Low-income groups and behaviour change interventions: a review of intervention content, effectiveness and theoretical frameworks

Incorporating Cardiovascular Risk Assessment into Adolescent Reproductive Health and Primary Care Visits

STUDY OBJECTIVE

This study aimed to evaluate the usability and feasibility of incorporating a cardiovascular risk assessment tool into adolescent reproductive health and primary care visits.

DESIGN, SETTING, AND PARTICIPANTS

We recruited 60 young women ages 13-21 years to complete the HerHeart web-tool in 2 adolescent clinics in Atlanta, GA.

MAIN OUTCOME MEASURES

Participants rated the tool's usability via the Website Analysis and Measurement Inventory (WAMMI, range 0-95) and their perceived 10-year and lifetime risk of cardiovascular disease (CVD) on a visual analog scale (range 0-10). Participants' perceived risk, blood pressure, and body mass index were measured at baseline and 3 months after enrollment. Health care providers (HCP, n = 5) completed the WAMMI to determine the usability and feasibility of incorporating the HerHeart tool into clinical practice.

RESULTS

Adolescent participants and HCPs rated the tool's usability highly on the WAMMI with a median of 79 (interquartile range [IQR] 65, 84) and 76 (IQR 71, 84). At the baseline visit, participants' median perceived 10-year risk of a heart attack was 1 (IQR 0, 3), and perceived lifetime risk was 2 (IQR 0, 4). Immediately after engaging with the tool, participants' median perceived 10-year risk was 2 (IQR 1, 4.3), and perceived lifetime risk was 3 (IQR 1.8, 6). Thirty-one participants chose to set a behavior change goal, and 12 participants returned for follow-up. Clinical metrics were similar at the baseline and follow-up visits.

CONCLUSION

HerHeart is acceptable to young women and demonstrates potential for changing risk perception and improving health habits to reduce risk of CVD. Future research should focus on improving retention in studies to promote cardiovascular health within reproductive health clinics.

Behavior Change Techniques That Prevent or Decrease Obesity in Youth With a Low Socioeconomic Status: A Systematic Review and Meta-Analysis

Background: Interventions, targeting youth, are necessary to prevent obesity later in life. Especially youth with low socioeconomic status (SES) are vulnerable to develop obesity. This meta-analysis examines the effectiveness of behavioral change techniques (BCTs) to prevent or reduce obesity among 0 to 18-year-olds with a low SES in developed countries. Method: Intervention studies were identified from systematic reviews or meta-analyses published between 2010 and 2020 and retrieved from PsycInfo, Cochrane systematic review, and PubMed. The main outcome was body mass index (BMI), and we coded the BCTs. Results: Data from 30 studies were included in the meta-analysis. The pooled postintervention effects of these studies indicated a nonsignificant decrease in BMI for the intervention group. Longer follow-up (≥12 months) showed favorable differences for intervention studies, although that BMI change was small. Subgroup analyses showed larger effects for studies with six or more BCTs. Furthermore, subgroup analyses showed a significant pooled effect in favor of the intervention for the presence of a specific BCT (problem-solving, social support, instruction on how to perform the behavior, identification of self as role model, and demonstration of the behavior), or absence of a specific BCT (information about health consequences). The intervention program duration and age group of the study population did not significantly influence the studies' effect sizes. Conclusions: Generally, the effects of interventions on BMI change among youth with low SES are small to neglectable. Studies with more than six BCTs and/or specific BCTs had a higher likelihood of decreasing BMI of youth with low SES.

Designing a Contextualized Food-Based Strategy to Improve the Dietary Diversity of Children in Rural Farming Households in Central Uganda

BACKGROUND

Food-based strategies have a high potential of improving the diet quality and reducing the prevalence of nutrient deficiencies in agriculture-dependent communities. Their design is however complex with trade-offs that are rarely systematically presented to allow replication and efficient contextualization.

OBJECTIVE

The systematic design of a food-based strategy to improve the dietary diversity of children in rural farming communities in Uganda.

METHODS

The intervention mapping protocol was used to provide a systematic approach to developing theory-based and evidence-based intervention methods and strategy.

RESULTS

The priority behavioral and environmental determinants identified were related to food production, consumption, and efficacy while the personal determinants focused on knowledge, skills, self-efficacy, attitude, and outcome expectations. The aim of the resulting strategy was set to improve the availability, accessibility, and consumption of diverse foods, with a particular focus on production diversity, production practices, market access, and market diversity. Behaviour change methods were selected to enhance ability and self-efficacy, strategic goal setting, and provision of feedback. The strategy focused on household groups for learning, demonstration, practice, and social support. The validation showed that the determinants and actors incorporated in the strategy were important and relevant for improving the productivity, food availability, dietary diversity, livelihoods, and health of rural farming households and communities.

CONCLUSION

Application of the protocol yielded a contextualized food-based strategy that can be adjusted for use in other smallholder contexts in developing countries by piloting implementation plans based on the strategy; reassessing the key determinants and implementing the revised strategy; or replicating the whole design process.

Effects of interventions on the screening behavior in female first-degree relatives of breast cancer patients: A systematic review

BACKGROUND

Women are more likely to develop breast cancer if their first-degree relatives (FDRs) have the disease, but they are often unaware of their individual risk and conduct screening behaviors.

OBJECTIVE

This study aimed to evaluate the effectiveness of interventions in increasing breast self-examination, clinical breast examination, and mammography rates in FDRs of breast cancer patients.

METHODS

We selected randomized clinical trials and quasi-experimental studies in eight databases. Interventions in each study were categorized as "promising", or "non-promising" according to whether they led to a positive change in screening behaviors. Interventions were also coded using the Behavioral Change Techniques (BCTs) Taxonomy and a promise ratio calculated for each. BCTs with a promise ratio ≥2 was classified as "promising".

RESULTS

Thirteen studies with 21 different BCTs were included. The most frequent BCTs were "Prompts/cues", "Credible source", and "Instructions on how to perform the behavior". Seven BCTs had a promise ratio of ≥2 and the four most promising were "Information about health consequences" (promise ratio = 6), "Problem solving" (promise ratio = 4), "Demonstration of the behavior" (promise ratio = 4), and "Adding objects to the environment" (promise ratio = 4).

CONCLUSIONS

This review indicated an overall weak use of theory, and an insufficient description of several interventions to support the assessment of how specific BCTs were activated.

Guide Development for eHealth Interventions Targeting People With a Low Socioeconomic Position: Participatory Design Approach

BACKGROUND

People with a low socioeconomic position (SEP) are less likely to benefit from eHealth interventions, exacerbating social health inequalities. Professionals developing eHealth interventions for this group face numerous challenges. A comprehensive guide to support these professionals in their work could mitigate these inequalities.

OBJECTIVE

We aimed to develop a web-based guide to support professionals in the development, adaptation, evaluation, and implementation of eHealth interventions for people with a low SEP.

METHODS

This study consisted of 2 phases. The first phase involved a secondary analysis of 2 previous qualitative and quantitative studies. In this phase, we synthesized insights from the previous studies to develop the guide's content and information structure. In the second phase, we used a participatory design process. This process included iterative development and evaluation of the guide's design with 11 professionals who had experience with both eHealth and the target group. We used test versions (prototypes) and think-aloud testing combined with semistructured interviews and a questionnaire to identify design requirements and develop and adapt the guide accordingly.

RESULTS

The secondary analysis resulted in a framework of recommendations for developing the guide, which was categorized under 5 themes: development, reach, adherence, evaluation, and implementation. The participatory design process resulted in 16 requirements on system, content, and service aspects for the design of the guide. For the system category, the guide was required to have an open navigation strategy leading to more specific information and short pages with visual elements. Content requirements included providing comprehensible information, scientific evidence, a user perspective, information on practical applications, and a personal and informal tone of voice. Service requirements involved improving suitability for different professionals, ensuring long-term viability, and a focus on implementation. Based on these requirements, we developed the final version of "the inclusive eHealth guide."

CONCLUSIONS

The inclusive eHealth guide provides a practical, user-centric tool for professionals aiming to develop, adapt, evaluate, and implement eHealth interventions for people with a low SEP, with the aim of reducing health disparities in this population. Future research should investigate its suitability for different end-user goals, its external validity, its applicability in specific contexts, and its real-world impact on social health inequality.

Behaviour change techniques in physical activity-focused interventions for young people at risk of problematic substance use: A systematic review and meta-analysis

AIM

This systematic review investigates behaviour change techniques in interventions promoting physical activity for young people aged 12-25 years at heightened risk of problematic substance use, and the effect of these techniques on physical activity participation and substance use outcomes.

METHODS

Four databases (PsycINFO, CINAHL, SPORTDiscus and Medline) were searched between November 2020 and November 2022 for randomized and non-randomized controlled studies according to inclusion criteria. Meta-analyses were calculated using weighted, standardized averages of effect sizes (Hedges' g).

