Mediators and moderators of behavior change in patients with chronic cardiopulmonary disease: the impact of positive affect and self-affirmation.

Among patients with chronic cardiopulmonary disease, increasing healthy behaviors improves outcomes, but such behavior changes are difficult for patients to make and sustain over time. This study aims to demonstrate how positive affect and self-affirmation improve health behaviors compared with a patient education control group. The patient education (PE control) patients completed a behavioral contract, promising to increase their physical activity or their medication adherence and received an educational guide. In addition to the contract and guide, the positive affect/self-affirmation intervention (PA intervention) patients also learned to use positive affect and self-affirmation to facilitate behavior change. Follow-up was identical. In 756 patients, enrolled in three randomized trials, the PA intervention resulted in increased positive affect and more success in behavior change than the PE control (p < .01). Behavior-specific self-efficacy also predicted success (p < .01). Induction of positive affect played a critical role in buffering against the adverse behavioral consequences of stress. Patients who experienced either negative psychosocial changes (p < .05) or interval negative life events (p < .05) fared better with the PA intervention than without it. The PA intervention increased self-efficacy and promoted success in behavior change by buffering stress.

Translating basic behavioral and social science research to clinical application: the EVOLVE mixed methods approach.

OBJECTIVE: To describe a mixed-methods approach to develop and test a basic behavioral science-informed intervention to motivate behavior change in 3 high-risk clinical populations. Our theoretically derived intervention comprised a combination of positive affect and self-affirmation (PA/SA), which we applied to 3 clinical chronic disease populations. METHOD: We employed a sequential mixed methods model (EVOLVE) to design and test the PA/SA intervention in order to increase physical activity in people with coronary artery disease (post-percutaneous coronary intervention [PCI]) or asthma (ASM) and to improve medication adherence in African Americans with hypertension (HTN). In an initial qualitative phase, we explored participant values and beliefs. We next pilot tested and refined the intervention and then conducted 3 randomized controlled trials with parallel study design. Participants were randomized to combined PA/SA versus an informational control and were followed bimonthly for 12 months, assessing for health behaviors and interval medical events. RESULTS: Over 4.5 years, we enrolled 1,056 participants. Changes were sequentially made to the intervention during the qualitative and pilot phases. The 3 randomized controlled trials enrolled 242 participants who had undergone PCI, 258 with ASM, and 256 with HTN (n = 756). Overall, 45.1% of PA/SA participants versus 33.6% of informational control participants achieved successful behavior change (p = .001). In multivariate analysis, PA/SA intervention remained a significant predictor of achieving behavior change (p < .002, odds ratio = 1.66), 95% CI [1.22, 2.27], controlling for baseline negative affect, comorbidity, gender, race/ethnicity, medical events, smoking, and age. CONCLUSIONS: The EVOLVE method is a means by which basic behavioral science research can be translated into efficacious interventions for chronic disease populations.

Positive affect improves working memory: implications for controlled cognitive processing.

This study examined the effects of positive affect on working memory (WM) and short-term memory (STM). Given that WM involves both storage and controlled processing and that STM primarily involves storage processing, we hypothesised that if positive affect facilitates controlled processing, it should improve WM more than STM. The results demonstrated that positive affect, compared with neutral affect, significantly enhanced WM, as measured by the operation span task. The influence of positive affect on STM, however, was weaker. These results suggest that positive affect enhances WM, a task that involves controlled processing, not just storage processing. Additional analyses of recall and processing times and accuracy further suggest that improved WM under positive affect is not attributable to motivational differences, but results instead from improved controlled cognitive processing.

Positive feelings facilitate working memory and complex decision making among older adults.

The impact of induced mild positive feelings on working memory and complex decision making among older adults (aged 63-85) was examined. Participants completed a computer administered card task in which participants could win money if they chose from "gain" decks and lose money if they chose from "loss" decks. Individuals in the positive-feeling condition chose better than neutral-feeling participants and earned more money overall. Participants in the positive-feeling condition also demonstrated improved working-memory capacity. These effects of positive-feeling induction have implications for affect theory, as well as, potentially, practical implications for people of all ages dealing with complex decisions.

A randomized controlled trial of positive-affect induction to promote physical activity after percutaneous coronary intervention.

