Redesigning walking brochures using behaviour change theory: implications for walking intentions in natural environments.

Natural environments can be used to promote health through facilitating recreational walking. However, efforts to encourage this often neglect messages identified in psychological research that are effective at influencing intentions to walk. This is despite the National Institute for Health and Care Excellence stating that promotional efforts should utilize theoretical frameworks of behaviour change and be targeted towards less active adults. As an illustrative example, this experiment compared a prototypical recreational walking brochure with an "enhanced" version including such persuasive messages on people's intentions to walk for recreation in natural environments. The enhanced brochure heightened intentions for inexperienced recreational walkers through our hypothesized mechanisms, but appeared to dissuade already-experienced walkers. Optimal messaging strategies in recreational walking brochures require tailoring to more and less active readerships. Guidelines are provided for authors of recreational walking brochures, though the principles and techniques could easily be extended to other means of outdoor walking promotion.

Exercise interventions for smoking cessation.

BACKGROUND: Taking regular exercise, whether cardiovascular-type exercise or resistance exercise, may help people to give up smoking, particularly by reducing cigarette withdrawal symptoms and cravings, and by helping to manage weight gain. OBJECTIVES: To determine the effectiveness of exercise-based interventions alone, or combined with a smoking cessation programme, for achieving long-term smoking cessation, compared with a smoking cessation intervention alone or other non-exercise intervention. SEARCH METHODS: We searched the Cochrane Tobacco Addiction Group Specialised Register for studies, using the term 'exercise' or 'physical activity' in the title, abstract or keywords. The date of the most recent search was May 2019. SELECTION CRITERIA: We included randomised controlled trials that compared an exercise programme alone, or an exercise programme as an adjunct to a cessation programme, with a cessation programme alone or another non-exercise control group. Trials were required to recruit smokers wishing to quit or recent quitters, to assess abstinence as an outcome and have follow-up of at least six months. DATA COLLECTION AND ANALYSIS: We followed standard Cochrane methods. Smoking cessation was measured after at least six months, using the most rigorous definition available, on an intention-to-treat basis. We calculated risk ratios (RRs) and 95% confidence intervals (CIs) for smoking cessation for each study, where possible. We grouped eligible studies according to the type of comparison, as either smoking cessation or relapse prevention. We carried out meta-analyses where appropriate, using Mantel-Haenszel random-effects models. MAIN RESULTS: We identified 24 eligible trials with a total of 7279 adult participants randomised. Two studies focused on relapse prevention among smokers who had recently stopped smoking, and the remaining 22 studies were concerned with smoking cessation for smokers who wished to quit. Eleven studies were with women only and one with men only. Most studies recruited fairly inactive people. Most of the trials employed supervised, group-based cardiovascular-type exercise supplemented by a home-based exercise programme and combined with a multi-session cognitive behavioural smoking cessation programme. The comparator in most cases was a multi-session cognitive behavioural smoking cessation programme alone. Overall, we judged two studies to be at low risk of bias, 11 at high risk of bias, and 11 at unclear risk of bias. Among the 21 studies analysed, we found low-certainty evidence, limited by potential publication bias and by imprecision, comparing the effect of exercise plus smoking cessation support with smoking cessation support alone on smoking cessation outcomes (RR 1.08, 95% CI 0.96 to 1.22; I2 = 0%; 6607 participants). We excluded one study from this analysis as smoking abstinence rates for the study groups were not reported. There was no evidence of subgroup differences according to the type of exercise promoted; the subgroups considered were: cardiovascular-type exercise alone (17 studies), resistance training alone (one study), combined cardiovascular-type and resistance exercise (one study) and type of exercise not specified (two studies). The results were not significantly altered when we excluded trials with high risk of bias, or those with special populations, or those where smoking cessation intervention support was not matched between the intervention and control arms. Among the two relapse prevention studies, we found very low-certainty evidence, limited by risk of bias and imprecision, that adding exercise to relapse prevention did not improve long-term abstinence compared with relapse prevention alone (RR 0.98, 95% CI 0.65 to 1.47; I2 = 0%; 453 participants). AUTHORS' CONCLUSIONS: There is no evidence that adding exercise to smoking cessation support improves abstinence compared with support alone, but the evidence is insufficient to assess whether there is a modest benefit. Estimates of treatment effect were of low or very low certainty, because of concerns about bias in the trials, imprecision and publication bias. Consequently, future trials may change these conclusions.

Video-calls to reduce loneliness and social isolation within care environments for older people: an implementation study using collaborative action research.

BACKGROUND: Older people in care may be lonely with insufficient contact if families are unable to visit. Face-to-face contact through video-calls may help reduce loneliness, but little is known about the processes of engaging people in care environments in using video-calls. We aimed to identify the barriers to and facilitators of implementing video-calls for older people in care environments. METHODS: A collaborative action research (CAR) approach was taken to implement a video-call intervention in care environments. We undertook five steps of recruitment, planning, implementation, reflection and re-evaluation, in seven care homes and one hospital in the UK. The video-call intervention 'Skype on Wheels' (SoW) comprised a wheeled device that could hold an iPad and handset, and used Skype to provide a free video-call service. Care staff were collaborators who implemented the intervention within the care-setting by agreeing the intervention, recruiting older people and their family, and setting up video-calls. Field notes and reflective diaries on observations and conversations with staff, older people and family were maintained over 15 months, and analysed using thematic analysis. RESULTS: Four care homes implemented the intervention. Eight older people with their respective social contacts made use of video-calls. Older people were able to use SoW with assistance from staff, and enjoyed the use of video-calls to stay better connected with family. However five barriers towards implementation included staff turnover, risk averseness, the SoW design, lack of family commitment and staff attitudes regarding technology. CONCLUSIONS: The SoW intervention, or something similar, could aid older people to stay better connected with their families in care environments, but if implemented as part of a rigorous evaluation, then co-production of the intervention at each recruitment site may be needed to overcome barriers and maximise engagement.