RESULTS

Twenty-eight studies were included, 14 studies in the meta-analysis (intervention n = 1328; control n = 845). Reported BCTs included behavioural instructions, social comparison and goal setting. There was a significant effect of behaviour change techniques on combined substance use outcomes, such as cravings and consumption, for interventions reporting multiple behaviour change techniques (g = -0.33, p < .001, 95% CI [-0.50,-0.16]) or one single behaviour change technique (g = -1.84, p < .001, 95% CI [-2.89,-0.8]). Limitations include unexplained variance and limited reporting of relevant behaviour change technique data in the included studies.

CONCLUSION

The results indicate that using behaviour change techniques in interventions that promote physical activity for young people has an effect on substance use. Further research needs to be completed comparing the impact of the number and type of behaviour change technique, and improved reporting of intervention content is required.

Effects of interventions on life-space mobility for community-dwelling older adults: A systematic review and meta-analysis

AIM

The present study aimed to conduct a meta-analysis to evaluate the methods and effects of interventions to increase life-space mobility among community-dwelling older adults.

METHODS

Records were identified through nine databases. Eligible study designs for inclusion in the review were randomized controlled trials of interventions on life-space mobility for community-dwelling older adults. The risk of bias was assessed using the Risk of Bias 2 tool. We followed the Grading of Recommendations, Assessment, Development, and Evaluation approach to summarize the evidence.

RESULTS

Four studies (558 participants) identified via search strategies were included. Two studies involved individualized exercise and lifestyle interventions. In three out of the four studies, individual interventions were applied. Overall, when compared with a control group, the intervention group was more likely to positively affect increasing life-space mobility (standardized mean difference 0.47, 95% confidence interval [0.020 to 0.92]). The heterogeneity statistic indicated considerable heterogeneity (I2  = 84%). The evidence was downgraded one step owing to imprecision.

CONCLUSIONS

Interventions on increasing life-space mobility for community-dwelling older adults have a positive effect. Combination interventions may be more effective than single interventions, and individual interventions may be more effective than group interventions. However, owing to the limited number of studies, conducting further research to enhance the generalizability of results is crucial. Additionally, subgroup analysis should be conducted to clarify differences in intervention methods and effects. Geriatr Gerontol Int 2023; 23: 842-848.

Challenges and successes in the sustainment of Dutch community-level smoking cessation interventions for residents with a low socioeconomic position

BACKGROUND

When health promotion interventions are implemented, the gains are often short-lived, as interventions are seldom successfully sustained. The current study explores how and under what conditions community-level smoking cessation interventions for people with a lower socioeconomic position can be sustained, drawing upon interventions delivered in Dutch neighbourhoods with a predominantly low socioeconomic position.

METHODS

We conducted 15 semi-structured interviews with key stakeholders from three Dutch community-level smoking cessation interventions implemented at least three years prior. The topic guide was developed based on the Determinants of Innovation framework and transcripts were analysed thematically.

RESULTS

We identified several factors that promote the sustainment of smoking cessation community-level interventions: 1) structural, long-term funding through the commitment of health insurers and policy makers; 2) continued stakeholder enthusiasm and involvement; 3) training and time for professionals to discuss smoking cessation, thereby also increasing the visibility of the intervention for professionals and residents; 4) integrating the intervention with existing initiatives and adapting it to be compatible with current working practices of executive staff; and 5) planning for sustainment as a team from the outset.

CONCLUSIONS

The current study highlights challenges and successes in intervention sustainment for people with a lower socioeconomic position. Lack of structural funding was one of the most challenging aspects for intervention sustainment in which health insurers and policy makers can play an important role. Planning for sustainment from the outset would enable intervention coordinators to consider the abovementioned factors early on. This need not be done alone but can best be discussed within a team of stakeholders.

Efficacy of mindfulness and goal setting interventions for increasing resilience and reducing smoking in lower socio-economic groups: randomised controlled trial protocol

BACKGROUND

Smoking and resulting health problems disproportionately impact low socioeconomic status (SES) individuals. Building resilience presents an approach to 'closing the gap'. Mindfulness-based interventions and setting realistic goals are preferred in low socioeconomic communities. We aim to test if these interventions, delivered online and consolidated with peer support offered via ex-smokers, are successful in promoting smoking cessation and resilience. Our conceptualisation of resilience encompasses the inner capacity/skills and external resources (e.g., social support) which smokers utilise to bounce back from adversity. We include a process evaluation of barriers/facilitators to interventions and cost-effectiveness analysis (from health system perspective).

METHODS

We plan a four-arm parallel 12-month RCT with a 6-month follow-up to test the efficacy of three group-based interventions each followed by peer support. Arm 1: mindfulness-integrated cognitive behavioural therapy; Arm 2: mindfulness training; Arm 3: setting realistic goals; Arm 4: active control group directed to quit services. All interventions will be administered online. Participants are adult smokers in Australia (N = 812) who have an average weekly household income less than $457AUD or receive welfare benefits. Group-based interventions will occur over 6 months, followed by 6 months of forum-based peer support.

PRIMARY OUTCOME

self-reported 14-day period prevalence of smoking abstinence at 6 months, with remote biochemical verification of saliva cotinine (< 30 ng/mL). Secondary outcomes include: internal resilience (Connor-Davidson Resilience Scale-25); external resilience (ENRICHD social support tool); quality adjusted life years (EQ-5D-5L); self-efficacy for smoking abstinence (Smoking-Abstinence Self-Efficacy Questionnaire); motivation to quit smoking (Biener and Abrams Contemplation Ladder); nicotine dependence (Fagerstrom Test for Nicotine Dependency); equanimity (Equanimity Scale-16); stress (Perceived Stress Scale-10); goal assessment/attainment (Problems and Goals Assessment Scale).

DISCUSSION

This study is the first to compare resilience interventions for low SES smokers which have been identified by them as acceptable. Our various repeated measures and process evaluation will facilitate exploration of mechanisms of impact. We intervene within the novel framework of the Psychosocial Model of Resilience, applying a promising paradigm to address a critical and inequitable public health problem. Trial registration Australian New Zealand Clinical Trials Registry ID: ACTRN12621000445875, registered 19 April 2021 ( https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=381007&isReview=true ). The Universal Trial Number is U1111-1261-8951.

Digital health interventions to improve eating behaviour of people with a lower socioeconomic position: a scoping review of behaviour change techniques

Specific approaches are needed to reach and support people with a lower socioeconomic position (SEP) to achieve healthier eating behaviours. There is a growing body of evidence suggesting that digital health tools exhibit potential to address these needs because of its specific features that enable application of various behaviour change techniques (BCTs). The aim of this scoping review is to identify the BCTs that are used in diet-related digital interventions targeted at people with a low SEP, and which of these BCTs coincide with improved eating behaviour. The systematic search was performed in 3 databases, using terms related to e/m-health, diet quality and socioeconomic position. A total of 17 full text papers were included. The average number of BCTs per intervention was 6.9 (ranged 3-15). BCTs from the cluster 'Goals and planning' were applied most often (25x), followed by the clusters 'Shaping knowledge' (18x) and 'Natural consequences' (18x). Other frequently applied BCT clusters were 'Feedback and monitoring' (15x) and 'Comparison of behaviour' (13x). Whereas some BCTs were frequently applied, such as goal setting, others were rarely used, such as social support. Most studies (n = 13) observed a positive effect of the intervention on eating behaviour (e.g. having breakfast) in the low SEP group, but this was not clearly associated with the number or type of applied BCTs. In conclusion, more intervention studies focused on people with a low SEP are needed to draw firm conclusions as to which BCTs are effective in improving their diet quality. Also, further research should investigate combinations of BCTs, the intervention design and context, and the use of multicomponent approaches. We encourage intervention developers and researchers to describe interventions more thoroughly, following the systematics of a behaviour change taxonomy, and to select BCTs knowingly.

Integrating Financial Coaching and Referrals into a Smoking Cessation Program for Low-income Smokers: a Randomized Waitlist Control Trial

BACKGROUND

Financial distress is a barrier to cessation among low-income smokers.

OBJECTIVE

To evaluate an intervention that integrated financial coaching and benefits referrals into a smoking cessation program for low-income smokers.

DESIGN

Randomized waitlist control trial conducted from 2017 to 2019.

PARTICIPANTS

Adult New York City residents were eligible if they reported past 30-day cigarette smoking, had income below 200% of the federal poverty level, spoke English or Spanish, and managed their own funds. Pregnant or breastfeeding people were excluded. Participants were recruited from two medical centers and from the community.

INTERVENTION

The intervention (n = 208) offered smoking cessation coaching, nicotine replacement therapy, money management coaching, and referral to financial benefits and empowerment services. The waitlist control (n=202) was usual care during a 6-month waiting period.

