Improving dietary behavior: the effectiveness of tailored messages in primary care settings

Developing Mood-Based Computer-Tailored Health Communication for Smoking Cessation: Feasibility Randomized Controlled Trial

BACKGROUND

Computer-tailored health communication (CTHC), a widely used strategy to increase the effectiveness of smoking cessation interventions, is focused on selecting the best messages for an individual. More recently, CTHC interventions have been tested using contextual information such as participants' current stress or location to adapt message selection. However, mood has not yet been used in CTCH interventions and may increase their effectiveness.

OBJECTIVE

This study aims to examine the association of mood and smoking cessation message effectiveness among adults who currently smoke cigarettes.

METHODS

In January 2022, we recruited a web-based convenience sample of adults who smoke cigarettes (N=615; mean age 41.13 y). Participants were randomized to 1 of 3 mood conditions (positive, negative, or neutral) and viewed pictures selected from the International Affective Picture System to induce an emotional state within the assigned condition. Participants then viewed smoking cessation messages with topics covering five themes: (1) financial costs or rewards, (2) health, (3) quality of life, (4) challenges of quitting, and (5) motivation or reasons to quit. Following each message, participants completed questions on 3 constructs: message receptivity, perceived relevance, and their motivation to quit. The process was repeated 30 times. We used 1-way ANOVA to estimate the association of the mood condition on these constructs, controlling for demographics, cigarettes per day, and motivation to quit measured during the pretest. We also estimated the association between mood and outcomes for each of the 5 smoking message theme categories.

RESULTS

There was an overall statistically significant effect of the mood condition on the motivation to quit outcome (P=.02) but not on the message receptivity (P=.16) and perceived relevance (P=.86) outcomes. Participants in the positive mood condition reported significantly greater motivation to quit compared with those in the negative mood condition (P=.005). Participants in the positive mood condition reported higher motivation to quit after viewing smoking cessation messages in the financial (P=.03), health (P=.01), quality of life (P=.04), and challenges of quitting (P=.03) theme categories. We also compared each mood condition and found that participants in the positive mood condition reported significantly greater motivation to quit after seeing messages in the financial (P=.01), health (P=.003), quality of life (P=.01), and challenges of quitting (P=.01) theme categories than those in the negative mood condition.

CONCLUSIONS

Our findings suggest that considering mood may be important for future CTHC interventions. Because those in the positive mood state at the time of message exposure were more likely to have greater quitting motivations, smoking cessation CTHC interventions may consider strategies to help improve participants' mood when delivering these messages. For those in neutral and negative mood states, focusing on certain message themes (health and motivation to quit) may be more effective than other message themes.

Distinct patterns of personalised dietary advice delivered by a metabotype framework similarly improve dietary quality and metabolic health parameters: secondary analysis of a randomised controlled trial

Background

In a 12-week randomised controlled trial, personalised nutrition delivered using a metabotype framework improved dietary intake, metabolic health parameters and the metabolomic profile compared to population-level dietary advice. The objective of the present work was to investigate the patterns of dietary advice delivered during the intervention and the alterations in dietary intake and metabolic and metabolomic profiles to obtain further insights into the effectiveness of the metabotype framework.

Methods

Forty-nine individuals were randomised into the intervention group and subsequently classified into metabotypes using four biomarkers (triacylglycerol, HDL-C, total cholesterol, glucose). These individuals received personalised dietary advice from decision tree algorithms containing metabotypes and individual characteristics. In a secondary analysis of the data, patterns of dietary advice were identified by clustering individuals according to the dietary messages received and clusters were compared for changes in dietary intake and metabolic health parameters. Correlations between changes in blood clinical chemistry and changes in metabolite levels were investigated.

Results

Two clusters of individuals with distinct patterns of dietary advice were identified. Cluster 1 had the highest percentage of messages delivered to increase the intake of beans and pulses and milk and dairy products. Cluster 2 had the highest percentage of messages delivered to limit the intake of foods high in added sugar, high-fat foods and alcohol. Following the intervention, both patterns improved dietary quality assessed by the Alternate Mediterranean Diet Score and the Alternative Healthy Eating Index, nutrient intakes, blood pressure, triacylglycerol and LDL-C (p ≤ 0.05). Several correlations were identified between changes in total cholesterol, LDL-C, triacylglycerol, insulin and HOMA-IR and changes in metabolites levels, including mostly lipids (sphingomyelins, lysophosphatidylcholines, glycerophosphocholines and fatty acid carnitines).

Conclusion

The findings indicate that the metabotype framework effectively personalises and delivers dietary advice to improve dietary quality and metabolic health.

Clinical trial registration

isrctn.com, identifier ISRCTN15305840.

Expectations from a Home Cooking Program: Qualitative Analyses of Perceptions from Participants in "Action" and "Contemplation" Stages of Change, before Entering a Bi-Center Randomized Controlled Trial

Home cooking is an emerging strategy to improve nutrition; however, the literature lacks reports about patient expectations from culinary interventions. Personalized medicine utilizes knowledge about a person's genes; yet, behavioral factors, such as participant "readiness" to make a change, may also impact treatment preferences and outcomes. The purpose is to explore the expectations of participants in different stages of change from a home cooking intervention. Participants were recruited to a randomized controlled trial evaluating the impact of a home cooking intervention on weight. Stage of change assessed by a validated University of Rhode Island Change Assessment scale and expectations through an open-ended questionnaire. Sixteen (21%) participants were in the action stage of change, and 59 (79%) were in the contemplation stage. Participants from both groups shared similar expectations to achieve healthy eating and lifestyle goals and to adopt sustainable change. However, action group expectations also included expanding existing culinary knowledge and change of habits; the contemplation group expectations also included acquiring culinary knowledge, improving self-regulatory skills, and obtaining guidance and support. While action group participants were looking to expand existing knowledge and techniques, contemplation group participants were focusing on acquiring culinary knowledge and skills. This can potentially contribute to developing effective, personalized nutrition interventions.

Barriers and facilitators to diet, physical activity and lifestyle behavior intervention adherence: a qualitative systematic review of the literature

BACKGROUND

Consuming a balanced diet and regular activity have health benefits. However, many adults have a difficult time adhering to diet and activity recommendations, especially in lifestyle interventions. Adherence to recommendations could be improved if common facilitators and barriers are accounted for in intervention design. The aim of this systematic review was to understand perceived barriers and facilitators to lifestyle (diet and/or activity) intervention guidelines.

METHODS

This review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Studies included relied on qualitative methods to explore the barriers and facilitators healthy adults ([Formula: see text] 18 years) experienced in lifestyle interventions. Google Scholar, Cochrane Reviews, Medline, PubMed, and Web of Science were searched from January 2005 to October 2021. Main themes from each paper were thematically analyzed and reported as a barrier or facilitator to adherence at the individual, environment or intervention level using inductively derived themes. Study quality was assessed using the Critical Appraisal Skills Programme.

RESULTS

Thirty-five papers were included. Of these, 46% were conducted in North America and the majority had more female participants (86% in mixed-sex studies, 26% females only). Similar themes emerged across all three levels as facilitators and barriers. At the individual level, attitudes, concern for health and physical changes. At the environmental level, social support, social accountability, changeable and unchangeable aspects of the community. Finally, delivery and design and content at the intervention level. An additional facilitator at the intervention level included fostering self-regulation through Behavior Change Taxonomies (BCT).

CONCLUSIONS

Lifestyle interventions that foster self-regulatory skills, opportunities for social engagement and personalization of goals may improve behaviour adherence. This can be achieved through inclusion of BCT, tapering off of intervention supports, identification of meaningful goals and anticipated barriers with participants.

Accelerating technical change through ICT: Evidence from a video-mediated extension experiment in Ethiopia

Despite enthusiasm around applications of information and communications technologies (ICTs) to smallholder agriculture in many lower-income countries, there are still many questions on the effectiveness of ICT-based approaches. This study assesses the impacts of video-mediated agricultural extension service provision on farmers' adoption of improved agricultural technologies and practices in Ethiopia using data from a two-year randomized experiment. Our results show that the video-mediated extension approach significantly increases uptake of recommended technologies and practices by improving extension access and farmer knowledge. Specifically, we find that video-mediated extension reaches a wider audience than the government's conventional extension approach and leads to higher levels of farmer understanding and uptake of the subject technologies in those locations randomly assigned to the program. While our results also point to greater extension access and greater knowledge among female spouses in locations where both male and female spouses were targeted by the program, we do not find clear evidence that a more inclusive approach translates into higher uptake of the subject technologies. Finally, we find that the video-mediated approach becomes less costly as the scale of operation increases.

Primary care patients' and providers' perspectives about an online weight management program integrated with population health management: Post-intervention qualitative results from the PROPS study

Objective

To assess patients' and providers' attitudes about the online weight management program and population health management approach in the PROPS Study, which examined the effectiveness of these strategies in primary care.

Methods

We conducted semi-structured interviews with 22 patients and nine providers. Using thematic analysis, we analyzed transcripts of the interviews to identify key themes.

