A taxonomy of behaviour change methods: an Intervention Mapping approach.

In this paper, we introduce the Intervention Mapping (IM) taxonomy of behaviour change methods and its potential to be developed into a coding taxonomy. That is, although IM and its taxonomy of behaviour change methods are not in fact new, because IM was originally developed as a tool for intervention development, this potential was not immediately apparent. Second, in explaining the IM taxonomy and defining the relevant constructs, we call attention to the existence of parameters for effectiveness of methods, and explicate the related distinction between theory-based methods and practical applications and the probability that poor translation of methods may lead to erroneous conclusions as to method-effectiveness. Third, we recommend a minimal set of intervention characteristics that may be reported when intervention descriptions and evaluations are published. Specifying these characteristics can greatly enhance the quality of our meta-analyses and other literature syntheses. In conclusion, the dynamics of behaviour change are such that any taxonomy of methods of behaviour change needs to acknowledge the importance of, and provide instruments for dealing with, three conditions for effectiveness for behaviour change methods. For a behaviour change method to be effective: (1) it must target a determinant that predicts behaviour; (2) it must be able to change that determinant; (3) it must be translated into a practical application in a way that preserves the parameters for effectiveness and fits with the target population, culture, and context. Thus, taxonomies of methods of behaviour change must distinguish the specific determinants that are targeted, practical, specific applications, and the theory-based methods they embody. In addition, taxonomies should acknowledge that the lists of behaviour change methods will be used by, and should be used by, intervention developers. Ideally, the taxonomy should be readily usable for this goal; but alternatively, it should be clear how the information in the taxonomy can be used in practice. The IM taxonomy satisfies these requirements, and it would be beneficial if other taxonomies would be extended to also meet these needs.

Influencing organizations to promote health: applying stakeholder theory.

Stakeholder theory may help health promoters to make changes at the organizational and policy level to promote health. A stakeholder is any individual, group, or organization that can influence an organization. The organization that is the focus for influence attempts is called the focal organization. The more salient a stakeholder is and the more central in the network, the stronger the influence. As stakeholders, health promoters may use communicative, compromise, deinstitutionalization, or coercive methods through an ally or a coalition. A hypothetical case study, involving adolescent use of harmful legal products, illustrates the process of applying stakeholder theory to strategic decision making.

Finding theory- and evidence-based alternatives to fear appeals: Intervention Mapping.

Fear arousal-vividly showing people the negative health consequences of life-endangering behaviors-is popular as a method to raise awareness of risk behaviors and to change them into health-promoting behaviors. However, most data suggest that, under conditions of low efficacy, the resulting reaction will be defensive. Instead of applying fear appeals, health promoters should identify effective alternatives to fear arousal by carefully developing theory- and evidence-based programs. The Intervention Mapping (IM) protocol helps program planners to optimize chances for effectiveness. IM describes the intervention development process in six steps: (1) assessing the problem and community capacities, (2) specifying program objectives, (3) selecting theory-based intervention methods and practical applications, (4) designing and organizing the program, (5) planning, adoption, and implementation, and (6) developing an evaluation plan. Authors who used IM indicated that it helped in bringing the development of interventions to a higher level.

Methods for environmental change; an exploratory study.

BACKGROUND: While the interest of health promotion researchers in change methods directed at the target population has a long tradition, interest in change methods directed at the environment is still developing. In this survey, the focus is on methods for environmental change; especially about how these are composed of methods for individual change ('Bundling') and how within one environmental level, organizations, methods differ when directed at the management ('At') or applied by the management ('From'). METHODS: The first part of this online survey dealt with examining the 'bundling' of individual level methods to methods at the environmental level. The question asked was to what extent the use of an environmental level method would involve the use of certain individual level methods. In the second part of the survey the question was whether there are differences between applying methods directed 'at' an organization (for instance, by a health promoter) versus 'from' within an organization itself. All of the 20 respondents are experts in the field of health promotion. RESULTS: Methods at the individual level are frequently bundled together as part of a method at a higher ecological level. A number of individual level methods are popular as part of most of the environmental level methods, while others are not chosen very often. Interventions directed at environmental agents often have a strong focus on the motivational part of behavior change.There are different approaches targeting a level or being targeted from a level. The health promoter will use combinations of motivation and facilitation. The manager will use individual level change methods focusing on self-efficacy and skills. Respondents think that any method may be used under the right circumstances, although few endorsed coercive methods. CONCLUSIONS: Taxonomies of theoretical change methods for environmental change should include combinations of individual level methods that may be bundled and separate suggestions for methods targeting a level or being targeted from a level. Future research needs to cover more methods to rate and to be rated. Qualitative data may explain some of the surprising outcomes, such as the lack of large differences and the avoidance of coercion. Taxonomies should include the theoretical parameters that limit the effectiveness of the method.