MAIN MEASURES

Treatment engagement, self-reported 7-day abstinence, and financial stress at 6 months.

KEY RESULTS

At 6 months, intervention participants reported higher abstinence (17% vs. 9%, P=0.03), lower stress about finances (β, -0.8 [SE, 0.4], P=0.02), and reduced frequency of being unable to afford activities (β, -0.8 [SE, 0.4], P=0.04). Outcomes were stronger among participants recruited from the medical centers (versus from the community). Among medical center participants, the intervention was associated with higher abstinence (20% vs. 8%, P=0.01), higher satisfaction with present financial situation (β, 1.0 [SE, 0.4], P=0.01), reduced frequency of being unable to afford activities (β, -1.0 [SE, 0.5], P=0.04), reduced frequency in getting by paycheck-to-paycheck (β, -1.0 [SE, 0.4], P=0.03), and lower stress about finances in general (β, -1.0 [SE, 0.4], P = 0.02). There were no group differences in outcomes among people recruited from the community (P>0.05).

CONCLUSIONS

Among low-income smokers recruited from medical centers, the intervention produced higher abstinence rates and reductions in some markers of financial distress than usual care. The intervention was not efficacious with people recruited from the community.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03187730.

The Barriers and Facilitators of eHealth-Based Lifestyle Intervention Programs for People With a Low Socioeconomic Status: Scoping Review

Background

Promoting health behaviors and preventing chronic diseases through a healthy lifestyle among those with a low socioeconomic status (SES) remain major challenges. eHealth interventions are a promising approach to change unhealthy behaviors in this target group.

Objective

This review aims to identify key components, barriers, and facilitators in the development, reach, use, evaluation, and implementation of eHealth lifestyle interventions for people with a low SES. This review provides an overview for researchers and eHealth developers, and can assist in the development of eHealth interventions for people with a low SES.

Methods

We performed a scoping review based on Arksey and O’Malley’s framework. A systematic search was conducted on PubMed, MEDLINE (Ovid), Embase, Web of Science, and the Cochrane Library, using terms related to a combination of the following key constructs: eHealth, lifestyle, low SES, development, reach, use, evaluation, and implementation. There were no restrictions on the date of publication for articles retrieved upon searching the databases.

Results

The search identified 1323 studies, of which 42 met our inclusion criteria. An update of the search led to the inclusion of 17 additional studies. eHealth lifestyle interventions for people with a low SES were often delivered via internet-based methods (eg, websites, email, Facebook, and smartphone apps) and offline methods, such as texting. A minority of the interventions combined eHealth lifestyle interventions with face-to-face or telephone coaching, or wearables (blended care). We identified the use of different behavioral components (eg, social support) and technological components (eg, multimedia) in eHealth lifestyle interventions. Facilitators in the development included iterative design, working with different disciplines, and resonating intervention content with users. Facilitators for intervention reach were use of a personal approach and social network, reminders, and self-monitoring. Nevertheless, barriers, such as technological challenges for developers and limited financial resources, may hinder intervention development. Furthermore, passive recruitment was a barrier to intervention reach. Technical difficulties and the use of self-monitoring devices were common barriers for users of eHealth interventions. Only limited data on barriers and facilitators for intervention implementation and evaluation were available.

Conclusions

While we found large variations among studies regarding key intervention components, and barriers and facilitators, certain factors may be beneficial in building and using eHealth interventions and reaching people with a low SES. Barriers and facilitators offer promising elements that eHealth developers can use as a toolbox to connect eHealth with low SES individuals. Our findings suggest that one-size-fits-all eHealth interventions may be less suitable for people with a low SES. Future research should investigate how to customize eHealth lifestyle interventions to meet the needs of different low SES groups, and should identify the components that enhance their reach, use, and effectiveness.

Prevention of Cardiovascular Diseases in Community Settings and Primary Health Care: A Pre-Implementation Contextual Analysis Using the Consolidated Framework for Implementation Research

Cardiovascular diseases are the world’s leading cause of mortality, with a high burden especially among vulnerable populations. Interventions for primary prevention need to be further implemented in community and primary health care settings. Context is critically important to understand potential implementation determinants. Therefore, we explored stakeholders’ views on the evidence-based SPICES program (EBSP); a multicomponent intervention for the primary prevention of cardiovascular disease, to inform its implementation. In this qualitative study, we conducted interviews and focus groups with 24 key stakeholders, 10 general practitioners, 9 practice nurses, and 13 lay community partners. We used adaptive framework analysis. The Consolidated Framework for Implementation Research guided our data collection, analysis, and reporting. The EBSP was valued as an opportunity to improve risk awareness and health behavior, especially in vulnerable populations. Its relative advantage, evidence-based design, adaptability to the needs and resources of target communities, and the alignment with policy evolutions and local mission and vision, were seen as important facilitators for its implementation. Concerns remain around legal and structural characteristics and intervention complexity. Our results highlight context dimensions that need to be considered and tailored to primary care and community needs and capacities when planning EBSP implementation in real life settings.

Explanations for the Cloudy Evidence That Theory Benefits Health Promotion

Persuasive arguments for using theory have been influential in health behavior and health promotion research. The use of theory is expected to improve intervention outcomes and facilitate scientific advancement. However, current empirical evaluations of the benefits of theory have not consistently demonstrated strong effects. A lack of resolution on this matter can be attributed to several features of the current body of evidence. First, the use of theory may be confounded with other features that impact health-related outcomes. Second, measurement of theory use has not been reliable. Third, the field conflates models and theories. Lastly, the evidentiary status and applicability of theories are not considered. Addressing these challenges during the execution of meta-analyses and designing original research specifically to estimate the benefits of theory could improve research and practice.

Evaluating the feasibility and acceptability of an exercise and behaviour change intervention in socioeconomically deprived patients with peripheral arterial disease: The textpad study protocol

This pilot randomised controlled trial aims to assess the feasibility and acceptability of a 12-week home-based telehealth exercise and behavioural intervention delivered in socioeconomically deprived patients with peripheral artery disease (PAD). The study will also determine the preliminary effectiveness of the intervention for improving clinical and health outcomes. Sixty patients with PAD who meet the inclusion criteria will be recruited from outpatient clinic at the Freeman Hospital, United Kingdom. The intervention group will undergo telehealth behaviour intervention performed 3 times per week over 3 months. This program will comprise a home-based exercise (twice a week) and an individual lifestyle program (once per week). The control group will receive general health recommendations and advice to perform unsupervised walking training. The primary outcome will be feasibility and acceptability outcomes. The secondary outcomes will be objective and subjective function capacity, quality of life, dietary quality, physical activity levels, sleep pattern, alcohol and tobacco use, mental wellbeing, and patients’ activation. This pilot study will provide preliminary evidence of the feasibility, acceptability and effectiveness of home-based telehealth exercise and behavioural intervention delivered in socioeconomically deprived patients with PAD. In addition, the variance of the key health outcomes of this pilot study will be used to inform the sample size calculation for a future fully powered, multicentre randomized clinical trial.

Behaviour change interventions to promote health and well-being among older migrants: A systematic review

Background

Whether behaviour change interventions are effective for the maintenance of older migrants’ health and well-being is uncertain. A systematic review was conducted to assess evidence for the capacity of behaviour change techniques (BCTs) to promote the health and well-being of older migrants.

Methods

Electronic databases (Cochrane CENTRAL, Embase, Ovid MEDLINE and Web of Science) were searched systematically to identify relevant randomised controlled trials, pre–post studies and quasi-experimental studies published before March 2021. Additional articles were identified through citation tracking. Studies examining BCTs used to promote the health and/or well-being of older migrants were eligible. Two independent reviewers used the Behaviour Change Technique Taxonomy version 1 to extract data on BCTs. Data on intervention functions (IFs) and cultural adaption strategies were also extracted. Intervention contents (BCTs, IFs, culture adaption strategies) were compared across effective and ineffective interventions according to health and well-being outcome clusters (anthropometrics, health behaviour, physical functioning, mental health and cognitive functioning, social functioning and generic health and well-being).

Results

Forty-three studies (23 randomised controlled trials, 13 pre–post studies and 7 quasi-experimental studies) reporting on 39 interventions met the inclusion criteria. Thirteen BCTs were identified as promising for at least one outcome cluster: goal-setting (behaviour), problem-solving, behavioural contract, self-monitoring of behaviour, social support (unspecified), instruction on how to perform the behaviour, information about health consequences, information about social and environmental consequences, demonstration of the behaviour, social comparison, behavioural practice/rehearsal, generalisation of a target behaviour and addition of objects to the environment. Three BCTs (instruction on how to perform the behaviour, demonstration of the behaviour, and social comparison) and two IFs (modelling and training) were identified as promising for all outcome clusters.

