Using Implementation Intentions to Prevent Relapse after Psychological Treatment for Depression - the SMArT Intervention.

BACKGROUND: It is recognized that a significant proportion of people with depression are prone to relapse, even after successful treatment, and that self-management interventions should be developed and provided. There is evidence that implementation intentions (IMPS) can be successfully applied to health-related behaviours but their application to self-management of mental health problems has been limited. AIMS: This paper describes the design and initial evaluation of a Self-Management After Therapy (SMArT) intervention, which incorporated IMPS and followed psychological therapy for depression. We sought to assess the feasibility and acceptability of SMArT. METHOD: The SMArT intervention was designed with reference to the MRC guidance on developing and evaluating complex interventions and co-designed with and implemented in a UK Improving Access to Psychological Therapies (IAPT) service. Eleven patients who were in remission following treatment for depression received the SMArT intervention, provided by Psychological Wellbeing Practitioners (PWPs). The evaluation used routine IAPT outcome measures at each session, feedback from patients and PWPs, and analysis of the type of IMPS identified and their fidelity with the model. Six patients provided brief feedback about the intervention to an independent researcher. RESULTS: Feedback from patients and PWPs suggested that the intervention was feasible, acceptable and could potentially help patients to stay well after therapy. Patients confirmed the value of setting their own goals in the form of IMPS, receiving support from PWPs and in some cases from partners, friends and family members. CONCLUSIONS: Implementation intentions are a promising approach to support the self-management of depression.

Exploration of likely engagement with Monetary Contingency Contracts for weight loss: a questionnaire study.

Monetary Contingency Contracts (MCCs) are schemes that ask individuals to pledge money that is returned contingent on behaviour change. In relation to weight loss, this study explored likely levels of engagement with MCCs, how much individuals would be willing to pay into an MCC, and how these amounts vary under different contract conditions. Fifty-six individuals with BMI above 25 who were motivated to lose weight were recruited. The majority of participants (87.5%) indicated that they would be willing to engage with weight loss MCCs, but showed more reluctance to subscribe to pair-based MCCs which offered; (a) refunds contingent on the weight loss of a weight loss partner, and (b) 'all or nothing refunds' in which no reward is given for any weight loss below the target weight loss goal. This study provides preliminary evidence that individuals motivated to lose weight may be willing to engage with weight loss MCCs. Further research is needed to explore reasons for reluctance to subscribe to MCCs with certain conditions, to inform the design of future experimental studies testing the efficacy of MCCs as part of an intervention for weight loss.

A test of the Morality-Agency-Communion (MAC) model of respect and liking across positive and negative traits.

The Morality-Agency-Communion (MAC) model of respect and liking suggests that traits linked with morality are important for respect and liking; traits related to competence or assertiveness are important for respect and traits related to warmth are important for liking. However, tests of this model have tended not to consider traits related to immorality, incompetence, lack of assertiveness or coldness. This study addressed this issue by utilizing a within-subjects design in which participants were required to rate their respect and liking for individuals with specific trait types across four categories (moral; competence; assertiveness; and warmth) at three levels (positive, negative and neutral). The central tenets of the MAC model were supported for 'positive' traits (morality, competence, assertiveness and warmth). However, for 'negative' traits (immorality, incompetence and lack of assertiveness), individuals were similarly not liked and not respected. Individuals who were cold were respected more than liked. The findings of this study extend the MAC model by indicating that the amount that individuals are respected versus liked depends not only on trait type but also whether a trait is positive or negative.

The role of perseverative cognition in the job strain-health outcome relationship.

OBJECTIVE: Job strain has been implicated in a variety of adverse health outcomes, particularly cardiometabolic and inflammatory diseases. However, the mechanisms underlying these effects remain largely unknown. One possibility is that the maladaptive coping response to stress, (perseverative cognition (PC); the cognitive representation of past stressful events (rumination) or feared future events (worry)), either in work or more generally, mediates the relationship between job strain and physical disease. The aim of this study was thus to test the potential role of both general, and work- related PC as a mediating, or potentially moderating, mechanism between job strain and ill- health outcomes.Design & Measures:Using an online cross- sectional design, 650 full- time employees completed measures of job strain, general and work- related PC (rumination & worry) and health outcomes (burnout, somatization, health behaviours & sleep quality). RESULTS: General and work- related worry and rumination significantly mediated, often independently, the relationship between job strain and burnout, somatization, and sleep quality. No significant mediation effects were observed for health behaviours and no type of PC (general or work- related) moderated job strain- health outcome relations. CONCLUSION: Both general and work- related worry and rumination are likely to play important, and partly independent, roles in understanding the adverse relationships between job strain and various health outcomes.

