Development of theory-based health messages: three-phase programme of formative research

Salient beliefs about modifiable risk behaviours among patients living with diabetes, hypertension or both: A qualitative formative study

Background

Although there is evidence of the key role played by focusing on local knowledge in designing appropriate interventions regarding modifiable risk behaviours among patients living with diabetes and hypertension in Mangochi (and Malawi), little is known about local salient beliefs.

Aim

With a focus on the theory of planned behaviour as a theoretical lens, this study aimed to identify salient beliefs about modifiable risk behaviours among patients with diabetes, hypertension or both in Mangochi, south-eastern Malawi. Specifically, the objectives were to identify advantages and disadvantages (behavioural salient beliefs), people who approve or disapprove (normative salient beliefs) and enablers and barriers (control salient beliefs) for measures to change modifiable risk behaviours among patients with diabetes, hypertension or both in Mangochi, Malawi.

Setting

A hypertension diabetes clinic at Mangochi District Hospital, south-eastern Malawi.

Methods

A formative qualitative study of a quasi-experimental trial was conducted among 25 patients, purposefully sampled, who were living with diabetes, hypertension or both at Mangochi District Hospital in February 2019. Researchers conducted in-depth interviews with patients using an interview guide informed by the theory of planned behaviour’s elicitation interview guide. Thematic content analysis was used to identify emerging themes.

Results

A total of 25 participants were recruited, of which 12 (48%) were living with diabetes. Five thematic areas emerged from this analysis: physical and psychological fitness, social disconnection, perceived support systems, perceived enablers and perceived barriers to change.

Conclusion

Appropriate words for each salient belief were identified. Future researchers should use the identified salient beliefs when designing interventions based on the theory of planned behaviour in diabetes and hypertension.

Contribution

The paper adds to the body of knowledge informing the use of theory of planned behavior in addressing modifiable risk factors among practitioners, specialists and academics in primary care and Family Medicine in the field of noncommunicable diseases in Mangochi Malawi and beyond.

Parent Intention to Enroll in an Online Intervention to Enhance Health Behavior Change among Youth Treated with Psychotropic Medication Who Are Overweight or Obese: An Elicitation Study

Youth who are prescribed psychotropic medication are disproportionally affected by overweight/obesity (OW/OB), yet few interventions have been tailored to their needs. To develop new interventions, it is important to address the needs, preferences, and intentions of target users. Qualitative methods within the theory of planned behavior (TPB) framework were used in this study to identify salient beliefs which may influence attitudes associated with parents’ intentions to participate in a future online intervention designed to develop behavioral health coaching skills among parents and guardians. Twenty parents and guardians of youth with OW/OB who were taking psychotropic medications, and were eligible for the study, were recruited through TurkPrime. Parents and guardians identified key salient beliefs consistent with the theory of planned behavior including behavioral beliefs (e.g., access and convenience), normative beliefs (e.g., family), and control beliefs (e.g., cost) that may influence their decision to enroll in a future, parent-oriented intervention. The results of this study suggest important salient beliefs which may be included in future research, as well as specific preferences which may be used to guide the development of a future intervention. Future work should focus on the creation of a salient belief quantitative measure and assess the relationships of these beliefs to attitudinal constructs and behaviors.

An explorative study of beliefs in two groups of community health promoters of adolescent reproductive health in Indonesia: informed by theory of planned behavior

OBJECTIVE

To explore beliefs in specific social context and potential individual-level behavioral strategies used by two groups of community health promoters to foster their participation of promoting ARH.

DESIGN

Two phases of formative studies based on the Theory of Planned Behavior (TPB) was conducted with community health promoters in the integrated service center (pos pelayanan terpadu/posyandu), posyandu cadres and peer educators of three villages in Tengger, East Java, Indonesia.

RESULT

The phase one, conducted with posyandu cadres (n = 20) and peer educators (n = 21). A survey using open-ended questions and focus group discussion was carry out to elicit accessible behavioral (advantages and disadvantages), normative (references of who have significant roles for promoters) and control (personal or situational factors) beliefs related to ARH promotion. The content analysis, elicited 15 salient beliefs for posyandu cadre and 21 for the peer educators. In phase two, the participants who previously participated in phase 1 (posyandu cadres (n = 14 and peer educators (n = 21))), completed two questionnaires to measure the belief strength and evaluation of the beliefs.

CONCLUSIONS

The result showed that each group has different characteristic in the strength of their beliefs in promoting reproductive health. The findings highlight the social context underlying beliefs associated with ARH promotion and opportunities to enhance engagement with the different groups of community health promoters.

Attitude theory and measurement in implementation science: a secondary review of empirical studies and opportunities for advancement

BACKGROUND

Implementation science studies often express interest in "attitudes," a term borrowed from psychology. In psychology, attitude research has an established methodological and theoretical base, which we briefly summarize here. We then review implementation studies designed to measure attitudes and compare their definitions and methods with those from psychology.

METHODS

A recent review identified 46 studies empirically examining factors associated with implementation. For each of these studies, we evaluated whether authors included attitudes as a construct of interest, and if so, whether and how the construct was defined, measured, and analyzed.