Conclusions

Thirteen distinct BCTs are promising for use in future interventions to optimise health and well-being among older migrants. Future research should focus on the effectiveness of these BCTs (combinations) in various contexts and among different subgroups of older migrants, as well as the mechanisms through which they act. Given the scarcity of interventions in which cultural adaption has been taken into account, future behavioural change interventions should consider cultural appropriateness for various older migrant (sub)groups.

Trial registration

PROSPERO CRD42018112859.

Latent Heterogeneity in the Impact of Financial Coaching on Delay Discounting among Low-Income Smokers: A Secondary Analysis of a Randomized Controlled Trial

Low-income adults are significantly more likely to smoke, and face more difficulty in quitting, than people with high income. High rates of delay discounting (DD) may be an important factor contributing to the high rates of tobacco use among low-income adults. Future-oriented financial coaching may offer a novel approach in the treatment of smoking cessation among low-income adults. This secondary analysis (N = 251) of data from a randomized controlled trial examined the integration of future-oriented financial coaching into smoking cessation treatment for low-income smokers. Linear regression and finite mixture models (FMM) estimated the overall and the latent heterogeneity of the impact of the intervention versus usual care control on DD rates 6 months after randomization. Though standard linear regression found no overall difference in DD between intervention and control (β = −0.23, p = 0.338), the FMM identified two latent subgroups with different responses to the intervention. Subgroup 1 (79% of the sample) showed no difference in DD between intervention and control (β = 0.25, p = 0.08). Subgroup 2 (21% of the sample) showed significantly lower DD (β = −2.06, p = 0.003) among intervention group participants versus control at 6 months. Participants were more likely to be a member of subgroup 2 if they had lower baseline DD rates, were living at or below 100% of federal poverty, or were married/living with a partner. This study identified a group of low-income adults seeking to quit smoking who responded to financial coaching with decreased DD rates. These results can be used to inform future targeting of the intervention to individuals who may benefit most, as well as inform future treatment adaptations to support the subgroup of low-income smokers, who did not benefit.

Theoretical and practical approaches for dietary behavior change in urban socioeconomically disadvantaged adolescents: a systematic review

CONTEXT

There is limited evidence on strategies used to promote dietary behavior changes in socioeconomically disadvantaged urban adolescents and on their effectiveness.

OBJECTIVE

A synthesis of nutrition interventions used in this group of adolescents is provided in this systematic review.

DATA SOURCES

Five electronic databases (PubMed, Web of Science, CINAHL, PsycINFO, and ERIC) were searched until November 2020 to identify relevant studies.

DATA EXTRACTION

Forty-six manuscripts (n = 38 intervention studies) met the inclusion criteria. Quality was assessed with the Effective Public Health Practice Project Quality Assessment Tool. A qualitative synthesis summarizing data on study characteristics was conducted.

DATA ANALYSIS

Studies were classified by intervention type as those focusing on hedonic determinants of dietary intake (n = 1), environmental changes to promote a specific dietary intake (n = 3), cognitive determinants (n = 29), and multicomponent strategies (n = 13). The social cognitive theory was the most applied theoretical framework, either alone or combined with other frameworks. Most of the intervention studies targeted multiple dietary outcomes, and success was not always reported for each.

CONCLUSIONS

Despite the heterogeneity of the studies and lack of combination of dietary outcomes into dietary scores or patterns to evaluate changes on the individuals' whole diets, long-term, theory-driven interventions targeting a single dietary factor seem promising in obtaining sustainable dietary behavior changes.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42020188219.

Involving Children in Creating a Healthy Environment in Low Socioeconomic Position (SEP) Neighborhoods in The Netherlands: A Participatory Action Research (PAR) Project

To ensure that health behavior interventions for children living in low socioeconomic position (SEP) neighborhoods are in line with children’s wishes and needs, participation of the children in the development, implementation, and evaluation is crucial. In this paper, we show how children living in three low-SEP neighborhoods in the Netherlands can be involved in Participatory Action Research (PAR) by using the photovoice method, and what influences this research process. Observations, informal chats, semi-structured interviews, and focus group discussions with children and professionals were done to evaluate the research process. The photovoice method provided comprehensive information from the children’s perspectives. With the help of the community workers, the children identified feasible actions. We found that it is important to constantly discuss the research process with participants, start with a concrete question or problem, and adapt the project to the local context and skills of participants.

Attitudes Toward Health, Healthcare, and eHealth of People With a Low Socioeconomic Status: A Community-Based Participatory Approach

Low socioeconomic status (SES) is associated with a higher prevalence of unhealthy lifestyles compared to a high SES. Health interventions that promote a healthy lifestyle, like eHealth solutions, face limited adoption in low SES groups. To improve the adoption of eHealth interventions, their alignment with the target group's attitudes is crucial. This study investigated the attitudes of people with a low SES toward health, healthcare, and eHealth. We adopted a mixed-method community-based participatory research approach with 23 members of a community center in a low SES neighborhood in the city of Rotterdam, the Netherlands. We conducted a first set of interviews and analyzed these using a grounded theory approach resulting in a group of themes. These basic themes' representative value was validated and refined by an online questionnaire involving a different sample of 43 participants from multiple community centers in the same neighborhood. We executed three focus groups to validate and contextualize the results. We identified two general attitudes based on nine profiles toward health, healthcare, and eHealth. The first general attitude, optimistically engaged, embodied approximately half our sample and involved light-heartedness toward health, loyalty toward healthcare, and eagerness to adopt eHealth. The second general attitude, doubtfully disadvantaged, represented roughly a quarter of our sample and was related to feeling encumbered toward health, feeling disadvantaged within healthcare, and hesitance toward eHealth adoption. The resulting attitudes strengthen the knowledge of the motivation and behavior of people with low SES regarding their health. Our results indicate that negative health attitudes are not as evident as often claimed. Nevertheless, intervention developers should still be mindful of differentiating life situations, motivations, healthcare needs, and eHealth expectations. Based on our findings, we recommend eHealth should fit into the person's daily life, ensure personal communication, be perceived usable and useful, adapt its communication to literacy level and life situation, allow for meaningful self-monitoring and embody self-efficacy enhancing strategies.

A strengths-based, culturally responsive family intervention improves Latino kindergarteners' vocabulary and approaches to learning

Food routines are an ecocultural asset of Latino families. This cluster-randomized trial with 248 children (M_age  = 67 months; 50% girls; 13 schools) investigated the impact of a 4-week family program designed to capitalize on food routines in improving Latino kindergarteners' outcomes in the United States. There were moderate-to-large impacts on child vocabulary (especially food-related) at end-of-treatment and the 5-month follow-up, and suggestive evidence of moderate impacts on approaches to learning (ATL; including ATL math) and executive function at the 5-month follow-up (d = .38-.95). There were no statistically significant impacts on children's math or literacy skills. A strengths-based, culturally responsive family intervention that is integrated into Latino family life can improve the skills needed to succeed in school.

A Systematic Review of Interventions to Improve Healthcare Experiences and Access in Autism

Autistic individuals report barriers to accessing and receiving healthcare, and experience increased morbidity and mortality. This systematic review synthesizes 31 research studies evaluating interventions implemented to improve the healthcare experiences and/or access of autistic persons. Interventions were most commonly patient-focused (58.1%), focused on supporting the autistic individual to engage with, tolerate, or anticipate medical procedures, care, or settings. Fewer studies were provider-focused (48.4%) or organization-focused (6.5%). Interventions were typically evaluated using measures of reactions (45.2%) or behavior (48.4%), and outcomes were predominantly positive (80.6%). Further research is imperative and should look to how providers and organizations must change. Future research must be inclusive of the autistic community, must measure what matters, and must offer complete detail on interventions implemented.

Eye health profile of affordable eye care service users

CLINICAL RELEVANCE

Knowledge of the typical eye health profile of patients experiencing social or economic disadvantage is useful for health care modelling.

BACKGROUND

The aim of this work is to profile the ocular health and sociodemographic characteristics of Australian College of Optometry service users of all ages and to explore the relationships between key sociodemographic characteristics and eye health.

METHODS

For 3093 eye examinations, best-corrected distance visual acuity and mean spherical equivalent refractive error were tested non-parametrically by clinic category, remoteness area, number of co-morbidities, gender and indigenous status, also correlated against age and socioeconomic advantage/disadvantage. Covariates of interest were entered into linear mixed models of visual acuity and mean spherical equivalent refractive error, controlling for age. Risk estimates are reported for visual impairment (defined as ≤6/12 best-corrected distance visual acuity in one or both eyes) and ocular diagnoses.