Do implicit measures of attitudes incrementally predict snacking behaviour over explicit affect-related measures?

Various studies have demonstrated an association between implicit measures of attitudes and dietary-related behaviours. However, no study has tested whether implicit measures of attitudes predict dietary behaviour after controlling for explicit measures of palatability. In a prospective design, two studies assessed the validity of measures of implicit attitude (Implicit Association Test, IAT) and explicit measures of palatability and health-related attitudes on self-reported (Studies 1 and 2) and objective food (fruit vs. chocolate) choice (Study 2). Following regression analyses, in both studies, implicit measures of attitudes were correlated with food choice but failed to significantly predict food choice when controlling specifically for explicit measures of palatability. These consistent relationships emerged despite using different category labels within the IAT in the two studies. The current research suggests implicit measures of attitudes may not predict dietary behaviours after taking into account the palatability of food. This is important in order to establish determinants that explain unique variance in dietary behaviours and to inform dietary change interventions.

Perseverative cognition and health behaviours: exploring the role of intentions and perceived behavioural control.

OBJECTIVE: Worry and rumination (Perseverative Cognition, PC) have been associated with health behaviours, but the underlying mechanisms are unknown. Given the role of physiological experiences on perceived behavioural control (PBC) and emotion regulation on intention-health behaviour relationships, we tested whether: PC prospectively predicts poorer health behaviours; PC moderates the relationship(s) between intentions/PBC and health behaviour, as well as whether the relationship between PC and health behaviour is mediated by intentions and PBC. METHODS AND MEASURES: In a prospective design, 650 participants (mean age = 38.21 years; 49% female) completed baseline measures of intentions, PBC and PC (worry and rumination) and 590 (mean age = 38.68 years; 50% female) completed follow-up (Time 2) measures of health behaviours (physical activity, sleep, sedentary activity, unhealthy snacking) 1-week later. RESULTS: Worry and rumination (at T1) predicted poorer sleep quality. Worry, but not rumination, moderated PBC-physical activity frequency relations. Consistent with mediation, the indirect paths from both worry and rumination, through PBC, to sleep quality and total sleep time were significant. CONCLUSION: PC is associated with poorer sleep quality and PBC can play a mediating role in such relationships. Future research should further consider the role that PBC plays in PC-health behaviour relations.

Cross-sectional and prospective associations between stress, perseverative cognition and health behaviours.

OBJECTIVES: The Perseverative Cognition Hypothesis (proposing negative repetitive thinking has detrimental effects on physical health), has been extended to include health behaviours. This study aimed to examine relationships between perseverative cognition, stress and health behaviours. DESIGN: Participants (n = 336) completed online surveys twice, 3 months apart. MAIN OUTCOME MEASURES: Cross-sectional and prospective associations between perseverative cognition (worry, brooding and reflection), stress and health behaviours (sleep, diet, physical activity and alcohol). RESULTS: Analyses demonstrated associations between worry, brooding and reflection and health behaviours, cross-sectionally and prospectively, including sleep and unhealthy snacking. Adding perseverative cognition variables to models simultaneously, only two associations remained (brooding and unhealthy snacking, worry and poorer sleep quality). Controlling for stress, only the cross-sectional association between brooding and more unhealthy snacking remained significant and no significant interactions with stress were found. CONCLUSION: This study evidences associations between components of perseverative cognition and health behaviours cross-sectionally and prospectively.

Goal prioritization and behavior change: Evaluation of an intervention for multiple health behaviors.