BACKGROUND: Within 1 year after percutaneous coronary intervention, more than 20% of patients experience new adverse events. Physical activity confers a 25% reduction in mortality; however, physical activity is widely underused. Thus, there is a need for more powerful behavioral interventions to promote physical activity. Our objective was to motivate patients to achieve an increase in expenditure of 336 kcal/wk or more at 12 months as assessed by the Paffenbarger Physical Activity and Exercise Index. METHODS: Two hundred forty-two patients were recruited immediately after percutaneous coronary intervention between October 2004 and October 2006. Patients were randomized to 1 of 2 groups. The patient education (PE) control group (n = 118) (1) received an educational workbook, (2) received a pedometer, and (3) set a behavioral contract for a physical activity goal. The positive-affect/self-affirmation (PA) intervention group (n = 124) received the 3 PE control components plus (1) a PA workbook chapter, (2) bimonthly induction of PA by telephone, and (3) small mailed gifts. All patients were contacted with standardized bimonthly telephone follow-up for 12 months. RESULTS: Attrition was 4.5%, and 2.1% of patients died. Significantly more patients in the PA intervention group increased expenditure by 336 kcal/wk or more at 12 months, our main outcome, compared with the PE control group (54.9% vs 37.4%, P = .007). The PA intervention patients were 1.7 times more likely to reach the goal of a 336-kcal/wk or more increase by 12 months, controlling for demographic and psychosocial measures. In multivariate analysis, the PA intervention patients had nearly double the improvement in kilocalories per week at 12 months compared with the PE control patients (602 vs 328, P = .03). CONCLUSION: Patients who receive PA intervention after percutaneous coronary intervention are able to achieve a sustained and clinically significant increase in physical activity by 12 months. Trial Registration clinicaltrials.gov Identifier: NCT00248846.

A randomized controlled trial of positive-affect intervention and medication adherence in hypertensive African Americans.

BACKGROUND: Poor adherence explains poor blood pressure (BP) control; however African Americans suffer worse hypertension-related outcomes. METHODS: This randomized controlled trial evaluated whether a patient education intervention enhanced with positive-affect induction and self-affirmation (PA) was more effective than patient education (PE) alone in improving medication adherence and BP reduction among 256 hypertensive African Americans followed up in 2 primary care practices. Patients in both groups received a culturally tailored hypertension self-management workbook, a behavioral contract, and bimonthly telephone calls designed to help them overcome barriers to medication adherence. Also, patients in the PA group received small gifts and bimonthly telephone calls to help them incorporate positive thoughts into their daily routine and foster self-affirmation. The main outcome measures were medication adherence (assessed with electronic pill monitors) and within-patient change in BP from baseline to 12 months. RESULTS: The baseline characteristics were similar in both groups: the mean BP was 137/82 mm Hg; 36% of the patients had diabetes; 11% had stroke; and 3% had chronic kidney disease. Based on the intention-to-treat principle, medication adherence at 12 months was higher in the PA group than in the PE group (42% vs 36%, respectively; P =.049). The within-group reduction in systolic BP (2.14 mm Hg vs 2.18 mm Hg; P = .98) and diastolic BP (-1.59 mm Hg vs -0.78 mm Hg; P = .45) for the PA group and PE group, respectively, was not significant. CONCLUSIONS: A PE intervention enhanced with PA led to significantly higher medication adherence compared with PE alone in hypertensive African Americans. Future studies should assess the cost-effectiveness of integrating such interventions into primary care. Trial Registration clinicaltrials.gov Identifier: NCT00227175.

Increasing physical activity in patients with asthma through positive affect and self-affirmation: a randomized trial.