Results

Most patients found the online program to be well-structured and easy to use, although a few noted that the information was overwhelming or could be more personalized. Patients mentioned that the support from the population health managers was critical for their success, and several reported that they would have liked more involvement from their primary care provider or a dietitian. Providers also were satisfied with the interventions, and several stated that the population health management support was helpful because it added accountability. Providers suggested that the interventions could be improved by tailoring the information and integrating the online program with the electronic health record.

Conclusion

Most patients and providers were satisfied with the interventions, with several recommendations for improvements.

Innovation

These findings give additional information about patients' and providers' experience with this innovative approach for managing overweight and obesity in primary care.

Understanding the impact of social learning forms on environmentally sustainable consumption behavior among school children

Purpose

The learning environment is not a vacuum, but rather is rich in social contexts with innumerable points, interests, and beliefs. This takes one of the concepts of “social learning” which is not just a natural occurring phenomenon but also a way of organizing learning and communities of learners. Social Learning (SL) tends to refer to learning that takes place when divergent interests, norms and values of reality meet in an environment that is conducive to learning. This paper helps to determine the impact of SL forms on environmentally sustainable consumption behavior among school children.

Design/methodology/approach

After conducting an experimental study among school children, data were analyzed using ANOVA. The total sample size was 760.

Findings

SL forms as an intervention influence environmentally sustainable consumption behavior (ESCB) among school children. The findings of this paper suggest that SL techniques such as visuals had been able to positively impact the constructs like knowledge, comprehension, and application. This was very much supported by observations of children, interactions with them and the upfront support provided by school and teachers.

Research limitations/implications

Based on the result, the paper identified that although SL forms influence the ESCB, there is a need to identify the most effective SL forms having impact on ESCB.

Practical implications

This study will help marketers to understand that what type of learning forms can be used to enhance the environmentally sustainable consumption behavior among children.

Originality/value

This paper is completely an original work carried out by the author.

Evolution of Therapeutic Patient Education: A Systematic Scoping Review and Scientometric Analysis

Therapeutic patient education (TPE) aims to empower the patients and their caregivers to effectively care for and manage their conditions. Such educational programs have been shown to improve health behaviors, disease outcomes, and quality of life among different patient populations. The field of TPE has evolved extensively over decades, owing to interdisciplinary research. No study so far has been done to map this field, to identify the stakeholders and gaps requiring future research. By leveraging the theory of co-citation, CiteSpace was used to visualize the bibliographic data pertaining to TPE research. A total of 54,533 articles published in English language were analyzed to identify influential funders, regions, and institutes contributing to this field. Besides these, significant theoretical and empirical contributions that shaped this field were mapped. Our analysis revealed several important insights. Most of the important theories that helped shape TPE were inspired from the social sciences. Five important research themes were identified: disorders, study designs utilized in TPE research, the scope of the TPE literature and outcomes, and populations. The research focused on improving perceptions, behaviors, and attitudes toward health promotion, reducing stigma, self-management and medication adherence. Most of the research was developed in the context of high-income countries. Future research should involve patients and use digital technology. Meta-analytical studies need to be done to identify the effectiveness and moderators of TPE interventions across different disorders. Further research should involve low and middle-income countries (LMIC) to ensure knowledge and technology transfer.

Strategies for Promotion of a Healthy Lifestyle in Clinical Settings: Pillars of Ideal Cardiovascular Health: A Science Advisory From the American Heart Association

Engagement in healthy lifestyle behaviors is suboptimal. The vast majority of the US population does not meet current recommendations. A healthy lifestyle is defined by consuming a healthy dietary pattern, engaging in regular physical activity, avoiding exposure to tobacco products, habitually attaining adequate amounts of sleep, and managing stress levels. For all these health behaviors there are well-established guidelines; however, promotion in clinical settings can be challenging. It is critical to overcome these challenges because greater promotion of heathy lifestyle practices in clinical settings effectively motivates and initiates patient behavior change. The 5A Model (assess, advise, agree, assist, and arrange) was developed to provide a framework for clinical counseling with requisite attention to the demands of clinical settings. In this science advisory, we present strategies, based on the 5A Model, that clinicians and other health care professionals can use for efficient lifestyle-related behavior change counseling in patients at all levels of cardiovascular disease risk at every visit. In addition, we discuss the underlying role of psychological health and well-being in lifestyle-related behavior change counseling, and how clinicians can leverage health technologies when providing brief patient-centered counseling. Greater attention to healthy lifestyle behaviors during routine clinician visits will contribute to promoting cardiovascular health.

Evaluating the use of a recommender system for selecting optimal messages for smoking cessation: patterns and effects of user-system engagement

Background

Motivational messaging is a frequently used digital intervention to promote positive health behavior changes, including smoking cessation. Typically, motivational messaging systems have not actively sought feedback on each message, preventing a closer examination of the user-system engagement. This study assessed the granular user-system engagement around a recommender system (a new system that actively sought user feedback on each message to improve message selection) for promoting smoking cessation and the impact of engagement on cessation outcome.

Methods

We prospectively followed a cohort of current smokers enrolled to use the recommender system for 6 months. The system sent participants motivational messages to support smoking cessation every 3 days and used machine learning to incorporate user feedback (i.e., user’s rating on the perceived influence of each message, collected on a 5-point Likert scale with 1 indicating strong disagreement and 5 indicating strong agreement on perceiving the influence on quitting smoking) to improve the selection of the following message. We assessed user-system engagement by various metrics, including user response rate (i.e., the percent of times a user rated the messages) and the perceived influence of messages. We compared retention rates across different levels of user-system engagement and assessed the association between engagement and the 7-day point prevalence abstinence (missing outcome = smoking) by using multiple logistic regression.

Results

We analyzed data from 731 participants (13% Black; 73% women). The user response rate was 0.24 (SD = 0.34) and user-perceived influence was 3.76 (SD = 0.84). The retention rate positively increased with the user response rate (trend test P < 0.001). Compared with non-response, six-month cessation increased with the levels of response rates: low response rate (odds ratio [OR] = 1.86, 95% confidence interval [CI]: 1.07–3.23), moderate response rate (OR = 2.30, 95% CI: 1.36–3.88), high response rate (OR = 2.69, 95% CI: 1.58–4.58). The association between perceived message influence and the outcome showed a similar pattern.

Conclusions

High user-system engagement was positively associated with both high retention rate and smoking cessation, suggesting that investigation of methods to increase engagement may be crucial to increase the impact of the recommender system for smoking cessation.

Trial registration

Registration Identifier: NCT03224520. Registration date: July 21, 2017.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11803-8.

[Public Health Communication Studies in Japan]

Public health communication is an essential component of public health activities to protect and promote the health of all people in all communities. However, research is scarce on how to communicate public health issues effectively to the Japanese population. In this article, I outline the concept of public health communication, present our study findings, and discuss future challenges to developing public health communication programs. More studies are required to establish evidence-based practical guidelines on public health communication in Japan.

Using Serious Games for Antismoking Health Campaigns: Experimental Study

BACKGROUND

Serious games for health have been gaining in popularity among scholars and practitioners. However, there remain a few questions to be addressed.

OBJECTIVE

This study tests the effects of a serious game and fear appeals on smoking-related outcomes. More specifically, this research aims to understand how serious games function as a more effective vehicle for a health campaign than a traditional medium, such as a print-based pamphlet. Further, while serious games utilize a variety of persuasive strategies in the game's content, it is not clear whether fear appeals, which are widely used persuasive-message strategies for health, can be an effective strategy in serious games. Thus, we are testing the effect of fear appeals in a serious game.

METHODS

We created a computer game and a print brochure to educate participants about the risks of smoking. More specifically, a flash-based single-player game was developed in which players were asked to avoid cigarettes in the gameplay context. We also developed an online brochure based on existing smoking-related brochures at a university health center; antismoking messages on the computer game and in the brochure were comparable. Then, an experiment using a 2 (media type: game vs. print) x 2 (fearful image: fear vs. no-fear) between-subjects design was conducted. The study recruitment was announced to undergraduate students enrolled in a large, public Midwestern university in the United States. After a screening test, a total of 72 smokers, who reported smoking in the past 30 days, participated in the experiment.

RESULTS

Overall, gameplay, when compared to print-based pamphlets, had greater impacts on attitudes toward smoking and the intention to quit smoking. Further, the game's persuasive effects were especially pronounced when messages contained fear appeals. When fearful images were presented, participants in the game condition reported significantly more negative attitudes toward social smoking than those in the print condition [F(1,67)=7.28; P=.009; η_p2=0.10]. However, in the no-fear condition, there was no significant difference between the conditions [F(1,67)=0.25; P=.620]. Similarly, the intention to quit smoking [F(1,67)=4.64; P=.035; η_p2=0.07] and susceptibility [F(1,67)=6.92; P=.011; η_p2=0.09] were also significantly different between the conditions, but only when fear appeals were used.

CONCLUSIONS

This study extends fear appeal research by investigating the effects of different media types. It offers empirical evidence that a serious game can be an effective vehicle for fear appeals.