OBJECTIVES: Goal prioritization is a promising strategy for promoting health behavior change. The present research (a) tested whether goal prioritization engenders change in multiple health behaviors, (b) compared the effectiveness of prioritizing one versus two health behavior goals, and (c) assessed whether prioritization compromises the performance of nonprioritized behaviors. METHOD: Participants (N = 1,802) were randomly allocated to one of two intervention conditions (prioritize one vs. two behaviors) or two no-prioritization, control conditions. Participants in the intervention conditions self-selected the behavior(s) to prioritize from a given set. Goal priority and behavioral performance were assessed 8 weeks later. RESULTS: The prioritization interventions were successful in promoting goal priority and led to significantly greater behavior change compared to both control conditions. Prioritizing two health behavior goals led to increased behavioral performance compared to prioritizing a single goal. Goal prioritization did not lead to a decline in rates of performance of nonprioritized behaviors. CONCLUSIONS: The present findings offer new evidence that goal prioritization is effective in promoting health behavior change. Prioritizing health goals engenders behavior change for both one and two focal behaviors and does so without adversely affecting the performance of nonprioritized health behaviors. Further tests of interventions to promote the priority of health goals are warranted. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Health effects of psychological interventions for worry and rumination: A meta-analysis.

OBJECTIVE: Evidence suggests that perseverative cognition (PC), the cognitive representation of past stressful events (rumination) or feared future events (worry), mediates the relationship between stress and physical disease. However, the experimental evidence testing methods to influence PC and the subsequent relationship with health outcomes has not been synthesized. Therefore, the current review addressed these gaps. METHOD: Studies randomly assigning participants to treatment and control groups, measuring PC and a physical and/or behavioral health outcome after exposure to a nonpharmacological intervention, were included in a systematic review. Key terms were searched in Medline, PsycINFO and CINAHL databases. Of the screened studies (k = 10,703), 36 met the eligibility criteria. RESULTS: Random-effects meta-analyses revealed the interventions, relative to comparison groups, on average produced medium-sized effects on rumination (g = -.58), small-to-medium sized effects on worry (g = -.41) and health behaviors (g = .31), and small-sized effects on physical health outcomes (g = .23). Effect sizes for PC were negatively associated with effect sizes for health behaviors. (following outlier removal). Effect sizes for PC were significantly larger when interventions were delivered by health care professionals than when delivered via all other methods. No specific intervention type (when directly compared against other types) was associated with larger effect sizes for PC. CONCLUSIONS: Psychological interventions can influence PC. Medium-sized (negative) effect sizes for PC correspond with small (but positive) health behavior effect sizes. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Do socio-structural factors moderate the effects of health cognitions on COVID-19 protection behaviours?

OBJECTIVE: Adherence to protection behaviours remains key to curbing the spread of the SARS-CoV-2 virus that causes COVID-19, but there are substantial differences in individual adherence to recommendations according to socio-structural factors. To better understand such differences, the current research examines whether relationships between health cognitions based on the Reasoned Action Approach (RAA) and eight COVID-19 protection behaviours vary as a function of participant-level socio-structural factors. METHODS: Within-person design with behaviours nested within participants in a two-wave online survey (one week delay) conducted during the UK national lockdown in April 2020. A UK representative sample of 477 adults completed baseline measures from the RAA plus perceived susceptibility and past behaviour for eight protection behaviours, and self-reported behaviour one week later. Moderated hierarchical linear models with cross-level interactions were used to test moderation of health cognitions by socio-structural factors (sex, age, ethnicity, deprivation). RESULTS: Sex, ethnicity and deprivation moderated the effects of health cognitions on protection intentions and behaviour. For example, the effects of injunctive norms on intentions were stronger in men compared to women. Importantly, intention was a weaker predictor of behaviour in more compared to less deprived groups. In addition, there was evidence that perceived autonomy was a stronger predictor of behaviour in more deprived groups. CONCLUSION: Socio-structural variables affect how health cognitions relate to recommended COVID-19 protection behaviours. As a result, behavioural interventions based on social-cognitive theories might be less effective in participants from disadvantaged backgrounds.

Postnatal Exercise Partners Study (PEEPS): a pilot randomized trial of a dyadic physical activity intervention for postpartum mothers and a significant other.

