Factors influencing primary health care professionals' physical activity promotion behaviors: a systematic review.

BACKGROUND: Despite the promising findings related to the efficacy of interventions aimed at promoting physical activity (PA) in primary health care (PHC), the translation of these interventions to PHC practice does not always happen as desired. PURPOSE: To help understand why efficacious PHC-based PA interventions are not effectively translated to practice, this study systematically reviewed the literature on factors influencing PHC professionals' PA promotion practices. METHOD: Literature searches were conducted in Web of Science, PubMed, and PsycINFO for peer-reviewed articles published in English from 1990 onwards. Studies were included that met the following criteria: (1) involving PHC-based PA interventions, and (2) reporting factors influencing PHC professionals' PA promotion behaviors. Two researchers independently screened studies and extracted data. A narrative synthesis using thematic analysis was conducted to identify factors. RESULTS: Of the 4,469 identified articles, 59 were included in the review. Factors were identified by qualitative methods, barrier/facilitator ratings, and the examination of the relationship between factors and PA promotion, and the effectiveness of introduction strategies. Many factors related to the development, delivery, and effects of the innovation, the sociopolitical and organizational culture, resources, and support, patient and PHC professional characteristics, and innovation strategies were identified as potential influences on PHC professionals' PA promotion practices. However, the lack of evidence on the relationship between factors and PA promotion indicated insufficient evidence on PA promotion determinants. CONCLUSION: This extensive overview of potential factors can inform intervention developers and implementers on which factors may play a role when introducing PA interventions in PHC. Future research should further investigate relationships between factors and PA promotion, which should be guided by qualitative in-depth knowledge on influencing factors.

Factors influencing the introduction of physical activity interventions in primary health care: a qualitative study.

BACKGROUND: The introduction of efficacious physical activity (PA) interventions in routine primary health care (PHC) is a complex process. Understanding factors influencing the process can enhance the development of successful introduction strategies. PURPOSE: The aim of this qualitative study was to explore stakeholders' perceptions on factors influencing the introduction, i.e., adoption, implementation, and continuation, of PA interventions in PHC. METHOD: Twenty-eight semistructured interviews were held with intervention managers, PHC advisors, intervention providers, and referring general practitioners of five PA interventions delivered in PHC. A theoretical framework on the introduction of innovations in health care was used to guide the data collection. Influencing factors were identified using thematic analysis. RESULTS: Stakeholders reported preconditions for the introduction of PA interventions in PHC (e.g., support, resources, and networks and collaborations), in addition to characteristics of PA interventions (e.g., compatibility, flexibility, and intervention materials) and characteristics of PHC professionals (e.g., knowledge, positive attitudes, and beliefs about capabilities) perceived to enhance the introduction process. Furthermore, they proposed strategies for the development of PA interventions (e.g., involvement of future stakeholders, full development, and refinement) and strategies to introduce PA interventions in PHC (e.g., training, assistance, and reinforcement). The majority of the influencing factors were discussed specifically in relation to one or two stages. CONCLUSION: This study presents an overview of factors that are perceived to influence the introduction of PA interventions in PHC. It underscores the importance of taking these factors into account when designing introduction strategies and of giving special attention to the distinct stages of the process.

Dietary restraint and body mass change. A 3-year follow up study in a representative Dutch sample.

OBJECTIVE: To determine in a representative Dutch sample the association of dietary restraint, Concern for Dieting, and Weight Fluctuation with subsequent change in body mass index (BMI; in kg/m(2)) in addition to possible moderator effects of sex, level of education, age category, ethnicity, overweight level and physical activity. DESIGN: In a longitudinal study in a representative Dutch sample consisting of 675 participants (331 females, 344 males), dietary restraint (including Concern for Dieting and Weight Fluctuation) was assessed with the Restraint Scale at baseline, and also self-reported weight and height. Three years later, weight and height were also assessed. RESULTS: Dietary restraint was significantly associated with an increase in BMI after three years (B=.272, p=001). Inspection of the significant moderator effect of sex (B=-.387, p=.012) indicated that dietary restraint was significantly associated with increases in BMI only in females. There was no main effect for Concern for Dieting (p=.091). There was a moderator effect of sex on the association between Concern for Dieting and BMI change (B=-.424; p=.002): initial concern for dieting was positively associated with subsequent body mass gain only in women. Weight Fluctuation was significantly associated with an increase in BMI after three years (B=.162, p=008) and sex did not moderate this association. There were no moderator effects for level of education, age category, ethnicity, overweight level and physical activity. CONCLUSION: Dietary restraint and Concern for Dieting are associated with increases in BMI only in females. Weight Fluctuation is associated with increases in BMI in both males and females.