RESULTS

Most of the articles (29/46 [63%]) mention attitudes as an implementation factor. Six articles include a definition of the construct. Nineteen studies were designed to measure attitudes but lacked clarity in describing how attitudes were measured. Those that explained their measurement approach used methods that differed from one another and from validated methods in social psychology. Few articles described associated analyses or provided results specific to attitudes. Despite the lack of specificity regarding relevant measurement, analysis, and results, the articles often included causal conclusions about the role of attitudes.

CONCLUSIONS

Attitudes may be an important construct to implementation scientists, but studies to date are ambiguous in their definitions of attitudes and inconsistent in the methods used to measure and analyze attitudes. We discuss how implementation studies can apply psychology's standardized definitions, validated measurement approaches, and causal models that include attitudes. This application of attitude theory and methods could offer implementation research valuable scientific opportunities.

Characteristics and impact of theory of planned behavior interventions on smoking behavior: A systematic review of the literature

Theoretical frameworks such as the theory of planned behavior (TPB) can be applied to design and evaluate smoking behavior interventions. The present systematic review aimed to: (i) determine the characteristics of TPB-based interventions and their reported impact on smoking behavior and TPB variables, (ii) evaluate the level of methodological quality in the included studies, and (iii) assess the quality of the theoretical implementation. Studies were eligible for inclusion if the intervention targeted smoking behavior, was explicitly based on the TPB, and if smoking behavior or intention was measured at least at post-intervention. Relevant articles were identified through searches on databases and internet search engines, responses to messages sent on thematic forums, consultation of prominent authors, and manual searches on key websites and key TPB-publications. Seventeen studies met the inclusion criteria. A majority of studies (65%) targeted the student population (i.e., elementary school, high school, university). Interventions minimally included the provision of health messages. The proportion of studies that reported a significant impact on smoking behavior, intention, attitude, subjective norm, or PBC ranged between 42% and 50%. Regarding methodological quality, unclear or high risks of bias were notably found regarding the selection of participants, data collection methods, withdrawal and drop-outs, and blinding. Regarding theoretical implementation, the reciprocal link between intervention techniques and TPB variables targeted remain unclear for a majority of studies. To better inform tobacco prevention and TPB research, future studies should more systematically use rigorous methods when designing, implementing, and reporting TPB-based interventions.

Identifying Promising Messages to Increase Hurricane Mitigation Among Coastal Homeowners in the United States

Hurricanes threaten the physical and financial well-being of coastal residents throughout the United States. Though hurricane-related losses are largely avoidable through property mitigation (e.g., structural modifications to existing homes), few homeowners invest in mitigation. Communication campaigns, which have influenced risk-related behaviors in other domains, hold promise for persuading coastal residents to engage in hurricane mitigation. The development of successful campaign messages relies, in part, on formative research to assess the potential influence of candidate message strategies. We present results from mixed-methods, theory-driven research to identify promising beliefs for persuading homeowners in coastal/coastal-adjacent regions of Alabama and Florida to install a high wind-resistant (HWR) roof. In Study 1, we elicited homeowners' (n = 74) salient behavioral, normative, and control beliefs about installing an HWR roof. Using established procedures, we content analyzed open-ended responses and categorized them by thematic content. In Study 2, we surveyed another sample of homeowners (n = 533) to examine the extent to which salient beliefs/themes about installing an HWR roof (elicited in Study 1) are promising targets for a communication campaign, given their associations with homeowners' intentions to retrofit. Results demonstrate that across elicited beliefs, common themes include the protection and property resilience reroofing affords, and anticipated expenses and financial barriers associated with reroofing. The most promising beliefs include behavioral beliefs that installing an HWR roof will protect oneself and one's family, and normative beliefs about the likelihood that one's family and community will install an HWR roof. We discuss the implications of findings for the development of hurricane mitigation messaging.

Exploration of Alcohol Consumption Behaviours and Health-Related Influencing Factors of Young Adults in the UK

Hazardous alcohol consumption is ranked above illicit drug use with regards to health deterioration and social and economic burden. This study sought to clarify the factors influencing alcohol consumption and its prevalence in young adults. Demographics, alcohol consumption and lifestyle information were gathered via anonymous questionnaires during 2011-2019, crossing Reading, Surrey and Farnborough universities, UK. Controlling for confounders, a multinomial logistic regression was performed using SAS® 9.4 software. A total of 1440 students (43.5% males, 56.5% females; 54.4% Caucasians) with a mean (SD) age of 19.9 (2.73) were included. Among them, 68.9% consumed alcohol frequently and 31.7% had ≥12 units/week. Statistical analysis revealed that males consumed twice more alcohol than females, odds ratio (OR) 1.67 (95% confidence interval (CI) = 1.34-2.09), p-value < 0.01. Caucasians consumed up to five times more alcohol than other ethnicities, OR 4.55 (3.57-5.56), p-value < 0.01. Smokers consumed three times more alcohol than non-smokers, OR 2.69 (1.82, 3.99), p-value < 0.01. In general, the levels of alcohol consumption were positively associated with the levels of physical activity, OR 2.00 (1.17-3.42), p-value < 0.05 and negatively associated with recreational sedentary screen-time activities in males, OR 0.31 (0.12-0.86), p-value = 0.03. Focusing alcohol interventions toward Caucasians, smokers and physically active students, particularly males, may guide university strategies to reduce alcohol-related societal harm and risks of morbidity and mortality.

