Framed, Interactive Theory-Driven Texting: Effects of Message Framing on Health Behavior Change for Weight Loss

Improvements in Diet and Physical Activity-Related Psychosocial Factors Among African Americans Using a Mobile Health Lifestyle Intervention to Promote Cardiovascular Health: The FAITH! (Fostering African American Improvement in Total Health) App Pilot Study

BACKGROUND

African Americans continue to have suboptimal cardiovascular health (CVH) related to diet and physical activity (PA) behaviors compared with White people. Mobile health (mHealth) interventions are innovative platforms to improve diet and PA and have the potential to mitigate these disparities. However, these are understudied among African Americans.

OBJECTIVE

This study aims to examine whether an mHealth lifestyle intervention is associated with improved diet and PA-related psychosocial factors in African Americans and whether these changes correlate with diet and PA behavioral change.

METHODS

This study is a retrospective analysis evaluating changes in diet and PA-related self-regulation, social support, perceived barriers, and CVH behaviors (daily fruit and vegetable intake and moderate-intensity PA [MPA] per week) in 45 African American adults (mean age 48.7 years, SD 12.9 years; 33/45, 73% women) enrolled in the FAITH! (Fostering African American Improvement in Total Health) app pilot study. The intervention is a 10-week, behavioral theory-informed, community-based mHealth lifestyle intervention delivered through a mobile app platform. Participants engaged with 3 core FAITH! app features: multimedia education modules focused on CVH with self-assessments of CVH knowledge, self-monitoring of daily fruit and vegetable intake and PA, and a sharing board for social networking. Changes in self-reported diet and PA-related self-regulation, social support, perceived barriers, and CVH behaviors were assessed by electronic surveys collected at baseline and 28 weeks postintervention. Changes in diet and PA-related psychosocial factors from pre- to postintervention were assessed using paired 2-tailed t tests. The association of changes in diet and PA-related psychosocial variables with daily fruit and vegetable intake and MPA per week was assessed using Spearman correlation. Associations between baseline and 28-week postintervention changes in diet and PA-related psychosocial measures and CVH behaviors with covariates were assessed by multivariable linear regression.

RESULTS

Participants reported improvements in 2 subscales of diet self-regulation (decrease fat and calorie intake, P=.01 and nutrition tracking, P<.001), one subscale of social support for healthy diet (friend discouragement, P=.001), perceived barriers to healthy diet (P<.001), and daily fruit and vegetable intake (P<.001). Improvements in diet self-regulation (increase fruit, vegetable, and grain intake, and nutrition tracking) and social support for healthy diet (friend encouragement) had moderate positive correlations with daily fruit and vegetable intake (r=0.46, r=0.34, and r=0.43, respectively). A moderate negative correlation was observed between perceived barriers to healthy diet and daily fruit and vegetable intake (r=-0.25). Participants reported increases in PA self-regulation (P<.001). Increase in social support subscales for PA (family and friend participation) had a moderate positive correlation with MPA per week (r=0.51 and r=0.61, respectively).

CONCLUSIONS

Our findings highlight key diet and PA-related psychosocial factors to target in future mHealth lifestyle interventions aimed at promoting CVH in African Americans.

Choice architecture interventions to change physical activity and sedentary behavior: a systematic review of effects on intention, behavior and health outcomes during and after intervention

BACKGROUND

Choice architecture interventions, which subtly change the environment in which individuals make decisions, can be used to promote behavior change. This systematic review aimed to summarize studies on micro-environmental choice architecture interventions that encouraged physical activity or discouraged sedentary behavior in adults, and to describe the effectiveness of those interventions on these behaviors - and on related intentions or health outcomes - in presence of the intervention and after removal of the intervention (i.e. post-intervention, regardless of the time elapsed).

METHODS

We systematically searched PubMed, Embase, PsycINFO and the Cochrane Library for (quasi) experimental studies published up to December 2019 that evaluated the effect of choice architecture interventions on physical activity and sedentary behavior, as well as on intentions and health outcomes related to physical activity/sedentary behavior. Studies that combined choice architecture techniques with other behavior change techniques were excluded. All studies were screened for eligibility, relevant data was extracted and two independent reviewers assessed the methodological quality using the QualSyst tool.

RESULTS

Of the 9609 records initially identified, 88 studies met our eligibility criteria. Most studies (n = 70) were of high methodologic quality. Eighty-six studies targeted physical activity, predominantly stair use, whereas two studies targeted sedentary behavior, and one targeted both behaviors. Intervention techniques identified were prompting (n = 53), message framing (n = 24), social comparison (n = 12), feedback (n = 8), default change (n = 1) and anchoring (n = 1). In presence of the intervention, 68% of the studies reported an effect of choice architecture on behavior, whereas after removal of the intervention only 47% of the studies reported a significant effect. For all choice architecture techniques identified, except for message framing, the majority of studies reported a significant effect on behavioral intentions or behavior in presence of the intervention.

CONCLUSIONS

The results suggest that prompting can effectively encourage stair use in adults, especially in presence of a prompt. The effectiveness of the choice architecture techniques social influence, feedback, default change and anchoring cannot be assessed based on this review. More (controlled) studies are needed to assess the (sustained) effectiveness of choice architecture interventions on sedentary behavior and other types of physical activity than stair use.