Factors influencing the adoption, implementation, and continuation of physical activity interventions in primary health care: a Delphi study.

BACKGROUND: The introduction of efficacious physical activity interventions in primary health care is a complex process. Understanding factors influencing the process can enhance the development of effective introduction strategies. This Delphi study aimed to identify factors most relevant for the adoption, implementation, and continuation of physical activity interventions in primary health care by examining experts' opinions on the importance and changeability of factors previously identified as potentially relevant for the process. METHODS: In the first round, 44 experts scored factors on their importance for each stage of the introduction process, as well as on their changeability. In the second round, the same experts received a questionnaire containing a reduced list of factors, based on the first-round results. They were asked to indicate their top-10 most important factors for each stage, and to re-rate factors' changeability. Thirty-seven experts completed this round. RESULTS: Most important factors could be identified for each stage. Some factors were found important for a specific stage, e.g., the presence of intervention champions within the organization (adoption), provider knowledge (implementation), and the intervention's sustainability (continuation), while others were perceived important for all stages, i.e., the intervention's financial feasibility, the intervention's accessibility to the target group, and time to deliver the intervention. The majority of most important factors was perceived changeable. However, for some factors no consensus could be reached regarding their changeability. CONCLUSIONS: This study identified general and stage-specific factors relevant for the introduction of physical activity interventions in primary health care. It emphasizes the importance of taking these factors into account when designing introduction strategies, and of giving special attention to the distinct stages of the process. Due to lack of consensus on the changeability of most important factors, the extent to which these factors can be influenced by introduction strategies remains unclear.

Do major life events influence physical activity among older adults: the Longitudinal Aging Study Amsterdam.

BACKGROUND: Major life events are associated with a change in daily routine and could thus also affect habitual levels of physical activity. Major life events remain largely unexplored as determinants of older adults' participation in physical activity and sports. This study focused on two major life events, widowhood and retirement, and asked whether these major life events were associated with moderate to vigorous physical activity (MVPA) and sports participation. METHODS: Data from the first (1992-93) and second (1995-96) wave of the Longitudinal Aging Study Amsterdam (LASA), a prospective cohort study among Dutch adults aged 55 and older, were used. Change in marital status and employment status between baseline and follow-up was assessed by self-report. Time spent in MVPA (min/d) and sports participation (yes/no) was calculated based on the LASA Physical Activity Questionnaire. The association of retirement and widowhood with MVPA and sports participation was assessed in separate multivariate linear and logistic regression analyses, respectively. RESULTS: Widowhood - N=136 versus 1324 stable married- was not associated with MVPA (B= 3.5 [95%CI:-57.9;64.9]) or sports participation (OR= 0.8 [95%CI:0.5;1.3]). Retired participants (N= 65) significantly increased their time spent in MVPA (B= 32.5 [95%CI:17.8;47.1]) compared to participants who continued to be employed (N= 121), but not their sports participation. Age was a significant effect modifier (B= 7.5 [90%CI:-1.1;13.8]), indicating a greater increase in MVPA in older retirees. DISCUSSION: Our results suggest that the associations found varied by the two major life events under investigation. MVPA increased after retirement, but no association with widowhood was seen.

Changes in self-reported energy balance behaviours and body mass index during a mass media campaign.

