consumer and community representatives were tasked with (a) identifying the stakeholders involved in supporting adults experiencing emotional or psychological difficulties on account of their hearing loss, (b) describing the behaviors undertaken by each stakeholder group, and (c) selecting target behavior(s) that could optimally form the basis of an intervention program to improve the quality and frequency of support provided to people experiencing emotional and psychological problems in the audiology setting.

RESULTS

Participants identified 12 stakeholder groups involved in supporting adults with hearing loss experiencing emotional and psychological problems. The three behaviors voted by participants to be the most promising for a behavioral intervention included the clinician (a) asking about, (b) providing information on, and (c) delivering therapeutic intervention for emotional and psychological well-being within audiological service provision.

CONCLUSION

Consumer and community stakeholder representatives indicate a general desire for hearing health care clinicians to deliver support for the emotional and psychological issues that arise relating to hearing loss.

Overcoming Barriers to Injectable Therapies: Development of the ORBIT Intervention Within a Behavioural Change Framework

It is estimated among individuals with type 2 diabetes (T2D) requiring injectable therapies to achieve optimal glycaemic control, one-third are reluctant to initiate therapies, with approximately 80% choosing to discontinue or interrupt injectable regimens soon after commencement. Initiation of injectables is a complex issue, with effectiveness of such treatments undermined by non-adherence or poor engagement. Poor engagement and adherence are attributed to psychological aspects such as individuals’ negative perceptions of injectables, depression, anxiety, feelings of shame, distress and perceived lack of control over their condition. The aim of this study was to describe the development of a structured diabetes intervention to address psychological barriers to injectable treatments among a cohort of those with T2D; conducted within a behavioural change framework. An evidence base was developed to inform on key psychological barriers to injectable therapies. A systematic review highlighted the need for theory-based, structured diabetes education focussed on associated psychological constructs to inform effective, patient-centric provisions to improve injectable initiation and persistence. Findings from the focus groups with individuals who had recently commenced injectable therapies, identified patient-centric barriers to initiation and persistence with injectables. Findings from the systematic review and focus groups were translated via Behavioural Change Wheel (BCW) framework to develop an intervention for people with T2D transitioning to injectable therapies: Overcoming and Removing Barriers to Injectable Treatment in T2D (ORBIT). This article describes how psychological barriers informed the intervention with these mapped onto relevant components, intervention functions and selected behaviour change techniques, and finally aligned with behaviour change techniques. This article outlines the systematic approach to intervention development within the BCW framework; guiding readers through the practical application of each stage. The use of the BCW framework has ensured the development of the intervention is theory driven, with the research able to be evaluated and validated through replication due to the clarity around processes and tasks completed at each stage.

#LetsUnlitterUK: A demonstration and evaluation of the Behavior Change Wheel methodology

The Behavior Change Wheel is the most comprehensive and practically useful methodology available for developing behavior change interventions. The current article demonstrates how it can be applied to optimize pro-environmental behaviors and, in so doing, give interventionists access to a rigorous set of theories and techniques for systematically developing pro-environmental interventions. Section 1 describes the development of an intervention to increase people's intentions to post anti-littering messages on social media. Study 2 describes the development and evaluation of an intervention to increase people's actual anti-littering posts. Both evaluations are randomized controlled trials that compare the effectiveness of the developed intervention with interventions less informed by the Wheel. We found interventions completely informed by the Wheel to be more effective than interventions less (or not at all) informed by the Wheel. The discussion explores how the Behavior Change Wheel methodology can be used to design future pro-environment interventions.

Enhancing community weight loss groups in a low socioeconomic status area: Application of the COM-B model and Behaviour Change Wheel

Background

Obesity rates are higher among people of lower socioeconomic status. While numerous health behaviour interventions targeting obesity exist, they are more successful at engaging higher socioeconomic status populations, leaving those in less affluent circumstances with poorer outcomes. This highlights a need for more tailored interventions. The aim of this study was to enhance an existing weight loss course for adults living in low socioeconomic communities.

Methods

The Behaviour Change Wheel approach was followed to design an add‐on intervention to an existing local authority‐run weight loss group, informed by mixed‐methods research and stakeholder engagement.

Results

The COM‐B analysis of qualitative data revealed that changes were required to psychological capability, physical and social opportunity and reflective motivation to enable dietary goal‐setting behaviours. The resulting SMART‐C booklet included 6 weeks of dietary goal setting, with weekly behavioural contract and review.

Conclusion

This paper details the development of the theory‐ and evidence‐informed SMART‐C intervention. This is the first report of the Behaviour Change Wheel being used to design an add‐on tool to enhance existing weight loss services. The process benefitted from a further checking stage with stakeholders.

How is the Theoretical Domains Framework applied in designing interventions to support healthcare practitioner behaviour change? A systematic review

BACKGROUND

The use of theory is recommended to support interventions to promote implementation of evidence-based practices. However, there are multiple models of behaviour change which can be complex and lack comprehensiveness and are therefore difficult to understand and operationalize. The Theoretical Domains Framework sought to address these problems by synthesizing 33 models of behaviour or behaviour change. Given that it is 15 years since the first publication of the Theoretical Domains Framework (TDF), it is timely to reflect on how the framework has been applied in practice.

OBJECTIVE

The objective of this review is to identify and narratively synthesize papers in which the TDF, (including frameworks that incorporate the TDF) have been used have been used to develop implementation interventions.

METHODS

We searched MEDLINE, PsychINFO, CINAHL and the Cochrane databases using the terms: 'theoretical domains framework*' or TDF or Capability, Opportunity, Motivation to Behaviour (COM-B) or 'behav* change wheel' or 'BCW' AND implement* or improv* or quality or guideline* or intervention* or practice* or EBP or 'evidence based practice' and conducted citation and key author searches. The included papers were those that used any version of the TDF published from 2005 onwards. The included papers were subject to narrative synthesis.