Parents' and Peers' Autonomy Support and Exercise Intention for Adolescents: Integrating Social Factors from the Self-Determination Theory and the Theory of Planned Behaviour

Based on the theory of planned behaviour and self-determination theory, the objective of the present study was to analyse the relationship between (i) parents' and peers' autonomy support, and (ii) exercise intention in adolescents, while also considering the mediating role of attitude, control, subjective norms, and descriptive norms. A total of 428 secondary school students, aged between 13 and 19 years old (Mage = 15.30, SD = 1.15), filled in a questionnaire assessing the variables of interest. The relationships between the study variables were examined through a mediation model with bootstrapping technique (20,000 samples) using Mplus v. 7 software. The results showed that the perception of parents' autonomy support was positively and statistically significant associated with exercise intention; this occurring indirectly through attitude and control both in boys and girls, as well as through subjective norms in the case of girls. Conversely, the perception of peers' autonomy support was positively and statistically significant associated with exercise intention; this occurring directly both in boys and girls, as well as indirectly through attitude in the case of girls. These findings suggest that, by involving a form of pressure (i.e., subjective/descriptive norms), perceptions of autonomy support may play a more important role than other forms of social influence in predicting exercise intention in adolescents.

Socio-culturally mediated factors and lower level of education are the main influencers of functional cervical cancer literacy among women in Mayuge, Eastern Uganda

Background

Health literacy (HL) is the degree of an individual’s knowledge and capacity to seek, understand and use health information to make decisions on one’s health, yet information on the functional level of cervical cancer literacy in Mayuge and Uganda as a whole is lacking. We, therefore, assessed the level of functional cervical cancer literacy among women aged 18–65 years in Mayuge district in five functional HL domains; prior knowledge, oral, print, numeracy and e-health. Understanding the factors associated with cervical cancer literacy is also pertinent to cervical health communication programming, however, no study has documented this in Uganda and particularly in Mayuge. Mayuge is a rural population based cancer registry and one of the sites for piloting cancer control interventions in Uganda. We also assessed the factors associated with cervical cancer literacy and awareness about currently available cervical cancer preventive services.

Methods

The study protocol was approved by the Uganda Cancer Institute research and ethic committee (UCI-REC). In August 2017, we assessed five HL domains; cervical cancer knowledge, print literacy, oral literacy using audio-clip, numeral literacy and perceived e-HL among 400 women at household levels. Correct response was scored 1 and incorrect response was scored 0 to generate the mean percentage score for each domain. The mean scores were classified as limited, basic and proficient bands based on the McCormack HL cut-offs scale for knowledge, print, oral and e-health and Weiss cut-offs in the newest vital signs (NVS) for numeracy. We used the cervical cancer literacy scores to explore the effect of selected study variables on cervical cancer literacy. We also conducted five focus group discussions (FGDs) based on the theoretical constructs of the PEN-3 model.

Results

The majority (96.8%) of the participants demonstrated a limited level of cervical cancer literacy with a mean score of 42%. Women who had completed a primary level of education or lower (OR = 3.91; p = 0.044) were more likely to have limited cervical cancer literacy. The qualitative data indicated that the women had limited cervical cancer literacy coupled with limited decisional, social and financial support from their male partners with overall low locus of control. Most (92.3%) of the women were not aware of the available cervical cancer services and had no intention to screen (52.5%).

Conclusions

The women in Mayuge in general have limited cervical cancer literacy except oral HL domain. Limited cervical cancer literacy was highest among women with lower level of education and overall literacy seemed to be influenced on the higher side by socio-cultural constructs characterised by limited decisional, social and personal resources among the women with overall low locus of control. The Mayuge women further demonstrated scant knowledge about the available health services in their district and low intention to screen. Multi-strategy cervical health empowerment programme is needed to improve cervical HL using orally disseminated messages.

Predictors of Intentions to Make Healthier Eating Choices among Midwestern Truck Drivers

Truck drivers constitute a highly vulnerable population with very limited opportunities for healthy foods and healthy eating choices. This cross-sectional study assessed the utility of the Theory of Planned Behavior (TPB) in understanding and predicting healthy eating intention among Midwestern truck drivers in the United States. Participants were recruited through online trucker forums and advertisements at truck stops. Each participant completed an anonymous, web-based questionnaire that measured attitude, subjective norms, and perceived behavioral control. One hundred and forty-six truck drivers responded, with the average Body Mass Index (BMI) 32.7 and working as a truck driver for 10.3 years. Hierarchical multiple regression analysis assessed the predictive value of individual TPB constructs and the model. The predictive model containing the TPB constructs explained 18% of the variance in healthy eating intention, with attitude and subjective norm making significant and unique contributions. With the variance explained, the findings minimally supported the utility of TPB in understanding and predicting healthy eating intention among the truck drivers. These findings should be interpreted in view of the study limitations; the small sample size and being a self-report study. Notwithstanding, the findings highlight the importance of attitude and subjective norms in understanding and predicting healthy eating intention among Midwestern truck drivers in the United States.