Web-Based Intervention Using Behavioral Activation and Physical Activity for Adults With Depression (The eMotion Study): Pilot Randomized Controlled Trial.

BACKGROUND: Physical activity is a potentially effective treatment for depression and depressive relapse. However, promoting physical activity in people with depression is challenging. Interventions informed by theory and evidence are therefore needed to support people with depression to become more physically active. eMotion is a Web-based intervention combining behavioral activation and physical activity promotion for people in the community with symptoms of depression. OBJECTIVE: The objectives were to assess the feasibility and acceptability of delivering eMotion to people in the community with symptoms of depression and to explore outcomes. METHODS: Participants with elevated depressive symptoms were recruited from the community through various methods (eg, social media) and randomized to eMotion or a waiting list control group for 8 weeks. eMotion is an administratively supported weekly modular program that helps people use key behavior change techniques (eg, graded tasks, action planning, and self-monitoring) to re-engage in routine, pleasurable, and necessary activities, with a focus on physical activities. Feasibility data were collected that included the following: recruitment and trial retention rates; fidelity of intervention delivery, receipt, and enactment; and acceptability of the intervention and data collection procedures. Data were collected for the primary (depression) and secondary outcomes (eg, anxiety, physical activity, fidelity, and client satisfaction) at baseline and 2 months postrandomization using self-reported Web-based questionnaires and accelerometers. Delivery fidelity (logins, modules accessed, time spent) was tracked using Web usage statistics. Exploratory analyses were conducted on the primary and secondary outcomes. RESULTS: Of the 183 people who contacted the research team, 62 were recruited and randomized. The mean baseline score was 14.6 (SD 3.2) on the 8-item Patient Health Questionnaire depression scale (PHQ-8). Of those randomized, 52 participants provided accelerometer-recorded physical activity data at baseline that showed a median of 35.8 (interquartile range [IQR] 0.0-98.6) minutes of moderate-to-vigorous physical activity (MVPA) recorded in at least 10-minute bouts per week, with only 13% (7/52) people achieving guideline levels (150 minutes of MVPA per week). In total, 81% (50/62) of participants provided follow-up data for the primary outcome (PHQ-8), but only 39% (24/62) provided follow-up accelerometer data. Within the intervention group, the median number of logins, modules accessed, and total minutes spent on eMotion was 3 (IQR 2.0-8.0), 3 (IQR 2.0-5.0), and 41.3 (IQR 18.9-90.4), respectively. Acceptability was mixed. Exploratory data analysis showed that PHQ-8 levels were lower for the intervention group than for the control group at 2 months postrandomization (adjusted mean difference -3.6, 95% CI -6.1 to -1.1). CONCLUSIONS: It was feasible to deliver eMotion in UK communities to inactive populations. eMotion has the potential to be effective and is ready for testing in a full-scale trial. Further work is needed to improve engagement with both the intervention and data collection procedures. TRIAL REGISTRATION: ClinicalTrials.gov NCT03084055; https://clinicaltrials.gov/ct2/show/NCT03084055 (Archived by WebCite at http://www.webcitation.org/6zoyM8UXa).

How do brochures encourage walking in natural environments in the UK? A content analysis.

Although walking for leisure can support health, there has been little systematic attempt to consider how recreational walking is best promoted. In the UK, local authorities create promotional materials for walking networks, but little is known about whether they effectively encourage walking through persuasive messaging. Many of these materials pertain to walks in natural environments which evidence suggests are generally visited less frequently by physically inactive individuals. Consequently the present study explores whether and how recreational walking brochures use persuasive messages in their promotion of walks in natural environments. A coding taxonomy was developed to classify text in recreational walking brochures according to five behavioural content areas and 87 categories of potentially persuasive messages. Reliability of the taxonomy was ascertained and a quantitative content analysis was applied to 26 brochures collected from Devon, UK. Brochures often provided information about an advertised route, highlighted cultural and aesthetic points of interest, and provided directions. Brochures did not use many potentially effective messages. Text seldom prompted behaviour change or built confidence for walking. Social norm related information was rarely provided and there was a general lack of information on physical activity and its benefits for health and well-being. The limited range of message strategies used in recreational walking brochures may not optimally facilitate walking in natural environments for inactive people. Future research should examine the effects of theory-informed brochures on walking intentions and behaviour. The taxonomy could be adapted to suit different media and practices surrounding physical activity in natural environments.

Assessment of fidelity in individual level behaviour change interventions promoting physical activity among adults: a systematic review.

