Purpose: There is a dearth of studies on how to train physically active employees to act as peer leaders and use motivationally supportive communication to promote physical activity in their physically inactive colleagues. We delivered and evaluated a self-determination theory-based, peer-led, workplace group walking intervention. 

Methods: A 16-week pilot cluster randomized controlled trial with an enhanced (5 worksites; n=50 participants) and minimal treatment (3 worksites; n=47 participants) arms. All participants were given a Fitbit Zip and information on health benefits of walking. Enhanced treatment participants also had access to a mobile app incorporating behavior change techniques, were trained on principles of autonomous motivation, and had a peer leader trained in a motivationally supportive communication style. Feasibility measures (recruitment, drop-out rates, training and intervention acceptability) were estimated. Steps, minutes standing and sitting were measured using ActivPALs. Cardiometabolic risk factors (waist circumference and waist-to-height ratio) were assessed. Motivation to walk and well-being (affect at work, general psychological well-being) were measured using established questionnaires. All outcomes were assessed at baseline and post-intervention. Mixed modelling analyses, accounting for time and worksite clustering, were conducted. 

Results: We evidenced strong feasibility of recruitment, retention, and assessment procedures, and high levels of acceptability. The evidence for preliminary efficacy was mixed. Markers of cardio-metabolic risk improved in the enhanced treatment only (Cohen’s d=.10-.16). Autonomous motivation increased in both conditions. Significant improvements in time spent standing) and sitting  were observed in the enhanced treatment condition, but none of the time × condition interaction effects for steps, standing, or sitting were significant. For well-being, none of the main or interaction effects were significant. 

 Conclusions: High baseline scores in steps across both conditions suggest the presence of reactivity as a result of receiving the activity tracker and could explain lack of treatment effects regarding step count. However, given that this was a pilot, the strong evidence for feasibility and the fact that improvements were in the expected direction, suggest that the trial has the potential to be tested at a larger scale.

Purpose:

The study examines the perceptions and practices of professional stakeholders three years after completion of a community-based health promotion project addressing healthy eating and active living among families with young children. The project was carried out in three rural communities in Denmark and implemented a 19 months multi-component intervention within the framework of Project Health and Local Community, also referred to as Project SoL.

Methods:

The study was qualitative in nature and involved nine professional stakeholders with diverse roles in Project SoL. Three study participants were working for the local government and its public administration: an elected politician chairing the health policy committee, the head of the health department in the public administration, and a civil servant working with health promotion. Other study participants included a headmaster of a public primary school, an in-charge of a public kindergarten, a chair person of a local community development council, a member of a local business council, an editor-in-chief of a local TV-station, and a business partner of a local fitness center. All study participants were in-depth interviewed about their project-related perceptions and practices since project completion three years back. The interviews were digitally recorded and transcribed verbatim prior to being analyzed inductively through interpretive coding, categorization and thematic formation addressing the research question.

Findings:

The study showed that Project SoL had made a substantial and long-term impression on all study participants. Although their actions were no longer implemented with specific reference to the project, the values and principles of the project were still guiding their professional practices. These values and principles were not health specific but related to wider egalitarian and democratic epitomes such as involvement, empowerment, social mobilization, respectfulness and collaboration across settings and sectors. Coordinating structures that vanished upon project completion hampered continuation of joint action among stakeholders but did not affect their contribution to community-based actions within their respective professional networks.     

Conclusion:

Basic organisational structures are required to sustain complex community-based interventions for healthy living but values, principles and actions may endure provided that they are rooted in community needs and embraced by community stakeholders.   

Purpose: Early obesity prevention interventions are complex and vary in effectiveness. We aimed to unpack interventions using novel frameworks, taxonomies, and experience from four landmark trials forming the EPOCH collaboration. The objectives were to:

(1)    Deconstruct interventions into their components.

(2)    Identify lessons and recommendations for intervention planning, delivery, evaluation and implementation.

 Methods: 

This multimethod study included four world-first RCTs aimed at preventing childhood obesity within the first two years of life. Firstly, interventions were deconstructed into their components, including target behaviours, delivery features and Behaviour Change Techniques (BCTs), using the TIDieR checklist and the BCT Taxonomy v1. Published and unpublished intervention resources for each trial were coded twice by independent coders, and results were tabulated and analysed. Secondly, semi-structured interviews were conducted with principal investigators and intervention facilitators. The interview guide was informed by the UK Medical Research Council development-evaluation-implementation process framework, and inductive thematic analysis was used to draw out themes.