The ecological approach in health promotion programs: a decade later.

PURPOSE: Present a 10-year update of the ecologic model of health promotion published by Richard et al. in the American Journal of Health Promotion in 1996. APPROACH: We adapted and simplified the model by leaving out settings, focusing on levels, and incorporating interpersonal and individual levels and agents that are in control of environmental conditions. SETTING: Health care facilities, schools, workplaces, living environments, and public environments were represented in program descriptions. PARTICIPANTS: Forty-three program coordinators responsible for 47 programs were interviewed in the United States and The Netherlands. METHODS: A systematic interview protocol elicited general program descriptions and relevant aspects of the ecologic approach. Program aspects from written reports were coded by the authors into levels, interventions, targets, and strategies. RESULTS: The programs had 234 strategies and 276 targets, with a mean of 2.15 levels. Twenty-seven distinct intervention strategies were identified, with the most common being modification of an organization to which the at-risk individuals belong, followed by policy and community changes. CONCLUSION: Our data fit the ecologic model and our adaptations and indicate that over the past decade health promotion practice may have changed to include more multilevel programs. Systematic analysis of program strategies within and across environmental levels allows better understanding of the social ecology of health-related behavior and potential leverage points for change.

Walk Texas! 5-A-Day intervention for Women, Infant, and Children (WIC) clients: a quasi-experimental study.

This study was conducted to evaluate the Walk Texas! Clinical Counseling Guide for Nutrition, which is a brief, stage-based nutritional counseling guide designed for use in clinical settings. This study utilized a pre-test post-test quasi-experimental design, with two intervention and two comparison clinics that were matched for size and ethnicity. Intervention participants were staged for readiness to meet the 5-A-Day criteria for fruits and vegetables (F&V) and provided stage-based counseling. Women, Infant, and Children (WIC) counselors were trained to utilize the Walk Texas! brief staging instrument and to provide all counseling. Primary measures included: stage of change, barriers to change, attitudes toward F&V, self-efficacy, and self-reports of F&V consumption. These were collected at baseline and during follow-up visits to the WIC clinic. A total of 433 participants completed pre-test data across the four sites. A number of individuals transferred from their original clinic or did not return to their clinic during the study (n=62). Of the remaining 371 participants, a total of 225 participants returned at least two surveys, for a response rate of 60.6%. These were primarily native Spanish speaking, Hispanic women, of low educational level. Results were mixed. Although there was no significant increase in the cognitive constructs (self-efficacy, attitudes, etc.), participants in the intervention clinics reported a significant increase in stage of change and a composite measure of F&V in-take. In contrast, participants in the control clinics reported no change in these variables. Thus, there appears to be some utility in the use of the Walk Texas! Clinical Counseling Guide for Nutrition in this population.

Cigarette smoking and cessation among trade or technical school students in Texas.

UNLABELLED: Although students enrolled in trade or technical colleges are at an elevated risk for tobacco use, virtually no information exists regarding their smoking behaviors. OBJECTIVE AND PARTICIPANTS: In the present study, the authors examined (1) the prevalence of smoking and quitting among 617 students in 2 trade or technical colleges in East Texas and (2) on-campus media exposure to antitobacco messages. METHODS: Students voluntary completed the 42-item Texas Trade and Technical School Tobacco Survey during a required introductory-level class. RESULTS: Of the participating students, 34% reported past-30-day smoking (current smoking). Of current smokers, 74% reported a previous quit attempt and 64% wanted to quit before graduation. Although most current smokers expressed a desire to quit smoking, the antitobacco message they were least likely to see on campus was that regarding how to quit. Current smokers cited their own health as the most likely reason to quit smoking, and most reported wanting to quit on their own, without the use of resources. However, of the 9 listed resources, students were most likely to report the possible use of medication. CONCLUSIONS: Given that most smoking students desire to quit smoking--and that they are enrolled in trade or technical schools for an extended period of time--additional research should examine how successful interventions can be delivered at the trade or technical school itself.

