A lexicon for measuring maintenance of behavior change

Associations Between Changes in 24-Hour Movement Behaviors in Children and Adolescents During the COVID-19 Pandemic: A Systematic Review and Mediation-Based Meta-Analysis

BACKGROUND

Although 24-hour movement behaviors are known to be interconnected, limited knowledge exists about whether change in one behavior during the COVID-19 pandemic (eg, increased screen time) was associated with change in another (eg, reduced physical activity or sleep). This review estimates mediational associations between changes in children's physical activity, screen time, and sleep during the COVID-19 pandemic.

METHODS

We included studies published between January 1, 2020 and June 27, 2022, in the PubMed/MEDLINE, Embase, PsycINFO, SPORTDiscus, and Web of Science databases. Summary data were extracted from included studies and analyzed with random-effects meta-regression.

RESULTS

This review included 26 studies representing 18,959 children across 18 mid-high-income countries (53% male; mean age, 11.5 [2.9] y). There was very good evidence of decreased total daily physical activity (factor change, 0.62; 90% CI, 0.47-0.81) and strong evidence of increased screen time (1.56; 90% CI, 1.38-1.77). There was very good evidence of decreased moderate to vigorous physical activity (0.75; 90% CI, 0.62-0.90) and weak evidence of increased sleep (1.02; 90% CI, 1.00-1.04). Mediational analysis revealed strong evidence that most of the reduction in total daily physical activity from before, to during, the pandemic was associated with increased screen time (0.53; 90% CI, 0.42-0.67). We observed no further mediational associations.

CONCLUSION

Increased reliance on and use of screen-based devices during the COVID-19 pandemic can be linked with reduced child and adolescent physical activity. This finding links COVID-related restrictions to potential displacement effects within child and adolescent 24-hour movement behavior.

Experiences and Strategies Influencing Older Adults to Continue Playing Walking Football

Adults aged 55+ years are most likely to be inactive, despite research suggesting that older adults experience multiple benefits when participating in physical activity and sport. Limited research focuses on long-term continuation of sport participation in this population, especially in "adapted sports" like walking football. This study explored the experiences of walking football maintenance in 55- to 75-year-old players. Semistructured interviews were conducted, with 17 older adults maintaining walking football play over 6 months. The inductive analysis revealed five higher-order themes representing maintenance influences and two higher-order themes relating to maintenance mechanisms (i.e., the conscious process by which players maintain). Influences when maintaining walking football included individual- and culture-level influences (e.g., perceived benefits of maintenance and ability acceptance). Maintenance mechanisms included cognitions and behaviors (e.g., scheduling sessions and redefining physical activity expectations). Findings highlight novel implications for policy and practice, which are important to consider when delivering walking football to older adults.

Associations between objectively-measured and self-reported neighbourhood walkability on adherence and steps during an internet-delivered pedometer intervention

BACKGROUND

Accumulating evidence suggests that the built environment is associated with physical activity. The extent to which the built environment may support adherence to physical activity interventions is unclear. The aim of this study was to investigate whether the neighbourhood built environment constrains or facilitates adherence and steps taken during a 12-week internet-delivered pedometer-based physical activity intervention (UWALK).

METHOD

The study was undertaken in Calgary (Canada) between May 2016 and August 2017. Inactive adults (n = 573) completed a telephone survey measuring sociodemographic characteristics and perceived neighbourhood walkability. Following the survey, participants were mailed a pedometer and instructions for joining UWALK. Participants were asked to report their daily pedometer steps into the online program on a weekly basis for 12 weeks (84 days). Walk Score® estimated objective neighbourhood walkability and the Neighbourhood Environment Walkability Scale-Abbreviated (NEWS-A) measured participants self-reported neighbourhood walkability. Regression models estimated covariate-adjusted associations of objective and self-reported walkability with: 1) adherence to the UWALK intervention (count of days with steps reported and count of days with 10000 steps reported), and; 2) average daily pedometer steps.