UK Postal Delivery Workers' Occupational Sun Safety: Using Behavior Change Theories to Identify Intervention Pathways

Postal delivery workers have substantial sun exposure. In the United Kingdom (UK) a high proportion of workers possesses a sun sensitive skin type. This population is at elevated risk for skin cancer, yet uptake of sun safety practices is low. Studies are needed to identify the underlying factors that contribute to the uptake of occupational sun safety practices that may be targeted during behavior change interventions. This study integrated the Theory of Planned Behavior (TPB) and the Transtheoretical Model's stages of change (SoC) as guiding frameworks to identify underlying beliefs that influence UK postal delivery workers' uptake of occupational sun safety practices. Thirty-four workers participated in semi-structured interviews that used the SoC to establish current receptiveness to and adoption of two sun safety practices (using sunscreen of at least sun protection factor (SPF) 30 on exposed skin and wearing a wide-brimmed hat when working outdoors in the summer). Beliefs underlying current practices were elicited in accordance with the TPB and stratified by the SoC. For sunscreen use and wearing a wide-brimmed hat, 64% and 3% of participants were in the action or maintenance SoC, respectively. Behavioral and control beliefs differed by SoC, with those in the earlier stages more likely than those in the latter stages to report negative attitudes to, and difficulty enacting, sun safety practices. Normative beliefs concerning the views of colleagues and employers towards sunscreen were relatively consistent across the SoC. This study highlights the need for tailored and targeted behavior change interventions. The SoC-stratified accounts of the influence of TPB components on behavior provide a basis for bespoke interventions that reflect inter-individual and inter-practice differences in their working mechanisms.

Measurement properties of self-report pedestrians' road crossing behavior questionnaires constructed based on the theory of planned behavior: protocol for a systematic review

BACKGROUND

Pedestrians' unsafe crossing behavior exposes them at risk of trauma and death and puts a tremendous burden on the health care system. The theory of planned behavior (TPB) is one of the leading theoretical models used to develop pedestrians' road crossing behavior questionnaires, yet the quality of measurement properties of them has not been evaluated. The aim of the proposed systematic review is to evaluate the quality of measurement properties of the questionnaires constructed based on the TPB to predict pedestrians' road crossing behavior.

METHODS

We will include studies validating or evaluating one or more psychometric properties of the self-reported questionnaire employing the TPB for predicting pedestrians' road crossing behavior. A comprehensive search strategy will be formulated based on the components of review aim. The databases of MEDLINE, Embase, PubMed, Cochrane Library, PsycINFO, PsycARTICLES, and ProQuest, also grey literature and the reference lists of the included studies, will be searched. A hand search for the relevant journals and Google Scholar will be conducted. COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) Risk of Bias checklist will be used to evaluate the measurement properties of the included questionnaires. First, we will assess standards for the methodological quality of each study. Then, each scale or subscale of a questionnaire will be rated using the updated criteria for good measurement property. We will quantitatively pool or qualitatively summarize the results and will evaluate them against the criteria for good measurement properties. Finally, we will grade the pooled or summarized evidence using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach and provide recommendations for the most appropriate instrument.

DISCUSSION

The proposed systematic review will evaluate the measurement properties of self-report pedestrians' road crossing behavior questionnaires constructed based on the TPB. The findings will help researchers in selecting the appropriate TPB-based instrument for pedestrians' road crossing behavior.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017047793.

Young Adults' Engagement With a Self-Monitoring App for Vegetable Intake and the Impact of Social Media and Gamification: Feasibility Study

Background

Social media and gamification have been used in digital interventions for improving nutrition behaviors of young adults, but few studies measure engagement.

Objective

This feasibility study aimed to explore user engagement with a 4-week smartphone program for improving vegetable intake.

Methods

A goal setting and self-monitoring app was developed for feasibility testing. We assessed if additional components of gaming and/or social media support increased engagement. A 2 × 2 factorial study design was used with participants randomly allocated to each group. Engagement with the app (usage) was captured via inbuilt software, which recorded total days of app usage (duration) and the frequency of logging vegetable intake. Uptake of the social media (Facebook) content was measured by tracking views, likes, and comments on posts.

Results

Out of the 110 potential participants who completed the prescreening questionnaire online, 97 were eligible (mean age 24.8 [SD 3.4]). In total, 49% (47/97) of participants were retained at 4 weeks. Attrition within the first week was the highest among users of the gamified app without social support (Facebook; P<.001). Over the intervention period, 64% (62/97) of participants logged into their app, with vegetable intake recorded on average for 11 out of 28 days. The frequency of recording decreased each week (mean 4 [SD 2] days in week 1 versus mean 2 [SD 2] days in week 4). No effects of gaming or social support on the frequency of recording vegetables or the duration of app engagement were found. However, regardless of the app type, the duration of app engagement was significantly associated with vegetable intake post intervention (P<.001). In total, 60% of Facebook posts were viewed by participants but engagement was limited to likes, with no comments or peer-to-peer interaction observed.