Preschooler feeding practices and beliefs: differences among Spanish- and English-speaking WIC clients.

This study explored preschooler feeding practices and beliefs among Spanish- and English-speaking WIC participants in Texas. The Preschooler Feeding Questionnaire examined 9 dimensions of the parent-child feeding interaction among 235 caregivers. Results from ANOVA and post hoc analyses demonstrated significant differences in reported preschooler feeding practices and beliefs among Spanish-speaking Hispanics in comparison with English-speaking Hispanics and non-Hispanics. No significant differences were found between English-speaking Hispanics and non-Hispanics. Results indicated that acculturation may impact behaviors apart from ethnicity. Nutrition professionals should understand and acknowledge the cultural context of the parent-child feeding interaction when developing programs.

Texas college students' opinions of no-smoking policies, secondhand smoke, and smoking in public places.

Abstract. The authors examined college student opinions of no-smoking policies, secondhand smoke, and smoking in public places. A convenience sample of 1,188 (66.4% female; 26.9% White, 64.1% Black, and 9.0% Hispanic) students attending 5 Texas colleges volunteered to complete a 60-item anonymous survey on tobacco attitudes and behaviors. Results of our study showed that women, Black students, and nonsmoking students reported the most favorable attitudes toward no smoking. Male students, white students, and students who smoked in the past 30 days (current smokers) reported the least favorable attitudes. The lowest level of agreement by all subgroups was provided for prohibiting smoking everywhere on campus (inside and outside of buildings). Implications for tobacco control on college campuses are discussed.

Examining the perspectives of Texas minors cited for possession of tobacco.

This study examined the personal experiences of twenty 14-to-19-year-old Texas youth cited for tobacco possession and attending a court-mandated tobacco awareness class. Guided by labeling theory, focus group questions addressed the process of citation, how youth viewed themselves following citation, how parents and peers viewed youth following citation, and youths' views on the purpose and effects of the policy. Many youth felt stupid for being caught or determined that they were unlucky. Parents were upset that youth were caught smoking; however, most knew their children smoked. Peers felt sympathy for cited youth or made fun of them for being caught. Participants felt that the law was in existence to deter younger children from initiating smoking or to encourage older minors to quit smoking. However, youth also indicated that there was no purpose to the law and that instead of decreasing smoking it could lead to its continuation. Implications for practice are discussed.

A feedback model for applied research on tobacco control.

Although the health communication program feedback cycle is frequently referenced, the steps for moving between or within the sections of the model in a public health environment are rarely described. We detail the process by which the Texas Tobacco Research Consortium implemented the stage of "assessing effectiveness and making refinement" and expanded it to include a program assessment feedback model. Tools were developed to move the consortium through five stages of the expanded program assessment feedback model: 1) formulate research questions using logic models to identify key evaluation items, 2) format data displays from multiple data sources to address research questions, 3) use a facilitated group process to present and review research findings, 4) prepare group recommendations, and 5) involve local partners to translate recommendations into practice. The process allowed us to sift through a large volume of information and prepare data-based program recommendations. A Web-based reporting system provided timely access to community-based program activity data and process indicators that, when linked to logic models, provided actionable items for program improvement. Partnerships among researchers and state and local practitioners created the conditions for implementing the recommendations. Program changes included revisions to program materials, target audiences, and evaluation instruments for a community-based tobacco-cessation campaign. The systematic approach allowed translation of research into practice and should be applicable to other areas of population-based health promotion.

Health promotion in heart failure--a paradigm shift.

For people living with heart failure, levels of health exist along a continuum in correlation with the illness experience. A focus on health promotion rather than only disease or symptom management expands opportunities for self-care and presents an emerging paradigm shift in the care of people with heart failure. Results from 2 studies revealed that few health-promoting behaviors were reported by patients with heart failure until a focused intervention that emphasized health promotion as part of self-care was implemented.

