Enhanced Invitations Using the Question-Behavior Effect and Financial Incentives to Promote Health Check Uptake in Primary Care.

Background: Uptake of health checks for cardiovascular risk assessment in primary care in England is lower than anticipated. The question-behavior effect (QBE) may offer a simple, scalable intervention to increase health check uptake. Purpose: The present study aimed to evaluate the effectiveness of enhanced invitation methods employing the QBE, with or without a financial incentive to return the questionnaire, at increasing uptake of health checks. Methods: We conducted a three-arm randomized trial including all patients at 18 general practices in two London boroughs, who were invited for health checks from July 2013 to December 2014. Participants were randomized to three trial arms: (i) Standard health check invitation letter only; (ii) QBE questionnaire followed by standard invitation letter; or (iii) QBE questionnaire with offer of a financial incentive to return the questionnaire, followed by standard invitation letter. In intention to treat analysis, the primary outcome of completion of health check within 6 months of invitation, was evaluated using a p value of .0167 for significance. Results: 12,459 participants were randomized. Health check uptake was evaluated for 12,052 (97%) with outcome data collected. Health check uptake within 6 months of invitation was: standard invitation, 590 / 4,095 (14.41%); QBE questionnaire, 630 / 3,988 (15.80%); QBE questionnaire and financial incentive, 629 / 3,969 (15.85%). Difference following QBE questionnaire, 1.43% (95% confidence interval -0.12 to 2.97%, p = .070); following QBE questionnaire and financial incentive, 1.52% (-0.03 to 3.07%, p = .054). Conclusions: Uptake of health checks following a standard invitation was low and not significantly increased through enhanced invitation methods using the QBE.

Is there a role for patients and their relatives in escalating clinical deterioration in hospital? A systematic review.

BACKGROUND: Measures exist to improve early recognition of, and response to, deteriorating patients in hospital. However, deteriorating patients continue to go unrecognized. To address this, interventions have been developed that invite patients and relatives to escalate patient deterioration to a rapid response team (RRT). OBJECTIVE: To systematically review articles that describe these interventions and investigate their effectiveness at reducing preventable deterioration. SEARCH STRATEGY: Following PRISMA guidelines, four electronic databases and two web search engines were searched to identify literature investigating patient and relative led escalation. INCLUSION CRITERIA: Articles investigating the implementation or use of systems involving patients and relatives in the detection of clinical patient deterioration and escalation of patient care to address any clinical or non-clinical outcomes were included. Articles' eligibility was validated by a second reviewer (20%). DATA EXTRACTION: Data were extracted according to pre-defined criteria. DATA SYNTHESIS: Narrative synthesis was applied to included studies. MAIN RESULTS: Nine empirical studies and 36 grey literature articles were included in the review. Limited studies were conducted to establish the clinical effectiveness of patient and relative led escalation. Instead, studies investigated the impact of this intervention on health-care staff and available resources. Although appropriate, this reflects the infancy of research in this area. Patients and relatives did not overwhelm resources by activating the RRT. However, they did activate it to address concerns unrelated to patient deterioration. CONCLUSIONS: Activating a RRT may not be the most appropriate or cost-effective method of resolving non-life-threatening concerns.

Enhanced invitation methods and uptake of health checks in primary care: randomised controlled trial and cohort study using electronic health records.