The effects of public health insurance on health behaviors: Evidence from the fifth year of Medicaid expansion

This study examines the longer term relationship between public health insurance expansions and health behaviors. I leverage geographic and temporal variation in the implementation of the Affordable Care Act-facilitated Medicaid expansions and provide the first estimates of the expansions' behavioral impacts during their first 5 years. Using national survey data from the 2010 to 2018 Behavioral Risk Factors Surveillance System and a difference-in-differences regression design, I show that the Medicaid expansions increase utilization of certain forms of preventive care, while reducing heavy drinking. I also find suggestive evidence that the expansions reduce smoking and increase the probability of exercise. These results stand in contrast with earlier studies that used only 2 or 3 years of postexpansion data and found no detectable effect of the Medicaid expansions on health behaviors in the short run. My results, combined with evidence from previous studies, suggest that public insurance expansions may not prompt an immediate change in health behaviors, but newly eligible populations do increase investments in healthy behaviors over time. In the long run, Medicaid expansions may help reduce engagement in risky behaviors like drinking and smoking among low-income people.

Web-Based Tailored Messaging to Increase Vaccination: A Randomized Clinical Trial

BACKGROUND

To increase vaccine acceptance, we created a Web-based the "Vaccines and Your Baby" intervention (VAYB) that provided new parents with vaccine information messages tailored to vaccine beliefs and values. We evaluated the effectiveness of the VAYB by comparing timely uptake of infant vaccines to an untailored version of the intervention (UT) or usual care intervention (UC) only.

METHODS

Between April 2016 and June 2019, we conducted a randomized clinical trial. Pregnant women and new parents were randomly assigned to the VAYB, UT, or UC arms. In the VAYB and UT arms, participants were exposed to interventions at 4 time points from pregnancy until their child was 15 months of age. The primary outcome was up-to-date status for recommended vaccines from birth to 200 days of age. A modified intent-to-treat analysis was conducted. Data were analyzed with logistic regression to generate odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

We enrolled 824 participants (276 VAYB, 274 UT, 274 UC), 143 (17.4%) of whom were lost to follow-up. The up-to-date rates in the VAYB, UT, and UC arms were 91.44%, 92.86%, and 92.31%, respectively. Infants in the VAYB arm were not more likely to be up to date than infants in the UC arm (OR = 0.89; 95% CI, 0.45-1.76) or in the UT arm (OR = 0.82; 95% CI, 0.42-1.63). The odds of being up to date did not differ between UT and UC arms (OR = 1.08; 95% CI, 0.54-2.18).

CONCLUSIONS

Delivering Web-based vaccine messages tailored to parents' vaccine attitudes and values did not positively impact the timely uptake of infant vaccines.

Telephone-Delivered Dietary Intervention in Patients with Age-Related Macular Degeneration: 3-Month Post-Intervention Findings of a Randomised Controlled Trial

There is an evidence-practice gap between the dietary recommendations for age-related macular degeneration (AMD) presented in the literature and those practiced by patients. This study reports on the 3-month post-intervention results of a randomised controlled trial (RCT) evaluating telephone-delivered counselling to improve dietary behaviours among AMD patients. A total of 155 AMD patients (57% female, aged 78 ± 8 years; control: 78, intervention: 77), primarily residing in New South Wales, Australia, were recruited. Participants completed a baseline questionnaire and a short dietary questionnaire (SDQ-AMD). The intervention included an evidence-based nutrition resource and four monthly calls with a dietitian. Immediately post-intervention, intervention participants repeated the SDQ-AMD and completed a feedback form. At 3 months post-intervention, both study arms repeated the SDQ-AMD. Statistical analyses included t-tests and McNemar's test. Intervention participants reported satisfaction with the tailored phone calls, nutrition resource and nutrition education provided. At 3 months post-intervention, there was no statistically significant difference between study arms in the proportion of participants meeting the dietary goals nor in intake (mean servings ± SE) of total vegetables (primary outcome) and other key food groups; however, there was a significantly higher intake of nuts (secondary outcome) (3.96 ± 0.51 vs. 2.71 ± 0.32; p = 0.04) among participants in the intervention versus control group. Within the intervention arm, there were also significant improvements in intakes of the following secondary outcomes: dark green leafy vegetables (0.99 ± 0.17 vs. 1.71 ± 0.22; p = 0.003) and legumes (0.69 ± 0.10 vs. 1.12 ± 0.16; p = 0.02) and intake of sweets and processed/prepared foods (8.31 ± 0.76 vs. 6.54 ± 0.58, p = 0.01). In summary, although there were few dietary differences between study arms at 3 months post-intervention, the intervention involving four monthly calls was acceptable and helpful to the participants. This type of intervention therefore has the potential to provide people with AMD the needed support for improving their nutrition knowledge and dietary practices, especially if continued over a longer period.

Evaluation of Food-Intake Behavior in a Healthy Population: Personalized vs. One-Size-Fits-All

In public health initiatives, generic nutrition advice (GNA) from national guidelines has a limited effect on food-intake improvement. Personalized nutrition advice (PNA) may enable dietary behavior change. A monocentric, randomized, parallel, controlled clinical trial was performed in males (n = 55) and females (n = 100) aged 25 to 70 years. Participants were allocated to control, GNA or PNA groups. The PNA group consisted of automatically generated dietary advice based on personal metabolic health parameters, dietary intake, anthropometric and hemodynamic measures, gender and age. Participants who received PNA (n = 51) improved their nutritional intake status for fruits P (p < 0.0001), whole grains (p = 0.008), unsalted nuts (p < 0.0001), fish (p = 0.0003), sugar-sweetened beverages (p = 0.005), added salt (p = 0.003) and less unhealthy choices (p = 0.002), whereas no improvements were observed in the control and GNA group. PNA participants were encouraged to set a goal for one or multiple food categories. Goal-setting led to greater improvement of food categories within the PNA group including; unsalted nuts (p < 0.0001), fruits (p = 0.0001), whole grains (p = 0.005), fish (p = 0.0001), dairy (p = 0.007), vegetables (p = 0.01) and unhealthy choices (p = 0.02). In a healthy population, participants receiving PNA changed their food-intake behavior more favorably than participants receiving GNA or no advice. When personal goals were set, nutritional behavior was more prone to change.

Customers' perception of the attributes of different formats of menu labeling: a comparison between Korea and the U.S

BACKGROUND/OBJECTIVES

This study compared the perception of customers from Korea and the U.S. on the attributes of different formats of menu labeling The specific objectives were 1) to compare the customers' perceived usefulness, ease-of-understanding, clarity, and attractiveness of different formats of menu labeling between Korea and the U.S.; and 2) to compare the customers' use intention to different formats of menu labeling between Korea and the U.S.

SUBJECTS/METHODS

A survey was conducted in Korea and the U.S. The participants were allocated randomly to view 1 of the 7 restaurant menus that varied according to the following types of menu labeling formats: (type 1) kcal format, (type 2) traffic-light format, (type 3) percent daily intake (%DI) format, (type 4) kcal + traffic-light format, (type 5) kcal + %DI format, (type 6) traffic-light + %DI format, and (type 7) kcal + traffic-light + %DI format. A total of 279 Koreans and 347 Americans were entered in the analysis. An independent t-test and 1-way analysis of variance were performed.

RESULTS

Koreans rated type 4 format (kcal + traffic light) the highest for usefulness and attractiveness. In contrast, Americans rated type 7 (kcal + traffic light + %DI) the highest for usefulness, ease-of-understanding, attractiveness, and clarity. Significant differences were found in the customers' perceived attributes to menu labeling between Korea and the U.S. Americans perceived higher for all the 4 attributes of menu labeling than Koreans.

CONCLUSIONS

The study is unique in identifying the differences in the attributes of different formats of menu labeling between Korea and the U.S. Americans rated the most complicated type of menu labeling as the highest perception for the attributes, and showed a higher use intention of menu labeling than Koreans. This study contributes to academia and industry for practicing menu labeling in different countries using different formats.

Effect of a Short Message Service Intervention on Excessive Gestational Weight Gain in a Low-Income Population: A Randomized Controlled Trial

Objectives: The objective of this trial was to investigate the effect of educational short message service (SMS), or text messages, on excessive gestational weight gain (GWG) in a low-income, predominantly overweight/obese population. Methods: Participants (n = 83) were mostly overweight/obese women recruited at Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) clinics on the island of O’ahu, Hawai’i at 15–20 weeks gestational age. The intervention group received SMS on nutrition and physical activity during pregnancy designed to help them meet Institute of Medicine (IOM) guidelines for GWG and American College of Obstetricians and Gynecologists guidelines for exercise, respectively. The control group received SMS about general health topics during pregnancy, excluding nutrition and physical activity. Both groups received one text message per week for eighteen weeks. GWG was defined as the difference between the last self-reported weight taken before delivery and participants’ self-reported weight before pregnancy. Differences between study groups were examined using t-tests and Chi-square tests. Linear regression models were used to examine association of GWG with study group and other factors. Results: GWG was similar (p = 0.58) in the control group (14.1 ± 11.4 kg) and the intervention group (15.5 ± 11.6 kg). The percentage of participants exceeding IOM guidelines for GWG was similar (p = 0.51) in the control group (50.0%, n = 17) and the intervention group (60.5%, n = 23). Conclusions: GWG was not significantly different between intervention and control groups. Trials that begin earlier in pregnancy or before pregnancy with longer intervention durations and varying message frequency as well as personalized or interactive messages may be needed to produce significant improvements.

