Behavior Change Techniques Associated With Changes in Postintervention and Maintained Changes in Self-Efficacy For Physical Activity: A Systematic Review With Meta-analysis.

BACKGROUND: Self-efficacy is an important determinant of physical activity but it is unclear how best to increase self-efficacy for physical activity and to maintain these changes. PURPOSE: This systematic review aimed to identify which specific behavior change techniques (BCTs), BCT clusters, and number of BCTs were associated with changes in postintervention and maintained changes in self-efficacy for physical activity across all adult populations. METHODS: A systematic search yielded 180 randomized trials (204 comparisons) which reported changes in self-efficacy. BCTs were coded using the BCT Taxonomy v1. Hierarchical cluster analysis explored the clustering of BCTs. Meta-analyses and moderator analyses examined whether the presence and absence of individual BCTs in interventions were associated with effect-size changes for self-efficacy. RESULTS: Small intervention effects were found for postintervention self-efficacy for physical activity (d = 0.26; 95% CI: [0.21, 0.31]; I2 = 75.8 per cent). "Information about social, environmental, and emotional consequences" was associated with higher effect sizes, whereas "social support (practical)" was associated with lower effect sizes. Small and nonsignificant effects were found for maintained changes in self-efficacy for physical activity (d = 0.08; CI: [-0.05, 0.21]; I2 = 83.8 per cent). Lack of meaningful clustering of BCTs was found. A significant positive relationship was found between number of BCTs and effect sizes for maintained changes in self-efficacy for physical activity. CONCLUSIONS: There does not appear to be a single effective approach to change self-efficacy for physical activity in all adults: different approaches are required for different populations. Interventions with more BCTs seem more effective at maintaining changes in self-efficacy for physical activity.

Barriers and facilitators associated with attendance at hospital diabetes clinics among young adults (15-30 years) with type 1 diabetes mellitus: a systematic review.

Regular clinic attendance is recommended to facilitate self-management of diabetes. Poor attendance is common among young adults with type 1 diabetes mellitus (DM). This systematic review aimed to produce a narrative synthesis of the evidence regarding factors which promote or impede regular attendance at adult diabetes clinics among young adults (15-30 years) with type 1 DM. Studies reporting facilitators and barriers to clinic attendance were identified by searching four electronic databases, checking reference lists, and contacting diabetes research networks. A total of 12 studies (8 quantitative and 4 qualitative) met the inclusion criteria. Young adult's experiences transitioning from paediatric to adult diabetes care can influence attendance at the adult clinic positively if there is a comprehensive transition programme in place, or negatively if the two clinics do not communicate and provide adequate support. Post-transition, relationship development and perceptions of the value of attending the clinic are important for regular attendance. Controlled research is required to better understand decisions to attend or not attend outpatient services among people with chronic conditions. Service delivery must be sensitive to the developmental characteristics of young adults and tailored support may be required by young adults at greatest risk of non-attendance.

Which behaviour change techniques are most effective at increasing older adults' self-efficacy and physical activity behaviour? A systematic review.

BACKGROUND: Increasing self-efficacy is an effective mechanism for increasing physical activity, especially for older people. PURPOSE: The aim of this review was to identify behaviour change techniques (BCTs) that increase self-efficacy and physical activity behaviour in non-clinical community-dwelling adults 60 years or over. METHODS: A systematic search identified 24 eligible studies reporting change in self-efficacy for physical activity following an intervention. Moderator analyses examined whether the inclusion of specific BCTs (as defined by CALO-RE taxonomy) was associated with changes in self-efficacy and physical activity behaviour. RESULTS: Overall, interventions increased self-efficacy (d = 0.37) and physical activity (d = 0.14). Self-regulatory techniques such as setting behavioural goals, prompting self-monitoring of behaviour, planning for relapses, providing normative information and providing feedback on performance were associated with lower levels of both self-efficacy and physical activity. CONCLUSIONS: Many commonly used self-regulation intervention techniques that are effective for younger adults may not be effective for older adults.

'You feel like your whole world is caving in': A qualitative study of primary care patients' conceptualisations of emotional distress.

