Gareth John Hollands

Changing Human Behavior to Prevent Disease: The Importance of Targeting Automatic Processes

Much of the global burden of disease is associated with behaviors—overeating, smoking, excessive alcohol consumption, and physical inactivity—that people recognize as health-harming and yet continue to engage in, even when undesired consequences emerge. To date, interventions aimed at changing such behaviors have largely encouraged people to reflect on their behaviors. These approaches are often ineffectual, which is in keeping with the observation that much human behavior is automatic, cued by environmental stimuli, resulting in actions that are largely unaccompanied by conscious reflection. We propose that interventions targeting these automatic bases of behaviors may be more effective. We discuss specific interventions and suggest ways to determine whether and how interventions that target automatic processes can enhance global efforts to prevent disease.

The impact of communicating genetic risks of disease on risk-reducing health behaviour: systematic review with meta-analysis

Objective To assess the impact of communicating DNA based disease risk estimates on risk-reducing health behaviours and motivation to engage in such behaviours. Design Systematic review with meta-analysis, using Cochrane methods. Data sources Medline, Embase, PsycINFO, CINAHL, and the Cochrane Central Register of Controlled Trials up to 25 February 2015. Backward and forward citation searches were also conducted. Study selection Randomised and quasi-randomised controlled trials involving adults in which one group received personalised DNA based estimates of disease risk for conditions where risk could be reduced by behaviour change. Eligible studies included a measure of risk-reducing behaviour. Results We examined 10 515 abstracts and included 18 studies that reported on seven behavioural outcomes, including smoking cessation (six studies; n=2663), diet (seven studies; n=1784), and physical activity (six studies; n=1704). Meta-analysis revealed no significant effects of communicating DNA based risk estimates on smoking cessation (odds ratio 0.92, 95% confidence interval 0.63 to 1.35, P=0.67), diet (standardised mean difference 0.12, 95% confidence interval −0.00 to 0.24, P=0.05), or physical activity (standardised mean difference −0.03, 95% confidence interval −0.13 to 0.08, P=0.62). There were also no effects on any other behaviours (alcohol use, medication use, sun protection behaviours, and attendance at screening or behavioural support programmes) or on motivation to change behaviour, and no adverse effects, such as depression and anxiety. Subgroup analyses provided no clear evidence that communication of a risk-conferring genotype affected behaviour more than communication of the absence of such a genotype. However, studies were predominantly at high or unclear risk of bias, and evidence was typically of low quality. Conclusions Expectations that communicating DNA based risk estimates changes behaviour is not supported by existing evidence. These results do not support use of genetic testing or the search for risk-conferring gene variants for common complex diseases on the basis that they motivate risk-reducing behaviour. Systematic review registration This is a revised and updated version of a Cochrane review from 2010, adding 11 studies to the seven previously identified.

Altering micro-environments to change population health behaviour: towards an evidence base for choice architecture interventions

BackgroundThe idea that behaviour can be influenced at population level by altering the environments within which people make choices (choice architecture) has gained traction in policy circles. However, empirical evidence to support this idea is limited, especially its application to changing health behaviour. We propose an evidence-based definition and typology of choice architecture interventions that have been implemented within small-scale micro-environments and evaluated for their effects on four key sets of health behaviours: diet, physical activity, alcohol and tobacco use.DiscussionWe argue that the limitations of the evidence base are due not simply to an absence of evidence, but also to a prior lack of definitional and conceptual clarity concerning applications of choice architecture to public health intervention. This has hampered the potential for systematic assessment of existing evidence. By seeking to address this issue, we demonstrate how our definition and typology have enabled systematic identification and preliminary mapping of a large body of available evidence for the effects of choice architecture interventions. We discuss key implications for further primary research, evidence synthesis and conceptual development to support the design and evaluation of such interventions.SummaryThis conceptual groundwork provides a foundation for future research to investigate the effectiveness of choice architecture interventions within micro-environments for changing health behaviour. The approach we used may also serve as a template for mapping other under-explored fields of enquiry.

