Using Theories of Behavior Change to Develop Interventions for Healthy Aging.

Healthy aging requires people to adopt and maintain beneficial behaviors in all stages of the life span. Supporting behavior change, including via the motivation to make and maintain those changes, is therefore important for the promotion of healthy aging. The aim of this overview is to introduce theoretical frameworks from the psychology of motivation that lend themselves to the development of effective interventions promoting behavior change conducive to healthy aging. We discuss theoretical frameworks referring to the determinants, properties, and functionality of goals aimed at behavior change, and consider the implications of the various theories for designing interventions to support healthy aging. We first consider theories that focus on beliefs and attitudes as determinants of goals, then we address theories that focus on the structure and content as important properties of goals, and, finally, we examine theories drawing on conscious and nonconscious processes underlying the functionality of these goals. We will present if-then planning and mental contrasting, as well as nudging and boosting, that is, novel strategies of behavior change that support the creation of scalable interventions for healthy aging across the life span. Against this background, new perspectives emerge for modern, state-of-the-art, and individually tailored interventions with the aim of enhancing older people's healthy living.

Exploring factors influencing pregnant Women's attitudes, perceived subjective norms and perceived behavior control towards male involvement in maternal services utilization: a baseline findings from a community based interventional study from Rukwa, rural Tanzania.

BACKGROUND: Although male involvement enhances obstetric care-seeking behavior, the practice of male involvement in developing countries remains unacceptably low. Male involvement in maternal services utilization can be influenced by the attitude, subjective norm, and perceived behavior control of their female partners. Little is known about factors influencing pregnant women's attitudes, perceived subjective norms, and perceived behavior control towards male involvement in maternal services utilization. METHODS: A baseline community-based cross-sectional study whose target was pregnant women were performed from 1st June until 30th October 2017. A three-stage probability sampling technique was employed to obtain a sample of 546 pregnant women. A structured questionnaire that hinged the Theory of Planned Behavior was used. The questionnaire explored three main determinants of male involvement, which were: attitudes towards male involvement, perceived subjective norms towards male involvement, and perceived behavior control towards male involvement. RESULTS: After adjusting for the confounders, factors influencing positive attitude towards male involvement were age at marriage [19 to 24 yrs.,(AOR = 1.568 at 95% CI =1.044-2.353), more than 24 yrs. (AOR = 2.15 at 95% CI = 1.150-1.159)]; education status [primary school (AOR = 1.713 at 95% CI = 1.137-2.58)] and economic status [earning more than one dollar per day (AOR = 1.547 at 95% CI = 1.026-2.332)]. Factors influencing perceived subjective norms was only age at marriage [19 to 24 yrs., (AOR = 1.447 at 95% CI = 0.970-2.159), more than 24 years, (AOR = 2.331 at 95% CI = 1.261-4.308)]; factors influencing perceived behavior control were age at marriage [more than 24 years (AOR = 2.331 at 95%CI = 1.261-4.308)], and the intention to be accompanied by their male partners (AOR = 1.827 at 95%CI = 1.171-2.849). CONCLUSION: The study revealed that women who were married at an older age were more likely to have a positive attitude, subjective norms, and perceived behavior control towards male involvement in maternal services utilization than those who were married at a young age. Pregnant women who had primary education and earn more than a dollar per day were more likely to have positive attitudes towards male involvement than poor and uneducated pregnant women. The study recommends an interventional study to evaluate the influence attitude, subjective norms, and perceived behavior control on male involvement in maternal services utilization.

Socio-economic impact on involuntary admissions and coercive measures in psychiatric hospitals in Germany.