Conclusions

As duration of usage was associated with vegetable intake, a deeper understanding of factors influencing engagement is needed. Dimensions such as personal attributes and the setting and context require further exploration in addition to content and delivery.

Using the theory of planned behaviour and implementation intentions to reduce binge drinking in new university students

OBJECTIVE

Excessive alcohol consumption, including binge drinking, increases when students enter university. This study tests whether combining messages targeting theory of planned behaviour (TPB) constructs with if-then plans (i.e. implementation intentions) to avoid binge drinking reduces binge drinking in new university students.

DESIGN

One month after starting university, students (N = 407) were randomly assigned to condition in a 2 (TPB messages) × 2 (implementation intentions) factorial design.

MAIN OUTCOME MEASURES

Cognitions about binge drinking were assessed immediately post-intervention. Frequency of binge drinking was assessed at one-month follow-up (n = 205).

RESULTS

Participants who viewed the messages had significantly weaker intentions to engage in binge drinking and less favourable cognitions about binge drinking (affective attitude, descriptive norms, and self-efficacy) than those who did not view the messages. In addition, participants who formed an implementation intention to avoid binge drinking reported significantly fewer instances of binge drinking at follow-up.

CONCLUSION

The findings provide some support for the use of interventions based on the TPB to reduce intentions to engage in binge drinking and for forming implementation intentions to reduce the frequency of binge drinking in new university students. No evidence was found for the synergistic effect of combining the two interventions.

Sun protection and young female beachgoers: A formative theory-based approach to identifying key sun safe beliefs

ISSUE ADDRESSED

The prevalence of skin cancer remains at a high level in Australia. Young female Australian beachgoers are an at-risk population of skin cancer. Research on sun-protective beliefs held by this at-risk group is limited.

METHODS

Based on the Theory of Planned Behaviour (TPB), we conducted a formative study to understand key sun safe messages among young female beachgoers in Queensland, including an elicitation study (Phase 1; N = 21, M_age  = 24.30 years) and a two-wave questionnaire survey (Phase 2; N = 140, M_age  = 23.96 years).

RESULTS

Following content analysis and regression analyses, three key beliefs were identified: "be uncomfortable and/or unstylish" (behavioural belief), "friends and peers" (normative belief) and "lack of motivation to reapply sunscreen" (control belief).

CONCLUSIONS

The results highlight the influences of friends and peers on beachgoers' sun-protective behaviour for this young female adult cohort. Compared to previous findings among the general population, discrepancies in beliefs suggest interventions targeting this cohort should specifically focus on fashionable sun safe images and motivation to reapply sunscreen. SO WHAT?: Future health promotion and public education should utilise various strategies according to specific groups given the discrepancies identified in beliefs. For female beachgoers, sun safe images and motivations should be the primary foci.

Being active in pregnancy: Theory-based factors associated with physical activity among pregnant women

Although regular physical activity is recommended for pregnant women, compared to pre-pregnancy, antenatal physical activity often reduces or ceases completely. Drawing from the theory of planned behavior, self-determination theory, and theory on self-control, we aimed to test an integrative model of physical activity in a sample of pregnant women. The current study was conducted in Brisbane, Australia, in 2014-2015 using a prospective-correlational design with a one-week follow-up. Participants (N = 207, Time 1; Meanage = 30.03 years, SDage = 4.49 years) completed an initial survey measuring: intrinsic motivation from the self-determination theory, social cognitive constructs from the theory of planned behavior, and self-control from the self-control theory, followed by a self-report measure of physical activity one-week later (n = 117, Time 2). A well-fitting structural equation model accounted for 73 and 42 percent of the variance in intention and physical activity behavior, respectively. Perceived behavioral control and attitude, but not subjective norm, mediated the effect of intrinsic motivation on intention. Intention, perceived behavioral control, and self-control were positively associated with physical activity behavior. Future behavioral interventions aiming to promote physical activity during pregnancy, a period when the physical activity levels typically decline, should consider the multiple processes advocated in the integrative model as necessary for motivated action.

The Identification of Reasons, Solutions, and Techniques Informing a Theory-Based Intervention Targeting Recreational Sports Participation

PURPOSE

This study is the 3rd piece of formative research utilizing the theory of planned behavior to inform the development of a behavior change intervention. Focus groups were used to identify reasons for and solutions to previously identified key beliefs in addition to potentially effective behavior change techniques.

METHOD

A purposive sample of 22 first-year undergraduate students (n = 8 men; M_age = 19.8 years, SD = 1.3 years) attending a university in the North of England was used. Focus groups were audio-recorded; recordings were transcribed verbatim, analyzed thematically, and coded for recurrent themes.

RESULTS

The data revealed 14 reasons regarding enjoyment, 11 reasons for friends' approval, 11 reasons for friends' own participation, 14 reasons for the approval of family members, and 10 solutions to time constraints. Twelve distinct techniques were suggested to attend to these reasons and solutions.

CONCLUSION

This qualitative research will be used to inform the development of a theory-based intervention to increase students' participation in university recreational sports.