Results:

All trials commenced in the first six months of life, included a component related to lifestyle, and had the primary goal of preventing overweight and obesity. Each trial targeted 10 to 14 obesity-related behaviours, such as bottle-feeding, introducing solids, parent response to hunger cues, and limiting screen time. Key variations in delivery features related to intensity, delivery mode and tailoring. Across the four trials, 35(38%) of the possible 93 unique BCTs were coded. BCTs used across interventions included ones related to goals and planning, social support and consequences. More than 19(54%) of the BCTS were identified in only one or two of the trials. Qualitative interview content was coded into themes related to the planning, delivery, evaluation and implementation. Key recommendations from the interviews include the importance of collaboration with a range of stakeholders and consideration of implementation throughout the whole study process.

Conclusions:

The innovative combination of frameworks, taxonomies and interviews used in this multimethod study is a major step forward in understanding complex early obesity prevention interventions. A global trials registry is being established through the TOPCHILD collaboration to quantitatively explore the key components of these complex interventions that are associated with effectiveness.

Purpose

Parents are an important target for interventions to reduce children’s excessive intake of unhealthy snacks. Reducing unhealthy snacks consumption is a complex issue and interventions to date have not been effective. New interventions are needed, designed using best-practice, systematic approaches to increase their potential to achieve greater intervention effectiveness. We aimed to develop theoretically-grounded, evidenced-informed intervention content to support parents to limit purchasing of unhealthy snacks for their 3-7-year-old children.

Methods

This study used the Behaviour Change Wheel process to guide the design of a comprehensive package of intervention strategies, including those suitable for implementation in different environments within the socio-ecological model. This study synthesised evidence from two of our previous studies with parents of young children and published literature, in a behavioural analysis based on the Capability, Opportunity, Motivation and Behaviour model. Design focussed on gaps in the use of behaviour change approaches in past interventions.

Results

Thirteen intervention strategies were proposed to address parents’ psychological capability, physical and social opportunity, and reflective and automatic motivation, needed to limit unhealthy snack purchasing. Strategies were designed for implementation in the following setting: policy/society (5), food supply (3), community (3) and home (2). Most commonly proposed intervention functions included environmental restructuring, persuasion, enablement, coercion and education, and communication/marketing, guidelines, legislation, and environmental/social planning policy categories. Together strategies could include up to 38 unique behaviour change techniques, most commonly from the hierarchical clusters of antecedents and natural consequences.

Conclusions

Our study provides a road-map for future intervention research to comprehensively address parents’ provision of unhealthy snacks to their children. Proposed intervention content can be refined in proceeding stakeholder consultation and feasibility testing. This study is the first application of the Behaviour Change Wheel process to design an intervention targeting a reduction in unhealthy food purchasing in any age group. It adds to the evidence base and provides examples of a thorough application of the framework, which can be used as an exemplar for future nutrition intervention design and evaluation.

Purpose: Recruiting and retaining young adults (aged 17-35 years) in health research is a major challenge. The aim is to describe the strategies used to recruit and retain young adults in nutrition, physical activity and/or obesity intervention research, and the effectiveness of these strategies.

Methods: Six electronic databases were searched for RCTs published up to October 2018 that evaluated nutrition, physical activity and/or obesity interventions in young adults (17-35 years). Recruitment was considered effective if pre-determined goal sample size was met. Retention was considered effective if attrition was ≤20% for ≤6-month follow-up or ≤30% for >6-month follow-up. Effectiveness of individual recruitment and retention methods were calculated as the number of times the method was used in a study with effective recruitment or retention divided by the total number of times the method was used in a study.

Results: From 18,779 manuscripts identified, 94 RCTs were included. Median recruitment duration was 90 days (range: 7 to 1095), with a median efficiency of 2.1 participants recruited per day (range: 0.04 to 33.6). Forty-seven studies (50%) reported recruitment details, and of these 37 (79%) achieved successful recruitment (i.e. met goal sample size). Twelve recruitment strategies were effective in >50% of studies, with the most effective being face-to-face (i.e. health service appointments) (11 of 11 effective or 100%), followed by email, predominantly bulk email to university students (14 of 15 effective or 93%) and newspaper advertisements (7 of 8 effective or 88%). Adequate retention was achieved in 59 studies (63%). Six retention strategies were effective in >50% of studies, with course credit the most effective (13 of 15 effective or 87%), followed by prize/prize draw (7 of 10 effective or 70%) and financial compensation (26 of 38 effective or 68%). 