RESULTS

Visual impairment is more prevalent amongst service users examined in domiciliary settings. Increasing co-morbidities were associated with poorer best-corrected distance visual acuity. Aboriginal and Torres Strait Islander service users had lower visual impairment prevalence overall but proportionally fewer aged ≥50 years attended for eye care, compared to non-indigenous.

CONCLUSIONS

Domiciliary eye examinations detect remediable visual impairment. Federal public health interventions delivered by the Australian College of Optometry for Aboriginal and Torres Strait Islander eye care appear effective but may not reach all aged ≥ 50 years; further research is required. Identification of multiple co-morbidities should prompt optometrists to tailor public health messages and signpost to low vision services earlier.

Lessons From the Feasibility Testing of a Parent-Focused, Life Skills-Based Intervention to Prevent Obesity in Preschoolers From Underserved Families

This article describes lessons from the feasibility testing of a parent-focused, life skills-based intervention to promote healthy weight in 58 low-income children aged 2 to 5 years. This intervention was feasible and acceptable, with a potential to impact child weight and diet (calories) and parental quality of life (QOL). The group delivery approach through a partnering organization (Head Start) was a more efficient way to reach/engage parents. Compared with one-on-one sessions, the group could provide an avenue to enhance parental psychosocial well-being, given QOL improvements among parents in group sessions. Lessons will inform future research to test the effectiveness of life skills interventions.

Effectiveness of behaviour change techniques used in hand hygiene interventions targeting older children - A systematic review

BACKGROUND

Promoting good hand hygiene in older children is an important measure to reduce the burden of common diseases such as diarrhoea and acute respiratory infections. The evidence around what works to change this behaviour, however, is unclear.

OBJECTIVES

To aid future intervention design and effective use of resources, this review aims to identify the individual components used in hand hygiene interventions and assesses their contribution to intended behavioural change.

METHODS

We systematically searched seven databases for experimental studies evaluating hand hygiene interventions targeting children (age 5-12) and quantitively reporting hand hygiene behaviour. Interventions in each study were categorised as 'promising', or 'non-promising' according to whether they led to a positive change in the targeted behaviour. Behaviour change techniques (BCTs) were identified across interventions using a standard taxonomy and a novel promise ratio calculated for each (the ratio of promising to non-promising interventions featuring the BCT). 'Promising' BCTs were those with a promise ratio of ≥2. BCTs were ranked from most to least promising.

RESULTS

Our final analysis included 19 studies reporting 22 interventions across which 32 unique BCTs were identified. The most frequently used were 'demonstration of the behaviour', 'instruction on how to perform the behaviour' and 'adding objects to the environment'. Eight BCTs had a promise ratio of ≥2 and the five most promising were 'demonstration of the behaviour', 'information about social and environmental consequences', 'salience of consequences', 'adding objects to the environment', and 'instruction on how to perform the behaviour'.

CONCLUSIONS

Our findings suggest that hand hygiene interventions targeting older children should employ a combination of promising BCTs that ensure children understand the behaviour and the consequences of their hand hygiene habits, appropriate hardware is available, and social support is provided. Researchers are encouraged to consistently and transparently describe evaluated interventions to allow promising components to be identified and replicated.

An App-Based Parenting Program to Promote Healthy Energy Balance-Related Parenting Practices to Prevent Childhood Obesity: Protocol Using the Intervention Mapping Framework

BACKGROUND

The family environment plays an important role in the development of children's energy balance-related behaviors. As a result, parents' energy balance-related parenting practices are important targets of preventive childhood obesity programs. Families with a lower socioeconomic position (SEP) may benefit from participating in such programs but are generally less well reached than families with a higher SEP.

OBJECTIVE

This paper describes the application of the Intervention Mapping Protocol (IMP) for the development of an app-based preventive intervention program to promote healthy energy balance-related parenting practices among parents of children (aged 0-4 years) with a lower SEP.

METHODS

The 6 steps of the IMP were used as a theory- and evidence-based framework to guide the development of an app-based preventive intervention program.

RESULTS

In step 1, behavioral outcomes for the app-based program (ie, children have a healthy dietary intake, sufficient sleep, and restricted screen time and sufficient physical activity) and sociocognitive (ie, knowledge, attitudes, and self-efficacy) and automatic (ie, habitual behaviors) determinants of energy balance-related parenting were identified through a needs assessment. In step 2, the behavioral outcomes were translated into performance objectives. To influence these objectives, in step 3, theory-based intervention methods were selected for each of the determinants. In step 4, the knowledge derived from the previous steps allowed for the development of the app-based program Samen Happie! through a process of continuous cocreation with parents and health professionals. In step 5, community health services were identified as potential adopters for the app. Finally, in step 6, 2 randomized controlled trials were designed to evaluate the process and effects of the app among Dutch parents of infants (trial 1) and preschoolers (trial 2). These trials were completed in November 2019 (trial 1) and February 2020 (trial 2).

CONCLUSIONS

The IMP allowed for the effective development of the app-based parenting program Samen Happie! to promote healthy energy balance-related parenting practices among parents of infants and preschoolers. Through the integration of theory, empirical evidence, and data from the target population, as well as the process of continued cocreation, the program specifically addresses parents with a lower SEP. This increases the potential of the program to prevent the development of obesity in early childhood among families with a lower SEP.

TRIAL REGISTRATION

Netherlands Trial Register NL6727, https://www.trialregister.nl/trial/6727; Netherlands Trial Register NL7371, https://www.trialregister.nl/trial/7371.

Economic evaluation of a farm-to-Special Supplemental Nutrition Programme for Women, Infants and Children intervention promoting vegetable consumption

OBJECTIVE

To evaluate the cost and cost-effectiveness of a farm-to-Special Supplemental Nutrition Programme for Women, Infants and Children (WIC) intervention to promote vegetable intake and the redemption of WIC vouchers for produce purchases at farmers' markets.

DESIGN

An economic analysis was undertaken using data from a pilot of the intervention. Vegetable intake was assessed with a reflection spectroscopy device (the Veggie Meter® [VM]) and via self-report. Voucher redemption was reported by WIC. Total and per participant intervention costs and cost-effectiveness ratios (expressed as cost per intervention effect) were estimated in 2019 US dollars over a 6-month period from the perspective of the agency implementing the intervention.

SETTING

A large, urban WIC agency.

PARTICIPANTS

Participants were 297 WIC-enrolled adults.

RESULTS

Post-intervention, VM scores, self-reported vegetable intake and voucher redemption were higher in the intervention as compared with the control study group. Over the 6-month period, intervention costs were $31 092 ($194 unit cost per participant). Relative to the control group, the intervention cost $8·10 per increased VM score per participant, $3·85 per increased cup/d of vegetables consumed per participant and $3·29 per increased percentage point in voucher redemption per participant.

CONCLUSIONS

Intervention costs and cost-effectiveness ratios compared favourably with those reported for other interventions targeting vegetable intake in low-income groups, suggesting that the programme may be cost effective in promoting vegetable purchases and consumption. As there is no benchmark against which to compare cost-effectiveness ratios expressed as cost per unit of effectiveness, conclusions regarding whether this is the case must await further research.

Health Literacy in Schools? A Systematic Review of Health-Related Interventions Aimed at Disadvantaged Adolescents

Socioeconomically disadvantaged populations are at greater risk of adopting unhealthy behaviours and developing chronic diseases. Adolescence has been identified as a crucial life stage to develop lifelong healthy behaviours, with schools often suggested as the ideal environment to foster healthy habits. Health literacy (HL) provides a possible solution to promote such healthy behaviours. The aim of this study was to review school-based HL-related interventions targeting socioeconomically disadvantaged adolescents and to identify effective intervention strategies for this population. Searches were performed in six databases. Inclusion criteria included age: 12–16; the implementation of a school-based intervention related to HL aimed at socioeconomically disadvantaged populations; an intervention focused on: physical activity (PA), diet, mental health, substance abuse or sleep. Forty-one articles were included, with the majority focusing on PA and diet (n = 13), PA (n = 9) or mental health (n = 7). Few interventions focused solely on substance abuse (n = 2) or sleep (n = 1), and none targeted or assessed HL as an outcome measure. There was huge heterogeneity in study design, outcomes measures and effectiveness reported. Effective intervention strategies were identified that can be used to guide future interventions, including practical learning activities, peer support and approaches targeting the school environment, the parents or that link the intervention to the community.