BACKGROUND: Behaviour change interventions that promote physical activity have major implications for health and well-being. Measuring intervention fidelity is crucial in determining the extent to which an intervention is delivered as intended, therefore increasing scientific confidence about effectiveness. However, we lack a clear overview of how well intervention fidelity is typically assessed in physical activity trials. METHODS: A systematic literature search was conducted to identify peer - reviewed physical activity promotion trials that explicitly measured intervention fidelity. Methods used to assess intervention fidelity were categorised, narratively synthesised and critiqued using assessment criteria from NIH Behaviour Change Consortium (BCC) Treatment Fidelity Framework (design, training, delivery, receipt and enactment). RESULTS: Twenty eight articles reporting of twenty one studies used a wide variety of approaches to measure intervention fidelity. Delivery was the most common domain of intervention fidelity measured. Approaches used to measure fidelity across all domains varied from researcher coding of observational data (using checklists or scales) to participant self-report measures. There was considerable heterogeneity of methodological approaches to data collection with respect to instruments used, attention to psychometric properties, rater-selection, observational method and sampling strategies. CONCLUSIONS: In the field of physical activity interventions, fidelity measurement is highly heterogeneous both conceptually and methodologically. Clearer articulation of the core domains of intervention fidelity, along with appropriate measurement approaches for each domain are needed to improve the methodological quality of fidelity assessment in physical activity interventions. Recommendations are provided on how this situation can be improved.

Exercise interventions for smoking cessation.

BACKGROUND: Taking regular exercise may help people give up smoking by moderating nicotine withdrawal and cravings, and by helping to manage weight gain. OBJECTIVES: To determine whether exercise-based interventions alone, or combined with a smoking cessation programme, are more effective than a smoking cessation intervention alone. SEARCH METHODS: We searched the Cochrane Tobacco Addiction Group Specialized Register in April 2014, and searched MEDLINE, EMBASE, PsycINFO, and CINAHL Plus in May 2014. SELECTION CRITERIA: We included randomized trials which compared an exercise programme alone, or an exercise programme as an adjunct to a cessation programme, with a cessation programme (which we considered the control in this review). Studies were required to recruit smokers or recent quitters and have a follow-up of six months or more. Studies that did not meet the full inclusion criteria because they only assessed the acute effects of exercise on smoking behaviour, or because the outcome was smoking reduction, are summarised but not formally included. DATA COLLECTION AND ANALYSIS: We extracted data on study characteristics and smoking outcomes. Because of differences between studies in the characteristics of the interventions used we summarized the results narratively, making no attempt at meta-analysis. We assessed risk of selection and attrition bias using standard methodological procedures expected by The Cochrane Collaboration. MAIN RESULTS: We identified 20 trials with a total of 5,870 participants. The largest study was an internet trial with 2,318 participants, and eight trials had fewer than 30 people in each treatment arm. Studies varied in the timing and intensity of the smoking cessation and exercise programmes offered. Only one included study was judged to be at low risk of bias across all domains assessed. Four studies showed significantly higher abstinence rates in a physically active group versus a control group at end of treatment. One of these studies also showed a significant benefit for exercise versus control on abstinence at the three-month follow-up and a benefit for exercise of borderline significance (p = 0.05) at the 12-month follow-up. Another study reported significantly higher abstinence rates at six month follow-up for a combined exercise and smoking cessation programme compared with brief smoking cessation advice. One study showed significantly higher abstinence rates for the exercise group versus a control group at the three-month follow-up but not at the end of treatment or 12-month follow-up. The other studies showed no significant effect for exercise on abstinence. AUTHORS' CONCLUSIONS: Only two of the 20 trials offered evidence for exercise aiding smoking cessation in the long term. All the other trials were too small to reliably exclude an effect of intervention, or included an exercise intervention which may not have been sufficiently intense to achieve the desired level of exercise. Trials are needed with larger sample sizes, sufficiently intense interventions in terms of both exercise intensity and intensity of support being provided, equal contact control conditions, and measures of exercise adherence and change in physical activity in both exercise and comparison groups.

Selective advantage of mutant stem cells in human clonal hematopoiesis is associated with attenuated response to inflammation and aging.

Clonal hematopoiesis (CH) arises when hematopoietic stem cells (HSCs) acquire mutations, most frequently in the DNMT3A and TET2 genes, conferring a competitive advantage through mechanisms that remain unclear. To gain insight into how CH mutations enable gradual clonal expansion, we used single-cell multi-omics with high-fidelity genotyping on human CH bone marrow (BM) samples. Most of the selective advantage of mutant cells occurs within HSCs. DNMT3A- and TET2-mutant clones expand further in early progenitors, while TET2 mutations accelerate myeloid maturation in a dose-dependent manner. Unexpectedly, both mutant and non-mutant HSCs from CH samples are enriched for inflammatory and aging transcriptomic signatures, compared with HSCs from non-CH samples, revealing a non-cell-autonomous effect. However, DNMT3A- and TET2-mutant HSCs have an attenuated inflammatory response relative to wild-type HSCs within the same sample. Our data support a model whereby CH clones are gradually selected because they are resistant to the deleterious impact of inflammation and aging.

Effectiveness of a motivational interviewing intervention on weight loss, physical activity and cardiovascular disease risk factors: a randomised controlled trial with a 12-month post-intervention follow-up.