OBJECTIVE: The present study aimed to characterize involuntary psychiatric admissions and coercive measures within psychiatric hospitals regarding their temporal development and processual aspects. Moreover, the influence of socio-economic factors on involuntary admissions and coercive measures was investigated. METHODS: Different data sets from the federal state of North-Rhine Westphalia (NRW) were used in this study. In addition to a survey in which n = 33 hospitals responded (40.7%), official data from the Federal Health Ministry were analysed over a decade regarding involuntary admissions and coercive measures. These data were available for all n = 54 districts, respectively, all n = 81 psychiatric hospitals in NRW. Datasets were mainly analysed comparing different socio-economic clusters. RESULTS: The hospital admission rate increased significantly over time (from 1.12 to 1.34 per 1000 inhabitants) within ten years. However, whereas the admission rates differed significantly between socio-economic clusters, the amount of coercive measures used in the hospitals did not. Compared to general psychiatry and addiction medicine, geriatric psychiatry had the highest amount of involuntary admissions (12.2% under public law, 14.1% under civil law). Furthermore, most coercive measures lasted at least an hour. CONCLUSION: It seems that, despite intense discussions and enhanced efforts to reduce coercion, there are still some neglected aspects, such as the need for coercive measures and their duration, particularly in the geriatric psychiatric setting. In addition, the results show that further approaches to prevent involuntary admissions are needed to address other stakeholders beyond the hospitals and further aspects of the socio-economic environment.

National Institutes of Health social and behavioral research in response to the SARS-CoV2 Pandemic.

The COVID-19 pandemic has been mitigated primarily using social and behavioral intervention strategies, and these strategies have social and economic impacts, as well as potential downstream health impacts that require further study. Digital and community-based interventions are being increasingly relied upon to address these health impacts and bridge the gap in health care access despite insufficient research of these interventions as a replacement for, not an adjunct to, in-person clinical care. As SARS-CoV-2 testing expands, research on encouraging uptake and appropriate interpretation of these test results is needed. All of these issues are disproportionately impacting underserved, vulnerable, and health disparities populations. This commentary describes the various initiatives of the National Institutes of Health to address these social, behavioral, economic, and health disparities impacts of the pandemic, the findings from which can improve our response to the current pandemic and prepare us better for future infectious disease outbreaks.

Prevalence of the use of chemical restraint in the management of challenging behaviours associated with adult mental health conditions: A meta-synthesis.

WHAT IS KNOWN ON THE SUBJECT?: The use of chemical restraint in emergency situations is to control aggression or violence to protect consumers and staff and is to be used as a last resort when all other behavioural control alternatives have been exhausted. Chemical restraint involves the use of medication. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: This is the first paper to systematically review the prevalence of the use of chemical restraint. The use of chemical restraint is common across emergency departments and acute psychiatric inpatient units worldwide. Consumers who are restrained are also likely to receive chemical restraint. The studies reviewed demonstrate that there is a need for more standardized data collection so that clearer comparisons can be made between healthcare settings and countries. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Implications of practice include the need to report adverse events post-chemical restraint as these can deleteriously affect a person's physical health. Identification of and staff education about first-line management techniques before chemical restraint is administered are significant to reduce its use. ABSTRACT: Introduction Chemical restraint is used to manage uncontrolled aggression, agitation or violent behaviours of consumers with mental health disorders admitted to acute psychiatric or emergency settings. Aim This systematic review aimed to synthesize the international prevalence of chemical restraint for non-consenting adults. Method PsycINFO, CINAHL, MEDLINE/PubMed and Google Scholar databases were searched for peer-reviewed literature published between January 1996 and July 2018. This paper reports on data extracted from retrospective audits of chemical restraint practice. Results Forty-eight papers were included. The median prevalence of use of any restraint was 21.2% (25th% 8.0 to 75th% 36.3). Median prevalence of people who were chemically restrained, of all people restrained in any manner, was 43.1% (25th% 22.9% to 75th% 70.7%). Of all people admitted to facility(ies), the median prevalence of chemical restraint was 7.4% (25th% 2.7 to 75th% 17.6). There was no statistically significant difference in any prevalence measure considering healthcare setting or country. There was a significant decrease over the review period in the use of any restraint, including chemical restraint. Discussion and implications for practice This is the first known comprehensive meta-view of chemical restraint use worldwide, highlighting the need for standardized data collection to enable comparisons between healthcare settings and countries. Relevance statement There is an international imperative to reduce or eliminate the use of coercive practices, such as physical and chemical restraint, in mental health care. This study provides important information for mental health nursing by synthesizing the international prevalence of chemical restraint for non-consenting adults. This meta-view of the worldwide use of chemical restraint can inform ongoing efforts to reduce its use.