BACKGROUND: Prevention of (serious) overweight can be achieved by means of small behaviour changes in physical activity and/or diet. OBJECTIVE: To evaluate a mass media campaign promoting energy balance behaviours in a Dutch population. Effects were examined for body mass index (BMI) and five energy balance behaviours. METHODS: A representative cohort study of 1200 Dutch adults was employed. Data were collected at four moments. Two campaign waves were launched, following T1 (targeting the general adult population) and T2 [targeting low socio-economic status (SES) men], respectively. Regression analyses were performed to estimate the short-term and long-term effects of campaign exposure. RESULTS: In total, data of 1030 participants (86%) were available. Time trends showed unfavourable changes in most but not all energy balances behaviour for the total sample. No differences were found for BMI. No differences in the outcome measures were found as a result of exposure to the first campaign (19%). A short-term effect of exposure to the second campaign (29% exposure) was found (T2-T3), but only for low SES respondents, with increases in the attention being paid towards food choice (P = 0.02). At long term, BMI was less likely to increase among exposed people with a non-Dutch ethnicity (P = 0.01, T2-T4). CONCLUSIONS: Exposure to the campaign was low. The first campaign wave had no effects on BMI and energy balance behaviours. Small but favourable changes in attention towards food choice and BMI for at-risk populations were observed among those exposed to the second campaign wave.

Eating style, overeating and weight gain. A prospective 2-year follow-up study in a representative Dutch sample.

This study examined which individuals are particularly at risk for developing overweight and whether there are behavioral lifestyle factors that may attenuate this susceptibility. A prospective study with a 2-year follow-up was conducted in a sample representative of the general population of The Netherlands (n=590). Body mass change (self-reported) was assessed in relation to overeating and change in physical activity (both self-reported), dietary restraint, emotional eating, and external eating, as assessed by the Dutch Eating Behavior Questionnaire. There was a consistent main (suppressive) effect of increased physical activity on BMI change. Only emotional eating and external eating moderated the relation between overeating and body mass change. However, the interaction effect of external eating became borderline significant with Yes or No meaningful weight gain (weight gain >3%) as dependent variable. It was concluded that whilst increasing physical activity may attenuate weight gain, particularly high emotional eaters seem at risk for developing overweight, because overconsumption seems to be more strongly related to weight gain in people with high degrees of emotional eating.

Determinants of physical activity and exercise in healthy older adults: a systematic review.

BACKGROUND: The health benefits of regular physical activity and exercise have been widely acknowledged. Unfortunately, a decline in physical activity is observed in older adults. Knowledge of the determinants of physical activity (unstructured activity incorporated in daily life) and exercise (structured, planned and repetitive activities) is needed to effectively promote an active lifestyle. Our aim was to systematically review determinants of physical activity and exercise participation among healthy older adults, considering the methodological quality of the included studies. METHODS: Literature searches were conducted in PubMed/Medline and PsycINFO/OVID for peer reviewed manuscripts published in English from 1990 onwards. We included manuscripts that met the following criteria: 1) population: community dwelling healthy older adults, aged 55 and over; 2) reporting determinants of physical activity or exercise. The outcome measure was qualified as physical activity, exercise, or combination of the two, measured objectively or using self-report. The methodological quality of the selected studies was examined and a best evidence synthesis was applied to assess the association of the determinants with physical activity or exercise. RESULTS: Thirty-four manuscripts reporting on 30 studies met the inclusion criteria, of which two were of high methodological quality. Physical activity was reported in four manuscripts, exercise was reported in sixteen and a combination of the two was reported in fourteen manuscripts. Three manuscripts used objective measures, twenty-two manuscripts used self-report measures and nine manuscripts combined a self-report measure with an objective measure. Due to lack of high quality studies and often only one manuscript reporting on a particular determinant, we concluded "insufficient evidence" for most associations between determinants and physical activity or exercise. CONCLUSIONS: Because physical activity was reported in four manuscripts only, the determinants of physical activity particularly need further study. Recommendations for future research include the use of objective measures of physical activity or exercise as well as valid and reliable measures of determinants.

Investigating the associations among overtime work, health behaviors, and health: a longitudinal study among full-time employees.

BACKGROUND: It has often been suggested that high levels of overtime lead to adverse health outcomes. One mechanism that may account for this association is that working overtime leads to elevated levels of stress, which could affect worker's behavioral decisions or habits (such as smoking and lack of physical activity). In turn, this could lead to adverse health. PURPOSE: The present study examined this reasoning in a prospective longitudinal design. Data from the prospective 2-year Study on Health at Work (N = 649) were used to test our hypotheses. METHODS: Structural equation analysis was used to examine the relationships among overtime, beneficial (exercising, intake of fruit and vegetables) and risky (smoking and drinking) health behaviors, and health indicators (BMI and subjective health). RESULTS: Working overtime was longitudinally related with adverse subjective health, but not with body mass. Moreover, working overtime was associated with lower levels of physical activity and intake of fruit and vegetables, but not with smoking and drinking. Finally, higher levels of risky and lower levels of beneficial health behaviors were longitudinally associated with ill health. CONCLUSIONS: The relation between overtime and ill health is partly accounted for by the unhealthy lifestyle in which overworkers tend to engage. However, a direct longitudinal effect of overtime on health suggested that the effects of overtime on health may also partly be due to the sustained physiological activation that results from working overtime. Whereas working a moderate amount of overtime does not usually entail major health risks, these will increase with increasing overtime.