BACKGROUND: A national programme of health checks to identify risk of cardiovascular disease (CVD) is being rolled out but is encountering difficulties because of low uptake. OBJECTIVE: To evaluate the effectiveness of an enhanced invitation method using the question-behaviour effect (QBE), with or without the offer of a financial incentive to return the QBE questionnaire, at increasing the uptake of health checks. The research went on to evaluate the reasons for the low uptake of invitations and compare the case mix for invited and opportunistic health checks. DESIGN: Three-arm randomised trial and cohort study. PARTICIPANTS: All participants invited for a health check from 18 general practices. Individual participants were randomised. INTERVENTIONS: (1) Standard health check invitation only; (2) QBE questionnaire followed by a standard invitation; and (3) QBE questionnaire with offer of a financial incentive to return the questionnaire, followed by a standard invitation. MAIN OUTCOME MEASURES: The primary outcome was completion of the health check within 6 months of invitation. A p-value of 0.0167 was used for significance. In the cohort study of all health checks completed during the study period, the case mix was compared for participants responding to invitations and those receiving 'opportunistic' health checks. Participants were not aware that several types of invitation were in use. The research team were blind to trial arm allocation at outcome data extraction. RESULTS: In total, 12,459 participants were included in the trial and health check uptake was evaluated for 12,052 participants for whom outcome data were collected. Health check uptake was as follows: standard invitation, 590 out of 4095 (14.41%); QBE questionnaire, 630 out of 3988 (15.80%); QBE questionnaire and financial incentive, 629 out of 3969 (15.85%). The increase in uptake associated with the QBE questionnaire was 1.43% [95% confidence interval (CI) -0.12% to 2.97%; p = 0.070] and the increase in uptake associated with the QBE questionnaire and offer of financial incentive was 1.52% (95% CI -0.03% to 3.07%; p = 0.054). The difference in uptake associated with the offer of an incentive to return the QBE questionnaire was -0.01% (95% CI -1.59% to 1.58%; p = 0.995). During the study period, 58% of health check cardiovascular risk assessments did not follow a trial invitation. People who received an 'opportunistic' health check had greater odds of a ≥ 10% CVD risk than those who received an invited health check (adjusted odds ratio 1.70, 95% CI 1.45 to 1.99; p < 0.001). CONCLUSIONS: Uptake of a health check following an invitation letter is low and is not increased through an enhanced invitation method using the QBE. The offer of a £5 incentive did not increase the rate of return of the QBE questionnaire. A high proportion of all health checks are performed opportunistically and not in response to a standard invitation letter. Participants receiving opportunistic checks are at higher risk of CVD than those responding to standard invitations. Future research should aim to increase the accessibility of preventative medical interventions to increase uptake. Research should also explore the wider use of electronic health records in delivering efficient trials. TRIAL REGISTRATION: Current Controlled Trials ISRCTN42856343. FUNDING: This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 84. See the NIHR Journals Library website for further project information.

A Web-Based and Mobile Health Social Support Intervention to Promote Adherence to Inhaled Asthma Medications: Randomized Controlled Trial.

BACKGROUND: Online communities hold great potential as interventions for health, particularly for the management of chronic illness. The social support that online communities can provide has been associated with positive treatment outcomes, including medication adherence. There are few studies that have attempted to assess whether membership of an online community improves health outcomes using rigorous designs. OBJECTIVE: Our objective was to conduct a rigorous proof-of-concept randomized controlled trial of an online community intervention for improving adherence to asthma medicine. METHODS: This 9-week intervention included a sample of asthmatic adults from the United Kingdom who were prescribed an inhaled corticosteroid preventer. Participants were recruited via email and randomized to either an "online community" or "no online community" (diary) condition. After each instance of preventer use, participants (N=216) were required to report the number of doses of medication taken in a short post. Those randomized to the online community condition (n=99) could read the posts of other community members, reply, and create their own posts. Participants randomized to the no online community condition (n=117) also posted their medication use, but could not read others' posts. The main outcome measures were self-reported medication adherence at baseline and follow-up (9 weeks postbaseline) and an objective measure of adherence to the intervention (visits to site). RESULTS: In all, 103 participants completed the study (intervention: 37.8%, 39/99; control: 62.2%, 64/117). MANCOVA of self-reported adherence to asthma preventer medicine at follow-up was not significantly different between conditions in either intention-to-treat (P=.92) or per-protocol (P=.68) analysis. Site use was generally higher in the control compared to intervention conditions. CONCLUSIONS: Joining an online community did not improve adherence to preventer medication for asthma patients. Without the encouragement of greater community support or more components to sustain engagement over time, the current findings do not support the use of an online community to improve adherence. CLINICALTRIAL: International Standard Randomized Controlled Trial Number (ISRCTN): 29399269; http://www.isrctn.com/ISRCTN29399269/29399269 (Archived by WebCite at http://www.webcitation.org/6fUbEuVoT).

Partner- and planning-based interventions to reduce fat consumption: randomized controlled trial.