Active 10 - A new approach to increase physical activity in inactive people in England.

Public health physical activity (PA) guidelines are failing to increase levels of population PA, requiring a new approach. A national integrated marketing campaign was developed based on published literature and ethnographic research to get inactive lower socioeconomic 40-60 year olds to walk briskly for bouts of 10 or more minutes per day and move towards recommended levels of PA. National and local communications campaigns and partnerships promoted key messages and directed people to a free mobile phone app that provided the user with time, intensity and periodicity of walking, and included goal setting and encouragement to support behaviour change. Campaigns in the summers of 2017 and 2018 achieved around 500,000 downloads of the mobile phone app, with evaluation suggesting increases in brand and app awareness, and those taking action. Active 10 is a promising example of a physical activity promotion campaign based on evidence-based messages tailored for a target audience to change social norms rather than guidelines, an approach recognised as an effective population intervention for increasing walking.

Quality Improvement Project to Manage Workplace Violence in Hospitals: Lessons Learned.

BACKGROUND: The study of workplace violence has focused on quantifying the problem and profiling perpetrators and victims. Intervention studies are scarce. The diverse nature of violence risk in hospitals highlights the need for broad training in risk recognition and de-escalation. LOCAL PROBLEM: A violence management program was piloted on a general medical unit following staff requests for measures to protect them from patient and visitor violence. METHODS: An independent pre/posttest design measured changes in participant knowledge. The Staff Observation Assessment Scale Revised (SOAS-R) was used for data collection on aggression pre- and postimplementation. INTERVENTIONS: The violence management training program included in situ simulation training in de-escalation techniques. RESULTS: Knowledge of de-escalation techniques to reduce violence risk increased. Important lessons were learned for ongoing program implementation. CONCLUSIONS: Violence management programs can lead to more effective risk management. Instruments to collect data on aggression should be linked to mandatory incident reporting, and existing behavioral response teams should be involved in incident tracking.

Assessing the impact of care farms on quality of life and offending: a pilot study among probation service users in England.

OBJECTIVES: To assess the feasibility of conducting a cost-effectiveness study of using care farms (CFs) to improve quality of life and reduce reoffending among offenders undertaking community orders (COs). To pilot questionnaires to assess quality of life, connection to nature, lifestyle behaviours, health and social-care use. To assess recruitment and retention at 6 months and feasibility of data linkage to Police National Computer (PNC) reconvictions data and data held by probation services. DESIGN: Pilot study using questionnaires to assess quality of life, individually linked to police and probation data. SETTING: The pilot study was conducted in three probation service regions in England. Each site included a CF and at least one comparator CO project. CFs are working farms used with a range of clients, including offenders, for therapeutic purposes. The three CFs included one aquaponics and horticulture social enterprise, a religious charity focusing on horticulture and a family-run cattle farm. Comparator projects included sorting secondhand clothes and activities to address alcohol misuse and anger management. PARTICIPANTS: We recruited 134 adults (over 18) serving COs in England, 29% female. RESULTS: 52% of participants completed follow-up questionnaires. Privatisation of UK probation trusts in 2014 negatively impacted on recruitment and retention. Linkage to PNC data was a more successful means of follow-up, with 90% consenting to access their probation and PNC data. Collection of health and social-care costs and quality-adjusted life year derivation were feasible. Propensity score adjustment provided a viable comparison method despite differences between comparators. We found worse health and higher reoffending risk among CF participants due to allocation of challenging offenders to CFs, making risk of reoffending a confounder. CONCLUSIONS: Recruitment would be feasible in a more stable probation environment. Follow-up was challenging; however, assessing reconvictions from PNC data is feasible and a potential primary outcome for future studies.