BACKGROUND: Intensive diet and physical activity interventions have been found to reduce cardiovascular disease (CVD) risk, but are resource intensive. The American Heart Association recently recommended motivational interviewing (MI) as an effective approach for low-intensity interventions to promote health-related outcomes such as weight loss. However, there is limited research evaluating the long-term effectiveness of MI-based interventions on health-related outcomes associated with CVD risk. The current research evaluated the effectiveness of a six-month low-intensity MI intervention in a UK primary-care setting in maintaining reductions in CVD risk factors at12 months post-intervention. METHODS: Primary-care patients were randomised to an intervention group that received standard exercise and nutrition information plus up to five face-to-face MI sessions, delivered by a physical activity specialist and registered dietician over a 6-month period, or to a minimal intervention comparison group that received the standard information only. Follow-up measures of behavioural (vigorous and moderate physical activity, walking, physical activity stage-of-change, fruit and vegetable intake, and dietary fat intake) and biomedical (weight, body mass index [BMI], blood pressure, cholesterol) outcomes were taken immediately post-intervention and at a 12-month follow-up occasion. RESULTS: Intent-to-treat analyses revealed significant differences between groups for walking and cholesterol. Obese and hypercholesterolemic patients at baseline exhibited significant improvements in BMI and cholesterol respectively among those allocated to the intervention group compared to the comparison group. Post-intervention improvements in other health-related outcomes including blood pressure, weight, and BMI were not maintained. CONCLUSIONS: The present study suggests that a low-intensity MI counselling intervention is effective in bringing about long-term changes in some, but not all, health-related outcomes (walking, cholesterol levels) associated with CVD risk. The intervention was particularly effective for patients with elevated levels of CVD risk factors at baseline. Based on these findings future interventions should be conducted in a primary care setting and target patients with high risk of CVD. Future research should investigate how the long-term gains in health-related outcomes brought about by the MI-counselling intervention in the current study could be extended to a wider range of health outcomes.

A brisk walk, compared with being sedentary, reduces attentional bias and chocolate cravings among regular chocolate eaters with different body mass.

Poor self-regulation of high energy snacking has been linked to weight gain. Physical activity can acutely reduce chocolate consumption and cravings but the effects on attentional bias (AB) are unknown. The study aimed to test the effects of exercise among normal and overweight/obese individuals during temporary and longer abstinence. Participants were 20 normal and 21 overweight regular female chocolate eaters (after 24 h abstinence), and 17 females (after ≥1 week abstinence during Lent). They were randomly assigned to engage in 15 min brisk walking or rest, on separate days. AB was assessed using an adapted dot probe task pre and post-treatment at each session, with chocolate/neutral paired images presented for 200 ms (initial AB; IAB) or 1000 ms (maintained AB; MAB). Chocolate craving was assessed pre, during, immediately after, and 5 min and 10 min after treatment, using a 0-100 visual analogue score. Three-way mixed ANOVAs revealed that there was no significant interaction effect between group (i.e., BMI status, or abstinence status) and condition × time for craving and AB to chocolate cues. Fully repeated 2-way ANOVAS revealed a significant condition × time interaction for IAB (F(1,57)=6.39) and chocolate craving (F(2.34,133.19)=14.44). After exercise IAB (t(57)=2.78, p<0.01) was significantly lower than after the rest condition. Craving was significantly lower than the rest condition at all assessments post-baseline. A short bout of physical activity reduces cravings and AB to chocolate cues, relative to control, irrespective of BMI or abstinence period.

Effectiveness and cost-effectiveness of behavioural support for prolonged abstinence for smokers wishing to reduce but not quit: Randomised controlled trial of physical activity assisted reduction of smoking (TARS).

AIMS: For smokers unmotivated to quit, we assessed the effectiveness and cost-effectiveness of behavioural support to reduce smoking and increase physical activity on prolonged abstinence and related outcomes. DESIGN: A multi-centred pragmatic two-arm parallel randomised controlled trial. SETTING: Primary care and the community across four United Kingdom sites. PARTICIPANTS: Nine hundred and fifteen adult smokers (55% female, 85% White), recruited via primary and secondary care and the community, who wished to reduce their smoking but not quit. INTERVENTIONS: Participants were randomised to support as usual (SAU) (n = 458) versus multi-component community-based behavioural support (n = 457), involving up to eight weekly person-centred face-to-face or phone sessions with additional 6-week support for those wishing to quit. MEASUREMENTS: Ideally, cessation follows smoking reduction so the primary pre-defined outcome was biochemically verified 6-month prolonged abstinence (from 3-9 months, with a secondary endpoint also considering abstinence between 9 and 15 months). Secondary outcomes included biochemically verified 12-month prolonged abstinence and point prevalent biochemically verified and self-reported abstinence, quit attempts, number of cigarettes smoked, pharmacological aids used, SF12, EQ-5D and moderate-to-vigorous physical activity (MVPA) at 3 and 9 months. Intervention costs were assessed for a cost-effectiveness analysis. FINDINGS: Assuming missing data at follow-up implied continued smoking, nine (2.0%) intervention participants and four (0.9%) SAU participants achieved the primary outcome (adjusted odds ratio, 2.30; 95% confidence interval [CI] = 0.70-7.56, P = 0.169). At 3 and 9 months, the proportions self-reporting reducing cigarettes smoked from baseline by ≥50%, for intervention versus SAU, were 18.9% versus 10.5% (P = 0.009) and 14.4% versus 10% (P = 0.044), respectively. Mean difference in weekly MVPA at 3 months was 81.6 minutes in favour of the intervention group (95% CI = 28.75, 134.47: P = 0.003), but there was no significant difference at 9 months (23.70, 95% CI = -33.07, 80.47: P = 0.143). Changes in MVPA did not mediate changes in smoking outcomes. The intervention cost was £239.18 per person, with no evidence of cost-effectiveness. CONCLUSIONS: For United Kingdom smokers wanting to reduce but not quit smoking, behavioural support to reduce smoking and increase physical activity improved some short-term smoking cessation and reduction outcomes and moderate-to-vigorous physical activity, but had no long-term effects on smoking cessation or physical activity.