OBJECTIVE: The research tested the efficacy of partner- and planning-based interventions to reduce dietary fat intake over a 6-month period. DESIGN: Randomized controlled, blinded, parallel trial. METHODS: A computer randomization feature was used to allocate council employees (N = 427, of which 393 completed baseline measures) to one of four conditions (partner + implementation intentions, partner-only, implementation intentions, and control group) before they completed measures at baseline and follow-ups at 1, 3, and 6 months post-baseline. Outcome measures were comprised of validated self-report measures of dietary fat intake (saturated fat intake, fat intake, ratio of 'good' fats to 'bad' fats); psychosocial mediators (enjoyment, intention, self-efficacy, social influence, partner support); weight and waist size (baseline and 6 months only). RESULTS: Data from 393 participants were analysed in accordance with intention-to-treat analyses. All intervention groups reported greater reductions in fat intake than the control group at 3 months. The partner-based groups increased the ratio of 'good' fats to 'bad' fats at 3 and 6 months and lost more inches on their waist, versus the non-partner groups. The impacts of the partner-based manipulations on outcomes were partially mediated by greater perceived social influences, partner support, and enjoyment of avoiding high-fat foods. The partner-based interventions also increased intention and self-efficacy. However, the effects in this study were typically small and generally marginally significant. CONCLUSIONS: Partner-based interventions had some positive benefits on dietary-related outcomes at 3 and 6 months. Support for implementation intentions was more limited.

Development and validation of the Online Self-reported Walking and Exercise Questionnaire (OSWEQ).

BACKGROUND: Precise measurement of physical activity (PA) is required to identify current levels and changes in PA within a population, and to gauge effectiveness of interventions. METHODS: The Online Self-reported Walking and Exercise Questionnaire (OSWEQ) was developed for monitoring PA via the Web. Forty-nine participants (mean ± SD; age = 27 ± 11.9 yrs) completed the OSWEQ and International PA Questionnaire (IPAQ) short form 3 times [T1/T2/T3 (separated by 7-days)] and wore an Actigraph-GT3X-accelerometer for 7-days between T2-T3. For each measure, estimates of average MET·min·day(-1) and time spent in moderate PA (MPA), vigorous PA (VPA) and moderate and vigorous PA (MVPA) were obtained. RESULTS: The OSWEQ and IPAQ demonstrated test-retest reliability for MPA, VPA, and MVPA minutes and average MET·min·day(-1) between T1-T2 (OSWEQ range, r = .71-.77; IPAQ range, r = .59-.79; all, P < .01). The OSWEQ and IPAQ, compared with the GT3X, had lower estimates (mean error ± 95% PI) of MVPA MET·min·day(-1) by 150.4 ± 477.6 and 247.5 ± 477.5, respectively. CONCLUSIONS: The OSWEQ demonstrates good test-retest reliability over 7-days and better group level estimates of MET·min·day(-1) than the IPAQ, compared with the GT3X. These results suggest that the OSWEQ is a reliable and valid measure among young/working age adults and could be useful for monitoring PA trends over time.

Randomized controlled trial of collaborative implementation intentions targeting working adults' physical activity.

OBJECTIVE: The research tested the efficacy of planning and partner-based interventions to promote physical activity over six months. METHOD: Local government (council) employees (N = 257) were randomly allocated to one of four conditions (collaborative implementation intentions; partner-only; implementation intentions; control group) before completing measures at baseline and follow-ups at 1, 3 and 6 months. Outcome measures comprised validated self-report measures of physical activity: the international physical activity questionnaire (IPAQ; Craig et al., 2003) and self-report walking and exercise tables (SWET; Prestwich et al., 2012); psychosocial mediators (enjoyment, intention, self-efficacy, social influence); weight and waist size (baseline and 6 months only). RESULTS: As well as losing the most weight, there was evidence that participants in the collaborative implementation-intention group were more physically active than each of the other three groups at 1-, 3- and 6-month follow-ups. Those in the implementation-intention and partner-only conditions did not outperform the control group on most measures. CONCLUSION: Collaborative implementation intentions represent a potentially useful intervention to change important health behaviors that help reduce weight.

Reasons for binge drinking among undergraduate students: An application of behavioural reasoning theory.