Interdisciplinary team-based care for patients with chronic pain on long-term opioid treatment in primary care (PPACT) - Protocol for a pragmatic cluster randomized trial.

BACKGROUND: Chronic pain is one of the most common, disabling, and expensive public health problems in the United States. Interdisciplinary pain management treatments that employ behavioral approaches have been successful in helping patients with chronic pain reduce symptoms and regain functioning. However, most patients lack access to such treatments. We are conducting a pragmatic clinical trial to test the hypothesis that patients who receive an interdisciplinary biopsychosocial intervention, the Pain Program for Active Coping and Training (PPACT), at their primary care clinic will have a greater reduction in pain impact in the year following than patients receiving usual care. METHODS/DESIGN: This is an effectiveness-implementation hybrid pragmatic clinical trial in which we randomize clusters of primary care providers and their patients with chronic pain who are on long-term opioid therapy to 1) receive an interdisciplinary behavioral intervention in conjunction with their current health care or 2) continue with current health care services. Our primary outcome is pain impact (a composite of pain intensity and pain-related interference) measured using the PEG, a validated three-item assessment. Secondary outcomes include pain-related disability, patient satisfaction, opioids dispensed and health care utilization. An economic evaluation assesses the resources and costs necessary to deliver the intervention and its cost-effectiveness compared with usual care. A formative evaluation employs mixed methods to understand the context for implementation in the participating health care systems. DISCUSSION: This trial will inform the feasibility of implementing interdisciplinary behavioral approaches to pain management in the primary care setting, potentially providing a more effective, safer, and more satisfactory alternative to opioid-based chronic pain treatment. Clinical Trials Registration Number: NCT02113592.

Addressing people and place microenvironments in weight loss disparities (APP-Me): Design of a randomized controlled trial testing timely messages for weight loss behavior in low income Black and White Women.

BACKGROUND: Behavioral interventions for weight loss have been less effective in lower income and black women. These poorer outcomes may in part be related to these women having more frequent exposures to social and physical situations that are obesogenic, i.e., eating and sedentary cues or situations. OBJECTIVES: Working with obese, lower income Black and White Women, Addressing People and Place Microenvironments (APP-Me) was designed to create awareness of self-behavior at times and places of frequent eating and sedentary behavior. DESIGN: APP-Me is being evaluated in a randomized controlled trial with 240 participants recruited from federally qualified health centers located in a single Midwestern city. All participants complete four weeks of ecological momentary assessments (EMA) of situations and behavior. At the end of the four weeks, participants are randomized to enhanced usual care (UC) or UC plus APP-Me. METHODS: APP-Me is an automated short messaging system (SMS). Messages are text, image, audio, or a combination, and are delivered to participants' mobile devices with the intent of creating awareness at the times and places of frequent eating or sedentary behavior. The EMA data inform the timing of message deliveries. SUMMARY: This project aims to create and test timely awareness messages in a subpopulation that has not responded well to traditional behavioral interventions for weight loss. Novel aspects of the study include the involvement of a low income population, the use of data on time and place of obesogenic behavior, and message delivery time tailored to an individual's behavioral patterns.

Beyond Willpower: Strategies for Reducing Failures of Self-Control.

Almost everyone struggles to act in their individual and collective best interests, particularly when doing so requires forgoing a more immediately enjoyable alternative. Other than exhorting decision makers to "do the right thing," what can policymakers do to reduce overeating, undersaving, procrastination, and other self-defeating behaviors that feel good now but generate larger delayed costs? In this review, we synthesize contemporary research on approaches to reducing failures of self-control. We distinguish between self-deployed and other-deployed strategies and, in addition, between situational and cognitive intervention targets. Collectively, the evidence from both psychological science and economics recommends psychologically informed policies for reducing failures of self-control.

