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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.”


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)


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.


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)


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


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


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

http://www.prisma-statement.org/




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


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)


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


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


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

http://www.bct-taxonomy.com/




Systematic Reviews


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.


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.


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.


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.


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.


Single Primary Studies


Author

(Year)


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.


Author

(Year)


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


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


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


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).


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.


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


References

Ahola, A. J., & Groop, P. H. (2013). Barriers to self-management of diabetes.

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