General practitioners are tasked with determining the nature of patients' emotional distress and providing appropriate care. For patients whose symptoms appear to fall near the 'boundaries' of psychiatric disorder, this can be difficult with important implications for treatment. There is a lack of qualitative research among patients with symptoms severe enough to warrant consultation, but where general practitioners have refrained from diagnosis. We aimed to explore how patients in this potentially large group conceptualise their symptoms and consequently investigate lay understandings of complex distinctions between emotional distress and psychiatric disorder. Interviews were conducted with 20 primary care patients whom general practitioners had identified as experiencing emotional distress, but had not diagnosed with major depressive disorder. Participants described severe emotional experiences with substantial impact on their lives. The term 'depression' was used in many different ways; however, despite severity, they often considered their emotional experience to be different to their perceived notions of 'actual' depression or mental illness. Where anxiety was mentioned, use appeared to refer to an underlying generalised state. Participants drew on complex, sometimes fluid and often theoretically coherent conceptualisations of their emotional distress, as related to, but distinct from, mental disorder. These conceptualisations differ from those frequently drawn on in research and treatment guidelines, compounding the difficulty for general practitioners. Developing models of psychological symptoms that draw on patient experience and integrate psychological/psychiatric theory may help patients understand the nature of their experience and, critically, provide the basis for a broader range of primary care interventions.

Prioritising target behaviours for research in diabetes: Using the nominal group technique to achieve consensus from key stakeholders.

PLAIN ENGLISH SUMMARY: The behaviour of people with diabetes (e.g. taking medication) and the behaviour of doctors and other healthcare professionals (e.g. checking patients' blood sugar) are important. Our research group wanted to select one patient behaviour and one healthcare professional behaviour as topics to research in Ireland. Patients and healthcare professionals are not usually asked to help decide on research topics. In this study, we wanted to bring together patients, healthcare professionals and policy makers to help us decide on the most important target behaviours for research in diabetes in Ireland. We worked with 24 participants, including people with diabetes, diabetes healthcare professionals and policy makers. First, participants suggested behaviours they thought were important to target for research in diabetes. Participants then attended a meeting and ranked which of the behaviours were the most important and discussed the results of the rankings as a group. We identified the most highly ranked patient and healthcare professional behaviours. The top ranked behaviour for people with Type 1 diabetes was to 'take insulin as required' and for people with Type 2 diabetes was to 'attend and engage with structured education programmes'. 'Engage in collaborative goal setting with patients' was the top ranked behaviour for healthcare professionals. Our study shows it is possible for researchers to work with people with diabetes, healthcare professionals and policy makers to decide on research topics. The top ranked behaviours will now be researched by our group in Ireland. ABSTRACT: Background Working with patients, healthcare providers, and policy makers to prioritise research topics may enhance the relevance of research and increase the likelihood of translating research findings into practice. The aim of the present study was to work with key stakeholders to identify, and achieve consensus on, the most important target behaviours for research in diabetes in Ireland. Methods Twenty-four participants, including people with diabetes, diabetes healthcare professionals and policy makers, took part in a nominal group technique consensus process. Through an online survey, participants generated lists of important target behaviours in three areas: managing Type 1 diabetes, managing Type 2 diabetes and preventing Type 2 diabetes. Participants then attended a research prioritisation meeting and ranked target behaviours in two rounds, with group discussion between ranking rounds. For each of the three key areas, the six top ranked behaviours relevant to people with diabetes and healthcare professionals were identified. Results In most cases, the most highly ranked behaviour was the same for Ranking 1 and Ranking 2 and consensus increased in relation to endorsement of top ranked behaviours. However, some behaviours did change position between rankings. The top behaviour relevant to people with Type 1 diabetes was 'taking insulin as required' and for people with Type 2 diabetes was 'attending and engaging with structured education programmes'. 'Engage in collaborative goal setting with patients' was the top ranked behaviour relevant to healthcare professionals for managing both Type 1 and Type 2 diabetes. For preventing Type 2 diabetes, 'engage in healthy behaviours as a family' was the highest ranked population behaviour and 'attend and engage with behaviour change training' was the highest ranked professional behaviour. Conclusions It is possible to work with a diverse group of stakeholders to inform the diabetes research agenda. The priorities identified were co-produced by key stakeholders, including patients, healthcare professionals and policy makers, and will inform the development of a programme of behavioural research in diabetes in Ireland. The study also provides a worked example of a research prioritisation process using the nominal group technique, and identified limitations, which may be useful for other researchers.