Comparison of Simulated Treatment and Cost-effectiveness of a Stepped Care Case-Finding Intervention vs Usual Care for Posttraumatic Stress Disorder After a Natural Disaster.

Importance: Psychiatric interventions offered after natural disasters commonly address subsyndromal symptom presentations, but often remain insufficient to reduce the burden of chronic posttraumatic stress disorder (PTSD). Objective: To simulate a comparison of a stepped care case-finding intervention (stepped care [SC]) vs a moderate-strength single-level intervention (usual care [UC]) on treatment effectiveness and incremental cost-effectiveness in the 2 years after a natural disaster. Design, Setting, and Participants: This study, which simulated treatment scenarios that start 4 weeks after landfall of Hurricane Sandy on October 29, 2012, and ending 2 years later, created a model of 2 642 713 simulated agents living in the areas of New York City affected by Hurricane Sandy. Interventions: Under SC, cases were referred to cognitive behavioral therapy, an evidence-based therapy that aims to improve symptoms through problem solving and by changing thoughts and behaviors; noncases were referred to Skills for Psychological Recovery, an evidence-informed therapy that aims to reduce distress and improve coping and functioning. Under UC, all patients were referred only to Skills for Psychological Recovery. Main Outcomes and Measures: The reach of SC compared with UC for 2 years, the 2-year reduction in prevalence of PTSD among the full population, the 2-year reduction in the proportion of PTSD cases among initial cases, and 10-year incremental cost-effectiveness. Results: This population of 2 642 713 simulated agents was initialized with a PTSD prevalence of 4.38% (115 751 cases) and distributions of sex (52.6% female and 47.4% male) and age (33.9% aged 18-34 years, 49.0% aged 35-64 years, and 17.1% aged ≥65 years) that were comparable with population estimates in the areas of New York City affected by Hurricane Sandy. Stepped care was associated with greater reach and was superior to UC in reducing the prevalence of PTSD in the full population: absolute benefit was clear at 6 months (risk difference [RD], -0.004; 95% CI, -0.004 to -0.004), improving through 1.25 years (RD, -0.015; 95% CI, -0.015 to -0.014). Relative benefits of SC were clear at 6 months (risk ratio, 0.905; 95% CI, 0.898-0.913), with continued gains through 1.75 years (risk ratio, 0.615; 95% CI, 0.609-0.662). The absolute benefit of SC among cases was much stronger, emerging at 3 months (RD, -0.006; 95% CI, -0.007 to -0.005) and increasing through 1.5 years (RD, -0.338; 95% CI, -0.342 to -0.335). Relative benefits of SC among cases were equivalent to those observed in the full population. The incremental cost-effectiveness of SC compared with UC was $3428.71 to $6857.68 per disability-adjusted life year avoided, and $0.80 to $1.61 per PTSD-free day. Conclusions and Relevance: The results of this simulation study suggest that SC for individuals with PTSD in the aftermath of a natural disaster is associated with greater reach than UC, more effectiveness than UC, and is well within the range of acceptability for cost-effectiveness. Results should be considered in light of limitations inherent to agent-based models.

Sleep in children with Angelman syndrome: Parental concerns and priorities.

Angelman syndrome is a rare genetic syndrome, in which sleep disturbances are reported for 20-80% of individuals (Williams et al., 2006). This interview study delineated parental perceptions of sleep problems experienced by children with Angelman syndrome and the impact on parental sleep quality, health and wellbeing. The nature of desired interventions was also explored. Semi-structured interviews were completed with parents of 50 children, aged 16 months-15 years with Angelman syndrome who experienced current or historic sleep problems; predominantly night waking and settling problems. Parents were concerned by the impact of their child's sleep quality upon their own ability to function during the day. The importance of considering parental experiences was evidenced by variability in coping e.g. despite the persistence of sleep problems 20% of parents did not feel the need for any additional support. Amongst a range of types of further support desired, 27% cited further support with a behavioural intervention, and information about the trajectory of sleep problems in Angelman syndrome (18%). The results suggest that behavioural interventions supporting both children and parents in improving their sleep quality and well-being, and longitudinal research into sleep problems should be prioritised.