Comparison of a Collective Intelligence Tailored Messaging System on Smoking Cessation Between African American and White People Who Smoke: Quasi-Experimental Design

BACKGROUND

The Patient Experience Recommender System for Persuasive Communication Tailoring (PERSPeCT) is a machine learning recommender system with a database of messages to motivate smoking cessation. PERSPeCT uses the collective intelligence of users (ie, preferences and feedback) and demographic and smoking profiles to select motivating messages. PERSPeCT may be more beneficial for tailoring content to minority groups influenced by complex, personally relevant factors.

OBJECTIVE

The objective of this study was to describe and evaluate the use of PERSPeCT in African American people who smoke compared with white people who smoke.

METHODS

Using a quasi-experimental design, we compared African American people who smoke with a historical cohort of white people who smoke, who both received up to 30 emailed tailored messages over 65 days. People who smoke rated the daily message in terms of perceived influence on quitting smoking for 30 days. Our primary analysis compared daily message ratings between the two groups using a t test. We used a logistic model to compare 30-day cessation between the two groups and adjusted for covariates.

RESULTS

The study included 119 people who smoke (African Americans, 55/119; whites, 64/119). At baseline, African American people who smoke were significantly more likely to report allowing smoking in the home (P=.002); all other characteristics were not significantly different between groups. Daily mean ratings were higher for African American than white people who smoke on 26 of the 30 days (P<.001). Odds of quitting as measured by 30-day cessation were significantly higher for African Americans (odds ratio 2.3, 95% CI 1.04-5.53; P=.03) and did not change after adjusting for allowing smoking at home.

CONCLUSIONS

Our study highlighted the potential of using a recommender system to personalize for African American people who smoke.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02200432; https://clinicaltrials.gov/ct2/show/NCT02200432.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/jmir.6465.

Effectiveness of PUSH notifications from a mobile app for improving the body composition of overweight or obese women: a protocol of a three-armed randomized controlled trial

Background

The penetration level of mobile technology has grown exponentially and is part of our lifestyle, at all levels. The use of the smartphone has opened up a new horizon of possibilities in the treatment of health, not in vain, around 40% of existing applications are linked to the mHealth segment. Taking advantage of this circumstance to study new approaches in the treatment of obesity and prescription of physical activity is growing interest in the field of health. The primary outcome (obese adult women) will be assessed according to age, fitness status, weight, and body composition status. Data will be collected at enrollment and weekly during 6 months of intervention on dietary practices, physical activity, anthropometry, and body composition. Analysis of effect will be performed comparing the outcomes between intervention and control arms. The message delivery is in progress.

Methods

A 3-arm clinical trial was established. A series of quantitative and qualitative measures were used to evaluate the effects of self-weighing and the establishment of objectives to be reached concerning the prescription of physical activity. At the end of this pilot study, a set of appropriate measures and procedures were identified and agreed upon to determine the effectiveness of messaging in the form of PUSH technology. The results were recorded and analyzed to begin a randomized controlled trial to evaluate the effectiveness of the proposed methodology.

Conclusions

The study is anticipated to establish feasibility of using PUSH notifications to evaluate whether or not an intervention of 6 months, directed by a team formed by Dietician-Nutritionist and nursing professionals, by means of an application for Smartphone and a personal consultation, improves the body composition of adult women with a fat percentage equal to or higher than 30% at the beginning of the study.

Trial registration

Clinical Trials ID: NCT03911583. First Submitted: April 9, 2019. Ethical oversight is provided by the Bioethical Committee of Córdoba University and registered in the platform clinicaltrials.gov. The results will be published in peer-reviewed journals and analysis data will be made public.

Push Notifications From a Mobile App to Improve the Body Composition of Overweight or Obese Women: Randomized Controlled Trial

Background

Technology—in particular, access to the Internet from a mobile device—has forever changed the way we relate to others and how we behave in our daily life settings. In recent years, studies have been carried out to analyze the effectiveness of different actions via mobile phone in the field of health: telephone calls, short message service (SMS), telemedicine, and, more recently, the use of push notifications. We have continued to explore ways to increase user interaction with mobile apps, one of the pending subjects in the area of mHealth. By analyzing the data produced by subjects during a clinical trial, we were able to extract behavior patterns and, according to them, design effective protocols in weight loss programs.

Objective

A clinical trial was proposed to (1) evaluate the efficacy of push notifications in an intervention aimed at improving the body composition of adult women who are overweight or obese, through a dietary procedure, and (2) analyze the evolution of body composition based on push notifications and prescribed physical activity (PA).

Methods

A two-arm randomized controlled trial was carried out. A sample size of 117 adult obese women attended a face-to-face, 30-minute consultation once a week for 6 months. All patients were supplied with an app designed for this study and a pedometer. The control group did not have access to functionalities related to the self-monitoring of weight at home, gamification, or prescription of PA. The intervention group members were assigned objectives to achieve a degree of compliance with diet and PA through exclusive access to specific functionalities of the app and push notifications. The same diet was prescribed for all patients. Three possible PA scenarios were studied for both the control and intervention groups: light physical activity (LPA), moderate physical activity (MPA), and intense physical activity (IPA). For the analysis of three or more means, the analysis of variance (ANOVA) of repeated means was performed to evaluate the effects of the intervention at baseline and at 3 and 6 months.

Results

Receiving notifications during the intervention increased body fat loss (mean -12.9% [SD 6.7] in the intervention group vs mean -7.0% [SD 5.7] in the control group; P<.001) and helped to maintain muscle mass (mean -0.8% [SD 4.5] in the intervention group vs mean -3.2% [SD 2.8] in the control group; P<.018). These variations between groups led to a nonsignificant difference in weight loss (mean -7.9 kg [SD 3.9] in the intervention group vs mean -7.1 kg [SD 3.4] in the control group; P>.05).

Conclusions

Push notifications have proven effective in the proposed weight loss program, leading women who received them to achieve greater loss of fat mass and a maintenance or increase of muscle mass, specifically among those who followed a program of IPA. Future interventions should include a longer evaluation period; the impact of different message contents, as well as message delivery times and frequency, should also be researched.

Trial Registration

ClinicalTrials.gov NCT03911583; https://www.clinicaltrials.gov/ct2/show/NCT03911583

Ameliorating Food and Nutrition Security in Farm Households: Does Informatization Matter?

Improving food and nutrition security in Sub-Saharan Africa’s farm households has become a prominent priority subject for researchers and policymakers alike. Interestingly, it is realized through enhancement in dietary diversity and quality. To this end, better access to food and information is considered a prerequisite. Given that mobile phone coverage offers new prospects for increasing rural households’ access to information, can informatization (mobile phone used as a concrete example) possibly influence dietary diversity and quality? Cross-sectional data collected from farm households in Zambia is used to address this topic by applying the ordinary least square and endogenous switching regression (ESR). Household dietary diversity score was constructed based on a 7-days recall approach to measure consumption patterns. Our robust regression result indicates that mobile phone use positively and significantly influences dietary diversity and quality. Particularly, gender-disaggregated regression reveals that male-headed households have stronger positive associations than their counterparts. We also find that in comparison to non-adopters, adopters consume three more foods weekly. This is attributable to the income gains and increased frequency in information access on account of mobile phone adoption. Conversely, average consumption would increase by two more foods weekly if mobile phones were adopted in non-adopting households. Therefore, our study puts forwards substantial empirical evidence to warrant policy formulation directed at promoting informatization among farm households. Eventually, this could possibly recuperate dynamism in agricultural food production as food and nutrition security in farm households ameliorates.

Tailored texts: An application of regulatory fit to text messages designed to reduce high-risk drinking

This study used the regulatory focus/fit framework to compare the impact of text message wording on college students' drinking behaviors. In this 2 × 3 × 2 pre-test/post-test experiment, participants (N = 279) were randomly assigned to one of the three groups: messages matching regulatory focus (congruent group), messages mismatching regulatory focus (incongruent group), and general health messages (control group). Messages were tailored by regulatory fit (prevention-oriented or promotion-oriented). Mixed factorial analyses of covariance revealed that prevention-oriented individuals who received text messages incongruent with their regulatory focus reported drinking alcohol for more hours and were more likely to consume a higher quantity of drinks than participants in the congruent or control group. These findings suggest that health messages mismatched to a receiver's regulatory focus might exacerbate unhealthy behavior.

Primary Care Patients' and Providers' Perspectives about an Online Weight Management Program: a Qualitative Study

BACKGROUND

Primary care providers (PCPs) often take the lead role in caring for patients with overweight and obesity; however, few PCPs counsel patients about weight loss. Online weight management programs that are integrated within primary care may help address this gap in care.