Motivational support intervention to reduce smoking and increase physical activity in smokers not ready to quit: the TARS RCT.

Background: Physical activity can support smoking cessation for smokers wanting to quit, but there have been no studies on supporting smokers wanting only to reduce. More broadly, the effect of motivational support for such smokers is unclear. Objectives: The objectives were to determine if motivational support to increase physical activity and reduce smoking for smokers not wanting to immediately quit helps reduce smoking and increase abstinence and physical activity, and to determine if this intervention is cost-effective. Design: This was a multicentred, two-arm, parallel-group, randomised (1 : 1) controlled superiority trial with accompanying trial-based and model-based economic evaluations, and a process evaluation. Setting and participants: Participants from health and other community settings in four English cities received either the intervention (n = 457) or usual support (n = 458). Intervention: The intervention consisted of up to eight face-to-face or telephone behavioural support sessions to reduce smoking and increase physical activity. Main outcome measures: The main outcome measures were carbon monoxide-verified 6- and 12-month floating prolonged abstinence (primary outcome), self-reported number of cigarettes smoked per day, number of quit attempts and carbon monoxide-verified abstinence at 3 and 9 months. Furthermore, self-reported (3 and 9 months) and accelerometer-recorded (3 months) physical activity data were gathered. Process items, intervention costs and cost-effectiveness were also assessed. Results: The average age of the sample was 49.8 years, and participants were predominantly from areas with socioeconomic deprivation and were moderately heavy smokers. The intervention was delivered with good fidelity. Few participants achieved carbon monoxide-verified 6-month prolonged abstinence [nine (2.0%) in the intervention group and four (0.9%) in the control group; adjusted odds ratio 2.30 (95% confidence interval 0.70 to 7.56)] or 12-month prolonged abstinence [six (1.3%) in the intervention group and one (0.2%) in the control group; adjusted odds ratio 6.33 (95% confidence interval 0.76 to 53.10)]. At 3 months, the intervention participants smoked fewer cigarettes than the control participants (21.1 vs. 26.8 per day). Intervention participants were more likely to reduce cigarettes by ≥ 50% by 3 months [18.9% vs. 10.5%; adjusted odds ratio 1.98 (95% confidence interval 1.35 to 2.90] and 9 months [14.4% vs. 10.0%; adjusted odds ratio 1.52 (95% confidence interval 1.01 to 2.29)], and reported more moderate-to-vigorous physical activity at 3 months [adjusted weekly mean difference of 81.61 minutes (95% confidence interval 28.75 to 134.47 minutes)], but not at 9 months. Increased physical activity did not mediate intervention effects on smoking. The intervention positively influenced most smoking and physical activity beliefs, with some intervention effects mediating changes in smoking and physical activity outcomes. The average intervention cost was estimated to be £239.18 per person, with an overall additional cost of £173.50 (95% confidence interval -£353.82 to £513.77) when considering intervention and health-care costs. The 1.1% absolute between-group difference in carbon monoxide-verified 6-month prolonged abstinence provided a small gain in lifetime quality-adjusted life-years (0.006), and a minimal saving in lifetime health-care costs (net saving £236). Conclusions: There was no evidence that behavioural support for smoking reduction and increased physical activity led to meaningful increases in prolonged abstinence among smokers with no immediate plans to quit smoking. The intervention is not cost-effective. Limitations: Prolonged abstinence rates were much lower than expected, meaning that the trial was underpowered to provide confidence that the intervention doubled prolonged abstinence. Future work: Further research should explore the effects of the present intervention to support smokers who want to reduce prior to quitting, and/or extend the support available for prolonged reduction and abstinence. Trial registration: This trial is registered as ISRCTN47776579. Funding: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 27, No. 4. See the NIHR Journals Library website for further project information.

NHS pharmacological and behavioural support helps smokers wanting to quit, and physical activity may also help. It is unclear if behavioural support for those not ready to quit may lead to more quit attempts and abstinence from smoking. A total of 915 smokers who wanted to reduce their smoking, but who had not yet quit, were recruited and randomised to receive an intervention or brief support as usual (brief advice to quit), in Plymouth, London, Oxford and Nottingham. The intervention involved up to eight sessions (by telephone or in person) of motivational support to reduce smoking and increase physical activity (and more sessions to support a quit attempt). Participants self-reported smoking and physical activity information at the start of the trial and after 3 and 9 months. Self-reported quitters confirmed their abstinence with a biochemical test of expired air or saliva. Our main interest was in whether or not the groups differed in the proportion who remained abstinent for at least 6 months. Overall, only 1­2% remained abstinent for 6 months. Although it appeared that a greater proportion did so after receiving the intervention, because few participants were abstinent, the results are not conclusive. However, the intervention had beneficial effects on less rigorous outcomes, including a reduction in the self-reported number of cigarettes smoked, and a greater proportion of intervention than control participants with self-reported and biochemically verified abstinence at 3 months. The intervention also helped participants to reduce, by at least half, the number of cigarettes they smoked at 3 and 9 months, and to report more physical activity, but only at 3 months. Despite reasonable intervention engagement and some short-term changes in smoking and physical activity, the trial does not provide evidence that this intervention would help smokers to quit for at least 6 months nor would it be cost-effective, with an average cost of £239 per smoker.

Brisk walking reduces ad libitum snacking in regular chocolate eaters during a workplace simulation.