RESULTS

On average, participants undertook 8565 (SD = 3030) steps per day, reported steps on 67 (SD = 22.3) of the 84 days, and achieved ≥10000 steps on 22 (SD = 20.5) of the 84 days. Adjusting for covariates, a one-unit increase in self-reported walkability was associated on average with 45.76 (95CI 14.91, 76.61) more daily pedometer steps. Walk Score® was not significantly associated with steps. Neither objective nor self-reported walkability were significantly associated with the UWALK adherence outcomes.

CONCLUSION

The neighbourhood built environment may support pedometer-measured physical activity but may not influence adherence to pedometer interventions. Perceived walkability may be more important than objectively-measured walkability in supporting physical activity during pedometer interventions.

Participation Motives of Sport and Exercise Maintainers: Influences of Age and Gender

Promotion of physical activity has become a global priority for public health. While many people do not adhere to the recommendations, sport and exercise maintainers have found their right or fitting practice. Thus, assessing and knowing the participation motives across maintainers helps to improve our understanding of the sports and exercise practices and, thus, to recommend and to design physical activities and programmes that fit to individuals' motives. A modified version of the Bernese Motive and Goal Inventory was used in an Austria-wide cross-sectional study with 10646 sport and exercise maintainers (43% female). The study performed confirmatory factor analysis, examined measurement invariance, and compared participation motives. The results showed a good model fit and measurement invariance, indicating that the inventory can be applied independently of gender, age and years of sport/exercise experiences. Motives differed among gender, age and type of sports/exercise. Therefore, these variables should be considered in tailoring sport recommendations and interventions to promote adherence. Finally, the results are discussed by using the Self-Determination Theory indicating that sport and exercise maintainers pursue predominantly motives with intrinsic goal contents.

What Keeps Them Going, and What Gets Them Back? Older Adults’ Beliefs About Physical Activity Maintenance

Background and Objectives

The overall purpose of this article was to investigate beliefs related to physical activity maintenance among adults aged 60 years or older.

Research Design and Methods

Study 1 identified modal, salient behavioral, normative, and control beliefs using a free-response format. Study 2 was designed to gain a deeper understanding about these beliefs through in-depth semistructured interviews.

Results

Findings indicate that perceived physical and emotional benefits, scheduling and having a physical activity routine, social support, and features of indoor and outdoor locations are facilitating of maintenance. Some beliefs appear more relevant to sustained engagement in physical activity, while others may be more helpful for reengagement after 1 week of inactivity.

Discussion and Implications

This investigation raises new hypotheses for future research and provides insight for the use and adaptation of behavior change strategies that are potentially more acceptable and effective for the promotion of physical activity maintenance for older adults.

Mediators of Behavior Change Maintenance in Physical Activity Interventions for Young and Middle-Aged Adults: A Systematic Review

Background

Regular physical activity is important for maintaining physical and mental health. Benefits are optimized when physical activity is maintained. Understanding causal mechanisms is important to inform future interventions.

Purpose

To investigate mediators of physical activity maintenance.

Methods

Six databases were searched (Medline, EMBASE, PsycINFO, CINAHL, Cochrane Database of Systematic Reviews, and Web of Science). Eligibility criteria included adult nonclinical populations, validated measure of physical activity behavior at baseline and at least 6 months postbaseline, control/comparison group(s), and reported mediators of physical activity behavior change. Mediators were examined according to (i) formal mediation tests, (ii) mediator association with physical activity outcome, and (iii) intervention effects on mediators.

Results

There were few formal mediation tests conducted (n = 12/39 included studies), and various other methodological limitations were identified. There was some evidence that effective mediators in formal mediation tests at 6 months and later included the "behavioral processes of change" (n = 5/6). Many of the included interventions were not effective for changing targeted mediators (only 34% of 413 tests of mediator changes were significant).

Conclusions

There were a number of methodological and statistical limitations in the evidence base. In future, prespecified formal mediation tests should be carried out and could be aided by a formal framework. Social and environmental variables should be considered in addition to intrapersonal variables. Improving knowledge of how to change hypothesized mediators, based on theory and evidence, will reveal how physical activity behavior change maintenance can be achieved. Maintenance research would be enhanced by establishing a formal definition of behavior change "maintenance." PROSPERO registration: PROSPERO 2015:CRD- 42015025462.