RESULTS

A total of 3540 papers were identified and 60 were included. Thirty-two papers reported intervention design only and 28 reported intervention design and testing. Despite over 3000 citations there has been limited application to the point of designing interventions to support the best practice. In particular use of the framework has not been tried or tested in non-western countries and barely used in non-primary or acute care settings. Authors have applied the framework to assess barriers and facilitators successfully but reporting of the process of selection of behaviour change techniques and intervention design thereafter was variable.

CONCLUSION

Despite over three thousand citations of the framework there has been limited application to the point of designing interventions to support best practice. The framework is barely used in non-western countries or beyond primary or acute care settings. A stated purpose of the framework was to make psychological theory accessible to researchers and practitioners alike; if this is to be fully achieved, further guidance is needed on the application of the framework beyond the point of assessment of barriers and facilitators.

The Exercise Oncology Knowledge Mobilization Initiative: An International Modified Delphi Study

INTRODUCTION

Exercise is vital to health and well-being after a cancer diagnosis yet is poorly integrated in cancer care. Knowledge mobilization (KM) is essential to enhance exercise opportunities. We aimed to (1) develop and refine a list of highly important exercise oncology research and KM themes and (2) establish the relative importance of the themes for supporting the implementation of exercise as a standard of care for people living with and beyond cancer.

METHODS

Informed by the Co-Produced Pathway to Impact KM framework, a modified Delphi study approach was used to develop, rate, and rank exercise oncology research and KM themes through an international stakeholder workshop and a three-round iterative online survey. Open-ended stakeholder feedback from cancer survivors, healthcare practitioners (HCPs), qualified exercise professionals (QEPs), policy makers, and researchers was used to update themes between survey rounds. Themes were ranked from highest to lowest importance and agreement was examined across all stakeholders and within stakeholder groups.

RESULTS

A total of 269 exercise oncology stakeholders from 13 countries participated in the study. Twelve final exercise oncology research and KM themes were produced. The final top ranked research themes were related to: (1) QEP integration into primary cancer care teams, (2) Exercise oncology education for HCPs, and (3) Accessibility of cancer exercise programs & support services. There was statistically significant agreement between stakeholders (p<0.001) and within stakeholder groups (p's≤0.02) on the general rankings of themes (i.e., some themes generally ranked higher and lower compared to others). Low Kendall's W statistics indicated variability related to the specific ranked order of the themes between stakeholders and within stakeholder groups. Moreover, there were key differences in the rankings for specific themes between policy makers and other stakeholder groups that highlight potentially important discordance in the research and KM priorities for policy makers that warrants further study.

CONCLUSION

These findings can be used to guide initiatives and align stakeholders on priorities to support exercise implementation as a standard of cancer care. Additional research is needed to better understand the differences in the proposed research and KM priorities across stakeholders.

A Quality Improvement Education Pilot Project to Increase Recommendations for Physical Activity in Cancer Survivors

Physical activity can provide benefits for cancer survivors. A nurse-provided physical activity recommendation is strongly supported by evidence-based symptom interventions developed by the Oncology Nursing Society. This pilot project aimed to evaluate whether a focused quality improvement education (QIE) intervention could increase the frequency with which oncology nurses provide a physical activity recommendation to patients. Using The Expanded Learning Model for Systems to structure the project, the project team provided a multipronged educational approach with coaching through quality improvement activities to guide practice change. Oncology-focused clinical quality measures (CQMs) related to assessment for cancer-related fatigue and recommendation for physical activity provided the primary data used to evaluate the impact of the QIE intervention. CQM data demonstrated substantial increases in the frequency with which patients were assessed for fatigue and provided with a physical activity recommendation. This pilot project provides preliminary evidence that a QIE intervention supported by coaching can help facilitate evidence-based practice change. [J Contin Educ Nurs. 2021;52(4):184-191.].

The core components of cardio-oncology rehabilitation

The increased efficacy of cancer therapy has resulted in greater cancer survival and increasing number of people with cancer and cardiovascular diseases. The sharing of risk factors, the bidirectional relationship between cancer and cardiovascular diseases and the cardiotoxic effect of chemotherapy and radiotherapy, are the cause of the rapid expansion of cardio-oncology. All strategies to preserve cardiovascular health and mitigate the negative effect of cancer therapy, by reducing the cardiovascular risk, must be pursued to enable the timely and complete delivery of anticancer therapy and to achieve the longest remission of the disease. Comprehensive cardiac rehabilitation is an easy-to-use model, even in cancer care, and is the basis of Cardio-Oncology REhabilitation (CORE), an exercise-based multi-component intervention. In addition, CORE, besides using the rationale and knowledge of cardiac rehabilitation, can leverage the network of cardiac rehabilitation services to offer to cancer patients exercise programs, control of risk factors, psychological support, and nutrition counseling. The core components of CORE will be discussed, describing the beneficial effect on cardiorespiratory fitness, quality of life, psychological and physical well-being, and weight management. Furthermore, particular attention will be paid to how CORE can counterbalance the negative effect of therapies in those at heightened cardiovascular risk after a cancer diagnosis. Barriers for implementation, including personal, family, social and of the health care system barriers for a widespread diffusion of the CORE will also be discussed. Finally, there will be a call-to-action, for randomized clinical trials that can test the impact of CORE, on morbidity and mortality.

Improving young children's handwashing behaviour and understanding of germs: The impact of A Germ's Journey educational resources in schools and public spaces

CONTEXT

Effective handwashing can prevent the spread of germs, including Covid-19. However, young children can lack a fundamental understanding of germ transfer. A Germ's Journey educational resources were designed to support young children in learning about germs and handwashing. These resources include a book, website, song, online games and glo-gel activities that are informed by a behaviour change model.