OBJECTIVES: This study sought to apply behavioural reasoning theory (BRT) to the prediction of undergraduate students' binge drinking intentions and behaviour. The reasons students use to justify and defend binge drinking may provide important information on motivations underlying such behaviour. METHODS: Undergraduate students (N= 265) completed questionnaires assessing their reasons for and against binge drinking, attitude, subjective norm, perceived behavioural control, intention, and past behaviour. Frequency of binge drinking was assessed at 1-week follow-up (N= 172). RESULTS: A series of path analyses were conducted to assess the direct and indirect effects of the BRT variables on binge drinking intentions and behaviour. The variables under consideration accounted for 80% of the variance in binge drinking intentions (with past behaviour, reasons for binge drinking, and attitude having significant direct effects on intention), and 34% of the variance in binge drinking at 1-week follow-up (with past behaviour, perceived behavioural control, and intention having significant direct effects on future behaviour). Additional regression analyses revealed that respondents who strongly endorsed being sociable and having fun as reasons for binge drinking were more likely to intend to engage in binge drinking over the subsequent week. CONCLUSIONS: The results provide support for BRT as a framework for understanding undergraduate students' binge drinking intentions and behaviour, and suggest that interventions need to focus on the social reasons for engaging in binge drinking in undergraduate students.

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

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

Insight into sight, touch, taste and smell by multiple discriminations from norm.

The paper presents an innovative theory of perception of multiple features across and within modalities. Each step is illustrated by an aspect of data from diverse experiments. The theory is that a template or norm of previously configurated features is used to perceive an object in a situation, such as consuming an item of food or drink. A mouthful usually stimulates sight first and then touch, taste and smell, with thermal, irritative, kinaesthetic and auditory patterns often also involved. The visual information also typically includes meanings of words, numbers and pictures. Attended sensory and symbolic features of the situation are integrated by the individual into a multidimensional distance from the norm. Dimensions are calibrated in units of the response's discrimination between levels of each stimulus feature. This approach to perceptual performance is expounded for sensed and/or conceived visual features of drinks and foods, and their tasted or smelt constituents, or felt and heard cracking during a bite. In addition, the conceptual process that informs an analytical judgment can influence another judgment. Applying the concept to a stimulus forms a descriptive process. A concept may also be applied to another concept or to a description, giving greater depth of meaning to an integrative judgment. Furthermore, a description can be applied to an environmental source of stimulation, creating a percept that presumably is conscious, whereas unconceptualised stimulation may be subconscious.

A network-individual-resource model for HIV prevention.

HIV is transmitted through dyadic exchanges of individuals linked in transitory or permanent networks of varying sizes. A theoretical perspective that bridges key individual level elements with important network elements can be a complementary foundation for developing and implementing HIV interventions with outcomes that are more sustainable over time and have greater dissemination potential. Toward that end, we introduce a Network-Individual-Resource (NIR) model for HIV prevention that recognizes how exchanges of resources between individuals and their networks underlies and sustains HIV-risk behaviors. Individual behavior change for HIV prevention, then, may be dependent on increasing the supportiveness of that individual's relevant networks for such change. Among other implications, an NIR model predicts that the success of prevention efforts depends on whether the prevention efforts (1) prompt behavior changes that can be sustained by the resources the individual or their networks possess; (2) meet individual and network needs and are consistent with the individual's current situation/developmental stage; (3) are trusted and valued; and (4) target high HIV-prevalence networks.

Study protocol: a cluster randomised controlled trial of a school based fruit and vegetable intervention - Project Tomato.

BACKGROUND: The School Fruit and Vegetable Scheme (SFVS) is an important public health intervention. The aim of this scheme is to provide a free piece of fruit and/or vegetable every day for children in Reception to Year 2. When children are no longer eligible for the scheme (from Year 3) their overall fruit and vegetable consumption decreases back to baseline levels. This proposed study aims to design a flexible multi-component intervention for schools to support the maintenance of fruit and vegetable consumption for Year 3 children who are no longer eligible for the scheme. METHOD: This study is a cluster randomised controlled trial of Year 2 classes from 54 primary schools across England. The schools will be randomly allocated into two groups to receive either an active intervention called Project Tomato, to support maintenance of fruit intake in Year 3 children, or a less active intervention (control group), consisting of a 5 A DAY booklet. Children's diets will be analysed using the Child And Diet Evaluation Tool (CADET), and height and weight measurements collected, at baseline (Year 2) and 18 month follow-up (Year 4). The primary outcome will be the ability of the intervention (Project Tomato) to maintain consumption of fruit and vegetable portions compared to the control group. DISCUSSION: A positive result will identify how fruit and vegetable consumption can be maintained in young children, and will be useful for policies supporting the SFVS. A negative result would be used to inform the research agenda and contribute to redefining future strategies for increasing children's fruit and vegetable consumption. TRIAL REGISTRATION: Medical Research Council Registry code G0501297.

