Florida Atlantic University Christine E. Lynn College of Nursing
Health Behavior Change: An Update on the State of the Science
Teresa J. Sakraida, PhD, RN
Clinical Conference September 9-10, 2016
Christine E. Lynn College of Nursing
Issue of Health Behavior
Dorothy, 62 years, clinic visit for a
follow-up appointment.
What do you do when patients are less willing,
ready, and able to change their health behavior?
Review of the EHR indicates weight gain with
an increase of BMI to 29. She tells you that
she can’t give up eating foods she likes.
“There is no such thing as a diabetic diet now
days.” “I walk sometimes at the park.”
Christine E. Lynn College of Nursing
Background
Despite expanding treatment options and resources,<50%
do not achieve the target of HbA1c <7.0% based on
NHANES 2007-2010 cohort (Ali et al., 2013).
Behavior-oriented education enhances empowerment,
which enables responsibility for diabetes outcomes such as
quality of life and lifestyle change (Norris, 2002).
Tailored feedback messages more effective than generic
feedback in changing behavior (Kazdin, 2012)
Self-monitoring in combination with one self-regulation
technique, such as goal review was related diet and
physical activity intervention effectiveness (Mitchie et al., 2009)
Christine E. Lynn College of Nursing
Background
Substantial evidence that structured Diabetes Self-
Management Education (DSME), specific to diabetes
population and chronic disease self management is
effective
X-PERT patient program (Deakin 2006)
DESMOND program (Skinner 2006)
Standards guide practice- American Diabetes
Association (ADA) and the American Association of
Clinical Endocrinologists (AACE) guidelines point to
lifestyle modifications, including diet and exercise, as a
foundation for T2DM management.
Christine E. Lynn College of Nursing
Background- Barriers
Individual
Knowledge Empowerment
Health Literacy Motivation
Health Beliefs Self-Efficacy
Coping & Problem-Solving
Locus of Control
Depression
Anxiety Forgetting
Alcohol Use
Other Multiple Chronic Conditions
Environment
Social Support
Provider Factors
Socio-economic Factors
Distance to Health care
Health Determinants
- Nutrition
-Physical Activity
Self-Management
Ahola & Groop (2012, p. 414)
Christine E. Lynn College of Nursing
Aims
Systematic Review Scoping Review
Provide an overview of barriers to diabetes self-
management
An overview of state of the science literature
about health behavior change
Christine E. Lynn College of Nursing
Systematic review: Key questions
To identify effective health education and behavior
interventions of adult patients with type 2 diabetes.
The key questions are:
What interventions are most effective in diabetes
proximal outcomes glycemic control, weight, and
other lifestyle outcomes?
What are the most effective behavioral change
interventions?
What are the major gaps in the evidence base?
• A look at now and future think
Christine E. Lynn College of Nursing
Search Strategy
Scoping review using the Preferred Reporting Items for
Systematic Reviews and Meta-Analysis (PRISMA)
Guidelines (Moher, D., Liberati, A., Tetzlaff, J., Altman, D. G., & The
Prisma Group, 2009; PRISMA- http://www.prisma-statement.org).
Data Bases- Cochrane Database of Systematic
Reviews, OVID, and CINAHL
Search Terms
• Health Behavior Intervention; Health Behaviors; Behavior Change
• Diabetes, Type 2
Additional Limits: age ≥ 18 years, published in English,
years 2005-2015
Christine E. Lynn College of Nursing
Records identified through Cochrane Library database searching
(n= 956)
Scre
enin
g
In
clu
ded
Elig
ibili
ty
Id
enti
fica
tio
n
Records identified through OVID, CINAHL
(n = 9102)
7 articles (4 reviews & 3 primary studies) included
in Scoping review
Records screened (n=38)
Records excluded (n= 32)
Did not address health education-behavior change interventions in adults with T2DM
Full-text articles assessed for eligibility
(n =10)
Limited to reviews (n=38) Limited to 2005-2015 (n=38)
Records screened
(n=6)
Limited to relevancy (n = 172) Limited to 2005-2015 (n=89)
Records excluded (n= 2)
Did not address health education- behavior change intervention in adults with T2DM
Excluded (n =3) Provider adherence n= 2 Adolescents only n =1
Christine E. Lynn College of Nursing
Theoretical Foundation - Focus on cognitive constructs such as attitudes,
beliefs and expectations (related to outcomes,
self-belief or what other people might think)