RESEARCH GAP

Prior research has not evaluated the impacts of these resources on behavioural outcomes.

PURPOSE OF THE STUDY

Two intervention studies evaluated the impacts of these resources on both knowledge and behavioural outcomes.

METHOD

In Study 1, children (n = 225) were recruited from four schools and randomly assigned by classrooms to participate in a multicomponent intervention (vs. control). In Study 2, children (n = 104) were recruited from a museum and randomly assigned to participate in a song intervention (vs. control). Trained observers recorded participants' engagement in six handwashing behaviours and their understanding of germs. These behavioural and knowledge outcomes were analysed using regression and related analyses.

RESULTS

In Study 1, significant improvements were observed between baseline and follow up in the intervention group for both behavioural scores (Est = 0.48, SE = 0.14, t = 3.30, p = 0.001) and knowledge scores (Est = 2.14, SE = 0.52, z = 4.11, p < 0.001), whereas these improvements were not observed in the control group (ts < 1). In Study 2, the intervention group had significantly higher behavioural scores compared to the control group (Est. = -0.71, SE = 0.34, t = -2.07, p = 0.04).

CONCLUSION

This research demonstrates that specifically designed hand hygiene educational resources can improve handwashing practice and understanding in young children, and could lead to the reduction of the transmission of disease within this group.

Barriers and opportunities for cleanliness of shared sanitation facilities in low-income settlements in Kenya

Background

The sharing of sanitation facilities is a common practice in low-income areas in sub-Saharan Africa. However, shared sanitation is currently categorized as a limited sanitation service, and may therefore not count towards meeting the global goals. These shared facilities are often the only option available for most residents in low-income settlements, and improving their cleanliness and overall management is key to reducing open defecation and risk of disease. This study sought to investigate barriers and opportunities for improved cleanliness of shared sanitation facilities in low-income settlements of Kisumu city, Kenya.

Methods

Thirty-nine in-depth interviews and 11 focus group discussions were held with residents – mainly tenants and landlords – of a low-income settlement in Kisumu. Analysis followed a thematic approach to define the problem, specify the target behaviour and identify the changes needed.

Results

Sanitation facilities were mainly pit latrines, typically shared among landlords and tenants. Participants singled out behavioural (poor use of the shared toilets) and social (lack of cooperation in cleaning) challenges that led to unclean shared toilets. Available opportunities for improvement included instituting clear cleaning plans, improving communication among users, and enhanced problem-solving mechanisms between landlords and tenants. These approaches could form the basis for designing intervention strategies for improving the cleanliness of shared sanitation facilities.

Conclusion

The results highlight the need to focus on social aspects for improvement of cleanliness in shared sanitation facilities in low-income settlements. Through a social approach, shared sanitation facilities can be managed appropriately to provide the millions of low-income residents in Kenya an opportunity to access sanitation. This study provides further evidence on approaches for improved management of shared sanitation facilities in line with the World Health Organization’s (WHO) Joint Monitoring Program’s (JMP) recommendation for high quality shared facilities.

Moving through cancer: Setting the agenda to make exercise standard in oncology practice

LAY SUMMARY

International evidence-based guidelines support the prescription of exercise for all individuals living with and beyond cancer. This article describes the agenda of the newly formed Moving Through Cancer initiative, which has a primary objective of making exercise standard practice in oncology by 2029.

A co-production approach guided by the behaviour change wheel to develop an intervention for reducing sedentary behaviour after stroke

Background

Stroke survivors are highly sedentary; thus, breaking up long uninterrupted bouts of sedentary behaviour could have substantial health benefit. However, there are no intervention strategies specifically aimed at reducing sedentary behaviour tailored for stroke survivors. The purpose of this study was to use co-production approaches to develop an intervention to reduce sedentary behaviour after stroke.

Methods

A series of five co-production workshops with stroke survivors, their caregivers, stroke service staff, exercise professionals, and researchers were conducted in parallel in two-stroke services (England and Scotland). Workshop format was informed by the behaviour change wheel (BCW) framework for developing interventions and incorporated systematic review and empirical evidence. Taking an iterative approach, data from activities and audio recordings were analysed following each workshop and findings used to inform subsequent workshops, to inform both the activities of the next workshop and ongoing intervention development.

Findings

Co-production workshop participants (n = 43) included 17 staff, 14 stroke survivors, six caregivers and six researchers. The target behaviour for stroke survivors is to increase standing and moving, and the target behaviour for caregivers and staff is to support and encourage stroke survivors to increase standing and moving. The developed intervention is primarily based on co-produced solutions to barriers to achieving the target behaviour. The developed intervention includes 34 behaviour change techniques. The intervention is to be delivered through stroke services, commencing in the inpatient setting and following through discharge into the community. Participants reported that taking part in intervention development was a positive experience.

Conclusions

To our knowledge, this is the first study that has combined the use of co-production and the BCW to develop an intervention for use in stroke care. In-depth reporting of how a co-production approach was combined with the BCW framework, including the design of bespoke materials for workshop activities, should prove useful to other researchers and practitioners involved in intervention development in stroke.

How to increase chlamydia testing in primary care: a qualitative exploration with young people and application of a meta-theoretical model

Objective

The objective of this study was to explore young people’s perspectives barriers to chlamydia testing in general practice and potential intervention functions and implementation strategies to overcome identified barriers, using a meta-theoretical framework (the Behaviour Change Wheel (BCW)).