Workplace snacking can contribute to obesity. Exercise reduces chocolate cravings but effects on chocolate consumption are unknown. This study investigated the effect of brief exercise on ad libitum consumption during breaks in a computerised task. Seventy-eight regular chocolate eaters, age: 24.90±8.15 years, BMI: 23.56±3.78 kg/m(2) abstained for 2 days. They were randomly assigned to one of four conditions, in a 2 × 2 factorial design, involving either a 15 min brisk walk or quiet rest, and then computerised Stroop tasks with low or high demanding conditions, in three 180 s blocks with a 90 s interval. Throughout, a pre-weighed bowl of chocolates was available for ad libitum eating. A two-way ANOVA revealed no interaction effect of exercise and stress on total chocolate consumption, or main effect of stress, but a main effect of exercise [F(1, 74)=7.12, p<.01]. Mean (SD) chocolate consumption was less (t(73.5)=2.69, 95% CI for difference 3.4-22.9, ES=0.61) for the exercise (15.6 g) than control (28.8 g) group. Exercise also increased affective activation, but there was no mediating effect of change in affect on chocolate consumption. A brief walk may help to reduce ad libitum snacking in regular chocolate eaters.

An exercise intervention to prevent falls in people with Parkinson's disease: a pragmatic randomised controlled trial.

OBJECTIVES: To compare the effectiveness of an exercise programme with usual care in people with Parkinson's disease (PD) who have a history of falls. DESIGN: Pragmatic randomised controlled trial. SETTING: Recruitment was from three primary and four secondary care organisations, and PD support groups in South West England. The intervention was delivered in community settings. PARTICIPANTS: People with PD, with a history of two or more falls in the previous year, who were able to mobilise independently. INTERVENTION: 10 week, physiotherapy led, group delivered strength and balance training programme with supplementary home exercises (intervention) or usual care (control). MAIN OUTCOME MEASURE: Number of falls during the (a) 10 week intervention period and (b) the 10 week follow-up period. RESULTS: 130 people were recruited and randomised (64 to the intervention; 66 to usual care). Seven participants (5.4%) did not complete the study. The incidence rate ratio for falls was 0.68 (95% CI 0.43 to 1.07, p=0.10) during the intervention period and 0.74 (95% CI 0.41 to 1.33, p=0.31) during the follow-up period. Statistically significant between group differences were observed in Berg balance, Falls Efficacy Scale-International scores and recreational physical activity levels. CONCLUSIONS: The study did not demonstrate a statistically significant between group difference in falls although the difference could be considered clinically significant. However, a type 2 error cannot be ruled out. The findings from this trial add to the evidence base for physiotherapy and exercise in the management of people with PD. Trial registration ISRCTN50793425.

A novel method for assessing design fidelity in web-based behavioral interventions.

OBJECTIVE: Delivery is one of the most common ways of assessing fidelity in behavioral interventions. However, there is a lack of research reporting on how well an intervention protocol reflects its proposed theoretical principles (design fidelity). This study presents a systematic method for assessing design fidelity and applies it to the eMotion web-based intervention targeting physical activity and depression. METHOD: The eMotion intervention comprises of 13 web-based modules, designed according to an underlying intervention map. An independent rater with expertise in behavior change coded the presence or absence of behavior change techniques (BCTs) in the content of eMotion. Results of coding were compared to the intervention designers' a priori specification for interrater reliability. RESULTS: After discussion, the independent rater and the intervention designer had a high agreement for the presence of BCTs relating to behavioral activation (AC1 = 0.91) with "demonstration of behavior" and "monitoring of emotional consequences" having the lowest agreement (AC1 < 0.4). There was also high agreement for the presence of BCTs targeting physical activity (AC1 = 0.88) with "demonstration of behavior" and "monitoring of emotional consequences" having the lowest agreement (AC1 < 0.4). The eMotion description was then amended to align the interrater agreement. CONCLUSIONS: This study presents a novel method for assessing design fidelity. Developers of behavioral (and other multicomponent) interventions are encouraged to develop and refine this method and assess design fidelity in future interventions to ensure BCTs are operationalized as intended. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Integrating the promotion of physical activity within a smoking cessation programme: findings from collaborative action research in UK Stop Smoking Services.

BACKGROUND: Within the framework of collaborative action research, the aim was to explore the feasibility of developing and embedding physical activity promotion as a smoking cessation aid within UK 6/7-week National Health Service (NHS) Stop Smoking Services. METHODS: In Phase 1 three initial cycles of collaborative action research (observation, reflection, planning, implementation and re-evaluation), in an urban Stop Smoking Service, led to the development of an integrated intervention in which physical activity was promoted as a cessation aid, with the support of a theoretically based self-help guide, and self monitoring using pedometers. In Phase 2 advisors underwent training and offered the intervention, and changes in physical activity promoting behaviour and beliefs were monitored. Also, changes in clients' stage of readiness to use physical activity as a cessation aid, physical activity beliefs and behaviour and physical activity levels were assessed, among those who attended the clinic at 4-week post-quit. Qualitative data were collected, in the form of clinic observation, informal interviews with advisors and field notes. RESULTS: The integrated intervention emerged through cycles of collaboration as something quite different to previous practice. Based on field notes, there were many positive elements associated with the integrated intervention in Phase 2. Self-reported advisors' physical activity promoting behaviour increased as a result of training and adapting to the intervention. There was a significant advancement in clients' stage of readiness to use physical activity as a smoking cessation aid. CONCLUSIONS: Collaboration with advisors was key in ensuring that a feasible intervention was developed as an aid to smoking cessation. There is scope to further develop tailored support to increasing physical activity and smoking cessation, mediated through changes in perceptions about the benefits of, and confidence to do physical activity.