Eating style, overeating, and overweight in a representative Dutch sample. Does external eating play a role?

This study examined which individuals in particular are susceptible or resistant to develop overweight in our current obesogenic environment. A cross-sectional study was conducted in a sample of 1342 people representative of the general population in the Netherlands. Overweight-level (normal body weight> or =17.5 BMI [weight in kilograms/height in meters squared, as self-reported] <25) versus overweight ((BMI> or =25)) and overeating, as measured by questionnaire, were assessed in relation to dietary restraint, emotional eating and external eating, as assessed with the Dutch Eating Behaviour Questionnaire. Both dietary restraint and emotional eating moderated the relationship between overconsumption and overweight, but that there was no (positive) main effect or moderator effect for external eating. It was concluded that dietary restraint may prevent people who overeat from getting overweight. An individual's final level of body weight may possibly be determined more by people's tendency toward emotional eating than by people's sensitivity to environmental food cues.

Web-based tailored lifestyle programs: exploration of the target group's interests and implications for practice.

An important challenge in Web-based health promotion is to increase the reach of the target audience by taking the target groups' desires into consideration. Data from 505 members of a Dutch Internet panel (representative for Dutch Internet users) were used to asses the target group's interests and needs. 28% participated in Web-based tailored lifestyle programs, 57% expressed an interest in such programs, and 15% expressed no interest. Interest in Web-based programs was predominantly caused by a general interest in lifestyle and online tests. Participation in Web-based tailored lifestyle programs should not take more than 17 minutes per occasion. 84% were interested in follow-up testing after the initial participation. Responders were particularly interested in physical activity and nutrition. Hardly anyone was willing to pay for participation. The results from this study support the use of Web-based tailored lifestyle programs in behavior change efforts.

Rates and determinants of repeated participation in a web-based behavior change program for healthy body weight and healthy lifestyle.

BACKGROUND: In recent years, many tailored lifestyle counseling programs have become available through the Internet. Previous research into such programs has shown selective enrollment of relatively healthy people. However, because of the known dose-response relationship between the intensity and frequency of counseling and the behavior change outcomes, selective retention may also be a concern. OBJECTIVE: The aim of this study was to identify rates and determinants of repeat participation in a Web-based health behavior change program. METHODS: A Web-based health behavior change program aimed to increase people's awareness of their own lifestyle, to promote physical activity, and to prevent overweight and obesity was available on the Internet from July 2004 onward at no cost. Univariate and multivariate logistic regression analyses were conducted to identify characteristics of people who participated in the program more than once. Age, compliance with physical activity guidelines, body mass index, smoking status, and the consumption of fruit, vegetables, and alcohol were included in the analyses. RESULTS: A total of 9774 people participated in the baseline test, of which 940 used the site more than once (9.6%). After exclusion of individuals with incomplete data, 6272 persons were included in the analyses. Of these 6272 people, 5560 completed only the baseline test and 712 also participated in follow-up. Logistic regression predicting repeated use determined that older individuals were more likely to participate in follow-up than people aged 15-20 years. The odds ratios for the age categories 41-50, 51-60, and > 60 years were 1.40 (95% CI = 1.02-1.91), 1.43 (95% CI = 1.02-2.01), and 1.68 (95% CI = 1.03-2.72), respectively. Individuals who never smoked were more likely to participate repeatedly than current smokers and ex-smokers (OR = 1.44, 95% CI = 1.14-1.82 and OR = 1.49, 95% CI = 1.17-1.89, respectively). People meeting the guidelines for physical activity of moderate intensity (OR = 1.23 95% CI = 1.04-1.46) and for vegetable consumption (OR = 1.26 95% CI = 1.01-1.57) were also more likely to participate repeatedly than people who did not, as were obese people compared to individuals with normal weight (OR = 1.41 95% CI = 1.09-1.82). CONCLUSIONS: For some variables, this study confirms our concern that behavioral intervention programs may reach those who need them the least. However, contrary to most expectations, we found that obese people were more likely to participate in follow-up than people of normal body weight. The non-stigmatizing way of addressing body weight through the Internet may be part of the explanation for this. Our findings suggest that Web-based health behavior change programs may be more successful in the area of weight management than in many other health-related areas. They also stress the importance of adequate coverage of weight management in Web-based health promotion programs, as a driver to continue participation for overweight and obese people.