Mediators of physical activity adoption and maintenance among breast cancer survivors

The purpose of this study is to explore the mediators associated with physical activity (PA) within the adoption and maintenance phase of a PA intervention trial among breast cancer survivors. Overall, 192 breast cancer survivors (average age = 55.9 years) were randomized to an Intervention or Control group. Both groups received 8 calls in the first 3-months, 3 monthly calls, and then entered a no-contact maintenance phase for the remaining 6-months. Assessments were completed at baseline, 3-months, 6-months and 12-months. On average, participants were 55.9 years of age (SD = 9.8) and 2.9 years since diagnosis (SD = 2.2). In the adoption phase, all significant univariate mediators (self-efficacy, cognitive and behavioral processes and decisional balance cons) were included in the multivariate model. Results suggest self-efficacy (ab = 13.56, SE = 7.04) and behavioral processes (ab = 36.10, SE = 12.22) were significant for PA adoption. No mediators were identified in the maintenance phase. In the adoption phase, there were significant indirect effects of group on PA adoption through self-efficacy and behavioral processes. There were no indirect effects of group on PA maintenance.

Get Healthy, Stay Healthy: Evaluation of the Maintenance of Lifestyle Changes Six Months After an Extended Contact Intervention

Background

Extended intervention contact after an initial, intensive intervention is becoming accepted as best practice in behavioral weight control interventions. Whether extended contact mitigates weight regain in the longer term or it simply delays weight regain until after the extended intervention contact ceases is not clear.

Objective

This study aimed to evaluate, in multiple ways, maintenance of weight, diet, and physical activity outcomes following Get Healthy, Stay Healthy (GHSH), a text message–delivered extended contact intervention.

Methods

Clients completing the Get Healthy Service (GHS) lifestyle telephone coaching program were randomized to receive GHSH (n=114) or standard care (no additional contact, n=114) and were assessed at baseline (following completion of GHS), 6 months (following completion of GHSH), and 12 months (noncontact maintenance follow-up). At all 3 assessments, participants self-reported their body weight, waist circumference, physical activity (walking and moderate and vigorous sessions/week), and dietary behaviors (fruit and vegetable serves/day, cups of sweetened drinks per day, takeaway meals per week; fat, fiber, and total indices from the Fat and Fiber Behavior Questionnaire). Moderate-to-vigorous physical activity (MVPA) was also assessed via accelerometry. Maintenance was examined multiple ways: (1) using traditional methods to assess and compare group averages after some period of noncontact (ie, at 12 months), (2) using a novel approach to assess and compare group average changes over the first 6 months of noncontact, and (3) exploring individual participant changes (increase/decrease/no change) over the first 6 months of noncontact.

Results

Retention over the 12-month trial was high (92.5%, 211/228). Participants had a mean (SD) age of 53.4 (SD 12.3) years and a baseline body mass index of 29.2 (SD 5.9) kg/m². The between-group differences detected at 6 months were still present and statistically significant at 12 months for bodyweight (−1.33 kg [−2.61 to −0.05]) and accelerometer-assessed MVPA (24.9 min/week [5.8-44.0]). None of the other outcomes were significantly favored compared with the control group at 12 months. Changes over their first 6 months of noncontact for the GHSH group were significantly better than the control group in terms of accelerometer-measured MVPA and self-reported moderate activity (other differences between the groups were all nonsignificant). In addition to the maintenance seen in the group averages, most intervention participants had maintained their behavioral outcomes during the first 6 months of noncontact.

Conclusions

The GHSH participants were better off relative to where they were initially, and relative to their counterparts, not receiving extended contact in terms of MVPA. However, based on the between-group difference in bodyweight over the first 6 months of noncontact, GHSH does appear to simply delay the inevitable weight regain. However, this delay in weight regain, coupled with sustained improvements in MVPA, has public health benefits.

Trial Registration

Australian New Zealand Clinical Trials Registry ACTRN12613000949785; https://www.anzctr.org. au/Trial/Registration/TrialReview.aspx?id=364821&isReview=true

Fluctuation - a common but neglected pattern of physical activity behaviour: An exploratory review of studies in recent 20 years

BACKGROUND

Regular physical activity (PA) is beneficial for physical and psychological well-being, yet many people do not achieve these health benefits due to irregular PA participation which is also known as fluctuation. Limited attention has been given to the phenomenon of fluctuation in the PA behaviour literature.

