Ana Goode

Telephone-Delivered Interventions for Physical Activity and Dietary Behavior Change : An Updated Systematic Review

CONTEXT Telephone-delivered interventions targeting physical activity and dietary change have potential for broad population reach and thus have a role to play in addressing increasing rates of lifestyle-related chronic diseases. The purpose of this systematic review is to update the evidence for their potential to inform translation, including effectiveness in promoting maintenance, reporting on implementation, and costs. EVIDENCE ACQUISITION A structured search of PubMed, MEDLINE, and PsycINFO (January 2006 to April 2010) was conducted. Included studies reported on physical activity and/or dietary change in adults, delivered at least 50% of intervention contacts by telephone, and included a control group (except in dissemination studies). Detailed information on study design, intervention features, and behavioral outcomes was extracted, tabulated, and summarized. EVIDENCE SYNTHESIS Twenty-five studies (27 comparisons) were included: 16 for physical activity, two for diet, and seven for combined interventions. Twenty of 27 comparisons found evidence for initiation of behavior change (14 of 17 comparisons for physical activity; two of two for diet; four of eight for combined interventions). Ten of 25 studies evaluated post-intervention maintenance of change, with three reporting that maintenance was achieved for at least 50% of outcomes. Dissemination studies were rare (n=3), as were dose-response (n=2) and cost-effectiveness analyses (n=2). CONCLUSIONS Given the strength of evidence for telephone-delivered physical activity and dietary change interventions, greater emphasis on dissemination studies is warranted.

A Telephone-Delivered Physical Activity and Dietary Intervention for Type 2 Diabetes and Hypertension: Does Intervention Dose Influence Outcomes?

Purpose. To examine associations of intervention dose with behavior change outcomes in a telephone counseling intervention for physical activity and dietary change. Design. Secondary analysis of intervention participants from a cluster-randomized controlled trial. Setting. Primary care practices in a disadvantaged community in Queensland, Australia. Subjects. Adult patients with type 2 diabetes or hypertension. Intervention. Patients (n = 228) received telephone counseling over a 12-month period. The initiation phase (1–4 months) consisted of up to 10 weekly or fortnightly calls; the maintenance-enhancement phase (5–12 months) consisted of up to eight monthly calls. Measures. Intervention dose was defined as the number of calls completed in total and during each phase and was categorized into tertiles. Diet and physical activity were measured using validated self-report instruments. Analysis. Multivariate analyses of call completion and change in health behaviors. Results. Those completing a high number of calls were more likely to be female, white, older than 60 years, retired, and earning less than an average weekly Australian wage. Relative to low call completion, high completion during the maintenance-enhancement phase was associated with significantly greater (least squares mean [SE]) behavioral improvement for the following: total fat intake as percentage of calories (–3.58% [.74%]), saturated fat intake (–2.51% [.51%]), fiber intake (4.23 [1.20] g), and moderate-to-vigorous physical activity (187.82 [44.78] minutes). Conclusion. Interventions of longer duration may be required to influence complex behaviors such as physical activity and fat and fiber intake. (Am J Health Promot 2011;25[4]:257–263.)

Translation from research to practice: community dissemination of a telephone-delivered physical activity and dietary behavior change intervention.

Purpose: To describe the process of translating an evidence-based, telephone-delivered physical activity and dietary behavior change intervention from research into practice. Design: Descriptive case study. Setting/Subjects: Nongovernment, primary medical care–based community health organization. Intervention: Telephone-delivered intervention targeting physical activity and diet in primary medical care patients. Measures/Analysis: Systematic documentation of process outcomes related to intervention adoption and adaptation. Results: Research-community partnerships were critical in facilitating translation, including (1) an initial competitive advantage within a State Health Department–funded preventive health initiative; (2) advocacy to ensure the adoption of the intervention, (3) subsequent support for the adaptation of program elements to ensure fit of the program with the community organizations objectives and capacities, while maintaining feasible elements of fidelity with the original evidence-based program; (4) the integration of program management and evaluation systems within the community organization; and (5) ongoing support for staff members responsible for program delivery and evaluation. Preliminary process evaluation of the Optimal Health Program supports the acceptability and feasibility of the program within community practice. Conclusions: Intervention characteristics central to adoption can be influenced by research-community partnerships. It is likely that evidence-based interventions will need to be adapted for delivery within the real world. Researchers should endeavor to provide training and support to ensure, as much as possible, fidelity with the original program, and that the relevant adaptations are evidence based.

