Effectiveness and cost-effectiveness of a physical activity loyalty scheme for behaviour change maintenance: a cluster randomised controlled trial

Background
Increasing physical activity in the workplace can provide employee physical and mental health benefits, and employer economic benefits through reduced absenteeism and increased productivity. The workplace is an opportune setting to encourage habitual activity. However, there is limited evidence on effective behaviour change interventions that lead to maintained physical activity. This study aims to address this gap and help build the necessary evidence base for effective, and cost-effective, workplace interventions

Methods/design
This cluster randomised control trial will recruit 776 office-based employees from public sector organisations in Belfast and Lisburn city centres, Northern Ireland. Participants will be randomly allocated by cluster to either the Intervention Group or Control Group (waiting list control). The 6-month intervention consists of rewards (retail vouchers, based on similar principles to high street loyalty cards), feedback and other evidence-based behaviour change techniques. Sensors situated in the vicinity of participating workplaces will promote and monitor minutes of physical activity undertaken by participants. Both groups will complete all outcome measures. The primary outcome is steps per day recorded using a pedometer (Yamax Digiwalker CW-701) for 7 consecutive days at baseline, 6, 12 and 18 months. Secondary outcomes include health, mental wellbeing, quality of life, work absenteeism and presenteeism, and use of healthcare resources. Process measures will assess intervention “dose”, website usage, and intervention fidelity. An economic evaluation will be conducted from the National Health Service, employer and retailer perspective using both a cost-utility and cost-effectiveness framework. The inclusion of a discrete choice experiment will further generate values for a cost-benefit analysis. Participant focus groups will explore who the intervention worked for and why, and interviews with retailers will elucidate their views on the sustainability of a public health focused loyalty card scheme.

Discussion
The study is designed to maximise the potential for roll-out in similar settings, by engaging the public sector and business community in designing and delivering the intervention. We have developed a sustainable business model using a ‘points’ based loyalty platform, whereby local businesses ‘sponsor’ the incentive (retail vouchers) in return for increased footfall to their business.

Behaviour change techniques in home-based cardiac rehabilitation: a systematic review

BACKGROUND: Cardiac rehabilitation (CR) programmes offering secondary prevention for cardiovascular disease (CVD) advise healthy lifestyle behaviours, with the behaviour change techniques (BCTs) of goals and planning, feedback and monitoring, and social support recommended. More information is needed about BCT use in home-based CR to support these programmes in practice.

AIM: To identify and describe the use of BCTs in home-based CR programmes.

DESIGN AND SETTING: Randomised controlled trials of home-based CR between 2005 and 2015 were identified by searching MEDLINE(®), Embase, PsycINFO, Web of Science, and Cochrane Database.

METHOD: Reviewers independently screened titles and abstracts for eligibility. Relevant data, including BCTs, were extracted from included studies. A meta-analysis studied risk factor change in home-based and comparator programmes.

RESULTS: From 2448 studies identified, 11 of good methodological quality (10 on post-myocardial infarction, one on heart failure, 1907 patients) were included. These reported the use of 20 different BCTs. Social support (unspecified) was used in all studies and goal setting (behaviour) in 10. Of the 11 studies, 10 reported effectiveness in reducing CVD risk factors, but one study showed no improvement compared to usual care. This study differed from effective programmes in that it didn't include BCTs that had instructions on how to perform the behaviour and monitoring, or a credible source.

CONCLUSION: Social support and goal setting were frequently used BCTs in home-based CR programmes, with the BCTs related to monitoring, instruction on how to perform the behaviour, and credible source being included in effective programmes. Further robust trials are needed to determine the relative value of different BCTs within CR programmes.

A change in behaviour — getting the balance right for research and policy.

Behaviour change interventions offer clinical pharmacists many opportunities to optimise the use of medicines. ‘MINDSPACE’ is a framework used by a Government-affiliated organisation in the United Kingdom to communicate an approach to changing behaviour through policy. The Theoretical Domains Framework (TDF) organises constructs of psychological theories that are most relevant to behaviour change into 14 domains. Both frameworks offer a way of identifying what drives a change in behaviour, providing a target for an intervention. This article aims to compare and contrast MINDSPACE and the TDF, and serves to inform pharmacy practitioners about the potential strengths and weaknesses of using either framework in a clinical pharmacy context. It appears that neither framework can deliver evidence-based interventions that can be developed and implemented with the pace demanded by policy and practice-based settings. A collaborative approach would ensure timely development of acceptable behaviour change interventions that are grounded in evidence.