OBJECTIVE

The aim of this review was to explore and to map definitions, measurements, behavioural evidence, and factors related to PA fluctuation.

METHODS

Eligible studies were initially identified by a systematic search of articles conducted in four databases: Scopus, PubMed, PsycINFO, and SPORTDiscus between January 1996 and March 2016. Inclusion and exclusion criteria were set to check the eligibility of all articles. Additional articles were included by manual searching and expert recommendation.

RESULTS

Fifteen articles were finally included. Definitions of fluctuation are understood from two perspectives, either as a stage in the process of behaviour change, or as a particular PA phenomenon consisting of lapse and readoption. Common features were extracted: behavioural irregularity, high risk of drop-out, intention and readiness for PA, low automaticity, and limited self-regulation. Furthermore, fluctuation identification was summarised in three approaches such as stage algorithm, self-identified PA lapse and readoption, and prospective within-person variation in meeting the PA guidelines. Regarding the empirical evidence, this review found that people in PA fluctuation were significantly distinct from those in preparation and maintenance of PA behavioural performance, as well as distinct in psychosocial features.

CONCLUSIONS

Notwithstanding the limitations, this review has provided valuable insight into the phenomenon of PA fluctuation.

Effectiveness of physical activity interventions in achieving behaviour change maintenance in young and middle aged adults: A systematic review and meta-analysis

BACKGROUND

Physical activity (PA) interventions are generally effective in supporting short-term behaviour change, but increases are not always maintained. This review examined the effectiveness of PA interventions for behaviour change maintenance in young and middle-aged adults, and investigated which Behaviour Change Techniques (BCTs) and other intervention features were associated with maintenance.

METHODS

Six databases (Medline, EMBASE, PsycINFO, Cochrane Database of Systematic Reviews, CINAHL, Web of Science) were systematically searched. Eligibility criteria were controlled trials investigating the effectiveness of PA interventions with adult (mean age 18-64 years) non-clinical populations using validated measures of PA behaviour at baseline and ≥six months' post-baseline. Results were pooled in meta-analyses using standardised mean differences (SMD) at five time intervals (6-9, 9-15, 15-21, 21-24, >24 months). Moderator analyses investigated the influence of sample and intervention characteristics on PA maintenance at 6-9 months.

RESULTS

Sixty-two studies were included. PA interventions had a significant effect on behaviour maintenance 6-15 months post-baseline relative to controls. Interventions had a larger effect on maintenance at 6-9 months (SMD = 0.28; 95% CI: 0.20, 0.35; I² = 73%) compared to 9-15 months (SMD = 0.20; 95% CI: 0.13, 0.26; I² = 70%). Beyond 15 months, PA measurements were infrequent with little evidence supporting maintenance. Moderator analyses showed some BCTs and intervention settings moderated PA outcomes at 6-9 months. A multivariable meta-regression model showed interventions using the BCTs 'Prompt self-monitoring of behavioural outcome' (b = 1.46, p < 0.01) and 'Use of follow-up prompts' (b = 0.38, p < 0.01) demonstrated greater effectiveness at promoting PA maintenance at 6-9 months. Interventions implemented in primary care (versus community or workplace/university) settings (b = -0.13, p = 0.10) tended to demonstrate less effectiveness.

CONCLUSIONS

This review provides evidence of some effective BCTs for maintaining behaviour to 15 months. Greater consideration must be given to how future interventions encourage and measure maintenance of changes, and investigate broader psychological, social and environmental influences of PA behaviour.

PROSPERO REGISTRATION

PROSPERO 2015:CRD42015025462.

Maintenance of physical activity: Do we know what we are talking about?

Objective

Physical activity has to be performed regularly in order to achieve long-term health benefits. Studying the maintenance of physical activity and comparing study results requires a shared descriptive definition and a derived operationalization. Both are still lacking. The goal of this article is to briefly summarize how "maintenance of physical activity" is used in the scientific literature. Further, a descriptive definition and its operational application are introduced.