Developing an Unguided Internet-Delivered Intervention for Emotional Distress in Primary Care Patients: Applying Common Factor and Person-Based Approaches.

BACKGROUND: Developing effective, unguided Internet interventions for mental health represents a challenge. Without structured human guidance, engagement with these interventions is often limited and the effectiveness reduced. If their effectiveness can be increased, they have great potential for broad, low-cost dissemination. Improving unguided Internet interventions for mental health requires a renewed focus on the proposed underlying mechanisms of symptom improvement and the involvement of target users from the outset. OBJECTIVE: The aim of our study was to develop an unguided e-mental health intervention for distress in primary care patients, drawing on meta-theory of psychotherapeutic change and utilizing the person-based approach (PBA) to guide iterative qualitative piloting with patients. METHODS: Common factors meta-theory informed the selection and structure of therapeutic content, enabling flexibility whilst retaining the proposed necessary ingredients for effectiveness. A logic model was designed outlining intervention components and proposed mechanisms underlying improvement. The PBA provided a framework for systematically incorporating target-user perspective into the intervention development. Primary care patients (N=20) who had consulted with emotional distress in the last 12 months took part in exploratory qualitative interviews, and a subsample (n=13) undertook think-aloud interviews with a prototype of the intervention. RESULTS: A flexible intervention was developed, to be used as and when patients need, diverting from a more traditional, linear approach. Based on the in-depth qualitative findings, disorder terms such as "depression" were avoided, and discussions of psychological symptoms were placed in the context of stressful life events. Think-aloud interviews showed that patients were positive about the design and structure of the intervention. On the basis of patient feedback, modifications were made to increase immediate access to all therapeutic techniques. CONCLUSIONS: Detailing theoretical assumptions underlying Internet interventions for mental health, and integrating this approach with systematic in-depth qualitative research with target patients is important. These strategies may provide novel ways for addressing the challenges of unguided delivery. The resulting intervention, Healthy Paths, will be evaluated in primary care-based randomized controlled trials, and deployed as a massive open online intervention (MOOI).

Do single and multiple behavior change interventions contain different behavior change techniques? A comparison of interventions targeting physical activity in obese populations.

OBJECTIVE: Interventions to increase physical activity (PA) can target this behavior alone or as part of multiple health behavior change (MHBC) interventions. To date, little is known about the content of MHBC interventions compared with single health behavior change (SHBC) interventions. This study sought to compare the number and type of behavior change techniques (BCTs) in SHBC and MHBC interventions using a secondary analysis of studies included in a systematic review of PA interventions in obese populations. METHODS: BCTs used to increase PA (PA BCTs) in intervention descriptions of included studies were double coded using a standardized BCT taxonomy. Interventions were categorized as SHBC (targeting PA) or MHBC (targeting PA and diet) interventions. The mean number of PA BCTs for SHBC and MHBC interventions was compared using an independent-samples t test. Chi-square analyses for each BCT assessed differences in proportions of SHBC and MHBC interventions that contained that BCT. RESULTS: The MHBC obesity interventions contained a greater number of PA BCTs (M = 11.68) than the SHBC obesity interventions (M = 8.71). Six PA BCTs were more common in MHBC interventions. Two PA BCTs were more common in the SHBC interventions. CONCLUSIONS: SHBC and MHBC interventions may systematically differ not only in the number of behaviors targeted, but also in the numbers and type of BCTs used. This study demonstrates that intervention content should also be considered when assessing the relative effectiveness of SHBC and MHBC interventions.

A new measure of multimorbid illness and treatment representations: the example of diabetes and depression.