BACKGROUND: Patients with asthma engage in less physical activity than peers without asthma. Protocols are needed to prudently increase physical activity in asthma patients. We evaluated whether an educational intervention enhanced with positive-affect induction and self-affirmation was more effective than the educational protocol alone in increasing physical activity in asthma patients. METHODS: We conducted a randomized trial in New York City from September 28, 2004, through July 5, 2007; of 258 asthma patients, 252 completed the trial. At enrollment, control subjects completed a survey measuring energy expenditure, made a contract to increase physical activity, received a pedometer and an asthma workbook, and then underwent bimonthly follow-up telephone calls. Intervention patients received this protocol plus small gifts and instructions in fostering positive affect and self-affirmation. The main outcome was the within-patient change in energy expenditure in kilocalories per week from enrollment to 12 months with an intent-to-treat analysis. RESULTS: Mean (SD) energy expenditure at enrollment was 1767 (1686) kcal/wk among controls and 1860 (1633) kcal/wk among intervention patients (P = .65) and increased by 415 (95% CI, 76-754; P = .02) and 398 (95% CI, 145-652; P = .002) kcal/wk, respectively, with no difference between groups (P = .94). For both groups, energy expenditure was sustained through 12 months. No adverse events were attributed to the trial. In multivariate analysis, increased energy expenditure was associated with less social support, decreased depressive symptoms, more follow-up calls, use of the pedometer, fulfillment of the contract, and the intervention among patients who required urgent asthma care (all P < .10, 2-sided test). CONCLUSIONS: A multiple-component protocol was effective in increasing physical activity in asthma patients, but an intervention to increase positive affect and self-affirmation was not effective within this protocol. The intervention may have had some benefit, however, in the subgroup of patients who required urgent asthma care during the trial. Trial Registration clinicaltrials.gov Identifier: NCT00195117.

Predicting behavior in economic games by looking through the eyes of the players.

Social scientists often rely on economic experiments such as ultimatum and dictator games to understand human cooperation. Systematic deviations from economic predictions have inspired broader conceptions of self-interest that incorporate concerns for fairness. Yet no framework can describe all of the major results. We take a different approach by asking players directly about their self-interest--defined as what they want to do (pleasure-maximizing options). We also ask players directly about their sense of fairness--defined as what they think they ought to do (fairness-maximizing options). Player-defined measures of self-interest and fairness predict (a) the majority of ultimatum-game and dictator-game offers, (b) ultimatum-game rejections, (c) exiting behavior (i.e., escaping social expectations to cooperate) in the dictator game, and (d) who cooperates more after a positive mood induction. Adopting the players' perspectives of self-interest and fairness permits better predictions about who cooperates, why they cooperate, and when they punish noncooperators.

Randomized controlled trials of positive affect and self-affirmation to facilitate healthy behaviors in patients with cardiopulmonary diseases: rationale, trial design, and methods.

Secondary prevention of adverse outcomes in patients with cardiopulmonary disease requires that patients become actively engaged in self-management efforts such as participation in physical activity or medication adherence. However, despite assiduous efforts to find strategies that help cardiovascular patients to adopt and maintain such behaviors, many studies of interventions designed to improve physical activity and adherence to medication have shown disappointing results. To this end, the Translational Behavioral Science Research Consortium was created by the National Heart, Lung, and Blood Institute to identify promising, but underutilized findings from basic behavioral science that might have potential application for translation to clinical populations where behavioral change has been refractory to standard intervention approaches. This paper describes the rationale and methods of a novel research project designed to test the efficacy of a behavioral intervention that combines constructs from two behavioral science theories (positive affect and self-affirmation) in order to help patients with coronary artery disease, asthma, and hypertension successfully change behaviors. The project consists of an intervention framed upon positive affect and self-affirmation and tested in three concurrent randomized controlled trials among three distinct populations. Each trial had a qualitative phase that served as a formative stage to inform the intervention; a pilot phase during which the feasibility of the intervention was tested and refined; and a randomized controlled phase conducted to investigate the effects of the interventions in these three patient groups.

The influence of positive affect on the components of expectancy motivation.

The influence of positive affect on expectancy motivation was investigated in 2 studies. The results of Study 1 indicated that positive affect improved people's performance and affected their perceptions of expectancy and valence. In Study 1, in which outcomes depended on chance, positive affect did not influence people's perceptions of instrumentality. In Study 2, in which the link between performance and outcomes was specified, positive affect influenced all 3 components of expectancy motivation. Together, the results of Studies 1 and 2 indicated that positive affect interacts with task conditions in influencing motivation and that its influence on motivation occurs not through general effects, such as response bias or general activation, but rather through its influence on the cognitive processes involved in motivation.