OBJECTIVE

To identify perceptions of and experience with online weight management programs in general and with a proposed online program, to identify barriers to use, and to improve the design and content of our intervention, which included an online program plus population health management (PHM) support from primary care practices.

DESIGN

A mixed qualitative methods study including three patient focus groups and seven semi-structured interviews with healthcare providers.

PARTICIPANTS

A total of 13 adult patients (age range, 20-70) with body mass index (BMI) 27-35 kg/m² attended the focus groups. In-person semi-structured interviews were conducted with seven healthcare providers (three PCPs, two population health managers, one primary care nurse, and one registered dietitian).

MAIN MEASURES

We developed and used semi-structured focus groups and interview guides. The focus group and interviews were recorded and transcribed. Using grounded theory, we analyzed the transcripts to identify and extract common concepts and themes.

KEY RESULTS

Although patients and healthcare providers expressed positive opinions about online weight management programs, few patients had experience with them, and providers stated that such programs are not being widely implemented in primary care settings. Some participants highlighted the flexibility and low cost as strengths of online weight management tools compared with in-person programs. All participants had favorable opinions about our proposed intervention and were overwhelmingly positive about the combination of an online program and PHM support.

CONCLUSIONS

This study highlights the potential value of online weight management programs and PHM support in primary care.

CLINICAL TRIALS REGISTRATION

NCT02656693.

Dissemination and Effectiveness of the Peer Marketing and Messaging of a Web-Assisted Tobacco Intervention: Protocol for a Hybrid Effectiveness Trial

BACKGROUND

Smoking continues to be the leading preventable cause of death. Digital Interventions for Smoking Cessation (DISCs) are health communication programs accessible via the internet and smartphones and allow for greater reach and effectiveness of tobacco cessation programs. DISCs have led to increased 6-month cessation rates while also reaching vulnerable populations. Despite this, the impact of DISCs has been limited and new ways to increase access and effectiveness are needed.

OBJECTIVE

We are conducting a hybrid effectiveness-dissemination study. We aim to evaluate the effectiveness of a machine learning-based approach (recommender system) for computer-tailored health communication (CTHC) over a standard CTHC system based on quit rates and risk reduction. In addition, this study will assess the dissemination of providing access to a peer recruitment toolset on recruitment rate and variability of the sample.

METHODS

The Smoker-to-Smoker (S2S) study is a 6-month hybrid effectiveness dissemination trial conducted nationally among English-speaking, current smokers aged ≥18 years. All eligible participants will register for the DISC (Decide2quit) and be randomized to the recommender system CTHC or the standard CTHC, followed by allocation to a peer recruitment toolset group or control group. Primary outcomes will be 7-day point prevalence and risk reduction at the 6-month follow-up. Secondary outcomes include recruitment rate, website engagement, and patient-reported outcomes collected via the 6-month follow-up questionnaire. All primary analyses will be conducted on an intent-to-treat basis.

RESULTS

The project is funded from 2017 to 2020 by the Patient Centered Outcomes Research Institute. Enrollment was completed in early 2019, and 6-month follow-ups will be completed by late 2019. Preliminary data analysis is currently underway.

CONCLUSIONS

Conducting a hybrid study with both effectiveness and dissemination hypotheses raises some unique challenges in the study design and analysis. Our study addresses these challenges to test new innovations and increase the effectiveness and reach of DISCs.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/14814.

Use of financial incentives and text message feedback to increase healthy food purchases in a grocery store cash back program: a randomized controlled trial

Background

The HealthyFood (HF) program offers members up to 25% cash back monthly on healthy food purchases. In this randomized controlled trial, we tested the efficacy of financial incentives combined with text messages in increasing healthy food purchases among HF members.

Methods

Members receiving the lowest (10%) cash back level were randomized to one of six arms: Arm 1 (Usual Care): 10% cash back, no weekly text, standard monthly text; Arm 2: 10% cash back, generic weekly text, standard monthly text; Arm 3: 10% cash back, personalized weekly text, standard monthly text; Arm 4: 25% cash back, personalized weekly text, standard monthly text; Arm 5: 10 + 15%NET cash back, personalized weekly text, standard monthly text; and, Arm 6: 10 + 15%NET cash back, personalized weekly text, unbundled monthly text. In the 10 + 15%NET cash back, the cash back amount was the baseline 10% plus 15% of the net difference between healthy and unhealthy spending. The generic text included information on HF and healthy eating, while the personalized text had individualized feedback on purchases. The standard monthly text contained the cash back amount. The unbundled monthly text included the amount lost due to unhealthy purchases. The primary outcome was the average monthly percent healthy food spending. Secondary outcomes were the percent unhealthy food spending, and the percent healthy and unhealthy food items.

Results

Of the members contacted, 20 opted out, and 2841 met all inclusion criteria. There were no between-arm differences in the examined outcomes. The largest mean (standard deviation) difference in percent healthy spending was between Arm 1 (24.8% [11%]) and Arm 2 (26.8% [13%]), and the largest mean difference in percent unhealthy spending was also between Arm 1 (24.4% [20%]) and Arm 2 (21.7% [17%]), but no differences were statistically significant after correction for multiple comparisons.

Conclusions

None of the tested financial incentive structures or text strategies differentially affected food purchasing. Notably, more than doubling the cash back amount and introducing a financial disincentive for unhealthy purchases did not affect purchasing. These findings speak to the difficulty of changing shopping habits and to the need for innovative strategies to shift complex health behaviors.

Trial registration

NCT02486588 Increasing Engagement with a Healthy Food Benefit. The trial was prospectively registered on July 1, 2015.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-6936-5) contains supplementary material, which is available to authorized users.

Dietary intervention in patients with age-related macular degeneration: protocol for a randomised controlled trial

INTRODUCTION

Age-related macular degeneration (AMD) is a leading cause of blindness. After smoking, nutrition is the key modifiable factor in reducing AMD incidence and progression, and no other preventative treatments are currently available. At present, there is an evidence-practice gap of dietary recommendations made by eye care practitioners and those actually practised by patients with AMD. To address this gap, a telephone-delivered dietary intervention tailored to patients with AMD will be piloted. The study aims to improve dietary intake and behaviours in patients with AMD. This type of nutrition-focused healthcare is currently not considered in the long-term management of AMD and represents the first empirical evaluation of a telephone-supported application encouraging adherence to dietary recommendations for AMD.

METHODS AND ANALYSIS

140 participants with AMD will be recruited for this randomised controlled trial. Those lacking English fluency; unwilling to engage in the intervention or provide informed consent were excluded. Following the completion of the baseline questionnaire, participants will be randomised into one of two arms: intervention or wait-list control (70 each in the intervention and control groups). Intervention participants will receive a detailed mail-delivered workbook containing information on healthy eating behaviours that promote optimal macular health, as well as scheduled phone calls over 4 months from an accredited practising dietitian. Descriptive statistics and multivariate stepwise linear regressions analyses will be used to summarise and determine the changes in dietary intakes, respectively. Economic analysis will be conducted to determine intervention feasibility and possibility of a large-scale rollout.

ETHICS AND DISSEMINATION

The study was approved by the University of Sydney Human Research Ethics Committee (HREC) (Reference: HREC 2018/219). Study findings will be disseminated via presentations at national/international conferences and peer-reviewed journal articles.

TRIAL REGISTRATION NUMBER

ACTRN12618000527268; Pre-results.

Tipping the scales: Provider perspectives on a multi-disciplinary approach to obesity

IMPACT STATEMENT

Obesity is a major multi-faceted, chronic disease that increases the risk of morbidity and mortality of children and adults particularly impacting high-risk populations and those of lower socioeconomic status. Given provider time constraints, models of care to effectively and efficiently address obesity in primary care are key. Although physician recommendations can exert a powerful influence on behavior, providers often feel powerless to adequately address obesity due to the complexity of physical and behavioral health problems. This mini-review focuses on describing the feasibility and evidence for tackling obesity through provider-led multidisciplinary weight management programs.

Is it cost-effective to provide internet-based interventions to complement the current provision of smoking cessation services in the Netherlands? An analysis based on the EQUIPTMOD

BACKGROUND AND AIM

The cost-effectiveness of internet-based smoking cessation interventions is difficult to determine when they are provided as a complement to current smoking cessation services. The aim of this study was to evaluate the cost-effectiveness of such an alternate package compared with existing smoking cessation services alone (current package).

METHODS

A literature search was conducted to identify internet-based smoking cessation interventions in the Netherlands. A meta-analysis was then performed to determine the pooled effectiveness of a (web-based) computer-tailored intervention. The mean cost of implementing internet based interventions was calculated using available information, while intervention reach was sourced from an English study. We used EQUIPTMOD, a Markov-based state-transition model, to calculate the incremental cost-effectiveness ratios [expressed as cost per quality-adjusted life years (QALYs) gained] for different time horizons to assess the value of providing internet-based interventions to complement the current package.). Deterministic sensitivity analyses tested the uncertainty around intervention costs per smoker, relative risks, and the intervention reach.