Method

A rapid literature search was completed in order to summarize the different concepts and usages of the term “maintenance of physical activity.”

Results

"Maintenance of physical activity" is used and defined in different ways. All of them have strengths and weaknesses. An approach that respects the volatility of physical activity is lacking. That’s why the lapse–recovery relationship is introduced.

Conclusion

People’s physical activity volume is often volatile, which is crucial for defining and assessing "maintenance of physical activity". The lapse–recovery relationship is an individual-centered approach respecting this volatility. It refers to an intentionally changed behavior and uses lapses and recoveries as indicators to operationalize the maintenance of physical activity.

A systematic review of the literature on self-management interventions and discussion of their potential relevance for people living with HIV in sub-Saharan Africa

OBJECTIVE

This study systematically reviews the literature on self-management interventions provided by health care teams, community partners, patients and families and discusses the potential relevance of these interventions for people living with HIV in sub-Saharan Africa.

METHODS

We searched major databases for literature published between 1995 and 2012. 52 studies were included in this review.

RESULTS

The review found very few studies covering people living with HIV and generally inconclusive evidence to inform the development of chronic care policy and practice in sub-Saharan Africa.

CONCLUSION

Chronic care models and self-management interventions for sub-Saharan Africa has not been a research priority. Furthermore, the results question the applicability of these models and interventions in sub-Saharan Africa. There is a need for studies to fill this gap in view of the rapidly increasing number of people needing chronic care services in Africa.

PRACTICE IMPLICATIONS

The established practices for long-term support for HIV patients are still the most valid basis for promoting self-management. This will be the case until there are more studies which assess those practices and their effect on self-management outcomes and other studies which assess the utility and feasibility of applying chronic care models that have been developed in high-income countries.

Programmatic influences on outcomes of an evidence-based fall prevention program for older adults: a translational assessment

Investigating the implementation and dissemination of evidence-based health-promotion programs to reach large numbers of diverse older adults is needed. The purpose of this study is to examine relationships between class size and session attendance and assess differences in intervention outcomes based on these community-based fall prevention program characteristics. Pre-post data were analyzed from 2,056 falls prevention program participants. PROC MIXED for repeated measures and ordinary least squares regressions were employed. Approximately 32% of participants enrolled in recommended class sizes (eight to 12 participants) and 76.4% of enrolled seniors attended more than five of eight sessions. Enrolling in smaller class sizes was associated with higher class attendance (X (2) = 43.43, p < 0.001). Recommended class sizes and those with 13-20 participants reported significant improvements in falls efficacy and physical activity. Perfect attendance was associated with improvements in falls efficacy (t = 2.52, p < 0.05) and activity limitation (t = -2.66, p < 0.01). Findings can inform fall prevention program developers and lay leader deliverers about ideal class sizes relative to maximum intervention benefits and cost efficiency.

Personal and delivery site characteristics associated with intervention dosage in an evidence-based fall risk reduction program for older adults

The objective of this study is to identify sociodemographics of older adults enrolled in a nationally disseminated evidence-based fall risk reduction program, describe different delivery sites, and examine personal and site characteristics associated with intervention adherence. Data were analyzed from 6,922 older adults enrolled in A Matter of Balance/Volunteer Lay Leader (AMOB/VLL) model between 2006 and 2009. Intervention dosage was measured by workshop attendance. Logistic regression analyses examined factors associated with attendance levels. Intervention dosage differed by sociodemographic and delivery site characteristics. Patterns of intervention dose significantly differed between Hispanic and non-Hispanic White participants. Those with less education and living in rural areas were more likely to receive adequate program doses. Although senior services agencies offered the most programs, intervention adherence was more likely in nonaging service sites. Findings may help program administrators better understand and minimize attrition issues within their AMOB/VLL workshops.

Physical activity and/or dietary interventions in breast cancer survivors: a systematic review of the maintenance of outcomes

PURPOSE

Maintaining physical activity and dietary improvements achieved during an intervention is important for the long-term health outcomes of breast cancer survivors. This review aimed to determine: (a) the proportion of physical activity and/or dietary intervention trials in breast cancer survivors that assessed post-intervention maintenance of outcomes, (b) the proportion of trials that achieved successful post-intervention maintenance of outcomes, and (c) the sample, intervention, and methodological characteristics common among trials that achieved successful post-intervention maintenance of outcomes.