Relations between implicit and explicit measures of attitudes and measures of behavior: evidence of moderation by individual difference variables.

The moderating role of individual difference variables (Self-Reported Habit Index [SRHI], Need for Cognition [NFC]) on relationships between implicit (Implicit Association Test [IAT], Extrinsic Affective Simon Test [EAST]) or explicit measures of attitude and behavior is assessed in two studies. A dissociation pattern is found on self-report diary measures of behavior. In Study 1, the EAST-behavior relationship is moderated by SRHI; explicit measures of the attitude-behavior relationship are moderated by NFC. In Study 2, the IAT-behavior relationship is moderated by SRHI; explicit measures of the attitude-behavior relationship are moderated by NFC. Higher levels of SRHI and NFC are associated with stronger relationships between the implicit or explicit measures of attitude and the measure of behavior. In Study 2, the SRHI x IAT interaction is replicated for an objective behavior measure. Implications for understanding the relationship between implicit and explicit measures of attitudes and measures of behavior are discussed.

Promoting adherence to antibiotics: a test of implementation intentions.

OBJECTIVE: This prospective study tested whether implementation intentions increased adherence to short-term antibiotics in a patient sample. Implementation intentions specify exactly when and where an individual will undertake an activity. They may help people achieve health behaviours, such as taking medicines. METHODS: A total of 220 patients with an antibiotics prescription were randomly assigned to four groups (control, Theory of Planned Behaviour (TPB) questionnaire, TPB questionnaire+formed own implementation intention for taking the medicine, TPB questionnaire+researcher formed implementation intention). Participants were telephoned at the end of the course to record adherence. Two hundred and seven participants completed the study. RESULTS: At follow-up, adherence was high (75.8% reported no tablets left). Analysis revealed no significant difference in adherence between groups. CONCLUSION: High adherence to antibiotics was achieved, but not improved by implementation intentions. PRACTICE IMPLICATIONS: Providing information and telephone follow-up may have been the unintended effective intervention in this study.

Barriers to healthy eating amongst men: a qualitative analysis.

Currently, little is known about the meanings men attach to food or to the links between food and health. The burgeoning literature on men's health highlights forms of masculinity (e.g. risk-taking, invulnerability) as a factor (negatively) influencing men's health practices. The aim of this study was to provide an analysis of men's accounts of food and health using concepts pertaining to masculinity. We report on a qualitative analysis of a dataset comprising 24 interviews with UK men from a range of age and social class groups. Our findings suggest two principal barriers to healthy eating in men: cynicism about government health messages and a rejection of healthy food on grounds of poor taste and inability to satisfy. These findings are discussed in relation to masculine ideals such as rationality, autonomy and strength. The implications of our analysis for future research and men's health promotion policy are discussed.

Relation between breakfast food choices and knowledge of dietary fat and fiber among Swedish schoolchildren.

PURPOSE: To investigate dietary knowledge and beliefs of schoolchildren, in relationship to breakfast choices, with specific attention to fat and fiber content. METHODS: Food choice and perceptions were studied by interviews using the "stacking box methodology". Youth (n = 181) aged 11-15 years were instructed to select food items among photographs of breakfast foods. In addition to choosing their own typical breakfasts, they were asked to exchange foods in hypothetical breakfasts to create meals with less fat and more fiber. The interview also dealt with recent changes in breakfast habits, and perceptions of healthy breakfasts, dietary fat, and foods rich in fiber. Data were analyzed by logistic regression. RESULTS: Knowledge concerning sources and health attributes of dietary fiber was associated with usual consumption of bread and breakfast cereals rich in fiber. In a similar way, a positive attitude toward limited fat intake predicted consumption of reduced-fat milk products. However, no association was observed between food choices and knowledge of a food-packaging symbol indicating low-fat and fiber-enriched foods. CONCLUSION: Lack of awareness of, and knowledge about, healthy eating may be important barriers to the development of health promoting food habits by schoolchildren.