Methods

Twenty-eight semistructured individual interviews were conducted with 16–24 year olds from across the UK. Purposive and convenience sampling methods were used (eg, youth organisations, charities, online platforms and chain-referrals). An inductive thematic analysis was first conducted, followed by thematic categorisation using the BCW.

Results

Participants identified several barriers to testing: conducting self-sampling inaccurately (physical capability); lack of information and awareness (psychological capability); testing not seen as a priority and perceived low risk (reflective motivation); embarrassment, fear and guilt (automatic motivation); the UK primary care context and location of toilets (physical opportunity) and stigma (social opportunity). Potential intervention functions raised by participants included education (eg, increase awareness of chlamydia); persuasion (eg, use of imagery/data to alter beliefs); environmental restructuring (eg, alternative sampling methods) and modelling (eg, credible sources such as celebrities). Potential implementation strategies and policy categories discussed were communication and marketing (eg, social media); service provision (eg, introduction of a young person’s health-check) and guidelines (eg, standard questions for healthcare providers).

Conclusions

The BCW provided a useful framework for conceptually exploring the wide range of barriers to testing identified and possible intervention functions and policy categories to overcome said barriers. While greater education and awareness and expanded opportunities for testing were considered important, this alone will not bring about dramatic increases in testing. A societal and structural shift towards the normalisation of chlamydia testing is needed, alongside approaches which recognise the heterogeneity of this population. To ensure optimal and inclusive healthcare, researchers, clinicians and policy makers alike must consider patient diversity and the wider health issues affecting all young people.

Guidance for reporting intervention development studies in health research (GUIDED): an evidence-based consensus study

OBJECTIVE

To improve the quality and consistency of intervention development reporting in health research.

DESIGN

This was a consensus exercise consisting of two simultaneous and identical three-round e-Delphi studies (one with experts in intervention development and one with wider stakeholders including funders, journal editors and public involvement members), followed by a consensus workshop. Delphi items were systematically derived from two preceding systematic reviews and a qualitative interview study.

PARTICIPANTS

Intervention developers (n=26) and wider stakeholders (n=18) from the UK, North America and Europe participated in separate e-Delphi studies. Intervention developers (n=13) and wider stakeholders (n=13) participated in a 1-day consensus workshop.

RESULTS

e-Delphi participants achieved consensus on 15 reporting items. Following feedback from the consensus meeting, the final inclusion and wording of 14 items with description and explanations for each item were agreed. Items focus on context, purpose, target population, approaches, evidence, theory, guiding principles, stakeholder contribution, changes in content or format during the development process, required changes for subgroups, continuing uncertainties, and open access publication. They form the GUIDED (GUIDance for the rEporting of intervention Development) checklist, which contains a description and explanation of each item, alongside examples of good reporting.

CONCLUSIONS

Consensus-based reporting guidance for intervention development in health research is now available for publishers and researchers to use. GUIDED has the potential to lead to greater transparency, and enhance quality and improve learning about intervention development research and practice.

Immunisation status screening in the emergency department: Why are we forgetting the elderly?

BACKGROUND

Pneumonia is one of the most common reasons patients over the age of 65 years present to the Emergency Department (ED). There is a 23-valent pneumococcal vaccine (23vPPV) available under the National Immunisation Program (NIP) with demonstrated 61-71% effectiveness against Invasive Pneumococcal Disease (IPD), but only 51% of adults aged over 65 years are vaccinated in Australia.

METHODS

Short semi-structured interviews were conducted with emergency nurses working across a Local Health District in Sydney New South Wales (n=9) in order to determine their knowledge, behaviour and attitudes towards immunisation status screening in the elderly who present to the ED with pneumonia. Questions were structured to the COM-B Model (capability, opportunity and motivation to change behaviour), and a thematic analysis was conducted.

RESULTS

There were three major themes identified: (1) The importance of routinisation, (2) Low knowledge levels and, (3) The 'vaccination is for children' heuristic, as well as suggestions for future interventions to improve screening.

CONCLUSIONS

These findings clarify how to improve vaccine uptake amongst this vulnerable cohort. They suggest that emergency departments should provide education to nurses. In addition, checklists/tick boxes can prompt nurses whilst conducting routine work, which may lead to increased vaccination uptake.

Developing interventions to improve health: a systematic mapping review of international practice between 2015 and 2016

BACKGROUND

Researchers publish the processes they use to develop interventions to improve health. Reflecting on this endeavour may help future developers to improve their practice.

METHODS

Our aim was to collate, describe, and analyse the actions developers take when developing complex interventions to improve health. We carried out a systematic mapping review of empirical research studies that report the development of complex interventions to improve health. A search was undertaken of five databases over 2015-2016 using the term 'intervention dev*'. Eighty-seven journal articles reporting the process of intervention development were identified. A purposive subset of 30 articles, using a range of published approaches to developing interventions, was selected for in-depth analysis using principles of realist synthesis to identify the actions of intervention development and rationales underpinning those actions.

RESULTS

The 87 articles were from the USA (39/87), the UK (32/87), continental Europe (6/87), and the rest of the world (10/87). These mainly took a pragmatic self-selected approach (n = 43); a theory- and evidence-based approach, e.g. Intervention Mapping, Behaviour Change Wheel (n = 22); or a partnership approach, e.g. community-based participatory research, co-design (n = 10). Ten actions of intervention development were identified from the subset of 30 articles, including identifying a need for an intervention, selecting the intervention development approach to follow, considering the needs of the target population, reviewing published evidence, involving stakeholders, drawing or generating theory, and designing and refining the intervention. Rationales for these actions were that they would produce more engaging, acceptable, feasible, and effective interventions.

CONCLUSIONS

Developers take a variety of approaches to the international endeavour of complex intervention development. We have identified and described a set of actions taken within this endeavour regardless of whether developers follow a published approach or not. Future developers can use these actions and the rationales that underpin them to help them make decisions about the process of intervention development.