Hypertension Canada's 2017 Guidelines for the Diagnosis, Assessment, Prevention, and Treatment of Pediatric Hypertension.

After the 2016 guidelines for blood pressure measurement, diagnosis, and investigation of pediatric hypertension, we now present evidence-based guidelines for the prevention and treatment of hypertension in children. These guidelines were developed by Hypertension Canada's Guideline Committee pediatric subgroup after thorough evaluation of the available literature. Included are 10 guidelines specifically addressing health behaviour management, indications for drug therapy in children with hypertension, choice of therapy for children with primary hypertension, and goals of therapy for children with hypertension. Although the pediatric literature is inherently limited by small numbers of participants, fewer trials, and a prolonged latency to the development of vascular outcomes, this report reflects the current and highest level of evidence and provides guidance for primary care practitioners on the management of pediatric hypertension. Studies of therapeutic lifestyle modifications in children are available to guide current management and more antihypertensive drugs have been studied in children since the Food and Drug Administration Modernization Act. Consistent with Hypertension Canada's guideline policy, diagnostic and therapeutic algorithm tools will be developed and the guidelines will be reviewed annually and updated according to new evidence.

MAGIC Study: Aims, Design and Methods using SystemCHANGE™ to Improve Immunosuppressive Medication Adherence in Adult Kidney Transplant Recipients.

BACKGROUND: Among adult kidney transplant recipients, non-adherence to immunosuppressive medications is the leading predictor of poor outcomes, including rejection, kidney loss, and death. An alarming one-third of kidney transplant patients experience medication non-adherence even though the problem is preventable. Existing adherence interventions have proven marginally effective for those with acute and chronic illnesses and ineffective for adult kidney transplant recipients. Our purpose is to describe the design and methods of the MAGIC (Medication Adherence Given Individual SystemCHANGE™) trial METHODS/DESIGN: We report the design of a randomized controlled trial with an attention-control group to test an innovative 6-month SystemCHANGE™ intervention designed to enhance immunosuppressive medication adherence in adult non-adherent kidney transplant recipients from two transplant centers. Grounded in the Socio-Ecological Model, SystemCHANGE™ seeks to systematically improve medication adherence behaviors by identifying and shaping routines, involving supportive others in routines, and using medication taking feedback through small patient-led experiments to change and maintain behavior. After a 3-month screening phase of 190 eligible adult kidney transplant recipients, those who are <85 % adherent as measured by electronic monitoring, will be randomized into a 6-month SystemCHANGE™ intervention or attention-control phase, followed by a 6-month maintenance phase without intervention or attention. Differences in adherence between the two groups will be assessed at baseline, 6 months (intervention phase) and 12 months (maintenance phase). Adherence mediators (social support, systems-thinking) and moderators (ethnicity, perceived health) are examined. Patient outcomes (creatinine/blood urea nitrogen, infection, acute/chronic rejection, graft loss, death) and cost effectiveness are to be examined. DISCUSSION: Based on the large effect size of 1.4 found in our pilot study, intervention shows great promise for increasing adherence. Grounded in the socio-ecological model, SystemCHANGE™ seeks to systematically improve medication adherence behaviors by identifying and shaping routines, involving supportive others in routines, and using medication taking feedback through small patient-lead experiments to change and maintain behavior. Medication adherence will be measured by electronic monitoring. Medication adherence persistence will be examined by evaluating differences between the two groups at the end of the 6-and 12- month phases. Mediators and moderators of medication adherence will be examined. Patient outcomes will be compared and a cost-effectiveness analysis will be conducted. TRIAL REGISTRATION: ClinicalTrials.gov Registry: NCT02416479 Registered April 3, 2015.

The cost-effectiveness of grip on challenging behaviour: an economic evaluation of a care programme for managing challenging behaviour.