BACKGROUND: Depression is two to three times more common in people with diabetes than in the general population. Although multimorbid diabetes and depression is associated with poor health outcome, existing research has focused on patients׳ understanding and management of each condition in isolation. This study describes the development and validation of the Diabetes and Depression Representation and Management Questionnaire (DDRMQ), a measure of understanding, management and medication beliefs in people with diabetes and depression. METHODS: In Study 1, DDRMQ items were developed through further analysis of an earlier qualitative study and refined through 18 cognitive interviews. In Study 2, 334 adults with diabetes and depression from general practices, diabetes clinics and support groups completed the DDRMQ, demographic questions and validating measures. RESULTS: Factor analysis of the DDRMQ using principal axis factoring resulted in a 35 item scale organised into ten subscales. The modified measure had adequate internal and test-retest reliability. Initial evidence of construct validity was also demonstrated. LIMITATIONS: Low participant response rates and the high percentage of well-educated white participants limit the generalisability of results. As Study 2 was cross-sectional, future research is needed to establish if different ways of thinking about and managing diabetes and depression can predict patient outcome. CONCLUSIONS: The DDRMQ is the first measure of patient understanding, management and medication beliefs in people with established diagnoses of both diabetes and depression. The DDRMQ will facilitate an increased awareness of the patient experience of diabetes and depression and help inform patient centred care and intervention development for people with multiple conditions.

Delay in seeking medical help following Transient Ischemic Attack (TIA) or "mini-stroke": a qualitative study.

BACKGROUND: Prompt treatment following Transient Ischemic Attack (TIA) can reduce the risk of subsequent stroke and disability. However, many patients delay in making contact with medical services. This study aimed to explore TIA patients' accounts of delay between symptom onset and contacting medical services including how decisions to contact services were made and the factors discussed in relation to delay. METHODS: Twenty interviews were conducted with TIA patients in England. Using a previous systematic review as an initial framework, interview data were organised into categories of symptom recognition, presence of others and type of care sought. A thematic analysis was then conducted to explore descriptions of care-seeking relevant to each category. RESULTS: Delay in contacting medical services varied from less than an hour to eight days. Awareness of typical stroke symptoms could lead to urgent action when more severe TIA symptoms were present but could lead to delay when experienced symptoms were less severe. The role of friends and family varied widely from deciding on and enacting care-seeking decisions to simply providing transport to the GP practice. When family or friends played a greater role, and both made and enacted care-seeking decisions, delays were often shorter, even when patients themselves failed to identify symptoms. Healthcare professionals also impacted on patients' care-seeking with greater delays in seeking further care for the same episode described when patients perceived a lack of urgency during initial healthcare interactions. CONCLUSIONS: This study provides new information on patients' decisions to contact medical services following TIA and identifies overlapping factors that can lead to delay in receiving appropriate treatment. While recognition of symptoms may contribute to delay in contacting medical services, additional factors, including full responsibility being taken by others and initial healthcare interactions, can over-ride or undermine the importance of patients' own identification of TIA.

'The chicken and egg thing': cognitive representations and self-management of multimorbidity in people with diabetes and depression.

OBJECTIVE: Diabetes with depression is common and can lead to poorer outcomes in both conditions. The existing literature has demonstrated that patients' single condition representations inform self-management, but less is known about the composition and impact of multimorbid representations. This study aimed to explore accounts of multimorbidity with a focus on the content of cognitive representations and reported management of diabetes and depression. DESIGN: Semi-structured qualitative interviews were carried out with 17 people with diabetes and depression. Data were audio-taped, transcribed and analysed using an inductive thematic analysis and elements of grounded theory. RESULTS: The nature of multimorbid representations varied and some participants, in particular those who prioritised other conditions, described diabetes and depression as unrelated and managed each separately. Others saw interactions between conditions, often in terms of causation, and described how diabetes and depression management could be either integrated or conflicting. Problems taking multiple-medications were frequently described, but participants differed in the confidence with which they described representations of multimorbidity. CONCLUSION: People hold multimorbid representations that appear to impact on their preferred self-management. An awareness of patients' understanding of multimorbidity could have implications for the provision of care and intervention design in this population.