Background: Research suggests dyadic interventions can increase physical activity; such interventions are untested within postpartum parent couples. Methods: A three-armed pilot randomized trial addressed this gap and tested which type of dyadic intervention is most effective. Inactive postpartum mothers and a significant other were recruited in Australia (n = 143 assessed for eligibility) and randomised in a single-blinded fashion (i.e. participants were blinded) to 1 of 3 dyadic conditions involving a single face-to-face session with access to web-based group support: a minimal treatment control (n = 34), collaborative planning group (n = 38), or collaborative planning + need supportive communication group (n = 30). Participants were asked to wear their accelerometers for 8 days and completed self-report measures at baseline, end of intervention (week 4), and follow-up (week 12). We expected dyads in the collaborative planning + need supportive communication group would have the greatest increases in Physical Activity (PA), autonomous motivation, and partners' need supportive behaviours; and decreases in controlled motivation and controlling partner behaviours. Results: Results from 51 dyads using Bayesian actor-partner interdependence models provided some evidence for a small positive effect on total PA at follow-up for postpartum mothers in the collaborative planning group and for partners in the collaborative planning + need supportive communication group. Furthermore, partners in the collaborative planning + need supportive communication group were more likely to engage in some vigorous PA. At follow-up, postpartum mothers in the collaborative planning + need supportive communication group scored lower on personal autonomous reasons. Conclusions: The impact of prior specification mean intervention effects need to be interpreted with caution. Progression to a full trial is warranted.

Investigating which behaviour change techniques work for whom in which contexts delivered by what means: Proposal for an international collaboratory of Centres for Understanding Behaviour Change (CUBiC).

PURPOSE: Behaviour change techniques are fundamental to the development of any behaviour change intervention, but surprisingly little is known about their properties. Key questions include when, why, how, in which contexts, for which behaviours, in what combinations, compared with what, and for whom behaviour change techniques are typically effective. The aims of the present paper are to: (1) articulate the scope of the challenge in understanding the properties of behaviour change techniques, (2) propose means by which to tackle this problem, and (3) call scientists to action. METHODS: Iterative consensus (O'Connor et al., 2020, Br. J. Psychol., e12468) was used to elicit and distil the judgements of experts on how best to tackle the problem of understanding the nature and operation of behaviour change techniques. RESULTS: We propose a worldwide network of 'Centres for Understanding Behaviour Change' (CUBiC) simultaneously undertaking research to establish what are the single and combined properties of behaviour change techniques across multiple behaviours and populations. We additionally provide a first attempt to systematize an approach that CUBiC could use to understand behaviour change techniques and to begin to harness the efforts of researchers worldwide. CONCLUSION: Better understanding of behaviour change techniques is vital for improving behaviour change interventions to tackle global problems such as obesity and recovery from COVID-19. The CUBiC proposal is just one of many possible solutions to the problems that the world faces and is a call to action for scientists to work collaboratively to gain deeper understanding of the underpinnings of behaviour change interventions.

A meta-analysis of self-determination theory-informed intervention studies in the health domain: effects on motivation, health behavior, physical, and psychological health.

There are no literature reviews that have examined the impact of health-domain interventions, informed by self-determination theory (SDT), on SDT constructs and health indices. Our aim was to meta-analyse such interventions in the health promotion and disease management literatures. Studies were eligible if they used an experimental design, tested an intervention that was based on SDT, measured at least one SDT-based motivational construct, and at least one indicator of health behaviour, physical health, or psychological health. Seventy-three studies met these criteria and provided sufficient data for the purposes of the review. A random-effects meta-analytic model showed that SDT-based interventions produced small-to-medium changes in most SDT constructs at the end of the intervention period, and in health behaviours at the end of the intervention period and at the follow-up. Small positive changes in physical and psychological health outcomes were also observed at the end of the interventions. Increases in need support and autonomous motivation (but not controlled motivation or amotivation) were associated with positive changes in health behaviour. In conclusion, SDT-informed interventions positively affect indices of health; these effects are modest, heterogeneous, and partly due to increases in self-determined motivation and support from social agents.