Text Message Interventions for Physical Activity: A Systematic Review and Meta-Analysis

CONTEXT

Despite clear health benefits, many individuals fail to achieve the recommended levels of physical activity. Text message interventions to promote physical activity hold promise owing to the ubiquity of cell phones and the low expense of text message delivery.

EVIDENCE ACQUISITION

A systematic review and meta-analysis were performed to examine the impact of text message interventions on physical activity. Searches of PubMed, PsycINFO, Scopus, Cochrane, and ClinicalTrials.gov databases from inception to December 2017 were performed to identify studies investigating one-way text message interventionss to promote physical activity. A subset of RCTs, including an objective (accelerometer-based) physical activity outcome, were included in random-effects meta-analyses in 2018.

EVIDENCE SYNTHESIS

The systematic search revealed 944 articles. Of these, 59 were included in the systematic review (12 1-arm trials and 47 controlled trials; n=8,742; mean age, 42.2 years; 56.2% female). In meta-analyses of 13 studies (n=1,346), text message interventionss led to significantly greater objectively measured postintervention steps/day (Cohen's d=0.38, 95% CI=0.19, 0.58, n=10 studies). Analysis of postintervention moderate-to-vigorous physical activity found a similar but not statistically significant effect (Cohen's d=0.31, 95% CI= -0.01, 0.63, n=5 studies). Interventions with more components, tailored content, and interventions in medical populations led to nonsignificantly larger effect sizes compared with text message interventions without these features.

CONCLUSIONS

Text message interventions lead to higher objectively measured postintervention physical activity compared with control groups. More extensive, well-controlled studies are needed to examine this relationship further and identify characteristics of effective text message interventions.

Mobile Health Interventions for Physical Activity, Sedentary Behavior, and Sleep in Adults Aged 50 Years and Older: A Systematic Literature Review

We provide a systematic review of interventions utilizing mobile technology to alter physical activity, sedentary behavior, and sleep among adults aged 50 years and older. A systematic search identified 52 relevant articles (randomized control trial [RCT], quasi-experimental, pre/post single-group design). Of 50 trials assessing physical activity, 17 out of 29 RCTs and 13 out of 21 trials assessed for pre/post changes only supported the effectiveness of mobile interventions to improve physical activity, and 9 studies (five out of 10 RCTs and all four pre/post studies) out of 14 reduced sedentary behavior. Only two of five interventions improved sleep (one out of two RCTs and one out of three pre/post studies). Text messaging was the most frequently used intervention (60% of all studies) but was usually used in combination with other components (79% of hybrid interventions included SMS, plus either web or app components). Although more high-quality RCTs are needed, there is evidence supporting the effectiveness of mHealth approaches in those aged 50 years and older.

Persuasive System Design Principles and Behavior Change Techniques to Stimulate Motivation and Adherence in Electronic Health Interventions to Support Weight Loss Maintenance: Scoping Review

BACKGROUND

Maintaining weight after weight loss is a major health challenge, and eHealth (electronic health) solutions may be a way to meet this challenge. Application of behavior change techniques (BCTs) and persuasive system design (PSD) principles in eHealth development may contribute to the design of technologies that positively influence behavior and motivation to support the sustainable health behavior change needed.

OBJECTIVE

This review aimed to identify BCTs and PSD principles applied in eHealth interventions to support weight loss and weight loss maintenance, as well as techniques and principles applied to stimulate motivation and adherence for long-term weight loss maintenance.

METHODS

A systematic literature search was conducted in PsycINFO, Ovid MEDLINE (including PubMed), EMBASE, Scopus, Web of Science, and AMED, from January 1, 2007 to June 30, 2018. Arksey and O'Malley's scoping review methodology was applied. Publications on eHealth interventions were included if focusing on weight loss or weight loss maintenance, in combination with motivation or adherence and behavior change.

RESULTS

The search identified 317 publications, of which 45 met the inclusion criteria. Of the 45 publications, 11 (24%) focused on weight loss maintenance, and 34 (76%) focused on weight loss. Mobile phones were the most frequently used technology (28/45, 62%). Frequently used wearables were activity trackers (14/45, 31%), as well as other monitoring technologies such as wireless or digital scales (8/45, 18%). All included publications were anchored in behavior change theories. Feedback and monitoring and goals and planning were core behavior change technique clusters applied in the majority of included publications. Social support and associations through prompts and cues to support and maintain new habits were more frequently used in weight loss maintenance than weight loss interventions. In both types of interventions, frequently applied persuasive principles were self-monitoring, goal setting, and feedback. Tailoring, reminders, personalization, and rewards were additional principles frequently applied in weight loss maintenance interventions. Results did not reveal an ideal combination of techniques or principles to stimulate motivation, adherence, and weight loss maintenance. However, the most frequently mentioned individual techniques and principles applied to stimulate motivation were, personalization, simulation, praise, and feedback, whereas associations were frequently mentioned to stimulate adherence. eHealth interventions that found significant effects for weight loss maintenance all applied self-monitoring, feedback, goal setting, and shaping knowledge, combined with a human social support component to support healthy behaviors.

CONCLUSIONS

To our knowledge, this is the first review examining key BCTs and PSD principles applied in weight loss maintenance interventions compared with those of weight loss interventions. This review identified several techniques and principles applied to stimulate motivation and adherence. Future research should aim to examine which eHealth design combinations can be the most effective in support of long-term behavior change and weight loss maintenance.