Fulfilling food practices: Applying the capability approach to ethnographic research in the Northern Netherlands

Often, food practices are evaluated in terms of their healthiness or lack thereof, but fulfilling food practices based on other values and influenced by family members' capabilities are overlooked. This study analyses food practices in families with low socio-economic status, and aims to explain how family households come to prioritise one food practice over another. We conducted an ethnographic study using the capability approach as an analytical framework. In-depth interviews and observations concerning food patterns and health-related choices with family members from three generations were analysed. Two dimensions of fulfilling food practices which emerged from our study are having a healthy as well as harmonious meal. The families under study tended to prioritise having harmonious meals over having healthy meals, despite the attempts by mothers to serve healthy meals. This choice can be understood from the perspective of capabilities, such as being able to enjoy meals, eating what everybody else eats in the region, avoiding conflicts, creating good relationships with children and serving and organising meals with ease. Within the cultural environment, there prevailed a tendency not to care too much about nutritional outcomes, which also supported the preference for harmonious over healthy meals. In the decision about whether to have a healthy or a harmonious meal, children's agency often outweighed the voices of parents and grandparents. The capability approach helped unravel the complexity of family food practices and the role of intergenerational family dynamics in a setting of low socio-economic status. Acknowledging the multi-dimensional nature of food practices, and including dimensions beyond the food domain, such as harmony at the dinner table, contribute to a better understanding of this complexity. It also helps to shed new light on opportunity deprivation in households, for example in relation to agency, which should be accounted for in health interventions.

Effectiveness of behavioral interventions and behavior change techniques for reducing soft drink intake in disadvantaged adolescents: A systematic review and meta-analysis

Reducing sugar-sweetened beverage (SSB) intake is an important dietary target, especially among socioeconomically disadvantaged ethnic minority adolescents. This review and meta-analysis evaluated the effectiveness of behavioural interventions aiming to reduce SSB intake in socioeconomically disadvantaged ethnic minority adolescents and examined which behaviour change techniques (BCTs) were most effective. A systematic search was conducted using the PRISMA criteria. Quality assessments were done using the Cochrane criteria. In a narrative synthesis, studies were divided into effective and non-effective, and relative effectiveness ratios of individual BCTs were calculated. Pooled standardized mean differences (SMDs) and their 95% confidence intervals were estimated with random-effects models using cluster robust methods. Twenty-two studies were included in the qualitative synthesis. A meta-analysis (n = 19) revealed no significant between-group differences in reduction of SSB intake. Five self-regulatory BCTs had an effectiveness ratio >50%: feedback, goal-setting, action planning, self-monitoring and problem-solving/barrier identification. The risk of bias assessments were judged to be moderate to high risk for randomized controlled trials (RCTs) studies and low to moderate for pre-post studies. There was no indication of publication bias. In conclusion, self-regulatory BCTs may be effective components to change SSB behaviour. However, high-quality research is needed to evaluate the effectiveness of behavioural interventions and identify BCTs effective for reducing SSB intake among disadvantaged adolescents with ethnic minority backgrounds.

Which behaviour change techniques are effective to promote physical activity and reduce sedentary behaviour in adults: a factorial randomized trial of an e- and m-health intervention

BACKGROUND

E- and m-health interventions are promising to change health behaviour. Many of these interventions use a large variety of behaviour change techniques (BCTs), but it's not known which BCTs or which combination of BCTs contribute to their efficacy. Therefore, this experimental study investigated the efficacy of three BCTs (i.e. action planning, coping planning and self-monitoring) and their combinations on physical activity (PA) and sedentary behaviour (SB) against a background set of other BCTs.

METHODS

In a 2 (action planning: present vs absent) × 2 (coping planning: present vs absent) × 2 (self-monitoring: present vs absent) factorial trial, 473 adults from the general population used the self-regulation based e- and m-health intervention 'MyPlan2.0' for five weeks. All combinations of BCTs were considered, resulting in eight groups. Participants selected their preferred target behaviour, either PA (n = 335, age = 35.8, 28.1% men) or SB (n = 138, age = 37.8, 37.7% men), and were then randomly allocated to the experimental groups. Levels of PA (MVPA in minutes/week) or SB (total sedentary time in hours/day) were assessed at baseline and post-intervention using self-reported questionnaires. Linear mixed-effect models were fitted to assess the impact of the different combinations of the BCTs on PA and SB.

RESULTS

First, overall efficacy of each BCT was examined. The delivery of self-monitoring increased PA (t = 2.735, p = 0.007) and reduced SB (t = - 2.573, p = 0.012) compared with no delivery of self-monitoring. Also, the delivery of coping planning increased PA (t = 2.302, p = 0.022) compared with no delivery of coping planning. Second, we investigated to what extent adding BCTs increased efficacy. Using the combination of the three BCTs was most effective to increase PA (x² = 8849, p = 0.003) whereas the combination of action planning and self-monitoring was most effective to decrease SB (x² = 3.918, p = 0.048). To increase PA, action planning was always more effective in combination with coping planning (x² = 5.590, p = 0.014; x² = 17.722, p < 0.001; x² = 4.552, p = 0.033) compared with using action planning without coping planning. Of note, the use of action planning alone reduced PA compared with using coping planning alone (x² = 4.389, p = 0.031) and self-monitoring alone (x² = 8.858, p = 003), respectively.

CONCLUSIONS

This study provides indications that different (combinations of) BCTs may be effective to promote PA and reduce SB. More experimental research to investigate the effectiveness of BCTs is needed, which can contribute to improved design and more effective e- and m-health interventions in the future.

TRIAL REGISTRATION

This study was preregistered as a clinical trial (ID number: NCT03274271 ). Release date: 20 October 2017.

Identifying Effective Behavior Change Techniques for Alcohol and Illicit Substance Use During Pregnancy: A Systematic Review

Background

During pregnancy, consuming alcohol and using illicit drugs can have serious health implications for both mother and child. Behavioral change interventions, especially those underpinned by theoretical constructs, can be effective in reducing harmful substance use among pregnant women.

Purpose

To understand what type of behavior change mechanisms could be useful in reducing alcohol consumption or achieving abstinence from illicit drug use during pregnancy, this review aimed to identify behavior change techniques (BCTs), the smallest, active components of interventions that may be effective. It also aimed to establish the extent that psychosocial-based theories were used to inform intervention design.

Methods

To identify eligible randomized controlled trials (RCTs), five databases were searched electronically from the end search dates of the most recent Cochrane systematic reviews on behavioral interventions for each behavior, until March 2018. Within the RCTs, intervention descriptions were analyzed for BCT content and extent of theory use in the intervention design process and outcome measurements, in each trial, was established. “Effectiveness percentages,” the number of times a BCT had been a component of an effective intervention divided by the total number of interventions it had been used in, were calculated for BCTs used in two or more trials.

Results

Including all RCTs from the Cochrane reviews, and those published subsequently, nine alcohol and six illicit drug trials were identified. Interventions tested in four alcohol RCTs and no illicit drugs RCTs showed positive results. Subsequent data were extracted for alcohol consumption trials only. Thirteen BCTs showed “potential effectiveness” for alcohol consumption. Six of nine included alcohol trials reported using theory but not extensively.

Conclusions

Action planning, behavioral contract, prompts/cues, self-talk, offer/direct toward written material, problem solving, feedback on behavior, social support (unspecified), information about health consequences, behavior substitution, assess current readiness and ability to reduce excess alcohol consumption, goal setting (behavior), and tailor interactions appropriately are BCTs that could be useful in helping reduce alcohol consumption among pregnant women.

Cooking for Vitality: Pilot Study of an Innovative Culinary Nutrition Intervention for Cancer-Related Fatigue in Cancer Survivors

(1) Background: Cancer-related fatigue (CRF) is one of the most prevalent and distressing side effects experienced by patients with cancer during and after treatment, and this negatively impacts all aspects of quality of life. An increasing body of evidence supports the role of poor nutritional status in the etiology of CRF and of specific diets in mitigating CRF. We designed a group-based two session culinary nutrition intervention for CRF, Cooking for Vitality (C4V), aimed at increasing understanding of how food choices can impact energy levels and establishing basic food preparation and cooking skills as well as the application of culinary techniques that minimize the effort/energy required to prepare meals. The purpose of this pilot mixed-method study was to evaluate: Feasibility of the experimental methods and intervention; acceptability and perceived helpfulness of intervention; and to obtain a preliminary estimate of the effectiveness of the intervention on fatigue (primary outcome), energy, overall disability, and confidence to manage fatigue (secondary outcomes). (2) Methods: Prospective, single arm, embedded mixed-methods feasibility study of cancer survivors with cancer-related fatigue was conducted. Participants completed measures at baseline (T0), immediately following the intervention (T1), and three months after the last session (T2). Qualitative interviews were conducted at T2. (3) Results: Recruitment (70%) and retention (72%) rates along with qualitative findings support the feasibility of the C4V intervention for cancer survivors living with CRF (program length and frequency, ease of implementation, and program flexibility). Acceptability was also high and participants provided useful feedback for program improvements. Fatigue (FACT-F) scores significantly improved from T0–T1 and T0–T2 (p < 0.001). There was also a significant decrease in disability scores (WHO-DAS 2.0) from T0–T2 (p = 0.006) and an increase in POMS-Vigor (Profile of Mood States) from T0–T1 (p = 0.018) and T0–T2 (p = 0.013). Confidence in managing fatigue improved significantly from T0–T1 and T0–T2 (p < 0.001). (4) Conclusions: The results suggest that the C4V program was acceptable and helpful to patients and may be effective in improving fatigue levels and self-management skills. A randomized controlled trial is required to confirm these findings.