TRIAL REGISTRATION

PROSPERO, CRD42017080545.

Exercise is medicine in oncology: Engaging clinicians to help patients move through cancer

Multiple organizations around the world have issued evidence-based exercise guidance for patients with cancer and cancer survivors. Recently, the American College of Sports Medicine has updated its exercise guidance for cancer prevention as well as for the prevention and treatment of a variety of cancer health-related outcomes (eg, fatigue, anxiety, depression, function, and quality of life). Despite these guidelines, the majority of people living with and beyond cancer are not regularly physically active. Among the reasons for this is a lack of clarity on the part of those who work in oncology clinical settings of their role in assessing, advising, and referring patients to exercise. The authors propose using the American College of Sports Medicine's Exercise Is Medicine initiative to address this practice gap. The simple proposal is for clinicians to assess, advise, and refer patients to either home-based or community-based exercise or for further evaluation and intervention in outpatient rehabilitation. To do this will require care coordination with appropriate professionals as well as change in the behaviors of clinicians, patients, and those who deliver the rehabilitation and exercise programming. Behavior change is one of many challenges to enacting the proposed practice changes. Other implementation challenges include capacity for triage and referral, the need for a program registry, costs and compensation, and workforce development. In conclusion, there is a call to action for key stakeholders to create the infrastructure and cultural adaptations needed so that all people living with and beyond cancer can be as active as is possible for them.

A cross sectional survey of internet use among a highly socially disadvantaged population of tobacco smokers

Background

Tobacco smoking is highest among population groups which are the most socially disadvantaged. Internet-based smoking cessation programs have been found to be effective, though rates of internet access are not well known in these groups. This study describes the rates of internet use and types of technology used to access the internet by a population of socially disadvantaged smokers. The study also examined relationships between sociodemographic and smoking behaviours with amount of internet use and type of device used.

Methods

A cross-sectional survey of 369 clients (response rate 77%) from two non-government community service organisations in metropolitan New South Wales, Australia was conducted using touchscreen computers. Descriptive statistics and logistic regressions were used to examine results.

Results

Eligible participants ranged from 19 to 88 years old current tobacco users. Over half (58%) of the participants reported weekly or more frequent use of the internet with less than a third (28%) not having any access. The odds of using the internet at least weekly decreased with age and as heaviness of smoking increased (OR = 0.94, p < 0.001; OR = 0.81, p = 0.022, respectively). Odds of internet use were higher as income increased (OR = 2.74, p < 0.001 for individuals earning $201–$400 per week; OR = 2.83, p = 0.006 for individuals earning > $400 per week). Device use differed for age and income.

Conclusions

Internet-based interventions appear to reach the majority of socially disadvantaged populations. It is expected that this reach will continue to grow, making internet-based interventions a potential platform for providing care to low socioeconomic individuals who smoke, however inequalities may be exacerbated for those individual without internet access.

Implications

Internet use among socially disadvantaged tobacco users is moderate (58%). An internet-based smoking cessation intervention for socially disadvantaged tobacco users may be an effective intervention however, older, heavier tobacco users may not benefit as easily due to limited internet access and therefore acknowledging these limitations when developing an intervention can help to acknowledge limitation of intervention reach.

Breaking barriers: using the behavior change wheel to develop a tailored intervention to overcome workplace inhibitors to breaking up sitting time

BACKGROUND

The workplace is a prominent domain for excessive sitting. The consequences of increased sitting time include adverse health outcomes such as cardiovascular disease and poor mental wellbeing. There is evidence that breaking up sitting could improve health, however, any such intervention in the workplace would need to be informed by a theoretical evidence-based framework. The aim of this study was to use the Behaviour Change Wheel (BCW) to develop a tailored intervention to break up and reduce workplace sitting in desk-based workers.

METHODS

The BCW guide was followed for this qualitative, pre-intervention development study. Semi-structured interviews were conducted with 25 office workers (26-59 years, mean age 40.9 [SD = 10.8] years; 68% female) who were purposively recruited from local council offices and a university in the East of England region. The interview questions were developed using the Theoretical Domains Framework (TDF). Transcripts were deductively analysed using the COM-B (Capability, Opportunity, Motivation - Behaviour) model of behaviour. The Behaviour Change Technique Taxonomy Version 1 (BCTv1) was thereafter used to identify possible strategies that could be used to facilitate change in sitting behaviour of office workers in a future intervention.

RESULTS

Qualitative analysis using COM-B identified that participants felt that they had the physical Capability to break up their sitting time, however, some lacked the psychological Capability in relation to the knowledge of both guidelines for sitting time and the consequences of excess sitting. Social and physical Opportunity was identified as important, such as a supportive organisational culture (social) and the need for environmental resources (physical). Motivation was highlighted as a core target for intervention, both reflective Motivation, such as beliefs about capability and intention and automatic in terms of overcoming habit through reinforcement. Seven intervention functions and three policy categories from the BCW were identified as relevant. Finally, 39 behaviour change techniques (BCTs) were identified as potential active components for an intervention to break up sitting time in the workplace.

CONCLUSIONS

The TDF, COM-B model and BCW can be successfully applied through a systematic process to understand the drivers of behaviour of office workers to develop a co-created intervention that can be used to break up and decrease sitting in the workplace. Intervention designers should consider the identified BCW factors and BCTs when developing interventions to reduce and break up workplace sitting.

Behavioural analysis of postnatal physical activity in the UK according to the COM-B model: a multi-methods study

OBJECTIVE

Develop a behavioural analysis of factors influencing postnatal physical activity (PA) according to the 'capability, opportunity, motivation and behaviour' (COM-B) model of behaviour to inform intervention development using the Behaviour Change Wheel (BCW).