Using the question-behavior effect to change multiple health behaviors: An exploratory randomized controlled trial.

Asking questions about a behavior has been found to influence subsequent performance of that behavior, a phenomenon termed the question-behavior effect (QBE). The present study addressed two under-researched questions concerning the QBE: (1) Can the QBE be used to change multiple health behaviors, and (2) does enhancing dissonance during questionnaire completion increase the magnitude of the QBE? Participants (N = 1534) were randomized to one of three conditions (dissonance-enhanced QBE; standard QBE; control) that targeted three health-protective behaviors (eating fruit and vegetables, physical activity, dental flossing) and three health-risk behaviors (alcohol intake, sedentariness, unhealthy snacking). The dissonance-enhanced intervention comprised a message designed to pressurize participants into forming healthful behavioral intentions. Behavior was assessed via self-reports at four-week follow up. Findings showed significant overall effects of the QBE both in increasing performance of health-protective behaviors (p = .001) and in reducing performance of health-risk behaviors (p = .04). Compared to the standard QBE condition, the dissonance-enhanced QBE intervention increased performance of health-protective behaviors (p = .04) and marginally reduced performance of health-risk behaviors (p = .07). The dissonance-enhanced QBE intervention outperformed the control condition in all analyses. This is the first report that a brief QBE intervention influences performance of multiple health behaviors. Findings supported the idea that magnifying dissonance increases the impact of the QBE.

Preoperative Interventions for Alcohol and Other Recreational Substance Use: A Systematic Review and Meta-Analysis.

Background: Preoperative alcohol and other recreational substance use (ORSU) may catalyze perioperative complications. Accordingly, interventions aiming to reduce preoperative substance use are warranted. Methods: Studies investigating interventions to reduce alcohol and/or ORSU in elective surgery patients were identified from: Cochrane Library; MEDLINE; PSYCINFO; EMBASE; and CINAHL. In both narrative summaries of results and random effects meta-analyses, effects of interventions on perioperative alcohol/ORSU, complications, mortality and length of stay were assessed. Primary Results: Nine studies (n = 903) were included. Seven used behavioral interventions only, two provided disulfiram in addition. Pooled analyses found small effects on alcohol use (d: 0.34; 0.05-0.64), though two trials using disulfiram (0.71; 0.36-1.07) were superior to two using behavioral interventions (0.45; -0.49-1.39). No significant pooled effects were found for perioperative complications, length of hospital stay or mortality in studies solely targeting alcohol/ORSU. Too few interventions targeting ORSU (n = 1) were located to form conclusions regarding their efficacy. Studies were generally at high risk-of-bias and heterogeneous. Conclusions: Preoperative interventions were beneficial in reducing substance use in some instances, but more high-quality studies targeting alcohol/ORSU specifically are needed. The literature to date does not suggest that such interventions can reduce postoperative morbidity, length of hospital stay or mortality. Limitations in the literature are outlined and recommendations for future studies are suggested.

Developing a socio-ecological model of dietary behaviour for people living with diabetes or high blood glucose levels in urban Nepal: A qualitative investigation.

Instances of non-communicable diseases such as diabetes are on the rise globally leading to greater morbidity and mortality, with the greatest burden in low and middle income countries [LMIC]. A major contributing factor to diabetes is unhealthy dietary behaviour. We conducted 38 semi structured interviews with patients, health professionals, policy-makers and researchers in Kathmandu, Nepal, to better understand the determinants of dietary behaviour amongst patients with diabetes and high blood glucose levels. We created a social ecological model which is specific to socio-cultural context with our findings with the aim of informing culturally appropriate dietary behaviour interventions for improving dietary behaviour. Our findings show that the most influential determinants of dietary behaviour include cultural practices (gender roles relating to cooking), social support (from family and friends), the political and physical environment (political will, healthy food availability) and individuals' motivations and capabilities. Using these most influential determinants, we suggest potentially effective dietary interventions that could be implemented by policy makers. Our findings emphasise the importance of considering socio-cultural context in developing interventions and challenges one-size-fits-all approaches which are often encouraged by global guidelines. We demonstrate how multifaceted and multi layered models of behavioural influence can be used to develop policy and practice with the aim of reducing mortality and morbidity from diabetes.

