[DNVF Memorandum: Objectives and Methods of Physical Activity-Related Health Services Research]. / DNVF Memorandum ­ Ziele und Methoden bewegungsbezogener Versorgungsforschung.

The DNVF Memorandum: Objectives and Methods of Physical Activity-Related Health Services Research summarizes, for the first time, the highly interdisciplinary and interprofessional field of physical activity-based health care in the German healthcare system. In addition to providing a conceptual framework and definition of key measures and concepts in physical activity-related health care research, existing research gaps and needs are identified, and methods for advancing this relatively young field of research are described. A particular focus of this study is the relevant outcome parameters and their standardized assessment using established and valid measurement tools. The memorandum aims to establish a general understanding of the complex subject of promoting physical activity and sports therapy in the context of healthcare, to give an impulse to new research initiatives, and to integrate the currently available strong evidence on the effectiveness of physical activity and exercise into healthcare.

Development, implementation and formative evaluation of a motivational-volitional intervention to promote sustainable physical activity in breast cancer survivors.

OBJECTIVE: The aim of the current project was the development, implementation and evaluation of the programme, Motivational-Volitional Intervention-Movement After Breast Cancer (Mo-Vo-BnB), an intervention for the sustainable promotion of physical activity of breast cancer survivors. METHODS: In a multi-stage interdisciplinary development process, the pedagogical-didactic, psychological and physical evidence-based programme was developed and implemented for women after breast cancer who were approved for medical rehabilitation and were minimally, physically active (<60 min/week). Train-the-trainer seminars were carried out for the implementation. Four sessions were implemented in two German clinics. The training quality, didactic methods and accompanying material were evaluated 6 weeks and 12 months after implementation by patients, trainers and project members (n = 127 evaluations). RESULTS: The standardised and published MoVo-BnB programme can provide practical and quality training. Content and methods can be implemented according to the manual. Training quality, didactic methods, and accompanying materials were evaluated positively. CONCLUSION: The results suggest that MoVo-BnB is a useful standardised intervention for promoting the physical activity of breast cancer survivors. The demonstrated process is also suitable for other projects. CLINICAL TRIAL REGISTRATION: German Clinical Trials Register (DRKS): DRKS00011122; Trial registration date: 2016 October 13.

Supporting patient adherence to physical activity and exercise: evaluation of a behavior change counseling training program for physiotherapists.

BACKGROUND: Physiotherapists promote physical activity and exercise, yet patient adherence is often poor. To support patient adherence, behavior change techniques (BCTs) should be applied. These are insufficiently covered in physiotherapy curricula. OBJECTIVE: The aim of this study was to evaluate a behavior change counseling training program for physiotherapists. The specific aims were to investigate: (1) physiotherapists' satisfaction with the training; (2) changes in physiotherapists' knowledge of BCTs and communication techniques immediately after the training and 6 weeks later; and (3) changes in physiotherapists' self-reported use of these techniques 6 weeks after the training. METHODS: We conducted a single-group pre-post intervention study. Data of 56 physiotherapists (47 female, mean age 48.0 years) who participated in the training program "BeFo" (German: "Bewegungstherapie-Fortbildungen") were analyzed. Knowledge of BCTs and communication techniques, intention to apply these techniques, action and coping planning were assessed at baseline (t1), after the training (t2), and 6 weeks later (t3) using questionnaires. Participants' satisfaction was evaluated at t2, their use of BCTs and communication techniques at t1 and t3. RESULTS: Fifty-four participants (96.4%) were satisfied with BeFo. One-way repeated-measures ANOVAs and Friedman's ANOVA revealed increased knowledge (Chi2(2) = 28.12, p < .001) and improved action planning (F(2, 98) = 22.65; p < .001) and coping planning (F(2, 100) = 19.28, p < .001) at t2 and t3. Higher use of BCTs and communication techniques at t3 was identified when participants with high baseline values were excluded. CONCLUSION: BeFo could be successfully implemented for physiotherapists. Our results imply that BeFo is a promising approach to improve physiotherapists' behavior change counseling skills.