Behaviour change techniques to facilitate physical activity in older adults: what and how

Physical inactivity in older adults presents a significant problem within modern societies globally. Using a mixed-method approach, this study explored strategies for the development and delivery of physical activity (PA) interventions by investigating what behaviour change techniques (BCTs) are useful, and how these techniques should be implemented to be feasible for older adults. Sixty-six older adults completed a survey indicating the most useful BCTs, mapping on to motivational, volitional and automatic factors. Of these, 48 older adults participated in an interview exploring strategies for a PA intervention targeted at older adults. The most useful BCT identified in the survey was autonomy support (61.3%), followed by instruction to perform the behaviour (43.5%) and having a credible source of information about PA (42.6%). The key themes discussed in the interviews included providing support in making an informed choice, instruction on how to perform PA, information about health consequences, social support, goal setting, action and coping plans, behavioural demonstration and practice, and monitoring PA. The interviews also revealed key aspects of programme implementation including face-to-face delivery, followed up with additional materials; low cost; age-appropriate PA level; and individualised approach. Interventions assisting older adults in increasing their PA participation across a range of settings should incorporate BCTs targeting multiple processes, while tailoring their delivery to older adults’ preferences to ensure their feasibility in supporting regular PA engagement.

Assessing and Validating an Educational Resource Package for Health Professionals to Improve Smoking Cessation Care in Aboriginal and Torres Strait Islander Pregnant Women

Australian Aboriginal pregnant women have a high smoking prevalence (45%). Health professionals lack adequate educational resources to manage smoking. Resources need to be tailored to ensure saliency, cultural-sensitivity and account for diversity of Indigenous populations. As part of an intervention to improve health professionals' smoking cessation care in Aboriginal pregnant women, a resource package was developed collaboratively with two Aboriginal Medical Services. The purpose of this study was to assess and validate this resource package. A multi-centred community-based participatory 4-step process (with three Aboriginal Medical Services from three Australian states), included: (1) Scientific review by an expert panel (2) 'Suitability of Materials' scoring by two Aboriginal Health Workers (3) Readability scores (4) Focus groups with health professionals. Content was analysed using six pre-determined themes (attraction, comprehension, self-efficacy, graphics and layout, cultural acceptability, and persuasion), with further inductive analysis for emerging themes. Suitability of Material scoring was adequate or superior. Average readability was grade 6.4 for patient resources (range 5.1-7.2), and 9.8 for health provider resources (range 8.5-10.6). Emergent themes included 'Getting the message right'; 'Engaging with family'; 'Needing visual aids'; and 'Requiring practicality under a tight timeframe'. Results were presented back to a Stakeholder and Consumer Aboriginal Advisory Panel and resources were adjusted accordingly. This process ensured materials used for the intervention were culturally responsive, evidence-based and useful. This novel formative evaluation protocol could be adapted for other Indigenous and culturally diverse interventions. The added value of this time-consuming and costly process is yet to be justified in research, and might impact the potential adaption by other projects.

A randomized controlled trial of a brief online intervention to reduce alcohol consumption in new university students: Combining self-affirmation, theory of planned behaviour messages, and implementation intentions

OBJECTIVES

Excessive alcohol consumption increases when students enter university. This study tests whether combining (1) messages that target key beliefs from the theory of planned behaviour (TPB) that underlie binge drinking, (2) a self-affirmation manipulation to reduce defensive processing, and (3) implementation intentions (if-then plans to avoid binge drinking) reduces alcohol consumption in the first 6 months at university.

DESIGN

A 2 (self-affirmation) × 2 (TPB messages) × 2 (implementation intention) between-participants randomized controlled trial with 6-month follow-up.

METHODS

Before starting university, students (N = 2,951) completed measures of alcohol consumption and were randomly assigned to condition in a full-factorial design. TPB cognitions about binge drinking were assessed immediately post-intervention (n = 2,682). Alcohol consumption was assessed after 1 week (n = 1,885), 1 month (n = 1,389), and 6 months (n = 892) at university. TPB cognitions were assessed again at 1 and 6 months.

RESULTS

Participants who received the TPB messages had significantly less favourable cognitions about binge drinking (except perceived control), consumed fewer units of alcohol, engaged in binge drinking less frequently, and had less harmful patterns of alcohol consumption during their first 6 months at university. The other main effects were non-significant.

CONCLUSIONS

The findings support the use of TPB-based interventions to reduce students' alcohol consumption, but question the use of self-affirmation and implementation intentions before starting university when the messages may not represent a threat to self-identity and when students may have limited knowledge and experience of the pressures to drink alcohol at university. Statement of contribution What is already known on this subject? Alcohol consumption increases when young people enter university. Significant life transitions represent potential teachable moments to change behaviour. Interventions with a strong theoretical basis have been found to be more effective. What does this study add? A brief online intervention delivered to students before they start university can reduce alcohol consumption. The theory of planned behaviour can be used to inform the design of interventions to change health behaviour.