• Health Belief Model (Rosenstock, et al. 1988)
• Theory of Reasoned Action and Planned Behavior (Ajzen, 2002)
• Social Cognitive Theory (Bandura, 1986)
• Protection Motivation Theory (Rogers, 1975)
• Chronic Illness Trajectory Model (Corbin, 1998; Corbin
& Strauss, 1998)
• Control Theory (Carver & Scheier, 1999)
Christine E. Lynn College of Nursing
Taxonomy of Behavior Change Techniques
Provide information
on consequences of
behaviour in general
9 Set graded tasks
2 Provide information
on consequences of
behaviour to the
individual
10 Prompt review of
behavioural goals
3 Provide information
about others' approval
11 Prompt review of
outcome goals
4 Provide normative
information about
others' behaviour
12 Provide rewards
contingent on effort or
progress towards
behaviour
5 Goal setting
(behaviour)
13 Provide rewards
contingent on
successful behaviour
6 Goal setting
(outcome) 14 Shaping
7 Action planning
15 Prompt
generalisation of target
behaviour
8 Barrier
identification/problem
solving
16 Prompt self-
monitoring of
behaviour
17 Prompt self-
monitoring of
behavioural outcome
18 Prompt focus on
past success
19 Provide feedback
on performance
20 Provide information
on where and when to
perform the behaviour
21 Provide instruction
on how to perform the
behaviour
22 Model or
demonstrate the
behaviour
23 Teach to use
prompts / cues
24 Environmental
restructuring
25 Agree on
behavioural contract
26 Prompt practice
27 Use follow-up
prompts
28 Facilitate social
comparison
29 Plan social support
/ social change
30 Prompt
identification as a role
model/position
advocate
31 Prompt anticipated
regret
32 Fear arousal
33 Prompt self-talk
34 Prompt use of
imagery
35 Relapse prevention
/ coping planning
36 Stress
management
37 Emotional control
training
38 Motivational
interviewing
39 Time management
40 General
communication skills
training
41 Stimulate
anticipation of future
rewards
A classification to support replication of behavioral change techniques Behavioral Change Taxonomy (BCT) Project, UK Medical Research Council (Michie et al., 2013).
Purpose: Identify active ingredient(s) of interventions behaviors. Users: Intervention designers, researchers, practitioners, systematic reviewers and all those wishing to communicate the content of behavior change interventions.
• 93 clustered techniques (BCT Taxonomy version BCTTv1) • Online training available at www.bct-taxonomy.com
Appraisal: • Work is underway to link BCTs to Theory • Developing a framework for designing behavior change
interventions
Christine E. Lynn College of Nursing
Systematic Reviews
Christine E. Lynn College of Nursing
Author
(Year)
Review Type Topic
Population
No. of
Studies
Total No.
Subjects
Variable
Key Outcomes
Duke
et al.
(2009)
Systematic
Review
Meta-
analysis
Individual
Patient
Education
(IPE)
defined as
Face-to
Face on
wide range
of SM
issues
Type 2
Diabetes
N =5 facetime
range of 2-4
hours face
time
N= 9
RCTs
n= 6 IPE
to usual
care
n =3 IPE
to group
ed.
N =
1359 Glycemic Control (GC)
n=6 did not significantly improve GC HbA1c-> WMD -0.1%(95% CI -0.3-0.1, p =0.33) over
12-18 month period. (Subgroup analysis, n=3
significant benefit of IPE with higher HbA1c at
baseline>8%; HbA1c-> WMD -0.3(95% CI -0.5 to -0.1,
p =0.007) over 12-18 month period).
n =3 of IPE compared to Group Ed did not
significantly improve GC HbA1c-> WMD 0.03%(95% CI -0.02-0.1, p =0.22) over
12-18 month period
BMI and BP- No significant difference IPE to
usual care or IPE to grp ed.
Main Findings- IPE Benefit on glycemic control
when compared with usual care in a subgroup of those
with a baseline HbA1c greater than 8%. Overall no
significant difference between IPE and usual care. In
the small number of studies comparing group and
individual education, there was an equal impact on
HbA1c at 12 to 18 months.
Christine E. Lynn College of Nursing
Author
(Year)
Review
Type
Topic
Population
No. of
Studies
No.
Subjects
Variable
Key Outcomes
Vodopivec
et al. (2012)
Systematic
Review
Meta-
Analysis
Mobile
Phone
Messaging
Application
for
Preventive
health
Other
preventable
disease
N=4
RCTs
Quasi-
RCTs
Control
Before-
After;
Time
Series
only
studies to
assess
effects of
mobile
message
N=
1933 Health Behavior
N= 1705. Mobile phone messaging support for
smoking cessation resulted in a significant increase of
quit rates at 6 weeks (RR 2.20, 95% CI 1.79 to 2.70)
and 12 weeks follow-up (RR 1.55, 95% CI 1.30 to 1.84).