Promoting chronic disease management in persons with complex social needs: A qualitative descriptive study

While there are both ethical and practical imperatives to address health inequity issues related to chronic disease management for persons with social complexity, existing programs often do not appropriately address the needs of these individuals. This leads to low levels of participation in programs, suboptimal chronic disease management, and higher health-care utilization. The aims of this project were to describe the challenges related to availability, accessibility, and acceptability faced by socially complex patients with Chronic Obstructive Pulmonary Disease (COPD) who were eligible, but declined enrollment in a traditional Chronic Disease Management Program (CDMP). Using a qualitative descriptive study approach informed by a health equity lens, interviews with participants, managers, and a focus group with providers were used to gather data addressing the above aims. Qualitative data were analyzed using Braun and Clarke’s theoretical thematic analysis approach. The ability of participants to manage chronic disease was profoundly influenced by contextual and personal factors, such as poverty, disability, personal attitudes and beliefs (including shame, mistrust, and hopelessness), and barriers inherent in the organization of the health-care system. The existing chronic disease management program did not adequately address the most critical needs of socially complex patients. Challenges with accessibility and acceptability of chronic disease management and health services played important roles in the ways these socially complex participants managed their chronic illness. The individualistic approach to self-management of chronic illness inherent in conventional CDMP can be poorly aligned with the needs, capacity, and circumstances of many socially complex patients. Innovative models of care that promote incremental and guided approaches to enhancing health and improving self-efficacy need further development and evaluation.

What Competences Are Required to Deliver Person-Person Behaviour Change Interventions: Development of a Health Behaviour Change Competency Framework

BACKGROUND

The competence of the person delivering person-to-person behaviour change interventions may influence the effectiveness of the intervention. However, we lack a framework for describing the range of competences involved. The objective of the current work was to develop a competency framework for health behaviour change interventions.

METHOD

A preliminary framework was developed by two judges rating the relevance of items in the competency framework for cognitive behaviour therapies; adding relevant items from reviews and other competency frameworks; and obtaining feedback from potential users on a draft framework. The Health Behaviour Change Competency Framework (HBCCF) was used to analyse the competency content of smoking cessation manuals.

RESULTS

Judges identified 194 competency items as relevant, which were organised into two domains: foundation (12 competency topics comprising 56 competencies) and behaviour change (12 topics, 54 competencies); several of the 54 and 56 competencies were composed of sub-competencies (84 subcompetencies in total). Smoking cessation manuals included 14 competency topics from the foundation and behaviour change competency domains.

CONCLUSION

The HBCCF provides a structured method for assessing and reporting competency to deliver behaviour change interventions. It can be applied to assess a practitioner's competency and training needs and to identify the competencies needed for a particular intervention. To date, it has been used in self-assessments and in developing training programmes. We propose the HBCCF as a practical tool for researchers, employers, and those who design and provide training. We envisage the HBCFF maturing and adapting as evidence that identifies the essential elements required for the effective delivery of behaviour change interventions emerges.

Adapting Citizen Science to Improve Health in an Occupational Setting: Preliminary Results of a Qualitative Study

Health interventions often do not reach blue-collar workers. Citizen science engages target groups in the design and execution of health interventions, but has not yet been applied in an occupational setting. This preliminary study determines barriers and facilitators and feasible elements for citizen science to improve the health of blue-collar workers. The study was conducted in a terminal and construction company by performing semi-structured interviews and focus groups with employees, company management and experts. Interviews and focus groups were analyzed using thematic content analysis and the elements were pilot tested. Workers considered work pressure, work location and several personal factors as barriers for citizen science at the worksite, and (lack of) social support and (negative) social culture both as barriers and facilitators. Citizen science to improve health at the worksite may include three elements: (1) knowledge and skills, (2) social support and social culture, and (3) awareness about lifestyle behaviors. Strategies to implement these elements may be company specific. This study provides relevant indications on feasible elements and strategies for citizen science to improve health at the worksite. Further studies on the feasibility of citizen science in other settings, including a larger and more heterogeneous sample of blue-collar workers, are necessary.

Effectiveness of Interventions to Promote Healthy Eating Habits in Children and Adolescents at Risk of Poverty: Systematic Review and Meta-Analysis

The objective of this review was to provide an up-to-date review of trials that include behavioral intervention on the eating habits of children and adolescents at risk of poverty, applying meta-analysis to estimate the size of the intervention effect. A systematic literature search was performed in the following databases: MEDLINE via Pubmed and via EBSCOhost, LILACS and IBECS via VHL. The MeSH terms were used: "social class", "poverty", "diet", "health promotion" (PROSPERO ID: 183900). A total of 14 articles were finally included in this systematic review. The primary results of the included studies were meta-analyzed with the RevMan 5.3 program, assuming a random effects model. Analysis of the overall effect showed combined standardized mean differences (SMD) of 0.16 (CI 95%: [0.03, 0.30], I² = 76%). The p-value for the Z statistic was 0.02, which reflects accuracy in the effect estimation. When establishing subgroups based on the intervention tracking time points, studies that provided longer-term follow-up data showed a combined SMD of 0.15 (CI 95%: [-0.02, 0.32], I² = 81%]). Small effects of behavioral interventions were found to promote healthy eating habits, but better effects were shown in cases where the invention was followed up in the long term.

Combined group and home exercise programmes in community-dwelling falls-risk older adults: Systematic review and meta-analysis

OBJECTIVES

The objectives of this review were to (a) determine the effectiveness of combined group and home exercise programmes on falls risk factors and falls in community-dwelling older adults at risk of falling compared to no exercise controls; and (b) explore adherence and the behaviour change techniques employed in delivering these interventions.

METHODS

Five databases were selected to identify randomized controlled trials of exercise and/or physical activity interventions to prevent falls or to improve functional performance. PROSPERO CRD42018106111.

RESULTS

Eighteen trials involving 5,960 participants were included. Meta-analyses showed significant improvements in mobility after combined programmes measured by five times sit to stand (-1.42 times, 95% confidence interval [CI] -2.00 to -0.83), timed up and go (-0.94 s, 95% CI -1.76 to -0.12), and gait speed (0.05 m/s, 95% CI 0.02 to 0.07), but not single leg stance time, compared to controls. Combined programmes reduced injurious falls rate (0.77, 95% CI 0.65 to 0.91, I² = 0%) but not rate of falls (0.86, 95% CI 0.68 to 1.08, I² = 66%) compared to controls. There was no change in physical activity. Adherence ranged from 55-96%, with variability in the method of measurement of adherence. There was no clear relationship between adherence and outcomes. Most interventions used the behaviour change techniques of instruction/rehearsal/demonstration and feedback/monitoring.

CONCLUSION

Group exercise with a home programme resulted in better functional performance and falls-related outcomes compared with a no exercise control group. Further research is needed to identify behaviour change techniques to improve adherence to exercise in this population.

The Effectiveness of the Good Affordable Food Intervention for Adults with Low Socioeconomic Status and Small Incomes

Good Affordable Food (GAF) is a small-group nutrition education intervention for adults with low socioeconomic status and small incomes. It aims to empower participants to save money on groceries and consume healthier diets. This paper reports the short-term and longer-term effects on behavioural determinants and self-reported behavioural changes. A quasi-experimental control group design was applied with a baseline measurement, a post-test immediately after the intervention, and a follow-up measurement after six months. The study included 237 participants (intervention group: n = 131; control group: n = 106) at baseline, 197 at post-test, and 152 at follow-up. Data were collected by telephone, mostly using closed interview questions. Positive short-term and longer-term effects were found for attitude towards the costs of healthy foods, food label use, and the use of liquid butter or oil to prepare hot meals. Short-term intervention effects related to knowledge towards saving money on groceries, self-efficacy towards healthy eating, portion size awareness, and mindful eating. GAF was effective in changing some determinants and behaviours related to cost and food consumption, however, mostly in the short term. Thereby, it is an example of combining pricing and health information in nutrition education that developers of effective nutrition education for low-income groups can build on.

Development of a Living Lab for a Mobile-Based Health Program for Korean-Chinese Working Women in South Korea: Mixed Methods Study

BACKGROUND

Korean-Chinese (KC) women make up the largest group of female migrants in South Korea. To prevent and manage chronic diseases in middle-aged KC women working full time, it is necessary to develop health promotion programs that utilize an online platform because such a platform would allow individuals to participate in health promotion interventions at their convenience.