Let them eat fruit! The effect of fruit and vegetable consumption on psychological well-being in young adults: A randomized controlled trial

This study tested the psychological benefits of a 14-day preregistered clinical intervention to increase fruit and vegetable (FV) consumption in 171 low-FV-consuming young adults (67% female, aged 18-25). Participants were randomly assigned into a diet-as-usual control condition, an ecological momentary intervention (EMI) condition involving text message reminders to increase their FV consumption plus a voucher to purchase FV, or a fruit and vegetable intervention (FVI) condition in which participants were given two additional daily servings of fresh FV to consume on top of their normal diet. Self-report outcome measures were depressive symptoms and anxiety measured pre- and post-intervention, and daily negative and positive mood, vitality, flourishing, and flourishing behaviors (curiosity, creativity, motivation) assessed nightly using a smartphone survey. Vitamin C and carotenoids were measured from blood samples pre- and post-intervention, and psychological expectancies about the benefits of FV were measured post-intervention to test as mediators of psychological change. Only participants in the FVI condition showed improvements to their psychological well-being with increases in vitality, flourishing, and motivation across the 14-days relative to the other groups. No changes were found for depressive symptoms, anxiety, or mood. Intervention benefits were not mediated by vitamin C, carotenoids, or psychological expectancies. We conclude that providing young adults with high-quality FV, rather than reminding them to eat more FV (with a voucher to purchase FV), resulted in significant short-term improvements to their psychological well-being. These results provide initial proof-of-concept that giving young adults fresh fruit and vegetables to eat can have psychological benefits even over a brief period of time.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12615000183583.

Promising Themes for Antismoking Campaigns Targeting Youth and Young Adults

OBJECTIVES

Behavior change campaigns typically try to change beliefs that influence behaviors, with targeted beliefs comprising the campaign theme. We present an empirical approach for choosing among a large number of potential themes, and results from the implementation of this approach for campaigns aimed at 4 behavioral targets: (1) preventing smoking initiation among youth, and (2) preventing initiation, (3) stopping progression to daily smoking and (4) encouraging cessation among young adults.

METHODS

An online survey of 13- to 17-year-olds and 18- to 25-year-olds in the United States (US), in which 20 potential campaign themes were represented by 154 beliefs. For each behavioral target, themes were ranked based on the strength of belief-intention and belief-behavior associations and size of the population not already endorsing the beliefs.

RESULTS

The most promising themes varied across behavioral targets but 3 were consistently promising: consequences of smoking for mood, social acceptance and social popularity.

CONCLUSIONS

Using a robust and systematic approach, this study provides campaign developers with empirical data to inform their selection of promising themes. Findings related to the campaign to prevent initiation among youth informed the development of the US Food and Drug Administration's "The Real Cost" campaign.

A theory-based online health behaviour intervention for new university students (U@Uni:LifeGuide): results from a repeat randomized controlled trial

BACKGROUND

This paper reports the results of a repeat trial assessing the effectiveness of an online theory-based intervention to promote healthy lifestyle behaviours in new university students. The original trial found that the intervention reduced the number of smokers at 6-month follow-up compared with the control condition, but had non-significant effects on the other targeted health behaviours. However, the original trial suffered from low levels of engagement, which the repeat trial sought to rectify.

METHODS

Three weeks before staring university, all incoming undergraduate students at a large university in the UK were sent an email inviting them to participate in the study. After completing a baseline questionnaire, participants were randomly allocated to intervention or control conditions. The intervention consisted of a self-affirmation manipulation, health messages based on the theory of planned behaviour and implementation intention tasks. Participants were followed-up 1 and 6 months after starting university. The primary outcome measures were portions of fruit and vegetables consumed, physical activity levels, units of alcohol consumed and smoking status at 6-month follow-up.

RESULTS

The study recruited 2,621 students (intervention n=1346, control n=1275), of whom 1495 completed at least one follow-up (intervention n=696, control n=799). Intention-to-treat analyses indicated that the intervention had a non-significant effect on the primary outcomes, although the effect of the intervention on fruit and vegetable intake was significant in the per-protocol analyses. Secondary analyses revealed that the intervention had significant effects on having smoked at university (self-report) and on a biochemical marker of alcohol use.

CONCLUSIONS

Despite successfully increasing levels of engagement, the intervention did not have a significant effect on the primary outcome measures. The relatively weak effects of the intervention, found in both the original and repeat trials, may be due to the focus on multiple versus single health behaviours. Future interventions targeting the health behaviour of new university students should therefore focus on single health behaviours.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN07407344 .

Targets to promote swimming between the flags among Australian beachgoers

Visiting the beach is a popular activity, but the risk of drowning is real. Drownings are preventable, and swimming between the patrol flags can save lives. The aim of this study is to understand the beliefs people hold in relation to this important water safety behaviour. Participants (N= 514; females = 58%) who were residents of/visitors to coastal areas in South-East Queensland, Australia, completed a theory of planned behaviour belief-based questionnaire. The survey was designed to measure behavioural, normative and control beliefs guiding beachgoers' intentions to swim between the patrol flags. Controlling for age, gender and swimming ability, four critical beliefs (along with self-reported swimming ability) were identified as independently predicting intention. Specifically, the benefits of feeling safe and the cost of feeling limited in choice of where to swim, the social approval from partners and the inhibitor belief about better waves being outside the flags predicted intentions to swim between the flags. This study provides an understanding of the beliefs underlying Australian beachgoers' intentions to swim between the patrol flags. Attention to these targeted beliefs may assist in promoting more regular performance of this beach safety behaviour, thereby combating the increasing rates of drownings and surf rescues.