The effect persisted at 26 weeks if last values were
carried forward (RR 1.28, 95% CI 1.11 to 1.48).
Continuous abstinence at 26 weeks, allowing <3 ‘lapses’
of ≤ 2 cigarettes per lapse, was higher in the
intervention grp (RR 1.64, 95% CI 1.12 to 2.42),
whereas there was no impact on continuous complete
abstinence (RR 1.4, 95% CI 0.92 to 2.44).
N =99. Mobile phone messaging reminders to take
vitamin C tabs showed significantly higher self-reported
adherence, and a marginal reduction in the number of
missed tabs in the last 7 days compared to those who
did not receive any reminders (MD -0.80, 95% CI -1.55
to-0.05).
Main Findings- Low number of participants in combined with limitations of risk of bias and lack of
demonstrated causality, the evidence for support of behavioral health is of low to moderate quality.
The evidence is of high quality only for interventions aimed at smoking cessation.
Christine E. Lynn College of Nursing
Author
(Year)
Review
Type
Topic
Population
No. of
Studies
No. Subjects Variable
Key Outcomes
Pal et
al.
(2013)
Systematic
Meta-
analysis
Computer-
based self-
management
(CBSM)
interventions
Type 2 Diabetes
Clinic based;
home based;
mobile phone
based
N=16 RCTs
Compared
to standard
diabetes
care, non-
interactive
CBSM,
paper
education,
face-to -face
diabetes SM
N =3578 Glycemic Control (GC) Small benefit of CBSM. Pooled effect HbA1c->
WMD -0.2% (95% CI -0.4 to -0.1, p =0.009; 2637
participants; 11 trials).
(Subgroup analysis of mobile phone best effect
size, WMD -0.5% (95% CI -0.7 to -0.3, p =0.0001;
280 participants; 3 trials).
Depression, HRQOL, Weight, Lipids-
Current interventions do not show adequate
evidence for improving depression, HRQOL, or
weight. 4 out of the 5 interventions showed
benefits on lipid profile.
Main Findings- CBSM have a small beneficial effect on GC with a larger effect on the mobile
phone subgroup. No benefits on cognitive, behavioral or emotional outcomes.
Christine E. Lynn College of Nursing
Author
(Year) Review
Type
Topic
Population
No. of
Studies
No.
Subjects Variable
Key Outcomes
Attridge
et al.
(2014)
Systematic
Meta-
analysis
Culturally
appropriate
health
education
(CAHE) for
people of
ethnic
minority
groups
Type 2
Diabetes
N=28 RCTs
Compared
to usual
care
N= 7453 Glycemic Control (GC) Improvement at 3 months (mean difference (MD) -0.4% (95%
CI -0.5 to -0.2); 14 trials; 1442 participants; high-quality
evidence). At 6 months (MD -0.5% (95% CI -0.7 to -0.4); 14
trials; 1972 participants; high-quality evidence) post CAHE
intervention compared with ‘Usual Care’ control groups. This
control was sustained to a lesser extent at 12 months (MD -
0.2% (95% CI -0.3 to -0.04); 9 trials; 1936 participants) and at
24 months (MD -0.3% (95% CI -0.6 to -0.1); 4 trials; 2268
participants; moderate-quality evidence) post intervention.
Knowledge Knowledge scores showed improvement in the intervention at
three (standardized mean difference (SMD) 0.4 (95% CI 0.1 to
0.6), six (SMD 0.5 (95% CI 0.3 to 0.7) and 12 months (SMD
0.4 (95% CI 0.1 to 0.6) post CAHE intervention.
Lipids Reduction in triglycerides of 24 mg/dL (95% CI -40 to -8) at 3
months, but not sustained at 6 or 12 months. Neutral effects
on total cholesterol, LDL and HDL cholesterol at follow-up
point.
BP, BMI, self-efficacy and empowerment- Neutral effects
compared with control groups.
Main Findings- CAHE has short- to medium-term effects on GC and on knowledge of diabetes and
triglycerides. None of these studies were long-term trials, and so clinically important long-term outcomes
could not be studied. No studies included an economic analysis. The heterogeneity of the studies made
subgroup comparisons difficult to interpret with confidence.