[A Motivational-Volitional Program for Women after Breast Cancer Increases Physical Activity 12 Months Post Rehabilitation - Results of a Prospective Controlled Trial]. / Ein motivational-volitionales Programm für Frauen nach Brustkrebs verbessert die sportliche Aktivität 12 Monate nach der Rehabilitation ­ Ergebnisse einer prospektiven kontrollierten Studie.

PURPOSE: To assess the effectiveness of a motivational-volitional program for women after breast cancer (MoVo-BnB) who engage less than 60 minutes per week in physical activity. METHODS: This is a non-randomised, prospective bi-centered controlled trial in 2 in-patient medical rehabilitation centers. Data are assessed at 4 measurement points: at admission, discharge, 6 and 12 months post discharge. The control group (CG; n=266) has received the standard rehabilitation, and the intervention group (IG; n=279) attended additionally the group program (4 sessions lead by physiotherapeutic and health pedagogic personnel). The primary outcome is self-reported physical activity (BSA-F); secondary outcomes are health related quality of life (QLQ-C30), breast cancer specific quality of health (QLQ-BR23) and program acceptance. Analysis of change are performed by ANCOVA for each follow-up, adjusting for baseline values. RESULTS: At 12 months follow up, the level of exercise in the intervention group is 22 min/week higher than in the control group (95% CI: 2,6 to 41.5; p=0.02). Further, 49.1% of the intervention group exercises for at least 60 min/week compared to 37.6% of the control group (p≤0.01). We have observed no significant differences between the groups for quality of life. The participants' evaluation of the intervention is positive and does not differ substantially between the 2 clinics (p=0.3). CONCLUSION: Our findings demonstrate that a cognitive-behavioral program based on the motivation-volitional model can lead to long-term improvement in exercise behavior in breast cancer patients, who is initially minimally active. Physical activity should be encouraged after breast cancer diagnosis. The results suggest that practitioners working in cancer aftercare might like to consider using a motivational-volitional program for improving and maintaining physical activity behavior for physical sedentary target groups.

Effects of a workplace physical activity intervention on cognitive determinants of physical activity: a randomized controlled trial.

OBJECTIVE: The present randomized controlled trial evaluated if a workplace physical activity (PA) program that comprises both a PA component and a psychological coaching component (PA + C) is more effective in changing cognitive determinants of PA than a PA program without coaching component. Design:N = 213 employees were cluster-randomly assigned to two groups: the PA + C group received the MoVo-work intervention, combining a psychological coaching component and a PA component. The PA group received the PA component without psychological coaching. Main Outcome Measures: Strength of goal intention, self-efficacy, outcome expectations, action planning and barrier management were assessed at five time points (before and at the end of the intervention, as well as 6 weeks, 6 months and 12 months after the intervention). Results: After six weeks and one year, respectively, the PA + C group showed significantly higher goal intentions (p = .018) and self-efficacy beliefs (p = .006) than the PA group; and, at a descriptive level, a clear tendency towards better barrier management. Conclusions: The results indicate that a workplace PA program, including psychological coaching, may partially improve the effects of a pure PA program on critical motivational and volitional determinants of PA behavioural change among employees.

A group- and smartphone-based psychological intervention to increase and maintain physical activity in patients with musculoskeletal conditions: study protocol for a randomized controlled trial ("MoVo-App").