METHODS

A structured search of PubMed, CINAHL, Medline via Ovid, Web of Science, CENTRAL, and PsycInfo was conducted for articles published until March 2012. Included trials had to evaluate a randomized controlled trial of a physical activity and/or dietary behavior change intervention that targeted breast cancer survivors and report on between-group differences of behavioral outcomes at end-of-intervention and at least 3 months post-intervention follow-up. Methodological quality of included trials was also assessed.

RESULTS

The search resulted in 1,298 publications. Of 63 identified trials that assessed end-of-intervention outcomes, 10 (16 %) assessed post-intervention maintenance of outcomes; four of these 10 trials achieved successful maintenance. Due to the limited number and heterogeneity of the four trials, few commonalities in sample, intervention, and methodological characteristics were identified.

CONCLUSION

Assessing post-intervention maintenance of physical activity and dietary outcomes in breast cancer survivors is rare. There is a pressing need to direct more attention to this issue to inform the development of interventions to improve the long-term health outcomes for the growing number of breast cancer survivors.

IMPLICATIONS FOR CANCER SURVIVORS

For breast cancer survivors, maintaining regular physical activity and a healthy diet are important to enhancing health and well-being over the long-term. More research is needed to identify the best ways of supporting survivors to make and maintain these lifestyle changes.

Falls efficacy among older adults enrolled in an evidence-based program to reduce fall-related risk: sustainability of individual benefits over time

Grand-scale community rollouts of evidence-based programs seldom have the capacity to examine long-term sustainability of beneficial effects among older adults. This study examined the effectiveness of A Matter of Balance/Volunteer Lay Leader Model, an evidence-based fall risk reduction program, to sustain fall-related efficacy improvements among 282 older adult participants using data collected at 3 time points: baseline, postintervention, and 6-month follow-up. A linear mixed model and multilevel logistic regression models were used. Falls Efficacy Scale and individual item scores significantly increased from baseline to postintervention. While most efficacy-related scores tapered after postintervention, all changes remained significant at 6-month follow-up.

Outcomes of online support and resources for cancer survivors: a systematic literature review

OBJECTIVE

This study aims to review systematically the available literature on health outcomes of online cancer support and resources.

METHODS

We searched major databases with the following selection criteria: (1) empirical study on use of online support or resources by cancer survivors, (2) reporting effects or outcomes of online support or resources, (3) focusing on adult cancer survivors, and (4) peer-reviewed articles published by 2010.

RESULTS

A total of 24 studies (37 articles) were included in the review. Most studies were focused on breast cancer survivors and had small sample sizes. Fifteen studies employed a cross-sectional design including eight qualitative studies. Only five studies used pre-post design, and four employed RCT design. The outcome measures have focused on psychosocial effects; most studies reported positive effects, although none of the RCT studies reported significant outcomes.

CONCLUSION

Existing studies of online cancer support and resources have demonstrated preliminary but inconclusive evidence for positive outcomes. We call for additional studies with rigorous study designs and the inclusion of more diverse participants and cancer conditions.

PRACTICE IMPLICATIONS

Connecting diverse cancer survivors to culturally appropriate, evidence-based online support and resources is a strategy to enhance health outcomes.

The science of sustaining health behavior change: the health maintenance consortium

OBJECTIVE

To enhance understanding of the long-term maintenance of behavior change, as well as effective strategies for achieving sustainable health promotion and disease prevention through the Health Maintenance Consortium (HMC).

METHODS

This introductory research synthesis prepared by the resource center gives context to this theme issue by providing an overview of the HMC and the articles in this journal.

RESULTS

It explores the contributions to our conceptualization of behavior change processes and intervention strategies, the trajectory of effectiveness of behavioral and social interventions, and factors influencing the long-term maintenance of behavioral and social interventions.

CONCLUSIONS

Future directions for furthering the science of maintaining behavior change and reducing the gaps between research and practice are recommended.