Conclusion: This is the largest review to date that has synthesised retention and recruitment rates of interventions targeting nutrition, physical activity or overweight/obesity in young adults. Among studies that reported recruitment and retention details, findings demonstrate most were successful in recruiting young adults (79% effective) but retaining this group was more challenging (63% effective). Greater efforts to retain young adults are required.

Purpose

High salt intake is a risk factor for hypertension. We examined the feasibility of a novel intervention to encourage individuals with raised blood pressure to reduce their salt intake by purchasing lower-salt products when grocery shopping.

Methods

Forty-seven adults with a record of high blood pressure were recruited from GP practices and randomised to receive the intervention (n=31); or a generic salt-reduction advice leaflet (control, n=16). The intervention comprised a 30-minute behavioural support session with a healthcare practitioner in primary care and use of a theoretically-informed smartphone app (Salt-Swap) to help participants choose lower-salt foods when grocery shopping.  Primary outcomes were progression criteria for a larger trial: follow-up attendance, use of the Salt-Swap app and fidelity of intervention delivery. Secondary outcomes included the change in salt intake (24-hr urinary sodium) and blood pressure after six weeks. A qualitative assessment was conducted in a subgroup, using the think-aloud method and semi-structured interviews to explore the impact of advice to reduce salt intake on shopping behaviours and purchasing decisions, analysed thematically.

Results

Progression criteria were met, with 96% (45/47) follow-up, 87% (27/31) of intervention participants using the app more than once in month one, and 81% fidelity of intervention delivery. Salt intake decreased in both groups, (intervention -0.2g/d, 95% CI -1.4 to 0.9; control -1.0 g/d, 95% CI -2.4 to 0.4) as did systolic blood pressure (intervention -1.0 mmHg, 95% CI -5.5 to 3.6; control -1.1 mmHg, 95% CI-6.7 to 4.4). There was no significant difference between groups. Qualitative research with 17 participants showed Salt-Swap increased participants’ knowledge of the sources of dietary salt, increased use of product nutrition labels for salt, and changed purchasing behaviours that could help to reduce salt intake. Participants’ successfully identified lower-salt products with the app but reported insufficient product coverage as the main barrier to use.  

Conclusions and implications

It would be feasible to conduct a larger definitive trial to assess the intervention’s effect on blood pressure.  The Salt-Swap app was popular among participants, but the number of products recognised by the app must be increased for it to be useful to more participants.   

Purpose: Reports of participant experiences with weight-loss maintenance programs are sparse and their perceptions of the challenges of losing and maintaining weight are not well understood. This study explores how participants with chronic disease account for their engagement with an extended contact weight-loss maintenance program and what role the behaviour-change program plays in their ongoing weight management.

Methods: Qualitative telephone interviews were conducted with participants 6-months after starting a lifestyle-based weight loss maintenance program, which followed an 18-week weight loss program. Interviews were audio-recorded and transcribed verbatim. Two researchers used a thematic inductive approach to identify common themes generated from interview content. Themes were checked against the data and interpretations refined in consultation with an independent researcher.

Results: Of 17 participants interviewed 9 were male, 16 had lost ≥5% of body weight prior to starting the maintenance program, and 12 had maintained their weight loss after 6 months of program participation. Participants’ accounts of the role of the program centred on how the program kept them ‘on track’ and helped them ‘back on track’. The analysis generated four themes describing the means by which participants’ ongoing weight management was shaped, namely: Personal Responsibility, Real-Life, Sense of Agency, and Self-regulation. Accounts of weight-loss management reflected a complex interplay between real life threats and a sense of personal responsibility, and the services offered by the program. The program’s value was the capacity to enable reconciliation between personal responsibility for weight management and challenges posed by their real-life situations by supporting a sense of agency and self-regulation. In supporting agency and allowing self-regulation, the program was compatible with feeling personal responsibility for their ongoing weight management. Participants were able to enact the ‘personal responsibility for health’ discourse by picking and choosing from the services available as their weight management circumstances dictated.

Conclusions: Service providers of weight loss maintenance program can use these insights to better support individuals to overcome real-life threats and make positive health choices for ongoing weight management, as well as to inform and facilitate program monitoring and improvement.