OBJECTIVE: The objective of the study was to evaluate the cost-effectiveness of implementing the Grip on Challenging Behaviour care programme (GRIP) on dementia special care units in comparison with usual care. METHODS: A stepped wedge design was used. Challenging behaviour and quality of life were measured using the Cohen Mansfield Agitation Inventory (CMAI) and the QUALIDEM. Quality-adjusted life years (QALYs) were calculated using the EuroQol-5D. Psychoactive medication use (range 0-5 per measurement) and sick leave were registered. Costs included medication, time spent on challenging behaviour and education. Costs and effects were analysed using linear multilevel regression. Incremental cost-effectiveness ratios were calculated. Statistical uncertainty was estimated using bootstrapping. RESULTS: Seventeen dementia special care units participated. GRIP led to improvement on the QUALIDEM subscale social relations (1.6; 95% CI 0.18 to 3.4) and on the use of psychoactive medication (-0.73; 95% CI -1.1 to -0.46) and to a decrease in QALYs (-0.02; 95% CI -0.06 to -0.003). No significant effects on CMAI, sick leave and other QUALIDEM subscales were found. The intervention was not cost-effective in comparison with usual care with regard to CMAI score, QALYs and sick leave. The willingness to pay should be 320€/point improvement on the QUALIDEM subscale social relations and 370€/psychoactive medication less to reach a 0.95 probability of cost-effectiveness. CONCLUSION: It depends on how much society is willing to pay whether GRIP can be considered cost-effective. Because the appropriateness of the current methods for analysing cost-effectiveness in this specific population is uncertain, the positive effects on behaviour, medication and job satisfactions should also be taken in account in the decision making.

Chronic Obstructive Pulmonary Disease-Evolving Concepts in Treatment: Advances in Pulmonary Rehabilitation.

Over the past three decades, pulmonary rehabilitation has risen to the stature as a gold standard for the treatment of chronic obstructive pulmonary disease (COPD). This rise is owing to both the development of science explaining mechanisms underlying its effectiveness and the demonstration of its substantial benefits across multiple outcome areas of importance to patients. Arguably, pulmonary rehabilitation provides the greatest improvements of any therapy in the areas of dyspnea-relief, exercise performance, and functional and health status. Emerging science also indicates that it reduces subsequent health care utilization and-when administered in the perihospital period-mortality risk. These beneficial effects are realized despite the fact that pulmonary rehabilitation has virtually no direct effect on lung function in COPD. Instead, this comprehensive, patient-centered intervention reduces the negative effects from systemic morbidity (such as muscle wasting) and comorbidity (such as depression and anxiety) that frequently accompany COPD. Two major components of pulmonary rehabilitation are exercise training and behavioral interventions. An example of the latter is a collaborative action plan for the early recognition and prompt treatment of the COPD exacerbation. Innovation in pulmonary rehabilitation includes (1) expanding its applicability, such as demonstrating effectiveness in the non-COPD respiratory patient, in milder COPD, in the periexacerbation period, and its provision in the home and community settings; (2) improving its process, such as refining the self-management and behavioral interventions, and the promotion of physical activity in the home and community settings; and (3) promoting its accessibility, such as exploring its potential usefulness in nontraditional settings (the home and community) and developing technology to assist in its implementation.

Efficient and Effective Change Principles in Active Videogames.

Active videogames have the potential to enhance population levels of physical activity but have not been successful in achieving this aim to date. This article considers a range of principles that may be important to the design of effective and efficient active videogames from diverse discipline areas, including behavioral sciences (health behavior change, motor learning, and serious games), business production (marketing and sales), and technology engineering and design (human-computer interaction/ergonomics and flow). Both direct and indirect pathways to impact on population levels of habitual physical activity are proposed, along with the concept of a game use lifecycle. Examples of current active and sedentary electronic games are used to understand how such principles may be applied. Furthermore, limitations of the current usage of theoretical principles are discussed. A suggested list of principles for best practice in active videogame design is proposed along with suggested research ideas to inform practice to enhance physical activity.