BACKGROUND: Interventions designed to increase the level of physical activity are crucial in the treatment of patients with musculoskeletal conditions. The psychological group-based intervention MoVo-LISA based on the Motivation-Volition (MoVo) Process Model has been shown to effectively promote physical activity. The aim of this study is to evaluate whether a MoVo-based app (MoVo-App) subsequent to MoVo-LISA during orthopedic inpatient care can support people to increase and maintain their amount of physical activity. METHODS/DESIGN: In this parallel-group randomized controlled trial, patients with musculoskeletal disorders will be randomized to either (a) a combination of the group-based intervention program MoVo-LISA to promote physical activity plus the MoVo-App or (b) the group-based intervention program alone without the app. The intervention group will receive the MoVo-App after discharge from inpatient rehabilitation. They receive help to increase and maintain their level of physical activity (initiated by the group program) by tracking their health goals, activity plans, major barriers, and barrier management that were developed during the group-based program. We will recruit 224 initially minimally active participants during orthopedic rehabilitation care. Outcomes are assessed at clinic admission; discharge; 6 weeks; and 3 (post-treatment), 6, and 12 months after discharge (follow-up). The primary outcome is sport activity (active/inactive and minutes of activity) at 6-month follow-up. Secondary outcomes are movement activity, cognitive mediators of behavioral change (e.g., self-efficacy, action planning), and health-related variables (e.g., pain intensity, depression). To evaluate intervention effects, linear mixed effects models (both on intention-to-treat basis with an additional per-protocol analysis) will be conducted with each outcome variable and with time as the within-subjects factor and group as the between-subjects factor, along with all two-way interactions and accounting for covariates as fixed effects. DISCUSSION: This is the first evaluation of the effectiveness of an app in combination with a face-to-face group intervention to promote physical activity. The approach of using an app in addition to an effective face-to-face intervention program, both based on the MoVo model, might sustain positive intervention effects introduced in routine health care. TRIAL REGISTRATION: The trial "A group- and smartphone-based psychological intervention to increase physical activity in patients with musculoskeletal conditions: A randomized controlled trial" is registered at the World Health Organization International Clinical Trials Registry Platform via the German Clinical Studies Trial Register (DRKS), DRKS00014814. Registered on 18 October 2018; URL: https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00014814.

[Cross-sectional study on skin tears in fragile, aging skin: nursing deficits in a common problem in Germany]. / Querschnittstudie zu Skin Tears in fragiler Altershaut.

Cross-sectional study on skin tears in fragile, aging skin: nursing deficits in a common problem in Germany Abstract. Background: Skin tears are internationally classified as a common phenomenon in elderly people. Methods of prevention, early detection, classification, and specific treatment of skin tears are internationally established. Up to now skin tears have received little attention in Germany, and the present state of studies is insufficient. Aim: The aim of this study was to reveal for the first time the nurses' perspective in Germany concerning skin tears. Methods: A cross-sectional design was conducted in an online survey to ask general and geriatric nurses about frequency, classification systems, terminology, risk factors, prevention, and treatment methods concerning skin tears. Results: With 137 completely answered questionnaires, persons from various nursing disciplines and regions were reached. The incidence of skin tears was rated by 83.2 % of the respondents as common or very common, whereas 37 different terms for skin tears had been used. Numerous risk factors and methods of prevention were named; however, classification systems are hardly known. Knowledge about dressings is partially inadequate. Conclusions: An explicit and standard terminology for the phenomenon "skin tear" as well as the utilization of international classification systems are urgently needed in Germany. Evidence-based treatment and prevention should become standard in Germany. Beginning in nursing school and nursing college, specific education and counselling must be established for nurses as well as for patients and their caregivers.

Exercise promotion in physiotherapy: A qualitative study providing insights into German physiotherapists' practices and experiences.

BACKGROUND: Although exercise promotion is a central task of physiotherapists, there is limited evidence about physiotherapists' experiences with exercise promotion and their promotion practices. OBJECTIVES: To investigate how physiotherapists working in outpatient settings in Germany promote exercise and to explore their experiences with and views on exercise promotion. DESIGN: Qualitative study with semi-structured interviews. METHODS: We conducted qualitative semi-structured interviews with a purposive sample of physiotherapists. Data were analysed following Mayring's content analytical approach using deductive and inductive methods. Physiotherapists' methods of exercise promotion were classified using the behaviour change technique (BCT) taxonomy by Michie and colleagues. Further categories were formed in an inductive manner. RESULTS: Six female and three male physiotherapists (age: 21-55 years, professional experience: 0.5-31 years) were interviewed. We identified the use of 17 distinct BCTs across the interviews (6-13 per interview), most commonly goal setting (behaviour), instruction on how to perform a behaviour and behavioural practice/rehearsal. Four inductive main categories were formed: "barriers and challenges", "facilitators", "responsibilities" and "dealing with setbacks". Lack of patient interest and motivation was named as a main challenge. While the therapists feel responsible for instructing exercise, not all of them regard it as their role to motivate patients. Resistance or lacking compliance lead therapists to either apply strategies to proceed or quit exercise promotion. CONCLUSIONS: Our research implies substantial individual differences in exercise promotion between therapists. A more consistent approach, more competencies to support unmotivated patients as well as a clearer definition of physiotherapists' role in exercise promotion might be needed.