DESIGN

Cross-sectional, multi-method study using semi-structured interviews and a quantitative questionnaire.

SETTING

Children's centres and mother and baby groups in Hertfordshire and Cambridgeshire, UK.

PARTICIPANTS

Convenience samples of postnatal women were interviewed (n=16) and completed the questionnaire (n=158).

METHODS

Semi-structured interviews followed a preprepared topic guide exploring the COM-B model components and analysed using framework analysis. The questionnaire, based on the self-evaluation of behaviour questionnaire, was adapted using patient and public involvement and findings from the interviews. Questionnaire participants rated their agreement with 22 predefined statements related to COM-B model components. Mean, SD and 95% CI were calculated and each item categorised according to importance. Demographic data were collected.

RESULTS

The questionnaire identified that new mothers would be more active if they had more time, felt less tired, had accessible childcare, were part of a group, advised by a healthcare professional, able to develop a habit and had more motivation. Additional themes emerging from qualitative data were engaging in PA groups with other new mothers, limited physical stamina following complicated births, social interaction, enjoyment and parental beliefs as motivation, provision of child-friendly PA facilities and environments and babies' unpredictable routines.

CONCLUSION

The behavioural analysis presented in this paper identifies and adds detail on the range of factors influencing the target behaviour. Some are unique to the target population, requiring targeted interventions for postnatal women, whereas some are individualised, suggesting the need for individually tailored interventions. We will use the behavioural analysis presented to design an intervention using the subsequent steps in the BCW.

Development of a context-sensitive physical activity intervention for persons living with HIV and AIDS of low socioeconomic status using the behaviour change wheel

Background

Regular physical activity (PA) has been recommended for the management of HIV and AIDS. The purpose of this study was to develop a contextualised intervention for promoting PA among women living with HIV and AIDS (WLWHA) of low socioeconomic status (SES). A secondary aim of the study was to optimise the PA intervention using behavioural theory/ frameworks derived from preliminary studies and the literature.

Methods

The Behaviour Change Wheel (BCW) for designing behaviour change interventions was used. This method was further supplemented by evidence from the literature, systematic literature review (SLR), a concurrent mixed methods study and two cross-sectional studies. The SLR aided in determining the theoretical frameworks to inform the intervention, the specific PA behaviours to be targeted by the intervention, the intervention functions, the intervention policy category and the mode of delivery of the intervention. The concurrent mixed methods study was used to identify key factors that needed to change in order for participants to engage in regular PA. The first cross-sectional study was used to determine the gender to be targeted by the study. The second cross-sectional study was used to determine the domain and intensity of PA to target in the intervention.

Results

A face-to-face context-sensitive PA intervention employing 14 behavioural change techniques was designed. The PA intervention (a) utilised the Transtheoretical model of behaviour change and the Social Cognitive theory as the underpinning theoretical frameworks (b) included convenient PAs, such as walking, doing simple home-based exercises, engaging in activities of daily living or doing simple exercises at the community centre (c) used education, reward, training in PA, modelling exercise activities and enablement to increase the opportunity to engage in PA as intervention functions (d) used service provision as policy priorities, and (e) used a direct face-to-face mode of delivery.

Conclusions

The PA intervention emphasises behavioural techniques for increasing PA participation, such as goal-setting, self-monitoring, strategies for overcoming PA barriers, social support and rewards. The intervention employs strategies that highlight low-cost local PA resources and opportunities to help HIV infected women of low SES to participate in PA. The BCW provides a useful and comprehensive framework for the development of evidence and theory-based PA interventions for PLWHA of low SES. The BCW can thus be used in the development of interventions that ‘talk’ to policy by bridging the health inequality gap.

Q sample construction: a novel approach incorporating a Delphi technique to explore opinions about codeine dependence

BACKGROUND

Q methodology is an evidenced approach to researching subjectivity, involving a combination of qualitative and quantitative techniques. The methodology has been used successfully in healthcare research to explore the opinions of patients and healthcare providers about topics such as the illness experience, healthcare services, clinical practice and professional training. Q methodology studies require the generation of a Q sample, a set of opinion statements representing the phenomenon of interest. This paper describes a novel and rigorous approach to develop a Q sample for a study exploring misusers' opinions about over-the-counter (OTC) codeine dependence and critically examines the associated methodological issues.

METHODS

Development of the Q sample in this study involved three steps; (1) identification of opinion statements via a comprehensive literature search, (2) application of a theoretical framework, the Capability, Opportunity, Motivation - Behaviour (COM-B) model of behaviour, to group and then reduce the number of statements and (3) use of a Delphi technique to achieve expert consensus on the final selection of statements. The Delphi component involved a multidisciplinary panel of 15 addiction experts comprised of doctors, nurses, pharmacists, psychologists and researchers, who were recruited purposively. Experts rated each statement using a 5-point scale of perceived importance. Two Delphi rounds were undertaken and consensus for inclusion of a statement was set at a median score of ≥4 and an interquartile range of ≤1.

RESULTS

A total of 842 statements representing codeine misusers' opinions about OTC codeine dependence were identified from the literature. Statements were grouped thematically using the COM-B framework and representative statements were selected, reducing the number to 111. After two Delphi rounds, addiction experts achieved consensus on 46 statements which formed the final Q sample.

CONCLUSIONS

This paper describes a new and systematic approach to Q sample construction and explores associated methodological issues that could be useful for those considering Q methodology and for furthering the rigour of this research technique.

What do cost-effective health behaviour-change interventions contain? A comparison of six domains

OBJECTIVES

To help implement behaviour change interventions (BCIs) in practice it is important to be able to characterize their key components. This study compared broad features of cost-effective BCIs that addressed smoking, diet, physical activity, alcohol and sexual health. It also assessed the association of these with the magnitude of the cost-effectiveness estimates.