Statin prescription initiation and lifestyle behaviour: a primary care cohort study

BACKGROUND: Statin prescribing and healthy lifestyles contribute to declining cardiovascular disease mortality. Recent guidelines emphasise the importance of giving lifestyle advice in association with prescribing statins but adherence to healthy lifestyle recommendations is sub-optimal. However, little is known about any change in patients' lifestyle behaviours when starting statins or of their recall of receiving advice. This study aimed to examine patients' diet and physical activity (PA) behaviours and their recall of lifestyle advice following initiation of statin prescribing in primary care.

METHOD: In 12 general practices, patients with a recent initial prescription of statin therapy, were invited to participate. Those who agreed received a food diary by post, to record food consumed over 4 consecutive days and return to the researcher. We also telephoned participants to administer brief validated questionnaires to assess typical daily diet (DINE) and PA level (Godin). Using the same methods, food diaries and questionnaires were repeated 3 months later. At both times participants were asked if they had changed their behaviour or received advice about their diet or PA.

RESULTS: Of 384 invited, 122 (32 %) participated; 109 (89.3 %) completed paired datasets; 50 (45.9 %) were male; their mean age was 64 years. 53.2 % (58/109) recalled receiving lifestyle advice. Of those who did, 69.0 % (40/58) reported having changed their diet or PA, compared to 31.4 % (16/51) of those who did not recall receiving advice. Initial mean daily saturated fat intake (12.9 % (SD3.5) of total energy) was higher than recommended; mean fibre intake (13.8 g/day (SD5.5)), fruit/vegetable consumption (2.7 portions/day (SD1.3)) and PA levels (Godin score 7.1 (SD13.9)) were low. Overall, although some individuals showed evidence of behaviour change, there were no significant changes in the proportions who reported high or medium fat intake (42.2 % v 49.5 %), low fibre (51.4 % v 55.0 %), or insufficient PA (80.7 % v 83.5 %) at 3-month follow-up.

CONCLUSION: Whilst approximately half of our cohort recalled receiving lifestyle advice associated with statin prescribing this did not translate into significant changes in diet or PA. Further research is needed to explore gaps between people's knowledge and behaviours and determine how best to provide advice that supports behaviour change.

Domestic Violence Perpetrators - Evidence informed responses

Domestic violence is a serious, widespread public, social and health problem that affects the lives of many women, children and men. There is also evidence to suggest it has one of the highest rates of recidivism. This comprehensive book provides an overview of what the research tells us about the perpetrators of domestic violence and what works, and what doesn’t, in promoting positive change.

Collecting together the most up-to-date evidence from the international literature and bringing psychological, sociological, gendered and socio-political theoretical perspectives to bear on the issue, the book explores:
- what domestic violence is, why it happens and how it can be measured
- who the perpetrators of domestic violence are, including discussion of non-stereotypical patterns such as male victims, female perpetrators, couples where the abuse is mutual, and couples with abusive relationships who want the abuse to end but the relationship to be sustained
- strategies for engaging perpetrators in interventions and for promoting behaviour change
- evidence-informed interventions, programmes and policies for working with perpetrators
- where robust evidence is lacking and more research needs to be undertaken.

Signalling changes to individuals who show resistance to change can reduce challenging behaviour

Background & objectives Several neurodevelopmental disorders are associated with resistance to change and challenging behaviours – including temper outbursts – that ensue following changes to routines, plans or expectations (here, collectively: expectations). Here, a change signalling intervention was tested for proof of concept and potential practical effectiveness. Methods Twelve individuals with Prader-Willi syndrome participated in researcher- and caregiver-led pairing of a distinctive visual-verbal signal with subsequent changes to expectations. Specific expectations for a planned subset of five participants were systematically observed in minimally manipulated natural environments. Nine caregivers completed a temper outburst diary during a four week baseline period and a two week signalling evaluation period. Results Participants demonstrated consistently less temper outburst behaviour in the systematic observations when changes imposed to expectations were signalled, compared to when changes were not signalled. Four of the nine participants whose caregivers completed the behaviour diary demonstrated reliable reductions in temper outbursts between baseline and signalling evaluation. Limitations An active control group for the present initial evaluation of the signalling strategy using evidence from caregiver behaviour diaries was outside the scope of the present pilot study. Thus, findings cannot support the clinical efficacy of the present signalling approach. Conclusions Proof of concept evidence that reliable pairing of a distinctive cue with a subsequent change to expectation can reduce associated challenging behaviour is provided. Data provide additional support for the importance of specific practical steps in further evaluations of the change signalling approach.

Characteristics of change triggered temper outbursts in children with PWS and ASD and how these may impact on the efficacy of behavioural intervention strategies.