Effectiveness of a motivational-volitional group intervention to increase physical activity among breast cancer survivors compared to standard medical rehabilitation-Study protocol of a prospective controlled bi-centred interventional trial.

Despite proven benefits of regular physical activity, the majority of breast cancer survivors do not meet recommended physical activity guidelines. The Motivation-Volition (MoVo) Concept was designed to help people to set up and maintain a health-enhancing lifestyle. Studies have proven the short- and long-term efficacy of the MoVo intervention programmes. The intervention consists of four group sessions (60 min). The sessions contain informational parts, structured training in setting goals, planning exercises, problem-solving, single person working and group discussion. We apply a sequential control group design in two inpatient rehabilitation facilities to evaluate the effect of a motivational-volitional group intervention compared to standard rehabilitation. Our target groups are inactive women after breast cancer. Primary outcome is the amount of physical activity per week. Secondary outcomes include physical functioning, fatigue and depression. 800 patients diagnosed with breast cancer on medical rehabilitation will be included, 400 participants per clinic and group. Participants will be assessed by questionnaires upon clinic arrival, before discharge and six and twelve months after discharge. The study will provide evidence on the effect of a MoVo group intervention for physical inactive women after breast cancer. Positive results may have an impact on long-term improvement in exercise behaviour and health status.

Behaviour change techniques applied in interventions to enhance physical activity adherence in patients with chronic musculoskeletal conditions: A systematic review and meta-analysis.

OBJECTIVE: To identify Behaviour Change Techniques (BCTs) applied in interventions to enhance physical activity (PA) adherence in patients with chronic musculoskeletal conditions and to investigate the effectiveness of these interventions in increasing PA adherence. METHODS: A systematic search of seven databases was conducted. We included (cluster/quasi-) randomised controlled trials comparing behaviour change interventions to no/placebo/minimal interventions or usual care and involving at least a three-month post-intervention follow-up. Methodological quality was assessed, study characteristics and BCTs were narratively summarised and a meta-analysis was conducted. RESULTS: Across 22 included studies, we coded 8-18 BCTs (mean = 11.2) in intervention and 0-12 (mean = 3.5) in control groups. Common BCTs were "graded tasks", "goal setting", "self-monitoring", "problem solving" and "feedback". Meta-analyses of 17 studies revealed a small medium-term effect (3-6 months post-intervention, standardised mean difference (SMD) = 0.20, 95% CI 0.08-0.33) and no long-term effect (7-12 months post-intervention, SMD = 0.13, 95% CI -0.02 to 0.28). Subgroup analysis yielded a higher effect (SMD = 0.29, 95% CI 0.19-0.40) for interventions using a greater number of BCTs. CONCLUSION: There is moderate quality evidence that interventions using BCTs are effective to enhance medium-term physical activity adherence. PRACTICE IMPLICATION: While superiority of single BCTs was not shown, it is likely that using more BCTs results in better adherence.

[Low-Intensity Interventions to Reduce Depressive Symptoms before Outpatient Psychotherapy - A Systematic Literature Review]. / Niedrigintensive Interventionen zur Reduktion depressiver Symptome vor Beginn einer ambulanten Psychotherapie.

Psychotherapeutic resources are limited, leading to prolonged waiting periods prior to outpatient psychotherapy. Low-intensity interventions have the potential to bridge such treatment gaps. This systematic review aims to identify interventions targeting depressive symptoms implemented prior to outpatient psychotherapy, and to assess their effectiveness and acceptance. 22 studies were identified. Interventions were classified as active waiting, self-help, guided self-help, brief single-strand interventions, and low-intensity psychotherapy. Evidence of intervention effectiveness is limited; intervention acceptance varies between interventions. The resulting classification illustrates a range of innovative interventions which can be implemented into routine care depending on existing resources and preferences. Different models for the provision of low-intensity interventions are discussed.