GPs' assessment of patients' readiness to change diet, activity and smoking.

BACKGROUND: The Stages of Change Model is increasingly used for lifestyle counselling. In general practice, the use of algorithms to measure stage of change is limited, but for successful counselling it is important to know patients' readiness to change. AIM: To assess the accuracy of the assessment of patients' readiness to change fat consumption, physical activity, and smoking by GPs and general practice registrars. DESIGN OF STUDY: Cross-sectional questionnaire-based survey. SETTING: One hundred and ninety-nine patients at elevated cardiovascular risk aged 40-70 years, 24 GPs, and 21 registrars in Dutch general practices. METHOD: Patients were asked to complete an algorithm to measure their motivation to change fat consumption, physical activity, and smoking. GPs and registrars were given descriptions of the stages of change for the three lifestyles, and were asked to indicate the description that matched their patient. Cohen's kappa was calculated as measure of agreement between patients and GPs/registrars. RESULTS: Registrars' patients were younger, and less often overweight and hypertensive than GPs' patients. Cohen's kappa for smoking was moderate (0.50, 95% confidence interval [CI] = 0.34 to 0.67 for GPs and 0.47, CI = 0.27 to 0.68 for registrars). Agreement for fat and activity was poor to fair. No differences in accuracy were observed between GPs and registrars (P = 0.07-0.83). CONCLUSIONS: Low accuracy indicates that counselling in general practice is often targeted at the wrong people at the wrong time. Improvements can possibly be achieved by making registration of lifestyle parameters in patient records common practice, and by simply asking patients where they stand in respect to lifestyle change.

Factors associated with physical therapists' implementation of physical activity interventions in The Netherlands.

BACKGROUND: Physical therapists play an important role in the promotion of physical activity (PA) and the effectiveness of PA interventions. However, little is known about the extent to which they implement PA interventions following the intervention protocol and about the factors influencing their implementation behaviors. OBJECTIVE: The study objective was to investigate physical therapists' implementation fidelity regarding PA interventions, including completeness and quality of delivery, and influencing factors with a Theoretical Domains Framework-based questionnaire. DESIGN: The study was based on a cross-sectional design. METHODS: A total of 268 physical therapists completed the Determinants of Implementation Behavior Questionnaire. Questions about completeness and quality of delivery were based on components and tasks of PA interventions as described by the Royal Dutch Society for Physical Therapy. Multilevel regression analyses were used to identify factors associated with completeness and quality of delivery. RESULTS: High implementation fidelity was found for the physical therapists, with higher scores for completeness of delivery than for quality of delivery. Physical therapists' knowledge, skills, beliefs about capabilities and consequences, positive emotions, behavioral regulation, and the automaticity of PA intervention delivery were the most important predictors of implementation fidelity. Together, the Theoretical Domains Framework accounted for 23% of the variance in both total completeness and total quality scores. LIMITATIONS: The cross-sectional design precluded the determination of causal relationships. Also, the use of a self-report measure to assess implementation fidelity could have led to socially desirable responses, possibly resulting in more favorable ratings for completeness and quality. CONCLUSIONS: This study enhances the understanding of how physical therapists implement PA interventions and which factors influence their behaviors. Knowledge about these factors may assist in the development of strategies to improve physical therapists' implementation behaviors.

Nutrition guidance in Dutch family practice: behavioral determinants of reduction of fat consumption.