The feasibility of recruiting patients with early COPD to a pilot trial assessing the effects of a physical activity intervention.

AIM: To determine the feasibility of recruiting patients with early chronic obstructive pulmonary disease (COPD) to the Health Enhancing Activity in Lung THerapy (HEALTH) exercise and education programme. METHODS: Patients with early COPD were identified from general practices. Those meeting the study inclusion criteria were administered tiotropium throughout the study period. Participants were randomised to either an eight-week health enhancing and physical activity (HEPA) programme, or to a control group (usual care). Behavioural, physiological and psychosocial outcome measures were reported preand post-intervention. RESULTS: Out of 27 practices approached, 16 (59.3%) agreed to participate. Of 215 potentially eligible patients contacted, 60 (27.9%) replied. Twenty (33.3%) were randomised to either HEPA intervention (n=10) or usual care (n=10). Fourteen patients attended a postintervention assessment. CONCLUSION: This study provides valuable information on the feasibility of conducting such a trial involving a physical activity intervention.

Modifiable risk factors for mortality in revision total hip arthroplasty for periprosthetic fracture.

AIMS: The aim of this study was to identify modifiable risk factors associated with mortality in patients requiring revision total hip arthroplasty (THA) for periprosthetic hip fracture. METHODS: The electronic records of consecutive patients undergoing revision THA for periprosthetic hip fracture between December 2011 and October 2018 were reviewed. The data which were collected included age, sex, body mass index (BMI), American Society of Anesthesiologists (ASA) classification, the preoperative serum level of haemoglobin, time to surgery, operating time, blood transfusion, length of hospital stay, and postoperative surgical and medical complications. Univariate and multivariate logistic regression analyses were used to determine independent modifiable factors associated with mortality at 90 days and one year postoperatively. RESULTS: A total of 203 patients were identified. Their mean age was 78 years (44 to 100), and 108 (53%) were female. The median time to surgery was three days (interquartile range (IQR) 2 to 5). The mortality rate at one year was 13.8% (n = 28). The commonest surgical complication was dislocation (n = 22, 10.8%) and the commonest medical complication within 90 days of surgery was hospital-acquired pneumonia (n = 25, 12%). Multivariate analysis showed that the rate of mortality one year postoperatively was five-fold higher in patients who sustained a dislocation (odds ratio (OR) 5.03 (95% confidence interval (CI) 1.60 to 15.83); p = 0.006). The rate of mortality was also four-fold higher in patients who developed hospital-acquired pneumonia within 90 days postoperatively (OR 4.43 (95% CI 1.55 to 12.67); p = 0.005). There was no evidence that the time to surgery was a risk factor for death at one year. CONCLUSION: Dislocation and hospital-acquired pneumonia following revision THA for a periprosthetic fracture are potentially modifiable risk factors for mortality. This study suggests that surgeons should consider increasing constraint to reduce the risk of dislocation, and the early involvement of a multidisciplinary team to reduce the risk of hospital-acquired pneumonia. We found no evidence that the time to surgery affected mortality, which may allow time for medical optimization, surgical planning, and resource allocation. Cite this article: Bone Joint J 2020;102-B(5):580-585.

Adding web-based behavioural support to exercise referral schemes for inactive adults with chronic health conditions: the e-coachER RCT.