Heritable variation in seed sex ratio of the stinging nettle (Urtica dioica).

Male and female flowering plants of the dioecious Urtica dioica occur in approximately equal numbers in our study area on the coastal sand dunes of Meijendel. The seed sex ratio (SSR, fraction of males) collected from female plants in the field varied between 0.05 and 0.76, and differed significantly between maternal parents. After one generation of selection for either high or low SSR, female plants produced seed batches with sex ratios as extreme as 0.08 and 0.73. Natural populations of U. dioica harbour considerable genetic variation in SSR.

Developmental stages in public health partnerships: a practical perspective.

Health education practitioners often form and provide support to partnerships directed toward public health goals. The authors viewed the start-up of a state health department/multiuniversity partnership for the evaluation of the state's tobacco settlement pilot project using the lens of the Tuckman four-stage model of group development. The four stages--forming, storming, norming, and performing--occurred in sequence but with pronounced overlap. Two types of performing--institutional and group performing--were observed. An awareness of group developmental stages can allow leaders and members to improve the ways their partnership works together. Applying Tuckman's model also can allow expectations about the group's progress and members' interactions to be managed so that tasks are aligned with the appropriate stage of development. Finally, for partnerships that have a long life span, understanding that the stages may occur several times throughout the group's existence can acclimate members to shifting responsibilities and relationships over time.

Keeping the focus on public health: the struggles of a tobacco prevention task force.

This case study examines a nonlegislative task force as it struggled to reach internal consensus despite external political constraints. The study highlights the convergence of politics and science, revealing complex issues likely to be confronted by advocates and public health officials. Three themes capture participants' experiences: context, sizing up the opportunities and constraints; task force process, tacit strategy to operate outside the political context and play the science card; and aftermath, a glass half full. The task force took advantage of ambiguous parameters, crafting a comprehensive statewide plan to reduce tobacco use and breaking out of the common public health paradigm of allowing budget considerations to drive program design. These internal victories could not sustain a policy success in the legislature. However, the group's product sets science-based standards for future program development, and the task force's process provides valuable insights into other states developing tobacco prevention and control policies.

The relationship between hardiness, supervisor support, group cohesion, and job stress as predictors of job satisfaction.

PURPOSE: This study tested a conceptual model based on research supporting the relationship between the predictors of hardiness, supervisor support, and group cohesion and the criterions of job stress and job satisfaction and between the predictor of job stress and the criterion of job satisfaction. DESIGN: The study employed a cross-sectional research design. Survey data were collected as part of the baseline measures assessed prior to an organizational hardiness intervention. SETTING: Worksite of Dell Computer Corporation in Austin, Texas. SUBJECTS: The subjects included 160 full-time Dell employees recruited from a convenience sample representing nine work groups (response rate = 90%). MEASURES: Hardiness was measured using the Dispositional Resilience Scale (DRS), job stress was measured using the Perceived Work Stress Scale (PWSS), and supervisor support, group cohesion, and job satisfaction were measured using a proprietary employee attitude survey. RESULTS: In the proposed model, high hardiness, supervisor support, and group cohesion were related to lower levels of job stress, which in turn was related to higher levels of job satisfaction. The model also proposed direct paths from hardiness, supervisor support, and group cohesion to job satisfaction. Path analysis was used to examine the goodness of fit of the model. The proposed model was a good fit for the data (chi 2[1, N = 160] = 1.85, p = .174) with the exception of the direct path between group cohesion and job satisfaction. Substantial portions of the variances in job stress (R2 = .19) and job satisfaction (R2 = .44) were accounted for by the predictors. CONCLUSION: Implications for targeted worksite health promotion efforts to lower job stress and enhance job satisfaction are discussed.

State legislators' beliefs about legislation that restricts youth access to tobacco products.