BACKGROUND: Studies have shown that the psychosocial determinants attitude, self-efficacy, subjective norm, and health threat are important in predicting intention to change fat consumption. However, the role of habit in relation to these determinants is still largely unknown. OBJECTIVE: We aimed to assess whether and how habit influences intention in relation to attitude, self-efficacy, subjective norm, and health threat. DESIGN: Cross-sectionally, we studied the self-reported psychosocial determinants and intention of 105 (52 intervention, 53 control) patients who participated in a family practice-based tailored nutrition counseling intervention study for lowering cardiovascular risk. Fat intake 15 mo before the assessment of psychosocial determinants was used as a measure of habit. We used logistic regression analyses to develop a model predicting intention to change fat consumption. RESULTS: Our regression model explained 43% of the variance in intention. Patients who perceived higher subjective norm or more social support had a higher intention. Habit was a significant predictor of intention in interaction with self-efficacy and health threat. Attitude, health threat, age, and group membership (ie, whether patients had been in the intervention group or the control group of the intervention study) were also included in the regression model. CONCLUSIONS: The results suggest that habit in addition to subjective norm and the other more frequently investigated psychosocial determinants are important in predicting intention to change fat consumption. To achieve sustainable health improvement through nutrition education programs, these programs should therefore start focusing more on subjective norm and habit.

Lifestyle, nutritional status, health, and mortality in elderly people across Europe: a review of the longitudinal results of the SENECA study.

This article provides an overview of the longitudinal Survey in Europe on Nutrition and the Elderly: a Concerted Action (SENECA) study, which was designed to assess differences in dietary and lifestyle factors among elderly Europeans, and to identify the factors that contribute to healthy aging. Elderly people from Belgium, Denmark, France, Italy, Portugal, Spain, Switzerland, and The Netherlands participated in the SENECA study. Standardized measurements were conducted at baseline in 1988-1989 and were repeated in 1993 and 1999. Diet, physical activity, and smoking, as well as maintenance of health and survival, were assessed. At baseline, considerable differences in lifestyle factors existed among elderly people. Mealtime patterns as well as dietary intake varied across Europe, and geographical patterns were apparent. Similar results were found for engagement in sport or professional activities. The smoking prevalence among women was generally low. Distinct geographical differences were also observed in percentages of deaths during the SENECA study and in overall survival time. A healthy lifestyle was related to stable self-perceived health, a delay in functional dependence, and mortality. Inactivity and smoking, and to a lesser extent a low-quality diet, increased mortality risk. A combined effect of multiple unhealthy lifestyle factors was also observed. The SENECA study showed that a healthy lifestyle at older ages is related to a delay in the deterioration of health status and a reduced mortality risk. Improving and maintaining a healthy lifestyle in elderly people across Europe is a great challenge for the European Community.

Stage-matched nutrition guidance: stages of change and fat consumption in Dutch patients at elevated cardiovascular risk.

OBJECTIVE: To assess the effects of stage-matched nutrition counseling on stages of change and fat intake. DESIGN: Controlled clinical trial. SETTING: 9 family practices in a family medicine practice network. PARTICIPANTS: 143 patients at elevated cardiovascular risk, aged 40 to 70 years. INTERVENTION: Intervention patients received stage-matched counseling from their family physician and a dietitian. Control patients received usual care. MAIN OUTCOME MEASURES: Stages of change and fat intake were measured at baseline and after 6 and 12 months. ANALYSIS: Chi-squared tests, t tests, and regression analyses (alpha = .05) were conducted. RESULTS: More patients in the intervention group than in the control group were in the postpreparation stage after 6 months (70% vs 35%; P < .01) but not after 12 months (70% vs 55%; P = .10). Between 0 and 12 months, the reduction in total fat intake (-5.6% kcal vs -2.4% kcal) was largest in the intervention group. CONCLUSIONS AND IMPLICATIONS: Stage-matched nutrition counseling promotes movement through stages of change, resulting in a reduced fat intake. Our results partly support stages of change as a tool for behavior change. Movement across stages of change was not an intermediating factor in the intervention effects. Research should focus on feasible ways to keep patients in the postpreparation stage.

Combinations of techniques that effectively change health behavior: evidence from Meta-CART analysis.