Effects of a Sports-Oriented Primary School on Students' Physical Literacy and Cognitive Performance.

As only a small group of children fulfil the guidelines for physical activity, interventions are necessary to promote active lifestyles. We examined the effects of a sports-oriented primary school (N = 79) in comparison to a regular primary school (N = 90) on students' physical literacy and cognitive performance. To evaluate the implementation of the sports-oriented school curriculum a process evaluation was conducted, in which the school curriculum was analysed and guideline-based interviews were carried out with the schoolteachers and the school director. To measure students' physical literacy and cognitive performance several tests were used. Small positive effects of the sports-oriented primary school on students' physical literacy were shown in standing long jump and attitudes towards physical activity. There were no differences between the groups regarding cognitive performance. This study provides the first insights on how a sports-oriented school can promote students' physical literacy in the future. The results are in line with previous research that shows that when children spend more time in physical education and overall physical activities at school, no negative consequences result for their cognitive performance. In future, long-term evaluations of the effects of sports-oriented schools are required to receive valid results on the effects on students.

The two sides of goal intentions: Intention self-concordance and intention strength as predictors of physical activity.

OBJECTIVE: The present research introduces an extended conceptualisation of self-concordance, which is considered an attribute not only of goals, but also of goal intentions. Based on a corresponding operationalisation, we investigate the interplay of both intention strength and intention self-concordance in the prediction of physical activity. DESIGN: Data were taken from a longitudinal study of 134 obese people who were asked to fill out a questionnaire three times every six months. MAIN MEASURES: Physical activity and intention self-concordance were measured by validated scales. Intentions strength was assessed by an item typically employed in the extant literature. RESULTS: Logistic regression analyses and path analyses showed both intention strength and self-concordance to be significant predictors of changes in physical activity over time. Additional analyses found self-efficacy to be a significant predictor of intention strength and self-concordance; for outcome expectations this was not the case. CONCLUSIONS: Findings support the idea that intention strength and self-concordance are two critical facets of a goal intention that need to be considered in the prediction of physical activity participation. Whereas intention strength refers to the degree of determination with which a goal intention is adopted, self-concordance rather captures the quality of this intention.

Increasing physical activity in patients with mental illness--A randomized controlled trial.

OBJECTIVE: The objective of the study was to evaluate whether a motivational-volitional intervention program offered in addition to an existing sport program during stationary treatment is capable of establishing a post-stationary increase in physical activity in persons with mental illness. METHODS: N=112 in-patients were initially randomly assigned to the control group (CG; standard rehabilitation) or intervention group (IG; standard rehabilitation plus intervention). Assessments were conducted at four measurement points. RESULTS: At 6 months follow up, the level of exercise in the IG was 95 min/week higher than in the CG (p=.02). The participants of the IG were able to increase their level of goal intention until 6 months follow up (t2: p=.03; t4: p=.005); levels of self-efficacy of the IG increased during intervention (t2: p=.001). Changes in volitional aspects were significant over time (t1-t3), but not specifically for the IG. CONCLUSIONS: The intervention was effective at increasing the level of physical activity in patients with mental illness who were initially minimally active. PRACTICE IMPLICATIONS: Our results suggest that it could be of great use to place the emphasis of a physical activity-enhancing intervention on its motivational effect since volitional aspects are already taken into sufficient account in standard rehabilitation.

Two-year follow-up of an interdisciplinary cognitive-behavioral intervention program for obese adults.

Intervention programs for treating adiposity which focus on dietary change and physical exercise often do not lead to the desired long-term reduction in weight. This article reports on the effectiveness of M.O.B.I.L.I.S., a standardized theory-driven intervention program. Participants are taught cognitive-behavioral strategies of goal setting, action planning, barrier management, and self-monitoring. Persons with obesity (N=316) responded to a public advertisement to participate in the intervention program (IG) or comparison group (CG; quasi-experimental design). Assessments were conducted at four time points, with the last assessment being conducted two years after baseline. At the 24-month follow-up, the IG showed weight loss of 5.57%, whereas the CG lost 1.12% of their weight (t1-t4, p < .01). The results yielded significant interaction terms (group x time), indicating that the intervention had a substantial effect on food choice and level of physical exercise (p < .01). The IG showed significantly enhanced self-efficacy, stronger goal intentions, and more detailed implementation intentions than the CG at follow-ups. The intervention program has the potential to evoke enduring changes in the cognitions we hypothesized to be responsible for inducing obese adults to begin and continue regular exercise and healthy eating behavior, resulting in substantial weight loss.