Understanding knowledge sharing in the work context by applying a belief elicitation study

Purpose

– This paper aims to investigate cognitive antecedents of knowledge sharing (KS) by applying a belief elicitation study and embedding KS in an organizationally relevant context, work meetings.

Design/methodology/approach

– The study was carried out in two phases: an elicitation study (n = 18), and a survey (n = 200) based on its findings. The method, which combines a qualitative and a quantitative approach, is frequently used in the study of other behaviors (e.g. health behaviors) when applying the theory of planned behavior (TPB).

Findings

– Belief-based measures, informed by the elicitation study, were meaningful predictors of KS intentions. In line with TPB, attitudes, subjective norms and perceived behavioral control explained 47.7 per cent of the variance in KS intentions, which together with perceived behavioral control explained 55.2 per cent of the variance in KS behavior. Behavioral beliefs reflecting positive collective outcomes (new perspectives, knowledge diffusion/collective learning, increased interaction) were the most important predictors.

Research limitations/implications

– Single organization and the study design limit generalizability of the results.

Practical implications

– The findings suggest that by eliciting shared beliefs relating to specific KS behaviors, organizations may come a long way in understanding and subsequently influencing these behaviors.

Originality/value

– This is the first study to apply TPB on KS by investigating the underlying beliefs using an elicitation study. By demonstrating its utility, the study not only lays avenue for evidence-based interventions to improve KS in organizations, but also presents a method that bridges the gap between quantitative and qualitative approaches to KS.

A meta-analysis of the effect of new-media interventions on sexual-health behaviours

BACKGROUND AND OBJECTIVES

Direct access to individuals in non-intrusive ways, as well as the technical abilities of new-media to provide tailored information in relatively inexpensive ways, creates a unique opportunity for the delivery of health-related information. The aim of the present research was to examine the effect that new-media-based sexual-health interventions have on sexual-health behaviours in non-clinical populations and to determine the factors that moderate the effect of technology-based sexual-health interventions on sexual--health behaviours.

DATA SOURCES

A systematic literature search of the following databases was conducted: MEDLINE, psycINFO, Global health, and EMBASE, using terms that captured three subject areas-'Sexual-health', 'New Technology' and 'Intervention'.

STUDY ELIGIBILITY CRITERIA

Randomised controlled trial, or a quasi-experiment; delivered exclusively via new-media; included sexual risk behaviour change as an outcome measure and delivered to non-clinical groups.

RESULTS

Twelve studies tested the effect of new-media interventions on condom use, whereas nine tested the effect on sexually transmitted disease testing. Results indicated that new-media interventions led to significant increases in both outcomes; however, these effects were not homogeneous. Moderation analyses revealed that interactivity of the intervention, target population and study design influenced the efficacy of interventions on both sexual-health outcomes, whereas intervention duration influenced sexually transmitted infection testing.

CONCLUSIONS AND IMPLICATIONS

Interventions aiming to improve condom use are more successful when an interactive component is used. Further research needs to be conducted to reach specific at-risk populations.

A theory-based online health behaviour intervention for new university students (U@Uni): results from a randomised controlled trial

Background

Too few young people engage in behaviours that reduce the risk of morbidity and premature mortality, such as eating healthily, being physically active, drinking sensibly and not smoking. This study sought to assess the efficacy and cost-effectiveness of a theory-based online health behaviour intervention (based on self-affirmation theory, the Theory of Planned Behaviour and implementation intentions) targeting these behaviours in new university students, in comparison to a measurement-only control.

Methods

Two-weeks before starting university all incoming undergraduates at the University of Sheffield were invited to take part in a study of new students’ health behaviour. A randomised controlled design, with a baseline questionnaire, and two follow-ups (1 and 6 months after starting university), was used to evaluate the intervention. Primary outcomes were measures of the four health behaviours targeted by the intervention at 6-month follow-up, i.e., portions of fruit and vegetables, metabolic equivalent of tasks (physical activity), units of alcohol, and smoking status.

Results

The study recruited 1,445 students (intervention n = 736, control n = 709, 58% female, Mean age = 18.9 years), of whom 1,107 completed at least one follow-up (23% attrition). The intervention had a statistically significant effect on one primary outcome, smoking status at 6-month follow-up, with fewer smokers in the intervention arm (8.7%) than in the control arm (13.0%; Odds ratio = 1.92, p = .010). There were no significant intervention effects on the other primary outcomes (physical activity, alcohol or fruit and vegetable consumption) at 6-month follow-up.

Conclusions

The results of the RCT indicate that the online health behaviour intervention reduced smoking rates, but it had little effect on fruit and vegetable intake, physical activity or alcohol consumption, during the first six months at university. However, engagement with the intervention was low. Further research is needed before strong conclusions can be made regarding the likely effectiveness of the intervention to promote health lifestyle habits in new university students.

Trial registration

Current Controlled Trials, ISRCTN67684181.