Evaluating the Maintenance of Lifestyle Changes in a Randomized Controlled Trial of the 'Get Healthy, Stay Healthy' Program

Background Extending contact with participants after initial, intensive intervention may support maintenance of weight loss and related behaviors. Objective This community-wide trial evaluated a text message (short message service, SMS)-delivered, extended contact intervention (‘Get Healthy, Stay Healthy’ (GHSH)), which followed on from a population-level, behavioral telephone coaching program. Methods This study employed a parallel, randomized controlled trial: GHSH compared with no continued contact (standard practice). Participants (n=228) were recruited after completing a 6-month lifestyle telephone coaching program: mean age = 53.4 (standard deviation (SD)=12.3) years; 66.7% (152/228) female; mean body mass index (BMI) upon entering GHSH=29.5 kg/m2 (SD = 6.0). Participants received tailored text messages over a 6-month period. The message frequency, timing, and content of the messages was based on participant preference, ascertained during two tailoring telephone calls. Primary outcomes of body weight, waist circumference, physical activity (walking, moderate, and vigorous sessions/week), and dietary behaviors (fruit and vegetable serves/day, cups of sweetened drinks per day, takeaway meals per week; fat, fiber and total indices from the Fat and Fiber Behavior Questionnaire) were assessed via self-report before (baseline) and after (6-months) extended contact (with moderate-vigorous physical activity (MVPA) also assessed via accelerometry). Results Significant intervention effects, all favoring the intervention group, were observed at 6-months for change in weight (-1.35 kg, 95% confidence interval (CI): -2.24, -0.46, P=.003), weekly moderate physical activity sessions (0.56 sessions/week, 95% CI: 0.15, 0.96, P=.008) and accelerometer-assessed MVPA (24.16 minutes/week, 95% CI: 5.07, 43.25, P=.007). Waist circumference, other physical activity outcomes and dietary outcomes, did not differ significantly between groups. Conclusions The GHSH extended care intervention led to significantly better anthropometric and physical activity outcomes than standard practice (no contact). This evidence is useful for scaling up the delivery of GHSH as standard practice following the population-level telephone coaching program.

The BeUpstanding Program TM : Scaling up the Stand Up Australia Workplace Intervention for Translation into Practice

Context and purpose Too much sitting is now recognised as a common risk factor for several health outcomes, with the workplace identified as a key setting in which to address prolonged sitting time. The Stand Up Australia intervention was designed to reduce prolonged sitting in the workplace by addressing influences at multiple-levels, including the organisation, the environment, and the individual. Intervention success has been achieved within the context of randomised controlled trials, where research staff deliver several of the key intervention components. This study describes the initial step in the multi-phase process of scaling up the Stand Up Australia intervention for workplace translation. Methods A research-government partnership was critical in funding and informing the prototype for the scaled up BeUpstanding program™. Evidence, protocols and materials from Stand Up Australia were adapted in collaboration with funding partner Workplace Health and Safety Queensland to ensure consistency and compatibility with existing government frameworks and resources. In recognition of the key role of workplace champions in facilitating workplace health promotion programs, the BeUpstanding program™ is designed to be delivered through a stand-alone, free, website-based toolkit using a ‘train the champion’ approach. Key findings and significance The BeUpstanding program™ was influenced by the increasing recognition of prolonged sitting as an emerging health issue as well as industry demand. The research-government partnership was critical in informing and resourcing the development of the scaled-up program.

Relationship Between Intervention Dose and Outcomes in Living Well With Diabetes—A Randomized Trial of a Telephone-Delivered Lifestyle-Based Weight Loss Intervention

Purpose. To examine associations of intervention dose with weight, physical activity, glycemic control, and diet outcomes in a randomized trial of a telephone counseling intervention. Design. Study design was a secondary analysis of intervention group. Setting. Study setting was primary care practices in a disadvantaged community in Australia. Subjects. Participants were adult patients with type 2 diabetes (n = 151). Intervention. Up to 27 telephone counseling calls were made during 18 months. Measures. Intervention dose was assessed as the number of calls completed (in tertile categories). Primary outcomes were weight and HbA1c, and moderate to vigorous intensity physical activity via accelerometer. Secondary outcomes were dietary energy intake and diet quality via a validated questionnaire. Analysis. Analyses employed were bivariate associations of call completion with sociodemographics, and confounder-adjusted linear mixed models for associations of call completion with outcomes (multiple imputation of missing data). Results. Only previous diagnosis of depression/anxiety had a statistically significant (p= .008) association with call completion. Call completion was significantly associated with weight loss (p < .001) but not the other outcomes (p > .05). Relative to low call completion, mean weight loss (as a percentage of baseline weight) was greater in the high–call completion group by −3.3% (95% confidence interval, −5.0% to −1.5%). Conclusion. Increased dose of intervention was associated with greater weight loss. More needs to be done to retain patients for the duration of weight loss and behavior change interventions, particularly those with diabetes and comorbid depression, who were the most difficult to engage.

Dissemination of an evidence-based telephone-delivered lifestyle intervention: factors associated with successful implementation and evaluation

To inform wider-scale dissemination efforts of health behavior change interventions, we need to better understand factors associated with successful implementation and evaluation in nonresearch settings. Using the experience of the Optimal Health Program dissemination (OHP), a 12-month evidence-based telephone-delivered intervention for physical activity, healthy eating, and weight loss, we provide a detailed account according to the reach, efficacy/effectiveness, adoption, implementation, and maintenance (RE-AIM) framework of the supports that were needed to facilitate the delivery and evaluation of the program in an applied community-based primary health care setting. Substantial initial research support including development of data collection procedures, staff training in intervention protocols, and ongoing support for fidelity of data collection and intervention delivery, as well as evaluation and reporting of outcomes was required. The RE-AIM framework can highlight common elements that will require attention from researchers to promote success of programs in applied settings.