OBJECTIVE

This study aimed to develop a living lab for a mobile-based health (LLm Health) program focused on improving the physical activity and cultural adaptation of KC women workers.

METHODS

We used a mixed methods design. Living lab principles were factored into the LLm Health program, including the use of multiple methods, user engagement, multistakeholder participants, real-life settings, and cocreation. The program was developed using the 4 steps of the intervention mapping method: needs assessment, setting of objectives, identification of intervention strategies, and intervention design. Needs assessment was conducted through a literature review, focus group interviews with a total of 16 middle-aged KC women, and an online survey related to health promotion of migrant workers given to 38 stakeholders. KC middle-aged women participated in the early stages of program development and provided the idea of developing programs and mobile apps to enhance physical activity and acculturation. The mobile app developed in the program was validated with the help of 12 KC women and 4 experts, including 3 nursing professors and a professor of physical education. They were asked to rate each item based on content, interface design, and technology on a 4-point scale using a 23-item Smartphone App Evaluation Tool for Health Care.

RESULTS

The LLm Health program comprised a 24-week walking program using Fitbit devices, the mobile app, and social cognitive interventions. The mobile app contained 6 components: a step counter, an exercise timer, an online chat function, health information, level of cardiovascular risk, and health status. The cultural aspects and lifestyles of KC women were accommodated in the entire process of program development. The content validity of the mobile app was found to be 0.90 and 0.96 according to the 12 KC women and 4 experts, respectively.

CONCLUSIONS

The mobile app was found to be valid and acceptable for KC women. The living lab approach was a useful strategy for developing a culturally adaptive LLm Health program for KC women workers, leading to their active participation in the overall research process, including needs assessment, program composition, and pre-evaluation.

Validation of Health Education Material for Youth: A Step to Ensure Implementation Fidelity in Community-Based Interventions

Health education materials such as flipbooks enhance learning and deliver key messages in a captivating mode. Validation of such materials is crucial to ensuring implementation fidelity. We conducted a study to achieve two objectives: (a) to develop two flipbooks, one each for adolescents and young married women (YMW); (b) to validate the flipbooks using five parameters, namely, content validity, construct validity, concurrent validity, relevance, and face validity. The study was a part of a community-based peer-led intervention on health, nutrition, and hygiene. The content validity and relevance were assessed by interviewing outreach workers (ORWs, n = 42) using self-administered five-point Likert scale-based tools. A pre- and post-intervention assessment of knowledge among adolescents (n = 100) and YMW (n = 50) across six out of 13 intervention sites was done to evaluate the construct validity. The two flipbooks contained 12 structured sessions with five key messages per session, in addition to illustrations, discussion points, and theme-based stories at the end of each session. The content and relevancy indices were ranked above 80% by ORW. There was a statistically significant increase in the knowledge scores of adolescents (p < 0.001) and YMW (p < 0.001) post intervention. The validation process helps in assessing the relevance and appropriateness of the education content for greater acceptance and responsiveness by the users.

The effectiveness of health professional-delivered interventions during the first 1000 days to prevent overweight/obesity in children: A systematic review

Childhood obesity is a global public health challenge. Early prevention, particularly during the first 1000 days, is advocated. Health professionals have a role to play in obesity prevention efforts, in part due to the multiple routine contacts they have with parents. We synthesized the evidence for the effectiveness of obesity prevention interventions delivered by health professionals during this time period, as reviews to date have not examined effectiveness by intervention provider. We also explored what behaviour change theories and/or techniques were associated with more effective intervention outcomes. Eleven electronic databases and three trial registers were searched from inception to 04 April 2019. A total of 180 studies, describing 39 trials involving 46 intervention arms, were included. While the number of interventions has grown considerably, we found some evidence for the effectiveness of health professional-delivered interventions during the first 1000 days. Only four interventions were effective on a primary (adiposity/weight) and secondary (behavioural) outcome measure. Twenty-two were effective on a behavioural outcome only. Several methodological limitations were noted, impacting on efforts to establish the active ingredients of interventions. Future work should focus on the conduct and reporting of interventions.

Using a nominal group technique to approach consensus on a resilience intervention for smoking cessation in a lower socioeconomic population

Background

Smoking prevalence remains inequitably high for lower SES (socioeconomic status) populations. The psychosocial interactive model of resilience theorises that resilience might be ‘switched on’ in order to support and/or maintain smoking cessation for these populations. This study aimed to develop a Resilience Intervention for Smoking Cessation (RISC) through reviewing the extant literature around efficacious interventions for smoking cessation. Deliberative democracy principles were then used to understand lay perspectives regarding this potential smoking cessation program.

Methods

Public health databases were searched to find efficacious psycho-social resilience interventions in the peer-reviewed literature for smoking cessation amongst lower SES populations. Potential components for RISC were selected based on evidence within the literature for their effectiveness. We then employed the Nominal Group Technique (NGT) to create discussion and consensus on the most socially appropriate and feasible components from the perspective of smokers from low SES areas. The NGT included 16 people from a lower SES population in southern metropolitan Adelaide who indicated they were seriously contemplating quitting smoking or had recently quit. Data were collected from multiple Likert ratings and rankings of the interventions during the NGT workshop and analysed descriptively. The Wilcoxon signed-ranked test was used where appropriate. Qualitative data were collected from participant reflections and group discussion, and analysed thematically.

Results

Six smoking cessation interventions, likely to enhance resilience, were selected as potential constituents for RISC: mindfulness training; setting realistic goals; support groups; smoke free environments; mobile phone apps; and motivational interviewing. Consensus indicated that mindfulness training and setting realistic goals were the most acceptable resilience enhancing interventions, based on perceived usefulness and feasibility.

Conclusions

This research applied principles from deliberative democracy in order to illuminate lay knowledge regarding an appropriate and acceptable smoking cessation resilience program for a lower SES population. This process of collaborative and complex knowledge-generation is critically important to confront inequities as an ongoing challenge in public health, such as smoking cessation for disadvantaged groups. Further research should involve development and trial of this resilience program.

Translating the Developmental Origins of Health and Disease concept to improve the nutritional environment for our next generations: a call for a reflexive, positive, multi-level approach

Evidence supporting the Developmental Origins of Health and Disease (DOHaD) hypothesis indicates that improving early life environments can reduce non-communicable disease risks and improve health over the lifecourse. A widespread understanding of this evidence may help to reshape structures, guidelines and individual behaviors to better the developmental conditions for the next generations. Yet, few efforts have yet been made to translate the DOHaD concept beyond the research community. To understand why, and to identify priorities for DOHaD Knowledge Translation (KT) programs, we review here a portion of published descriptions of DOHaD KT efforts and critiques thereof. We focus on KT targeting people equipped to apply DOHaD knowledge to their everyday home or work lives. We identified 17 reports of direct-to-public DOHaD KT that met our inclusion criteria. Relevant KT programs have been or are being initiated in nine countries, most focusing on secondary school students or care-workers-in-training; few target parents-to-be. Early indicators suggest that such programs can empower participants. Main critiques of DOHaD KT suggest it may overburden mothers with responsibility for children's health and health environments, minimizing the roles of other people and institutions. Simultaneously, though, many mothers-to-be seek reliable guidance on prenatal health and nutrition, and would likely benefit from engagement with DOHaD KT. We thus recommend emphasizing solidarity, and bringing together people likely to one day become parents (youth), people planning pregnancies, expecting couples, care workers and policymakers into empowering conversation about DOHaD and about the importance and complexity of early life environments.

Effectiveness of Interventions and Behaviour Change Techniques for Improving Dietary Intake in Young Adults: A Systematic Review and Meta-Analysis of RCTs

Poor eating habits are common during young adulthood and influence chronic disease morbidity. This systematic review evaluates the effectiveness of interventions aiming to improve dietary intake among young adults and, identifies which behaviour change techniques (BCTs) are most effective. Six electronic databases were searched for RCTs published until October 2018, and evaluating behavioural interventions assessing change in dietary intake in young adults (17–35 years). Of the 18,779 articles identified, 54 were included. Forty studies focused on fruit and/or vegetable intake, of which 63% showed a significant between-group difference in favour of the intervention group. Meta-analysis (n = 17) demonstrated a significant increase in fruit and vegetable intake of +68.6 g/day after three months of intervention and +65.8 g/day for interventions >3 months when compared to control. A meta-analysis (n = 5) on total energy intake found no significant differences between groups. The BCTs with the highest effectiveness ratio were habit formation (100%), salience of consequences (83%) and adding objects to the environment (70%). The review highlights the potential of behavioural interventions to improve young adults’ fruit and vegetable intake but was less convincing for other dietary outcomes. Due to the lack of studies including each BCT, the BCTs imperative to success could not be identified.