RESULTS

Internet-based interventions had an estimated pooled relative risk of 1.40; average costs per smoker of €2.71; and a reach of 0.41% of all smokers. The alternate package (i.e. provision of internet-based intervention to the current package) was dominant (cost-saving) compared with the current package alone (0.14 QALY gained per 1000 smokers; reduced health-care costs of €602.91 per 1000 smokers for the life-time horizon). The alternate package remained dominant in all sensitivity analyses.

CONCLUSION

Providing internet-based smoking cessation interventions to complement the current provision of smoking cessation services could be a cost-saving policy option in the Netherlands.

Efficacy of an SMS-Based Smoking Intervention Using Message Self-Authorship: A Pilot Study

Introduction

Text-message-based interventions hold great potential for intervention and are increasingly feasible, given advances in information technology.

Aims

This pilot randomized controlled trial (RCT) aims to compare the efficacy of self-versus expert-authored content delivered via text-messaging for smoking cessation.

Methods

Sixty-two participants aged 25-66 attended laboratory sessions pre- and post-30 days of text-messaging intervention. Participants were randomised to one of two experimental conditions - self-authorship (SA) only and SA with implementation intentions (SA+ii) - or active control. Participants composed 30-60 brief motivational cessation messages for use during their cessation attempt. SA+ii participants were further instructed to anticipate obstacles and form simple if-then plans to overcome them. Experimental groups received their self-authored texts during the intervention phase, whereas control participants received expert-authored messages.

Results

Overall, smoking decreased as measured by change in exhaled carbon monoxide (CO), F(1,59) = 4.43, p = 0.04. The SA+ii group showed slightly greater CO reduction (M = 3.63, SD = 5.39) than control (M = 0.03, SD = 5.80; t(40) = 2.08, p = 0.04). SA alone (M = 1.97, SD = 9.30) was not more effective than control.

Conclusions

SA does not appear to increase efficacy. However, this pilot supports prior research, indicating that text-based interventions can increase smoking cessation success and may decrease psychological symptoms of withdrawal. Much research is needed to identify ways to bolster intervention efficacy.

Congruence of stage-of-change for fruit, vegetables and take-out foods with consumption

Purpose

Young adults frequently engage in sub-optimal dietary behaviours, such as inadequate intakes of fruits and vegetables and excessive consumption of take-out meals. Theory-based interventions are suggested to promote dietary change. The transtheoretical model is an example that stages an individual’s readiness to change behaviours as precontemplation, contemplation, preparation, action and maintenance, and includes a series of processes that help people move between stages. The purpose of this study is to investigate whether self-reported usual dietary intakes of fruits and vegetables and take-out foods differ by reported stage-of-change.

Design/methodology/approach

Cross-sectional data from 250 overweight young adults, aged 18-35 years, who enrolled in a lifestyle intervention to prevent weight gain are analysed. Participant’s stage-of-change for increasing fruit and vegetable intakes and reducing take-out foods is determined using staging algorithms. This is compared with self-reported dietary intakes over the past month using a food frequency questionnaire. Differences in intakes and variety by stage-of-change are compared for fruits, vegetables and take-out foods.

Findings

Take-out foods differed between stages (p < 0.0001), with lower weekly intakes in action (309 g) and maintenance (316 g) compared with preparation (573 g). Daily fruit intakes and variety scores varied by stage-of-change (p < 0.0001), being highest for action and maintenance (261 g and 263 g, respectively, and variety scores of 1 and 2) compared with precontemplation, contemplation and preparation (all = 100 g and 0 for variety). Daily vegetable consumption and variety scores differed by stage (p = 0.009 and p = 0.025, respectively) being highest for action/maintenance (204 g and 2 for variety) versus precontemplation and preparation (<110 g daily and Variety 1).

Practical implications

The finding of no differences in intakes between precontemplation, contemplation or preparation stages implies that the adoption of the dietary behaviours is not a continuum but a move from pre-action to actioning the target intakes. This means that for planning health promotion and dietary counselling, assigning people to the three different pre-action stages may be unnecessary.

Originality/value

This study is the first to examine the congruence of self-reported readiness to change behaviour with dietary intakes of take-out foods as well as variety of fruit and vegetables in overweight young adults.

Systematic review and meta-analysis of remotely delivered interventions using self-monitoring or tailored feedback to change dietary behavior

Background

Self-monitoring (SM) of diet and tailored feedback (TF) have been suggested as tools for changing dietary behavior. New technologies allow users to monitor behavior remotely, potentially improving reach, adherence, and outcomes.

Objective

We conducted a systematic literature review and meta-analysis to address the following question: are remotely delivered standalone (i.e., no human contact) interventions that use SM or TF effective in changing eating behaviors?

Design

Five databases were searched in October 2016 (updated in September 2017). Only randomized controlled trials published after 1990 were included. Trials could include any adult population with no history of disordered eating which delivered an SM or TF intervention without direct contact and recorded actual dietary consumption as an outcome. Three assessors independently screened the search results. Two reviewers extracted the study characteristics, intervention details, and outcomes, and assessed risk of bias using the Cochrane tool. Results were converted to standardized mean differences and incorporated into a 3-level (individuals and outcomes nested in studies) random effects meta-analysis.

Results

Twenty-six studies containing 21,262 participants were identified. The majority of the studies were judged to be unclear or at high risk of bias. The meta-analysis showed dietary improvement in the intervention group compared to the control group with a standardized mean difference of 0.17 (95% CI: 0.10, 0.24; P < 0.0001). The I2 statistic for the meta-analysis was 0.77, indicating substantial heterogeneity in results. A "one study removed" sensitivity analysis showed that no single study excessively influenced the results.

Conclusions

Standalone interventions containing self-regulatory methods have a small but significant effect on dietary behavior, and integrating these elements could be important in future interventions. However, there was substantial variation in study results that could not be explained by the characteristics we explored, and there were risk-of-bias concerns with the majority of studies.

Sex Differences in the Association of Perceived Ambiguity, Cancer Fatalism, and Health-Related Self-Efficacy with Fruit and Vegetable Consumption

Adequate fruit and vegetable (FV) consumption is promoted as a means of preventing chronic health conditions, such as cardiovascular disease and cancer. This study investigated whether perceived ambiguity about cancer prevention recommendations, fatalistic beliefs about cancer, and health-related self-efficacy were associated with FV consumption and whether sex moderated these associations. Data from the five most recent waves (spanning 2011 to 2017) of the nationally representative Health Information National Trends Survey (N = 16,965) were used. Participants reported levels of perceived ambiguity, cancer fatalism, health-related self-efficacy, and daily FV consumption. Perceived ambiguity and cancer fatalism were negatively associated with FV consumption, ps <.001, whereas health-related self-efficacy was positively associated with FV consumption, b = 0.34, p < .001. Sex moderated these associations, ps <.05. Perceived ambiguity and cancer fatalism were more strongly associated with less FV consumption for men, bs < -0.31, ps <.001, than women, bs < -0.14, ps <.01. In contrast, health-related self-efficacy was more strongly associated with more FV consumption for women, b = 0.43, p < .001, than men, b = 0.26, p < .001. These results suggest that tailoring health messaging to target sex-specific barriers may improve their effectiveness.

Pain Self-Management for Veterans: Development and Pilot Test of a Stage-Based Mobile-Optimized Intervention

BACKGROUND

Chronic pain is a significant public health burden affecting more Americans than cardiovascular disease, diabetes, and cancer combined. Veterans are disproportionately affected by chronic pain. Among previously deployed soldiers and veterans, the prevalence of chronic pain is estimated between 44% and 60%.

OBJECTIVE

The objective of this research was to develop and pilot-test Health eRide: Your Journey to Managing Pain, a mobile pain self-management program for chronic musculoskeletal pain for veterans. Based on the transtheoretical model of behavior change, the intervention is tailored to veterans' stage of change for adopting healthy strategies for pain self-management and their preferred strategies. It also addresses stress management and healthy sleep, two components of promising integrated treatments for veterans with pain and co-occurring conditions, including posttraumatic stress disorder (PTSD) and traumatic brain injury. In addition, Health eRide leverages gaming principles, text messaging (short message service, SMS), and social networking to increase engagement and retention.

METHODS

Pilot test participants were 69 veterans recruited in-person and by mail at a Veterans Health Administration facility, by community outreach, and by a Web-based survey company. Participants completed a mobile-delivered baseline assessment and Health eRide intervention session. During the next 30 days, they had access to a Personal Activity Center with additional stage-matched activities and information and had the option of receiving tailored text messages. Pre-post assessments, administered at baseline and the 30-day follow-up, included measures of pain, pain impact, use of pain self-management strategies, PTSD, and percentage in the Action or Maintenance stage for adopting pain self-management, managing stress, and practicing healthy sleep habits. Global impressions of change and program acceptability and usability were also assessed at follow-up.