Christine E. Lynn College of Nursing
Author
(Year)
Design Sample Setting Approach Findings Outcomes Comment
Lawler
et al.
(2010)
Cluster
RCT
Theory-
Social
Cognitive
Theory
(Bandura)
N= 434
Type 2
Diabetes
↑BP
Primary
Care
Australia
10 clinics
randomly
assigned to
Telephone
Counseling vs.
Usual Care
Telephone
counseling- 18
phone called
over 12 months
from masters
level graduates
(training in
motivational
interviewing,
physical activity
promotion
Workbook-
Physical Activity
& Healthy eating
Measurement points- Baseline, 4 months, & 12
months. N= 426
Majority had ↑BP; 3 or more chronic
conditions; female; Caucasian;
married, non-smokers; and aged 58
years.
Impact on Multiple Health Behaviors-
Physical Activity (moderate), Healthy
Dietary Changes. Usual Care –
o 53.4% made no changes in health risk
behaviors at 12 month follow-up
o 32.8% reduced Health risk behaviors by one or
more
Telephone Counseling-
o 36.6% made no changes in health risk
behaviors at 12 mo.
o 52.5% reduced risk behaviors by at least one
Covariation among Health Behaviors Participants who made improvements in total fat,
saturated fat, vegetables, and physical activity
were significantly more likely to make greater
improvements to other unrelated behaviors(OR>2)
Inquiry about
changes in
underlying health
behaviors as
opposed to markers
of disease
management or
progression
Provides evidence
of health behaviors
change and co-vary
in the context of
multiple health
behavior
interventions.
This study agrees
with literature
supporting medium
to high intensity
interventions
Main Outcomes Telephone Counseling group were more than twice as likely than those in the Usual Care group to make
greater reductions in multiple behaviors over the intervention course (OR 2.42; 95%CI 1.43 to 4.11) p <.01
One behavior change was associated with changes in other behaviors with high co-variation across most
behaviors. eg. Physical activity changes associated with dietary changes.
Christine E. Lynn College of Nursing
Single Primary Studies
Christine E. Lynn College of Nursing
Author
(Year)
Design Sample Setting Approach Findings Outcomes Comment
Gabbay
et al.
(2013)
Pragmatic
RCT
Diabetes
Nurse Case
Management
and
Motivational
Interviewing
for Change
(DYNAMIC)
N =545
18-75
years
with
T2D
Primary
care
United
States
12 primary
care clinics in
2 health care
systems
Untreated usual
care control vs
Intervention
nurse case
management
motivational
interviewing
guided behavior
change
counseling (
Eight, 1 hour
visits with BSN
nurses)
Clinical Measures
Systolic blood pressure (SBP) was
better in the intervention than usual
care group (131 ± 15 vs.
135 ± 18 mmHg, respectively; P
< 0.05).
HbA1c, LDL, Diastolic BP
Improvements were seen in both the
control and intervention groups in
terms of HbA1c (from 9.1% to 8.0%
and from 8.8% to 7.8%, respectively),
low-density lipoprotein (LDL; from 127
to 100 mg/dL and from 128 to
102 mg/dL, respectively), and diastolic
blood pressure (from 78 to 74 mmHg
and from 80 to 74 mmHg, respectively).
Depression (CESD)- Measured
baseline, 1 year and 2 years
At the completion of the study, CES-D
scores were better in the intervention
than control group (10 ± 11 vs 14 ± 14,
respectively; P = 0.02), consistent with
a marked reduction in depressive
symptoms
MI for improvement of
patient outcomes has
shown mixed reviews
in patients with
diabetes. This study
using MI also
included diabetes
handouts, telephone,
email, and video
conferencing. Unclear
if MI was a major
ingredient or some
other dynamic.
Attended to MI fidelity
NCMs trained in MI
led to significant
improvements in
selected clinical
measures and
depression
Main Outcomes
The NCMs and MI improved SBP. The large decrease in HbA1c and LDL in the control group may have
obscured any intervention effect.
Christine E. Lynn College of Nursing
Author
(Year)
Design Sample Setting Approach Findings Outcomes Comment
Ambeba
et al.
(2014)
Secondary
analysis of
the Self-
Monitoring
and
Recording
using
technology
(SMART) trial
Single center
24 month study
N=210
Random
allocation to
3 groups
Paper diary,
Personal
Digital
Assistant
(PDA)
PDA +Daily
Feedback
(DF)
messages
Academic
Research
Center US
Effect of
tailored daily
feedback
message on
dietary intake
Intervention-
3
components
of standard
behavioral
intervention
Group
sessions
Dietary and
Exercise
goals
Self-
monitoring
Measurement points- 6-mo., 12-mo., 18
mo., 24 mo.