Crossing two types of implementation intentions with a protection motivation intervention for the reduction of saturated fat intake: a randomized trial.

Implementation intentions, namely specific plans regarding when, where and how an individual will act, increase the likelihood of action. There is evidence that implementation intentions should be particularly efficacious when combined with motivational interventions. However, this is yet to be tested in relation to the reduction of unhealthy behaviour. Thus the aim of this study was to examine the efficacy of combined motivation and implementation intention interventions for the reduction of saturated fat intake. It also tested a new form of implementation intention (reasoning implementation intentions). Participants from the UK (n = 210) were randomized to condition and asked either to form standard implementation intentions, reasoning implementation intentions, or received no implementation intention manipulation; and were exposed to protection motivation-based information, or not. Results showed that standard and reasoning implementation intentions were successful in reducing the proportion of food energy derived from saturated fat but the effects of the standard implementation intention were dependent on whether participants read the motivational message or not.

Goal desires moderate intention-behaviour relations.

Models such as the Extended Model of Goal-Directed Behaviour and the Theory of Planned Behaviour imply that the impact of one's goals on behaviour is mediated by more proximal determinants. We hypothesize that goals can have a broader and more dynamic impact on behaviour and, specifically, that goal desires can moderate the effect of intentions on behaviour. Four studies addressed this issue by examining the direct and moderated effects of goal desires on behaviour. All of the studies required participants to complete baseline measures and then a follow-up indicator of behaviour. In Study 1 (N=119) that focused on fruit intake, Study 2 (N=123) and Study 3 (N=96) concerned with drinking alcohol and Study 4 (N=109) regarding snack consumption, behavioural intentions were more reliably related to behaviour when goal desires were strong. The results of Study 3 suggested that goal desire stability increases the likelihood of this moderator effect emerging and Study 4 revealed that this effect was not suppressed by intention stability. The findings suggest that goals and behavioural intentions can operate simultaneously and jointly influence action, a view that contradicts predictions that the effects of goals are fully mediated by more proximal behavioural determinants.

Differential relations between two types of contact and implicit and explicit racial attitudes.

Contact with out-group members has been associated with more favourable explicit attitudes towards the out-group in general, largely via the mediation of reduced intergroup anxiety. In addition, there is now a growing body of evidence suggesting that contact relates to automatically activated evaluations termed implicit attitudes. However, research has not fully illuminated the mechanisms through which contact with outgroup members impacts on implicit attitudes. A study investigating this issue assessed White participants' (N=105) explicit attitudes, implicit attitudes, intergroup anxiety, and contact quantity and quality about Asians. Greater contact quality was related to more positive explicit attitudes, while contact quantity was associated with more positive implicit attitudes. Both effects were mediated by reduced intergroup anxiety.

How effective are interventions in improving dietary behaviour in low- and middle-income countries? A systematic review and meta-analysis.

Several interventions encouraging people to change their diet have been tested in low- and middle-income countries (LMICs) but these have not been meta-synthesised and it is not known which elements of these interventions contribute to their effectiveness. The current review addressed these issues. Randomised controlled trials of dietary interventions in LMICs were eligible and identified via eight publication databases. Elements of both the intervention and comparison groups (e.g., behaviour change techniques (BCTs), delivery mode), participant characteristics and risk of bias were coded. Random effects meta-analysis of 76 randomised controlled trials found, on average, small- to medium-sized but highly heterogeneous improvement in dietary behaviour following an intervention. Small and homogeneous improvements were found for BMI/weight, waist- and hip-circumference, with medium-sized, but heterogeneous, improvements in blood pressure and cholesterol. Although many BCTs have yet to be tested in this context, meta-regressions suggested some BCTs (action planning, self-monitoring of outcome(s) of behaviour; demonstration of behaviour) as well as individually randomised trials, adult- or hypertensive-samples and lack of blinding were associated with larger dietary behaviour effect sizes. Interventions to encourage people from LMICs to change their diet produce, on average, small-to-medium-sized effects. These effects may possibly be increased through the inclusion of specific BCTs and other study elements.