OBJECTIVE: Many health-promoting interventions combine multiple behavior change techniques (BCTs) to maximize effectiveness. Although, in theory, BCTs can amplify each other, the available meta-analyses have not been able to identify specific combinations of techniques that provide synergistic effects. This study overcomes some of the shortcomings in the current methodology by applying classification and regression trees (CART) to meta-analytic data in a special way, referred to as Meta-CART. The aim was to identify particular combinations of BCTs that explain intervention success. METHOD: A reanalysis of data from Michie, Abraham, Whittington, McAteer, and Gupta (2009) was performed. These data included effect sizes from 122 interventions targeted at physical activity and healthy eating, and the coding of the interventions into 26 BCTs. A CART analysis was performed using the BCTs as predictors and treatment success (i.e., effect size) as outcome. A subgroup meta-analysis using a mixed effects model was performed to compare the treatment effect in the subgroups found by CART. RESULTS: Meta-CART identified the following most effective combinations: Provide information about behavior-health link with Prompt intention formation (mean effect size g = 0.46), and Provide information about behavior-health link with Provide information on consequences and Use of follow-up prompts (g = 0.44). Least effective interventions were those using Provide feedback on performance without using Provide instruction (g = 0.05). CONCLUSIONS: Specific combinations of BCTs increase the likelihood of achieving change in health behavior, whereas other combinations decrease this likelihood. Meta-CART successfully identified these combinations and thus provides a viable methodology in the context of meta-analysis.

Measuring determinants of implementation behavior: psychometric properties of a questionnaire based on the theoretical domains framework.

BACKGROUND: To be able to design effective strategies to improve healthcare professionals' implementation behaviors, a valid and reliable questionnaire is needed to assess potential implementation determinants. The present study describes the development of the Determinants of Implementation Behavior Questionnaire (DIBQ) and investigates the reliability and validity of this Theoretical Domains Framework (TDF)-based questionnaire. METHODS: The DIBQ was developed to measure the potential behavioral determinants of the 12-domain version of the TDF (Michie et al., 2005). We identified existing questionnaires including items assessing constructs within TDF domains and developed new items where needed. Confirmatory factor analysis was used to examine whether the predefined structure of the TDF-based questionnaire was supported by the data. Cronbach's alpha was calculated to assess internal consistency reliability of the questionnaire, and domains' discriminant validity was investigated. RESULTS: We developed an initial questionnaire containing 100 items assessing 12 domains. Results obtained from confirmatory factor analysis and Cronbach's alpha resulted in the final questionnaire consisting of 93 items assessing 18 domains, explaining 63.3% of the variance, and internal consistency reliability values ranging from .68 to .93. Domains demonstrated good discriminant validity, although the domains 'Knowledge' and 'Skills' and the domains 'Skills' and 'Social/professional role and identity' were highly correlated. CONCLUSIONS: We have developed a valid and reliable questionnaire that can be used to assess potential determinants of healthcare professional implementation behavior following the theoretical domains of the TDF. The DIBQ can be used by researchers and practitioners who are interested in identifying determinants of implementation behaviors in order to be able to develop effective strategies to improve healthcare professionals' implementation behaviors. Furthermore, the findings provide a novel validation of the TDF and indicate that the domain 'Environmental context and resources' might be divided into several environment-related domains.

Respiratory morbidity and lung function in two Aboriginal communities in Western Australia.

OBJECTIVE: To examine differences in the rates of respiratory symptoms, asthma and levels of lung function in two remote Aboriginal communities. METHODOLOGY: Respiratory symptoms, smoking history, skin prick test responses to common allergens, serum IgE, lung function, airway responsiveness to methacholine and white blood cell counts were compared in two Aboriginal communities, one from the central desert (n = 84) and another from the tropical north (n = 209) of Western Australia. RESULTS: Compared with the tropical community, chest tightness and dyspnoea were more frequent and forced expiratory volume in 1 s and forced vital capacity were lower in the desert community, despite similar levels of wheeze, doctor-diagnosed asthma and skin prick test responses and lower levels of airway responsiveness and smoking. The total white cell and neutrophil counts were greater in the desert community. Serum IgE was very high and similar in both communities. CONCLUSIONS: Our findings show a low prevalence of asthma in children, a high prevalence of respiratory symptoms and low levels of lung function in remote Aboriginal communities. The greater prevalence of respiratory morbidity in the desert community was not explained by diagnosed asthma, airway hyperresponsiveness or cigarette smoking. The role of infection requires further investigation. The results suggest that the lower lung function observed in Aboriginal communities (compared with non-Aboriginal communities) results at least partly from environmental factors.