Percentage Change in Dietary
Measures
by time and feedback group, mixed-
model analysis
Significant within-group
decreases in energy (DFB,-22.8%,
P<.0001; no-DFB,-14.0%,P,
.0001) and total fat (DFB,-
10.4%,P= .0002;no-DFB,- 4.7%,P=
.02) for both the DFB and no-DFB
groups over time. In addition, the
DFB group had a significant within-
group decrease in saturated fat
intake (-11.3%, P= .005) over time.
Discussion- Findings suggest delivery of more frequent
tailored messages
Provide a change out of library of messages
to limit desensitization
DFB messages
delivered in real
time using mobile
devices can play
an important role
in the reduction
of energy and fat
intake.
Main Outcome-
Daily feedback messages tailored to diary entries and delivered in real time can enhance motivation
Christine E. Lynn College of Nursing
Author
(Year)
Design Sample Set Approach Findings Outcomes Comment
Hankonen
et al. (2015) Retrospect.
self-report
of BCT and
Outcomes
of Addition-
Plus trial
Intervention
Arm
N= 478,
intervention
arm n=239
Intensive
diabetes
treatment +
theory
based
individual
level
behavior
change
(duration 1
year)
U.K. Association
between
enactment
of BCTs and
outcomes
related to
physical
activity,
dietary
behaviors,
and weight
loss.
Addition-
Plus
Intervention
Behavior Change Techniques
Questionnaire assessed use of 8 BCTs
relating to physical activity and 8 BCTs
related to lower fat diet in the past 11
months.
Number of BCTs used
Number of BCTs used was significantly
associated with a ↓ in BMI over 1 year.
Using all BCTS lost more wt than those
using 0-10 BCTs
Specific BCTs associated with
behavior change and wt loss
Main effects were significant for goal
setting, goal review, and social support
Those who used goal setting lower-fat diet
and increased physical activity lost
significantly more weight (M change in
BMI = −.88 kg/m2, SD = 2.13) than those who
used goal setting for dietary change only
(M = .08 kg/m2, SD = 1.50, p = .029, N = 21)
or for neither behavior (M = .49 kg/m2,
SD = .98, p = .023, N = 13).
When used social support to change both
behaviors lost more weight.
Those who used goal review for both
behaviors lost more weight.
Clinical practice,
as use of a higher
number of BCTs
was related to
weight loss.
Future
interventions
should provide a
toolbox of BCTs
rather than teach
a few BCTs only.
Encourage
participants to
use as many BCTs
as possible on the
basis of evidence
that people who
use recommended
BCTs are more
likely to achieve
weight loss.
Main Outcomes
Higher number of BCTs used was associated with weight loss
Christine E. Lynn College of Nursing
Gaps In the Literature
Barriers to self-management
Tailored to the illness experience
Examine the active ingredients of BCTs
Study of culturally appropriate self-management
Engage in studies about technology delivery of
information and BCTs
Christine E. Lynn College of Nursing
Recommendations- Practice
Culturally Appropriate Health Education (CAHE) results
in significant improvements in HbA1c, triglycerides and
diabetes knowledge. The potential is reduction in
diabetes-related complications.
Recommend CAHE be an integral aspect of EB treatment
Delivered by trained/ certified personnel
Culturally appropriate- National Standards for Diabetes Self-
Management Education "the diabetes educational needs of the
target population....such as ethnic background" as an essential
standard (Funnell, 2009).
Christine E. Lynn College of Nursing
Recommendations- Research Bio-physiological Proximal Outcomes are central in
diabetes population RCTs. Worthy to consider other self-
management outcomes.
Selection of more than one theoretical foundation may
be indicated. For instance, human-technology interface.
Systematic approach to selection of integrated theories
for the research study
Provide cost effectiveness of the intervention
Measure for multiple chronic conditions
Long term, multi-center RCTs are needed to study if
effects are sustained.
Christine E. Lynn College of Nursing
Future Think is Now
Increased use of technology support for supporting
behavioral change is now and evolving with changing
technology
New foci- • Technology and behavioral change
• Mobile Phone Messaging tailored to and learning
condition concordant
• Targeted and precision health
• Tailor the intervention
• Multi-modal approaches for BCTs
Christine E. Lynn College of Nursing
References
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Christine E. Lynn College of Nursing
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Christine E. Lynn College of Nursing
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Christine E. Lynn College of Nursing
References
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