Better understanding of the cognitive framework for decision making among legislators is important for advocacy of health-promoting legislation. In 1994, the authors surveyed state legislators from North Carolina, Texas, and Vermont concerning their beliefs and intentions related to voting for a hypothetical measure to enforce legislation preventing the sale of tobacco to minors, using scales based on the theory of planned behavior. Attitude (importance), subjective norm (whether most people important to you would say you should or should not vote for the law), perceived behavioral control (ability to cast one's vote for the law), and home state were independently and significantly related to intention to vote for the law's enforcement. The results, including descriptive data concerning individual beliefs, suggest specific public health strategies to increase legislative support for passing legislation to restrict youth tobacco sales and, more generally, a framework for studying policy making and advocacy.

Nutrition and physical activity counseling practices of family practice residents.

BACKGROUND: Nutritional behaviors and physical activity can influence risk for the development and prognosis of cancer. This study reports findings of a literature review and a survey of nutrition and physical activity counseling practices of family practice (FP) residents. METHODS: 110 FP residents (response rate = 93.2%) from four clinics that received funding from the Texas Department of Health completed the survey. Hierarchical linear regression models were used to identify determinants of nutrition and physical activity counseling practices. RESULTS: About a fifth of the residents reported that they usually or always asked their patients about nutrition and physical activity. In general, residents were most likely to address these issues with asymptomatic obese adult patients. Perceived effectiveness was a significant predictor of both assessment and counseling, except for nutrition counseling for asymptomatic patients. Attitude toward behavioral counseling predicted assessment, but not counseling. Use of resources predicted counseling on both topics with all patients. CONCLUSION: FP residents assess and counsel about nutrition and physical activity at suboptimal rates. There is a need to convince residents of the value of such assessment and counseling and to increase their belief that patients will follow through on their recommendations.

Therapeutic equivalence study of two formulations (innovator v. generic) of beclomethasone dipropionate in adult asthmatic patients.

OBJECTIVE: To study the therapeutic equivalence of two formulations (innovator v. generic) of beclomethasone dipropionate (BDP) 400 micrograms twice daily administered per metered dose inhaler (MDI), in adults with moderate to severe asthma. METHODS: A double-blind randomised parallel-group trial was performed with a 2-week run-in and an 8-week treatment period. Thirty-six symptomatic adult asthmatics on a mean daily dose of 750 micrograms inhaled corticosteroids during run-in, a mean forced expiratory volume in 1 second (FEV1) of 70% predicted normal and a mean histamine concentration provoking a 20% reduction in FEV1 (histamine PC20) of 0.11 mg/l were randomised to one of the two treatment groups. Primary variables were morning peak expiratory flow (mPEF), FEV1 and histamine PC20. Secondary variables were beta 2-agonist use, symptom score and nocturnal awakening. The Schuirmann two one-sided tests procedure was used for the statistical analysis. Ninety-five per cent confidence intervals (CIs) were calculated for the differences in means. RESULTS: The mean differences end of treatment to baseline for the two formulations (Becotide and Beclate) respectively were: mPEF 5.6 l/min (CI - 16.4-27.6) and -22.3 l/min (CI -35.6(-)-9); FEV1 -2.9% (CI -11-5.2) and 0.2% (CI -4.8-5.2); Histamine PC20 -0.04 mg/ml (CI -0.15-0.06) and 0.02 mg/ml (CI -0.37-0.4). Changes in clinical variables were not conclusive. The mean differences with CIs for primary variables were contained within the limits set for equivalence. The sample size was sufficient to differentiate the groups for mPEF, but this was not of clinical significance. CONCLUSION: After 8 weeks of treatment the two formulations of BDP, delivered by MDI through a large-volume spacer, were therapeutically equivalent in moderate-to-severe asthmatic adults.

Fatal complication of paraffin plombage after half a century.

Complications following thoracic plombage for treatment of tuberculosis can be observed more than 50 years after placement of the filling. The management of these late complications is challenging and frequently requires surgical intervention. We report a patient who received a plombage in 1947. She was admitted to hospital with subfebrile temperature and hoarseness. A computed tomography scan of the chest revealed transthoracic penetration of the paraffin plombage with intrusion into the overlying soft tissue. The patient underwent excision and debridement of the paraffin wax mass followed by thoracoplasty. She then developed septicaemia and died due to multiple organ failure 23 days after the surgical intervention. Early ablation of plombage should be considered in order to prevent late complications.