Moderators of health behavior initiation and maintenance in a randomized telephone counseling trial

OBJECTIVE This study compares moderators of initiation and maintenance of health behavior changes. METHODS Data come from a cluster-randomized, 12-month telephone counseling intervention for physical activity and diet, targeting type 2 diabetes or hypertension patients (n=434, Australia,2005-2007). Demographic and health-related characteristics, theoretical constructs, and baseline behavioral outcomes were considered as moderators. Mixed models, adjusting for baseline values, assessed moderation of intervention effects for trial outcomes (physical activity, intakes of fat, saturated fat, fiber, fruit, vegetables) at end-of-intervention (12 months/initiation) and maintenance follow-up (18 months), and compared moderation between these periods. RESULTS Social support for physical activity and baseline physical activity were significant (p<0.05) moderators of physical activity at 12 months. Gender, marital status, social support for healthy eating, BMI, and number of chronic conditions were significant moderators of dietary changes at 12- and/or 18 months. Instances of moderation differing significantly between 12- and 18 months were: baseline physical activity for physical activity (initiation) and marital status for fat intake (maintenance). CONCLUSIONS This exploratory study showed that moderation of physical activity and diet effects sometimes differed between initiation and maintenance. To identify unique moderators for initiation and/or maintenance of behavior changes, future studies need to report on and statistically test for such differences.

'Get healthy, stay healthy': Protocol for evaluation of a lifestyle intervention delivered by text-message following the Get Healthy Information and Coaching Service®

BackgroundBehavioural lifestyle interventions can be effective at promoting initial weight loss and supporting physical activity and dietary behaviour change, however maintaining improvements in these outcomes is often more difficult to achieve. Extending intervention contact to reinforce learnt behavioural skills has been shown to improve maintenance of behaviour change and weight loss. This trial aims to evaluate the feasibility, acceptability and efficacy of a text message-delivered extended contact intervention to enhance or maintain change in physical activity, dietary behaviour and weight loss among participants who have completed a six month Government-funded, population-based telephone coaching lifestyle program: the Get Healthy Information and Coaching Service (GHS).Methods/DesignGHS completers will be randomised to the 6-month extended contact intervention (Get Healthy, Stay Healthy, GHSH) or a no contact control group (standard practice following GHS completion). GHSH participants determine the timing and frequency of the text messages (3–13 per fortnight) and content is tailored to their behavioural and weight goals and support preferences. Two telephone tailoring calls are made (baseline, 12-weeks) to facilitate message tailoring. Primary outcomes, anthropometric (body weight and waist circumference via self-report) and behavioural (moderate-vigorous physical activity via self-report and accelerometer, fruit and vegetable intake via self-report), will be assessed at baseline (at GHS completion), 6-months (end of extended contact intervention) and 12-months (6-months post intervention contact). Secondary aims include evaluation of: the feasibility of program delivery; the acceptability for participants; theoretically-guided, potential mediators and moderators of behaviour change; dose-responsiveness; and, costs of program delivery.DiscussionFindings from this trial will inform the delivery of the GHS in relation to the maintenance of behaviour change and weight loss, and will contribute to the broader science of text message lifestyle interventions delivered in population health settings.Trial registrationACTRN12613000949785

Telephone-delivered weight management services in the hospital outpatient setting: Decision-makers’ perceptions of their use in routine practice

AIM Providing effective weight management services to the growing number of overweight or obese hospital patients necessitates long-term service provision; however, it is arguably not within the acute-care hospital remit to provide such extended services. Referral to community-based programs is required to provide continuing weight management services. The Get Healthy Service is a free six-month, telephone-delivered lifestyle program, now offered in several states of Australia with potential for wide population reach. However, health practitioner referral into the service has been low. The study aimed to examine awareness and suitability of the Get Healthy Service for referral of hospital outpatients for weight management, among key health-care decision-makers. METHODS Nine key decision-makers from metropolitan and rural Queensland Health hospitals took part in semi-structured telephone interviews that were audio-recorded (January-July 2014), transcribed verbatim and thematically analysed. RESULTS Interviews revealed that most decision-makers had limited awareness of the Get Healthy Service but perceived the telephone service to be suitable for patient referrals. Incorporating Get Healthy Service referrals into patient care was seen to be potentially valuable and relatively easy to implement, with most interviewees suggesting that they would provide a Get Healthy Service brochure to patients who could then self-refer into the service. CONCLUSIONS The Get Healthy Service provides a referral model for weight management service provision that appears feasible for use in Queensland hospital settings. Increased awareness and a more integrated approach to referrals would likely result in improved enrolment to the service, with future research needed to demonstrate this.