METHODS

A content analysis of 79 interventions based on 338 intervention descriptions was conducted, using the Behaviour Change Wheel (BCW) to classify intervention content in terms of intervention functions, and the BCT taxonomy to identify and categorise component Behaviour Change Techniques (BCT). Regression analysis identified the association of these with upper (pessimistic) and lower (optimistic) cost-effectiveness estimates.

RESULTS

The most and least common functions and BCT clusters were education (82.3%) and shaping knowledge (79.7%), and coercion (3.8%) and covert learning (2.5%). Smoking interventions contained the largest ([Formula: see text] = 12) number of BCTs and were most cost-effective. Several other factors were associated with worse (coercionfunction βupper = 36551.24; shaping knowledgeBCT βlower = 2427.78; comparison of outcomesBCT βupper = 9067.32; repetition and substitutionBCT βupper = 7172.47) and better (modellingfunction βlower = -2905.3; environmental restructuringfunction βupper = -8646.28; reward and threatBCT βupper = -5577.59) cost-effectiveness (p<0.05).

DISCUSSION

Cost-effective BCIs rely heavily on education with smoking interventions exhibiting the most comprehensive range of BCTs. Providing an example to aspire to, restructuring the environment and rewarding positive behaviour may be associated with greater cost-effectiveness.

Using behaviour change theory to train health workers on tobacco cessation support for tuberculosis patients: a mixed-methods study in Bangladesh, Nepal and Pakistan

Background

Low- and middle-income countries (LMICs) are disproportionately impacted by interacting epidemics of tuberculosis (TB) and tobacco consumption. Research indicates behavioural support delivered by health workers effectively promotes tobacco cessation. There is, however, a paucity of training to support LMIC health workers deliver effective tobacco cessation behavioural support. The TB and Tobacco Consortium undertook research in South Asia to understand factors affecting TB health workers’ delivery of tobacco cessation behavioural support, and subsequently developed a training package for LMICs.

Methods

Using the “capability, opportunity, and motivation as determinants of behaviour” (COM-B) framework to understand any issues facing health worker delivery of behaviour support, we analysed 25 semi-structured interviews and one focus group discussion with TB health workers, facility in-charges, and national tuberculosis control programme (NTP) staff members in each country. Results were integrated with findings of an adapted COM-B questionnaire on health worker confidence in tobacco cessation support delivery, administered to 36 TB health workers. Based on findings, we designed a guide and training programme on tobacco cessation support for health workers.

Results

Qualitative results highlighted gaps in the majority of health workers’ knowledge on tobacco cessation and TB and tobacco interaction, inadequate training on patient communication, insufficient resources and staff support, and NTPs’ non-prioritization of tobacco cessation in all three countries. Questionnaire results reiterated the knowledge deficits and low confidence in patient communication. Participants suggested strengthening knowledge, skills, and competence through training and professional incentives. Based on findings, we developed an interactive two-day training and TB health worker guide adaptable for LMICs, focusing on evidence of best practice on TB and tobacco cessation support, communication, and rapport building with patients.

Conclusions

TB health workers are essential in addressing the dual burden of TB and tobacco faced by many LMICs. Factors affecting their delivery of tobacco cessation support can be identified using the COM-B framework, and include issues such as individuals’ knowledge and skills, as well as structural barriers like professional support through monitoring and supervision. While structural changes are needed to tackle the latter, we have developed an adaptable and engaging health worker training package to address the former that can be delivered in routine TB care.

Trial registration

ISRCTN43811467.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-3909-4) contains supplementary material, which is available to authorized users.

Physiotherapist-Led Physical Activity Interventions Are Efficacious at Increasing Physical Activity Levels: A Systematic Review and Meta-analysis

OBJECTIVE

Physical activity (PA) interventions to address noncommunicable disease (NCD) risk are commonly delivered in private practice and outpatient physiotherapy settings. This study reviewed the efficacy of physiotherapist-led physical activity (PLPA) interventions at improving PA levels.

DATA SOURCES

Twelve databases were searched using terms related to both physiotherapy and PA. English-language studies of all designs in adults were included. Meta-analyses were conducted separately for interventions measuring the following: (1) participants meeting recommended PA levels; (2) total PA at short- and long-term follow-up; and (3) total PA achieved after short and long PLPA interventions. Pooled effects were calculated using a fixed-effects model as standardized mean differences (SMDs). Nonstatistical analysis was used to identify the effect of PLPA interventions on the volume of PA performed at different intensities.

MAIN RESULTS

From an initial 4140 studies, 8 were retained, and risk of bias ranged from low to high. Meta-analysis showed the odds of adults meeting minimum recommended PA levels were doubled in groups provided a PLPA intervention [OR = 2.15, 95% confidence interval (CI) = 1.35-3.43]. Total PA levels were increased in the short term (SMD = 0.15, 95% CI = 0.03-0.27) but not in the long term. Longer term interventions did not improve outcomes. Nonstatistical analysis identified that PLPA interventions were efficacious at increasing the amount of PA adults performed at all intensities.

CONCLUSIONS

Clinic-based PLPA interventions delivered in private practice, primary care, and outpatient settings were efficacious at increasing PA in adults at risk of NCDs. Improvements did not last long term and were not enhanced with longer interventions.

Mothers and teenage daughters walking to health: using the behaviour change wheel to develop an intervention to improve adolescent girls' physical activity

OBJECTIVES

The majority of adolescent girls fail to meet public health guidelines for physical activity. Engaging mothers in the promotion of physical activity for their daughters may be an important strategy to facilitate behaviour change. The aim of this study was to use the behaviour change wheel (BCW) framework to design the components of an intervention to improve adolescent girls' physical activity.