RESULTS

Among the 44 veterans who completed the 30-day post assessment, there were statistically significant pre-post reductions in pain (P<.001) and pain impact (P<.001); there was some reduction in symptoms of PTSD (P=.05). There were significant pre-post increases in the percentage of participants in the Action or Maintenance stage for adopting pain self-management (P=.01) and for managing stress (P<.001) but not for practicing healthy sleep habits (P=.11). The global impressions of change measure showed that a majority had experienced some level of improvement. User ratings of acceptability were quite high; ratings of usability fell slightly below the mean for digital programs.

CONCLUSIONS

Preliminary data demonstrate the potential impact of the Health eRide program for chronic musculoskeletal pain for veterans. The results underscore that simultaneously addressing other behaviors may be a promising approach to managing pain and comorbid conditions. Additional formative research is required to complete development of the Health eRide program and to address areas of usability requiring improvement. A randomized trial with longer follow-up is needed to demonstrate the program's long-term effects on pain and pain self-management.

Critical review of behaviour change techniques applied in intervention studies to improve cooking skills and food skills among adults

BACKGROUND

Cooking and food skills interventions have grown in popularity; however, there is a lack of transparency as to how these interventions were designed, highlighting a need to identify and understand the mechanisms of behavior change so that effective components may be introduced in future work. This study critiques cooking and food skills interventions in relation to their design, behavior change techniques (BCTs), theoretical underpinnings, and outcomes.

METHODS

A 40-item CALO-RE taxonomy was used to examine the components of 59 cooking and food skills interventions identified by two systematic reviews. Studies were coded by three independent coders.

RESULTS

The three most frequently occurring BCTs identified were #1 Provide information on consequences of behavior in general; #21 Provide instruction on how to perform the behavior; and #26 Prompt Practice. Fifty-six interventions reported positive short-term outcomes. Only 14 interventions reported long-term outcomes containing BCTs relating to information provision.

CONCLUSION

This study reviewed cooking and food skills interventions highlighting the most commonly used BCTs, and those associated with long-term positive outcomes for cooking skills and diet. This study indicates the potential for using the BCT CALO-RE taxonomy to inform the design, planning, delivery and evaluation of future interventions.

Multiple Risk Factor Counseling to Promote Heart-healthy Lifestyles in the Chest Pain Observation Unit: Pilot Randomized Controlled Trial

OBJECTIVE

Admission to the chest pain observation unit (CPOU) may be an advantageous time for patients to consider heart-healthy lifestyle changes while undergoing diagnostic evaluation to rule out myocardial ischemia. The aim of this pragmatic trial was to assess the effectiveness of a multiple risk factor intervention in changing CPOU patients' health beliefs and readiness to change health behaviors. A secondary aim was to obtain preliminary estimates of the intervention's effect on diet, physical activity, and smoking.

METHODS

We conducted a pilot randomized controlled trial of a moderate-intensity counseling intervention that aimed to build motivation to change and problem-solving skills in 140 adult patients with at least one modifiable cardiovascular risk factor (CRF) who were admitted to the CPOU of an academic emergency department (ED) with symptoms of possible acute coronary syndrome. Study patients were randomly assigned to full counseling (face-to-face cardiovascular risk assessment and personalized counseling on nutrition, physical activity, and smoking cessation in the ED, plus two telephone follow-up sessions) or minimal counseling (brief instruction [<5 minutes] on benefits of modifying cardiovascular risk factors) by a cardiac rehabilitation specialist. We measured Health Belief Model constructs for ischemic heart disease, stage of change, and self-reported CRF-related behaviors (diet, exercise, and smoking) during 6-month follow-up using previously validated measures. We used linear mixed models and logistic regression (with generalized estimating equations) to compare continuous and dichotomous behavioral outcomes across treatment arms, respectively.

RESULTS

Approximately 20% more patients in the full counseling arm reported having received counseling on diet and physical activity during CPOU admission, compared to the minimal counseling arm; a similar proportion of patients in both counseling arms reported having received advice or assistance in quitting smoking. There were no significant differences between treatment arms for any cardiovascular health beliefs, readiness to change, or CRF-related behaviors during longitudinal follow-up. In secondary analyses in both treatment arms combined, however, patients showed significant differences between follow-up and baseline measurements: increases in the perceived benefits of improving CRF-related behaviors (27.7 vs. 26.6 on a scale from 7 to 35, p = 0.0001) and increased readiness to change dietary behavior and physical activity during follow-up-intake of saturated fat (83% vs. 49%), readiness to change fruit and vegetable consumption (83% vs 56%), and readiness to perform regular exercise (34% vs. 14%) at 6 months and baseline, respectively (p < 0.0001 for all comparisons in both treatment arms combined).

CONCLUSIONS

A multiple risk factor intervention that focused on increasing motivation to change and problem-solving skills did not significantly improve behavioral outcomes, compared to minimal counseling. Patients admitted to the CPOU demonstrated sustained changes in several cardiovascular health beliefs and risk-related behaviors during follow-up; this provides further evidence that the CPOU visit is a "teachable moment" for cardiovascular risk reduction. Future studies should evaluate the effectiveness of ED-initiated counseling interventions to engage patients in changing cardiovascular risk behaviors, in coordination with primary care.

Exploring the Potential for Technology-Based Nutrition Education Among WIC Recipients in Remote Alaska Native Communities

OBJECTIVE

Estimate media technology use in Alaska Native communities to inform the feasibility of technology-based nutrition education.

METHODS

A self-administered questionnaire was mailed to a random selection of about 50% of Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) authorized representatives in remote Alaska Native communities (n = 975). Media technology use, interest in media technology-based nutrition education, and potential barriers were assessed. Chi-square tests were used to investigate associations among technology use, age, and education.

RESULTS

Technology use was common among respondents (n = 368); use was significantly more common among younger age groups and participants with a higher level of education. Smartphone (78.8%) and Facebook (95.8%) use was comparable to national averages, but having a computer at home (38.4%) was much less likely. Less than 50% of participants have Internet access at home.

CONCLUSIONS AND IMPLICATIONS

Findings shed light on new opportunities for WIC and other programs to deliver nutrition education to Alaska Native people in remote communities.

Diabetes coaching for individuals with type 2 diabetes: A state-of-the-science review and rationale for a coaching model

Diabetes coaching is emerging as an important role in self-management and care. The conceptualization of coaching, and how to implement and evaluate coaching has not been articulated in the literature. The aim of the study was to review the literature to: (i) identify the components of coaching using a validated framework, including the description of the role of technology; (ii) describe the implementation and evaluation measures for diabetes coaching; and (iii) propose a diabetes coaching model for future implementation. The EMBASE, MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsychINFO and Cochrane Central Register of Controlled Trials databases were searched from inception to January 2015. Two evaluators independently screened and extracted data from eligible studies for descriptions of coaching. Eight trials met the selection criteria, with no consistency in the core components of coaching. However, elements noted across all studies included goal setting, diabetes knowledge acquisition, individualized care, and frequent follow-up. Only two studies leveraged technology for coaching communication purposes. Diabetes coaching is an intervention that can support the ongoing and complex needs of patients; however, implementation and evaluation strategies are limited in the literature. A diabetes coaching model is presented, derived from components identified throughout the literature with direction for implementation and evaluation approaches, and optimal integration into the healthcare system.

The Impact of Health Insurance on Preventive Care and Health Behaviors: Evidence from the First Two Years of the ACA Medicaid Expansions

The U.S. population receives suboptimal levels of preventive care and has a high prevalence of risky health behaviors. One goal of the Affordable Care Act (ACA) was to increase preventive care and improve health behaviors by expanding access to health insurance. This paper estimates how the ACA-facilitated state-level expansions of Medicaid in 2014 affected these outcomes. Using data from the Behavioral Risk Factor Surveillance System, and a difference-in-differences model that compares states that did and did not expand Medicaid, we examine the impact of the expansions on preventive care (e.g., dental visits, immunizations, mammograms, cancer screenings), risky health behaviors (e.g., smoking, heavy drinking, lack of exercise, obesity), and self-assessed health. We find that the expansions increased insurance coverage and access to care among the targeted population of low-income childless adults. The expansions also increased use of certain forms of preventive care, but there is no evidence that they increased ex ante moral hazard (i.e., there is no evidence that risky health behaviors increased in response to health insurance coverage). The Medicaid expansions also modestly improved self-assessed health.

Impact of a Collective Intelligence Tailored Messaging System on Smoking Cessation: The Perspect Randomized Experiment

Background

Outside health care, content tailoring is driven algorithmically using machine learning compared to the rule-based approach used in current implementations of computer-tailored health communication (CTHC) systems. A special class of machine learning systems (“recommender systems”) are used to select messages by combining the collective intelligence of their users (ie, the observed and inferred preferences of users as they interact with the system) and their user profiles. However, this approach has not been adequately tested for CTHC.

Objective

Our aim was to compare, in a randomized experiment, a standard, evidence-based, rule-based CTHC (standard CTHC) to a novel machine learning CTHC: Patient Experience Recommender System for Persuasive Communication Tailoring (PERSPeCT). We hypothesized that PERSPeCT will select messages of higher influence than our standard CTHC system. This standard CTHC was proven effective in motivating smoking cessation in a prior randomized trial of 900 smokers (OR 1.70, 95% CI 1.03-2.81).