BACKGROUND: There is modest evidence that exercise referral schemes increase physical activity in inactive individuals with chronic health conditions. There is a need to identify additional ways to improve the effects of exercise referral schemes on long-term physical activity. OBJECTIVES: To determine if adding the e-coachER intervention to exercise referral schemes is more clinically effective and cost-effective in increasing physical activity after 1 year than usual exercise referral schemes. DESIGN: A pragmatic, multicentre, two-arm randomised controlled trial, with a mixed-methods process evaluation and health economic analysis. Participants were allocated in a 1 : 1 ratio to either exercise referral schemes plus e-coachER (intervention) or exercise referral schemes alone (control). SETTING: Patients were referred to exercise referral schemes in Plymouth, Birmingham and Glasgow. PARTICIPANTS: There were 450 participants aged 16-74 years, with a body mass index of 30-40 kg/m2, with hypertension, prediabetes, type 2 diabetes, lower limb osteoarthritis or a current/recent history of treatment for depression, who were also inactive, contactable via e-mail and internet users. INTERVENTION: e-coachER was designed to augment exercise referral schemes. Participants received a pedometer and fridge magnet with physical activity recording sheets, and a user guide to access the web-based support in the form of seven 'steps to health'. e-coachER aimed to build the use of behavioural skills (e.g. self-monitoring) while strengthening favourable beliefs in the importance of physical activity, competence, autonomy in physical activity choices and relatedness. All participants were referred to a standard exercise referral scheme. PRIMARY OUTCOME MEASURE: Minutes of moderate and vigorous physical activity in ≥ 10-minute bouts measured by an accelerometer over 1 week at 12 months, worn ≥ 16 hours per day for ≥ 4 days including ≥ 1 weekend day. SECONDARY OUTCOMES: Other accelerometer-derived physical activity measures, self-reported physical activity, exercise referral scheme attendance and EuroQol-5 Dimensions, five-level version, and Hospital Anxiety and Depression Scale scores were collected at 4 and 12 months post randomisation. RESULTS: Participants had a mean body mass index of 32.6 (standard deviation) 4.4 kg/m2, were referred primarily for weight loss and were mostly confident self-rated information technology users. Primary outcome analysis involving those with usable data showed a weak indicative effect in favour of the intervention group (n = 108) compared with the control group (n = 124); 11.8 weekly minutes of moderate and vigorous physical activity (95% confidence interval -2.1 to 26.0 minutes; p = 0.10). Sixty-four per cent of intervention participants logged on at least once; they gave generally positive feedback on the web-based support. The intervention had no effect on other physical activity outcomes, exercise referral scheme attendance (78% in the control group vs. 75% in the intervention group) or EuroQol-5 Dimensions, five-level version, or Hospital Anxiety and Depression Scale scores, but did enhance a number of process outcomes (i.e. confidence, importance and competence) compared with the control group at 4 months, but not at 12 months. At 12 months, the intervention group incurred an additional mean cost of £439 (95% confidence interval -£182 to £1060) compared with the control group, but generated more quality-adjusted life-years (mean 0.026, 95% confidence interval 0.013 to 0.040), with an incremental cost-effectiveness ratio of an additional £16,885 per quality-adjusted life-year. LIMITATIONS: A significant proportion (46%) of participants were not included in the primary analysis because of study withdrawal and insufficient device wear-time, so the results must be interpreted with caution. The regression model fit for the primary outcome was poor because of the considerable proportion of participants [142/243 (58%)] who recorded no instances of ≥ 10-minute bouts of moderate and vigorous physical activity at 12 months post randomisation. FUTURE WORK: The design and rigorous evaluation of cost-effective and scalable ways to increase exercise referral scheme uptake and maintenance of moderate and vigorous physical activity are needed among patients with chronic conditions. CONCLUSIONS: Adding e-coachER to usual exercise referral schemes had only a weak indicative effect on long-term rigorously defined, objectively assessed moderate and vigorous physical activity. The provision of the e-coachER support package led to an additional cost and has a 63% probability of being cost-effective based on the UK threshold of £30,000 per quality-adjusted life-year. The intervention did improve some process outcomes as specified in our logic model. TRIAL REGISTRATION: Current Controlled Trials ISRCTN15644451. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 63. See the NIHR Journals Library website for further project information.

When health-care professionals refer patients with chronic conditions to an exercise referral scheme, the effects on long-term increases in physical activity are limited. We therefore developed the e-coachER support package to add to usual exercise referral schemes and to prompt the use of skills such as self-monitoring and goal-setting. This package was also intended to empower patients to increase their levels of physical activity long term. The seven-step programme was delivered online (via an interactive website). As part of the package, we mailed participants a guide for accessing the online programme, a pedometer and a fridge magnet with a notepad to record physical activity. We aimed to determine whether or not adding the e-coachER support to usual exercise referral schemes resulted in lasting changes in moderate and vigorous physical activity and whether or not it offers good value for money compared with exercise referral schemes alone. A total of 450 inactive individuals were recruited across Plymouth, Birmingham and Glasgow and were referred to an exercise referral scheme for the following participant-reported main reasons: weight loss (50%), low mood (19%), osteoarthritis (12%), type 2 diabetes (10%) and high blood pressure (8%). Half of the individuals were given access to the e-coachER support and the other half were not. All individuals were mailed a wrist-worn movement sensor (accelerometer) to wear for 1 week and a survey to assess other outcomes at the start of the study as well as at 4 and 12 months post randomisation. At the start of the study, the participants were inactive and most had multiple health conditions. The participants had an average body mass index of 33 kg/m² and an average age of 50 years. Most (83%) were white. Participants with access to e-coachER support were only slightly more active at 12 months than those who did not have access, but we cannot be confident in the findings because we had data from fewer participants than planned. The lack of a clear effect may have been as a result of around one-third of participants not accessing the website, but otherwise there was reasonable engagement. The provision of the e-coachER support package led to an additional cost of £439 per participant over a 12-month period.

Acute effects of brisk walking on urges to eat chocolate, affect, and responses to a stressor and chocolate cue. An experimental study.

The study aimed to investigate the effects of an acute exercise bout on urges to eat chocolate, affect, and psychological and physiological responses to stress and a chocolate cue. Following 3 days of chocolate abstinence, 25 regular chocolate eaters, took part, on separate days, in two randomly ordered conditions, in a within-subject design: a 15-min brisk semi-self-paced brisk walk or a passive control. Following each, participants completed two tasks: the Stroop colour-word interference task, and unwrapping and handling a chocolate bar. Chocolate urges [State Food Cravings Questionnaire (FCQ-S); Rodríguez, S., Fernández, M. C., Cepeda-Benito, A., & Vila, J. (2005). Subjective and physiological reactivity to chocolate images in high and low chocolate cravers. Biological Psychology, 70, 9-18], affective activation [Felt Arousal Scale; Svebak, S., & Murgatroyd, S. (1985). Metamotivational dominance: a multimethod validation of reversal theory constructs. Journal of Perception and Social Psychology, 48, 107-116], affective pleasure/valence [Feelings Scale; Hardy, C. J., & Rejeski, W. J. (1989). Not what, but how one feels: the measurement of affect during exercise. Journal of Sport and Exercise Psychology, 11, 304-317], and systolic/diastolic blood pressure (SBP/DBP) were assessed throughout. Exercise reduced chocolate urges and there was a trend towards attenuated urges in response to the chocolate cue. Exercise also attenuated SBP/DBP increases in response to the stressor and chocolate cue. The effects on urges varied across the dimensions of the FCQ-S.