STUDY DESIGN

Cross-sectional study to inform intervention development.

METHODS

The BCW framework was used to (1) understand the behaviour, (2) identify intervention functions and (3) select content and implementation options. A circular development process was undertaken by the research team to collectively design the intervention in accordance with the steps recommended by the BCW.

RESULTS

The BCW design process resulted in the selection of six intervention functions (education, persuasion, incentivization, training, modelling, enablement) and 18 behaviour change techniques delivered via group-based, face-to-face mode. Behaviour change technique groupings include: goals and planning; feedback and monitoring; social support; shaping knowledge; natural consequences; comparison of behaviour; associations; comparison of outcomes; reward and threat; identity; and, self-belief.

CONCLUSIONS

The BCW process allowed an in-depth consideration of the target behaviours and provided a systematic framework for developing the intervention. The feasibility and preliminary efficacy of the programme will be examined.

Development of a 5As-based technology-assisted weight management intervention for veterans in primary care

Background

Obesity is a worldwide epidemic, and its prevalence is higher among Veterans in the United States. Based on our prior research, primary care teams at a Veterans Affairs (VA) hospital do not feel well-equipped to deliver effective weight management counseling and often lack sufficient time. Further, effective and intensive lifestyle-based weight management programs (e.g. VA MOVE! program) are underutilized despite implementation of systematic screening and referral at all VA sites. The 5As behavior change model (Assess, Advise, Agree, Assist, Arrange) is endorsed by the United States Preventive Service Task Force for use in counseling patients about weight management in primary care and reimbursed by Medicare. In this paper, we describe the iterative development of a technology-assisted intervention designed to provide primary care-based 5As counseling within Patient-Centered Medical Homes without overburdening providers/healthcare teams.

Methods

Thematic analyses of prior formative work (focus groups with patients [n = 54] and key informant interviews with staff [n = 25]) helped to create a technology-assisted, health coaching intervention called Goals for Eating and Moving (GEM). To further develop the intervention, we then conducted two rounds of testing with previous formative study participants (n = 5 for Round 1, n = 5 for Round 2). Each session included usability testing of prototypes of the online GEM tool, pilot testing of 5As counseling by a Health Coach, and a post-session open-ended interview.

Results

Three main themes emerged from usability data analyses: participants’ emotional responses, tool language, and health literacy. Findings from both rounds of usability testing, pilot testing, as well as the open-ended interview data, were used to finalize protocols for the full intervention in the clinic setting to be conducted with Version 3 of the GEM tool.

Conclusions

The use of qualitative research methods and user-centered design approaches enabled timely detection of salient issues to make iterative improvements to the intervention. Future studies will determine whether this intervention can increase enrollment in intensive weight management programs and promote clinically meaningful weight loss in both Veterans and in other patient populations and health systems.

Explaining Consumer Safe Food Handling Through Behavior-Change Theories: A Systematic Review

Consumers often engage in unsafe food handling behaviors at home. Previous studies have investigated the ability of behavior-change theories to explain and predict these behaviors. The purpose of this review was to determine which theories are most consistently associated with consumers' safe food handling behaviors across the published literature. A standardized systematic review methodology was used, consisting of the following steps: comprehensive search strategy; relevance screening of identified references; confirmation of relevance and characterization of relevant articles; risk-of-bias assessment; data extraction; and descriptive analysis of study results. A total of 20 relevant studies were identified; they were mostly conducted in Australia (40%) and the United States (35%) and used a cross-sectional design (65%). Most studies targeted young adults (65%), and none focused on high-risk consumer groups. The outcomes of 70% of studies received high overall risk-of-bias ratings, largely due to a lack of control for confounding variables. The most commonly applied theory was the Theory of Planned Behavior (45% of studies), which, along with other investigated theories of behavior change, was frequently associated with consumer safe food handling behavioral intentions and behaviors. However, overall, there was wide variation in the specific constructs found to be significantly associated and in the percentage of variance explained in each outcome across studies. The results suggest that multiple theories of behavior change can help to explain consumer safe food handling behaviors and could be adopted to guide the development of future behavior-change interventions. In these contexts, theories should be appropriately selected and adapted to meet the needs of the specific target population and context of interest.

Physical activity levels and counseling by health care providers in cancer survivors

Physical activity guidelines for cancer survivors issued by the American Cancer Society and the American College of Sports Medicine emphasize the essential role of a health care provider (HCP) in counseling cancer survivors to achieve healthier lifestyles. However, research has not established whether HCP's recommendations to engage in physical activity are associated with increased physical activity levels of cancer survivors. The study examines this potential association using the 2005 and 2010 National Health Interview Survey data. The final analytic sample consisted of 3320 cancer survivors and 38,955 adults without cancer who reported seeing or talking to a HCP and if or not they had received a physical activity recommendation in the prior year. Consistent with the aforementioned guidelines, physical activity levels were categorized as inactive, insufficiently active, and sufficiently active (i.e., meeting guidelines). Average adjusted predictions and marginal effects were estimated from generalized ordered logit models. Multivariable regressions controlled for socio-demographic and health-related characteristics and survey year. On average, receipt of a HCP's physical activity recommendation was associated with a lower adjusted prevalence of inactivity by 8.3 percentage points and a higher adjusted prevalence of insufficient and sufficient activity by 4.6 and 3.7 percentage points, respectively, regardless of cancer diagnosis (P's<0.05). A HCP's recommendation is associated with higher levels of leisure-time aerobic physical activity among cancer survivors and adults without cancer. The communication between cancer survivors and their HCPs may act as a 'window' of opportunity to increase physical activity levels among the U.S. cancer survivors.