Background
Temper outbursts are prevalent in individuals with PWS and are often triggered by unexpected changes to routines or plans. However, such outbursts are also common in individuals with several other neurodevelopmental disorders, including those with a diagnosis of autism spectrum disorder (ASD). We compared the profile of temper outbursts in children with PWS to that in children with ASD. We examined whether differences in the temper outburst profile predicted differences in the outcomes of two caregiver led intervention strategies aiming to reduce change triggered outbursts.
Methods and results
Thirteen 7-15 year olds with PWS – taking part in a larger study involving 60 children evidencing temper outbursts following changes – were individually matched for age to children with ASD (mean ages: 10.70; 10.76 yrs). Caregivers participated in a structured/semi-structured interview on children's outbursts; completed a web-based outburst diary over a 6 month baseline; and are currently using either a change signalling intervention to reliably warn children of forthcoming changes; or a planning ahead intervention to reduce children's exposure to unexpected changes.
As reported at interview, on average, children with PWS showed more frequent temper outbursts than those with ASD (closer to daily vs. weekly). For seven children with PWS and six with ASD, 60% or more of their temper outbursts were reported to be triggered by changes. Whilst outbursts had similar durations when triggered by changes or by other events in children with PWS; change triggered outbursts in children with ASD were generally shorter. The most commonly reported outburst components in children with PWS included indicators of heightened emotional arousal but this was not the case for children with ASD. Data on behavioural change associated with each of the intervention strategies will be discussed.
Conclusions
Change triggered temper outbursts can be a problem for children PWS and ASD, however subtle differences appear to exist in the profile of these outbursts. Some of these differences may be relevant for the expected efficacy of different behavioural intervention strategies that target outbursts.
Summary
Temper outbursts (tantrums) were compared in children with PWS or autism spectrum disorder before and during use of one of two helping strategies. Helping strategies were led by caregivers and aimed to reduce outbursts that follow changes to routines or plans by making such changes more predictable, or by reducing the quantity of changes. Characteristics of outbursts may be important to help us predict which helping strategies may be most effective.

Reducing child conduct disordered behaviour and improving parent mental health in disadvantaged families: a 12 month follow-up and cost analysis of a parenting intervention

The effectiveness of the Incredible Years Basic parent programme (IYBP) in reducing child conduct problems and improving parent competencies and mental health was examined in a 12-month follow-up. Pre- to post-intervention service use and related costs were also analysed. A total of 103 families and their children (aged 32–88 months), who previously participated in a randomised controlled trial of the IYBP, took part in a 12-month follow-up assessment. Child and parent behaviour and well-being were measured using psychometric and observational measures. An intention-to-treat analysis was carried out using a one-way repeated measures ANOVA. Pairwise comparisons were subsequently conducted to determine whether treatment outcomes were sustained 1 year post-baseline assessment. Results indicate that post-intervention improvements in child conduct problems, parenting behaviour and parental mental health were maintained. Service use and associated costs continued to decline. The results indicate that parent-focused interventions, implemented in the early years, can result in improvements in child and parent behaviour and well-being 12 months later. A reduced reliance on formal services is also indicated.

Combining histology, stable isotope analysis and ZooMS collagen fingerprinting to investigate the taphonomic history and dietary behaviour of extinct giant tortoises from the Mare aux Songes deposit on Mauritius

Taphonomic research of bones can provide additional insight into a site's formation and development, the burial environment and ongoing post-mortem processes. A total of 30 tortoise (Cylindraspis) femur bone samples from the Mare aux Songes site (Mauritius)were studied histologically, assessing parameters such as presence and type of microbial alteration, inclusions, staining/infiltrations, the degree of microcracking and birefringence. The absence of microbial attack in the 4200 year old Mare aux Songes bones suggests the animals rapidly entered the soil whole-bodied and were sealed anoxically, although they suffered frombiological and chemical degradation (i.e. pyrite formation/oxidation, mineral dissolution and staining) related to changes in the site's hydrology. Additionally, carbon and nitrogen stable isotopeswere analysed to obtain information on the animals' feeding behaviour. The results show narrowly distributed δ13C ratios, indicating a terrestrial C3 plant-based diet, combined with a wide range in δ15N ratios. This is most likely related to the tortoises' drought-adaptive ability to change their metabolic processes, which can affect the δ15N ratios. Furthermore, ZooMS collagen fingerprinting analysis successfully identified two tortoise species (C. triserrata and C. inepta) in the bone assemblage,which,when combined with stable isotope data, revealed significantly different δ15N ratios between the two tortoise species. As climatic changes around this period resulted in increased aridity in the Mascarene Islands, this could explain the extremely elevated δ15N ratio in our dataset. The endemic fauna was able to endure the climatic changes 4200 years ago, although human arrival in the 17th century changed the original habitat to such an extent that it resulted in the extinction of several species. Fortunately we are still able to study these extinct tortoises due to the beneficial conditions of their burial environment, resulting in excellent bone preservation.