Cognitive mediation of intervention effects on physical exercise: causal models for the adoption and maintenance stage.

OBJECTIVE: To investigate how the effects of a group-based intervention program (MoVo-LISA) on exercise behaviour were mediated by cognitive variables. Different causal models mapping the short-term (adoption) and long-term (maintenance) intervention effects were tested using path analyses. DESIGN: N = 220 in-patients of a rehabilitation clinic were assigned to an usual care or intervention group (quasi-experimental design). Questionnaire-based assessment was conducted at baseline; discharge; and at six weeks, six months and 12 months post discharge. MEASURES: The potential mediator variables were outcome expectations, self-efficacy, strength of goal intention (intention strength), self-concordance, action planning and barrier management. RESULTS: Observed intervention effects on exercise behaviour (p < 0.05) were mediated by intention strength at the adoption and maintenance stages, by action planning only at the adoption, and by barrier management only at the maintenance stage. Self-efficacy and outcome expectations were only indirectly involved in these mediations by affecting intention strength and self-concordance. CONCLUSION: This is the first study to track the cognitive mediation processes of intervention effects on exercise behaviour over a long time-period by differentiating the adoption and maintenance stages of behaviour change. The findings emphasise the importance of deconstructing intervention effects (modifiability vs. predictive power of a mediator) to develop more effective interventions.

Changes in self-regulatory cognitions as predictors of changes in smoking and nutrition behaviour.

Most longitudinal, correlational studies on health-behaviour change examine effects of Time1 social-cognitive predictors on subsequent behaviour. In contrast, our research focuses on associations between changes in predictors with change in behaviour. The Health Action Process Approach (HAPA) distinguishes between motivational predictors for intention formation and volitional predictors for behavioural change and served as theoretical basis. Two online-studies were launched targeting different behaviours (low-fat diet, smoking), different samples (Study 1: N = 469; Study 2: N = 441) and different time spans (Study 1: 3 months, Study 2: 4 weeks). Data were analysed by means of structural equation modelling with latent difference scores. Both studies resulted in almost parallel prediction patterns. Change in risk awareness and change in outcome expectancies did not result in change in intentions, whereas change in self-efficacy was of crucial importance. Change in behaviour was associated with change in action planning and action control over and above the effects of intentions. In one study, increases in self-efficacy yielded increases in behaviour change. Results demonstrate that change in action planning and especially action control was of great importance for behaviour change across two different behaviours. Analysing change in social-cognitive predictors allows drawing precise conclusions for interventions.

Preventing chronic back pain: evaluation of a theory-based cognitive-behavioural training programme for patients with subacute back pain.

OBJECTIVE: For long-term treatment effects, patients with subacute back pain need to adhere to treatment recommendations beyond the prescribed exercise treatment. Adherence rates are as low as 30%, so we developed a cognitive-behavioural training programme to enhance patients' self-efficacy, maximise severity perceptions and reduce barrier perceptions. METHOD: A 2 x 4 (group x time) repeated measurement design was applied. Forty-seven patients with non-specific, subacute back pain were randomly assigned to a training group (exercise treatment plus cognitive-behavioural training programme) or a control group (exercise treatment only). RESULTS: Repeated measures ANOVA revealed significant main and interaction effects; the training group reported enhanced self-efficacy and severity perceptions, reduced barrier perceptions, and self-reported that they exercised more often than the control group over time. However, no group differences regarding pain intensity emerged. CONCLUSION: Our findings demonstrate that a short and inexpensive cognitive-behavioural training programme is an effective tool to enable back pain patients to follow treatment recommendations on a regular basis. PRACTICE IMPLICATIONS: The short and simple intervention can easily be conducted by personnel, other than psychologists, i.e., physiotherapists.