Methods

PERSPeCT is an innovative hybrid machine learning recommender system that selects and sends motivational messages using algorithms that learn from message ratings from 846 previous participants (explicit feedback), and the prior explicit ratings of each individual participant. Current smokers (N=120) aged 18 years or older, English speaking, with Internet access were eligible to participate. These smokers were randomized to receive either PERSPeCT (intervention, n=74) or standard CTHC tailored messages (n=46). The study was conducted between October 2014 and January 2015. By randomization, we compared daily message ratings (mean of smoker ratings each day). At 30 days, we assessed the intervention’s perceived influence, 30-day cessation, and changes in readiness to quit from baseline.

Results

The proportion of days when smokers agreed/strongly agreed (daily rating ≥4) that the messages influenced them to quit was significantly higher for PERSPeCT (73%, 23/30) than standard CTHC (44%, 14/30, P=.02). Among less educated smokers (n=49), this difference was even more pronounced for days strongly agree (intervention: 77%, 23/30; comparison: 23%, 7/30, P<.001). There was no significant difference in the frequency which PERSPeCT randomized smokers agreed or strongly agreed that the intervention influenced them to quit smoking (P=.07) and use nicotine replacement therapy (P=.09). Among those who completed follow-up, 36% (20/55) of PERSPeCT smokers and 32% (11/34) of the standard CTHC group stopped smoking for one day or longer (P=.70).

Conclusions

Compared to standard CTHC with proven effectiveness, PERSPeCT outperformed in terms of influence ratings and resulted in similar cessation rates.

ClinicalTrial

Clinicaltrials.gov NCT02200432; https://clinicaltrials.gov/ct2/show/NCT02200432 (Archived by WebCite at http://www.webcitation.org/6lEJY1KEd)

Lifestyle Medicine Strategies for Risk Factor Reduction, Prevention, and Treatment of Coronary Heart Disease: Part II

Coronary heart disease remains the leading killer of men and women in the United States. Coronary heart disease also represents one of the quintessential lifestyle-related diseases. Many of the major risk factors for coronary heart disease, including elevated cholesterol, high blood pressure, cigarette smoking, an inactive lifestyle, and obesity, have very significant lifestyle-related components. In part I of this review, the authors discussed the rationale for using lifestyle medicine strategies as part of a comprehensive approach to preventing, reducing the risk, or treating coronary heart disease. In part II, the authors focus on practical strategies for incorporating lifestyle medicine techniques into clinical practice. The overall framework is based on the American College of Cardiology's Bethesda Conference, which places risk factors into 4 categories depending on the likelihood that modifying a particular risk factor will result in lowering the risk of coronary heart disease. The authors have similarly grouped lifestyle medicine strategies to explore how these interventions can be employed in each of the classes of interventions defined by the American College of Cardiology. Although the authors recognize that individual clinicians have time constraints which affect utilization of lifestyle medicine strategies, the best outcomes can be achieved by combining these interventions with more traditional modalities for reducing the risk, preventing, or treating coronary heart disease.

Diabetes Diagnosis and Weight Loss in Middle-Aged Adults

Using three waves of Health and Retirement Study data, this study investigated whether (a) self-reported physician-diagnosed diabetes prior to 1994 predicted weight loss between 1994 and 1996 in adults who were aged 51 to 61 and relatively healthy but overweight in 1992 (n = 2,642) and (b) socioeconomic status influenced that relationship. The authors found that these overweight middle-aged adults were at least 50% more likely to report that they lost at least 10 pounds of excess body weight if they had been diagnosed with diabetes than if they had not. Furthermore, the authors found that neither education nor net worth predicted weight loss in these adults. Identifying the social, psychological, and physiological mechanisms linking chronic conditions and health behaviors can inform policy makers and health care providers and enhance the development of effective interventions to prevent or reduce health risks in middle-aged and older adults.

A Randomized Clinical Trial of a Tailored Lifestyle Intervention for Obese, Sedentary, Primary Care Patients

PURPOSE

The aim of the study was to test a tailored lifestyle intervention for helping obese primary care patients achieve weight loss and increase physical activity.

METHODS

We conducted a 24-month randomized clinical trial in Rhode Island. Primary care physicians identified obese, sedentary patients motivated to lose weight and increase their moderate to vigorous physical activity. These patients were randomized to 1 of 2 experimental groups: enhanced intervention (EI) or standard intervention (SI). Both groups received 3 face-to-face weight loss meetings. The enhanced intervention group also received telephone counseling calls, individually tailored print materials, and DVDs focused on diet and physical activity. Active intervention occurred in year 1 with a tapered maintenance phase in year 2.

RESULTS

Two hundred eleven obese, sedentary patients were recruited from 24 primary care practices. Participants were 79% women and 16% minorities. They averaged 48.6 years of age, with a mean body mass index (BMI) of 37.8 kg/m(2), and 21.2 minutes/week of moderate to vigorous physical activity. Significantly more EI participants lost 5% of their baseline weight than SI participants (group by visit, P <.001). The difference was significant during active treatment at 6 months (37.2% EI vs 12.9% SI) and 12 months (47.8% vs 11.6%), but was no longer significant during the maintenance phase at 18 months (31.4% vs 26.7%,) or 24 months (33.3% vs 24.6%). The EI group reported significantly more minutes of moderate to vigorous physical activity over time than the SI group (group by visit, P = 0.04). The differences in minutes per week at 6 months was 95.7 for the EI group vs 68.3 minutes for the SI group; at 12 months, it was 126.1 vs 73.7; at 18 months, 103.7 vs 63.7, and at 24 months, 101.3 vs 75.4. Similar trends were found for absolute weight loss and the percentage reaching national guidelines for physical activity.

CONCLUSION

A home-based tailored lifestyle intervention in obese, sedentary primary care patients was effective in promoting weight loss and increasing moderate to vigorous physical activity, with the effects peaking at 12 months but waning at 24 months.

Using Community-Based Participatory Processes to Bring Health Education Technology to Communities

The purpose of this paper is to describe a community-based participatory process of developing computer tailored messages (a form of technologically advanced health education materials) within a community-based lay health adviser program. This process included: 1) identifying the desired characteristics of the health education materials, 2) prioritizing the content and format of the health education materials, and 3) developing methods for distributing these materials. An overview of the lay health adviser program is presented, followed by a description of how each step was taken, a review of the health education method chosen (computer-tailored messages), and a discussion of the challenges and benefits of using community-based participatory processes to bring appropriate technology to communities.

The News on Health Behavior: Coverage of Diet, Activity, and Tobacco in Local Newspapers

News media are an important and influential part of the social environment, calling attention to certain issues by the amount and nature of their coverage. To better understand howhealth behaviors are covered, we examined more than 80, 000 stories in 1, 354 newspaper issues from four midsize Missouri communities. Health behavior stories were rare. Of 1, 373 stories (1. 7%) that addressed diet, physical activity, or tobacco, few were prominently located in the paper, and only half had a primary prevention focus. A large majority had no local angle, local quotes, or call to action for individuals or the community, and only 10% were generated by local reporters. Because the local newspaper can be especially influential in smaller communities, strategies are needed to help reporters and editors in these settings provide more and better coverage of health behavior-related stories.

Taking the Transtheoretical Model Into the Field: A Curriculum for Lay Health Advisors

The transtheoretical model (TTM) is a commonly applied theoretical perspective for understanding mammography behaviors and improving the effectiveness of one-on-one counseling. The North Carolina Breast Cancer Screening Program (NC-BCSP) developed a training curriculum to incorporate TTM into the advising practices of lay health advisors (LHAs). The TTM helped “natural helper” LHAs understand that women in their rural North Carolina communities were likely to be in different stages for mammography screening and hence required different messages. NC-BCSP staff believed that by combining an understanding of TTM with LHAs’ natural helping abilities we potentially increased the effectiveness of LHA advising. Our limited evaluation, based on LHA feedback, suggests the curriculum is a useful training tool, even for those unfamiliar with behavior change models. Our TTM curriculum serves as an example of a health behavior theory successfully operationalized outside academia for use in the field by lay people.

The Evolution of an Innovative Heart Disease Management Program for Older Women: Integrating Quantitative and Qualitative Methods in Practice

Few studies in the literature describe how to combine quantitative and qualitative methods to enhance the development of health education interventions. This article describes the evolution and refinement of an innovative disease management program “take PRIDE” for older adults with heart disease. Over 15 years, information obtained from data collection methods including telephone interviews, focus groups, face-to-face interviews, and program process data illuminated and guided subsequent refinement of the program and led to new iterations for different participants. Qualitative and quantitative data were incorporated into the two key areas of program development (theoretical framework, objectives, format, and content) and evaluation (evaluation design, sampling, and measurement). Combining both types of data enhanced the opportunity to detect needed program changes, to increase understanding of the mechanisms by which the program effects were produced, and to enhance the relevance of the program to different groups of program participants.