Transitions in Contentious Behaviour in Infancy and Later Aggressive Conduct Problems

Background. Individual trajectories toward aggression originate in early infancy, before there is intent to harm. We focused on infants who were contentious, i.e., prone to engage in anger and use of physical force with other people, and examined change in levels of contentiousness between 6 and 12 months of age with reference to later aggressive conduct problems.
Sample. The CCDS is a nationally representative sample of 321 firstborn children whose families were recruited from antenatal clinics in two National Health Service Trusts.
Method. Mothers, fathers, and a third family member or friend who knew infants well completed the Cardiff Infant Contentiousness Scale (CICS) at 6 months, which was stable form 6 to 12 months, and validated by direct observation of infants’ use of force against peers. Primary caregivers again completed the CICS at 12 months, and up to three informants completed the Child Behaviour Check List at mean ages of 36 and 84 months. We used Latent Transition Analysis to identify different groups of infants in respect to their patterns of contentiousness from 6 to 12 months.
Results
Three ordered classes of contentiousness from low to high were found at 6 and 12 months. Infants exposed to greater family adversity were more likely to move into the high-contentious class from 6 to 12 months. Higher contentiousness in infancy predicted more aggressive conduct problems at 33 months and thereafter.
Conclusions
Infants exposed to family adversity are already at disadvantage by 6 months and likely to escalate in their anger and aggressiveness over time.

Exploring the effects of a universal classroom management training programme on teacher and child behaviour: a group randomised controlled trial and cost analysis

Teachers frequently struggle to cope with conduct problems in the classroom. The aim of this study was to assess the effectiveness of the Incredible Years Teacher Classroom Management Training Programme for improving teacher competencies and child adjustment. The study involved a group randomised controlled trial which included 22 teachers and 217 children (102 boys and 115 girls). The average age of children included in the study was 5.3 years (standard deviation = 0.89). Teachers were randomly allocated to an intervention group (n = 11 teachers; 110 children) or a waiting-list control group (n = 11; 107 children). The sample also included 63 ‘high-risk’ children (33 intervention; 30 control), who scored above the cut-off (>12) on the Strengths and Difficulties Questionnaire for abnormal socioemotional and behavioural difficulties. Teacher and child behaviours were assessed at baseline and 6 months later using psychometric and observational measures. Programme delivery costs were also analysed. Results showed positive changes in teachers’ self-reported use of positive classroom management strategies (effect size = 0.56), as well as negative classroom management strategies (effect size = −0.43). Teacher reports also highlight improvements in the classroom behaviour of the high-risk group of children, while the estimated cost of delivering the Incredible Years Teacher Classroom Management Training Programme was modest. However, analyses of teacher and child observations were largely non-significant. A need for further research exploring the effectiveness and cost-effectiveness of the Incredible Years Teacher Classroom Management Training Programme is indicated.

Behavior change theory, content and delivery of interventions to enhance adherence in chronic respiratory disease: A systematic review

Background: We sought to describe the theory used to design treatment adherence interventions, the content delivered, and the mode of delivery of these interventions in chronic respiratory disease. Methods: We included randomized controlled trials of adherence interventions (compared to another intervention or control) in adults with chronic respiratory disease (8 databases searched; inception until March 2015). Two reviewers screened and extracted data: post-intervention adherence (measured objectively); behavior change theory, content (grouped into psychological, education and self-management/supportive, telemonitoring, shared decision-making); and delivery. “Effective” studies were those with p < 0.05 for adherence rate between groups. We conducted a narrative synthesis and assessed risk of bias. Results: 12,488 articles screened; 46 included studies (n = 42,91% in OSA or asthma) testing 58 interventions (n = 27, 47% were effective). Nineteen (33%) interventions (15 studies) used 12 different behavior change theories. Use of theory (n = 11,41%) was more common amongst effective interventions. Interventions were mainly educational, self-management or supportive interventions (n = 27,47%). They were commonly delivered by a doctor (n = 20,23%), in face-to-face (n = 48,70%), one-to-one (n = 45,78%) outpatient settings (n = 46,79%) across 2–5 sessions (n = 26,45%) for 1–3 months (n = 26,45%). Doctors delivered a lower proportion (n = 7,18% vs n = 13,28%) and pharmacists (n = 6,15% vs n = 1,2%) a higher proportion of effective than ineffective interventions. Risk of bias was high in >1 domain (n = 43, 93%) in most studies. Conclusions: Behavior change theory was more commonly used to design effective interventions. Few adherence interventions have been developed using theory, representing a gap between intervention design recommendations and research practice.