Using Aversive Images to Enhance Healthy Food Choices and Implicit Attitudes: An Experimental Test of Evaluative Conditioning

OBJECTIVE To examine the effect of communicating images of energy-dense snack foods paired with aversive images of the potential health consequences of unhealthy eating, on implicit and explicit attitudes and food choice behavior. DESIGN Participants were randomly allocated to either an evaluative conditioning (EC) procedure that paired images of snack foods with images of potential adverse health consequences or a control condition that featured images of snack foods alone. MAIN OUTCOME MEASURES Implicit attitudes were assessed pre- and post-intervention. Explicit attitudes and food choice behavior were assessed post-intervention. RESULTS The conditioning intervention made implicit attitudes toward energy-dense snacks more negative, with this effect greatest in those with relatively more favorable implicit attitudes toward these snacks at baseline. Participants in the conditioning intervention were more likely to choose fruit rather than snacks in a behavioral choice task, a relationship mediated by changes in implicit attitudes. CONCLUSION Presenting aversive images of potential health consequences with those of specific foodstuffs can change implicit attitudes, which impacts on subsequent food choice behavior.

Pinpointing needles in giant haystacks: use of text mining to reduce impractical screening workload in extremely large scoping reviews

In scoping reviews, boundaries of relevant evidence may be initially fuzzy, with refined conceptual understanding of interventions and their proposed mechanisms of action an intended output of the scoping process rather than its starting point. Electronic searches are therefore sensitive, often retrieving very large record sets that are impractical to screen in their entirety. This paper describes methods for applying and evaluating the use of text mining (TM) technologies to reduce impractical screening workload in reviews, using examples of two extremely large-scale scoping reviews of public health evidence (choice architecture (CA) and economic environment (EE)). Electronic searches retrieved >800,000 (CA) and >1 million (EE) records. TM technologies were used to prioritise records for manual screening. TM performance was measured prospectively. TM reduced manual screening workload by 90% (CA) and 88% (EE) compared with conventional screening (absolute reductions of ≈430 000 (CA) and ≈378 000 (EE) records). This study expands an emerging corpus of empirical evidence for the use of TM to expedite study selection in reviews. By reducing screening workload to manageable levels, TM made it possible to assemble and configure large, complex evidence bases that crossed research discipline boundaries. These methods are transferable to other scoping and systematic reviews incorporating conceptual development or explanatory dimensions.

Change in anxiety following successful and unsuccessful attempts at smoking cessation: cohort study

BACKGROUND Despite a lack of empirical evidence, many smokers and health professionals believe that tobacco smoking reduces anxiety, which may deter smoking cessation. AIMS The study aim was to assess whether successful smoking cessation or relapse to smoking after a quit attempt are associated with changes in anxiety. METHOD A total of 491 smokers attending National Health Service smoking cessation clinics in England were followed up 6 months after enrolment in a trial of pharmacogenetic tailoring of nicotine replacement therapy (ISRCTN14352545). RESULTS There was a points difference of 11.8 (95% CI 7.7-16.0) in anxiety score 6 months after cessation between people who relapsed to smoking and people who attained abstinence. This reflected a three-point increase in anxiety from baseline for participants who relapsed and a nine-point decrease for participants who abstained. The increase in anxiety in those who relapsed was largest for those with a current diagnosis of psychiatric disorder and whose main reason for smoking was to cope with stress. The decrease in anxiety on abstinence was larger for these groups also. CONCLUSIONS People who achieve abstinence experience a marked reduction in anxiety whereas those who fail to quit experience a modest increase in the long term. These data contradict the assumption that smoking is a stress reliever, but suggest that failure of a quit attempt may generate anxiety.

Non-conscious processes in changing health-related behaviour: a conceptual analysis and framework

ABSTRACT Much of the global burden of non-communicable disease is caused by unhealthy behaviours that individuals enact even when informed of their health-harming consequences. A key insight is that these behaviours are not predominantly driven by deliberative conscious decisions, but occur directly in response to environmental cues and without necessary representation of their consequences. Consequently, interventions that target non-conscious rather than conscious processes to change health behaviour may have significant potential, but this important premise remains largely untested. This is in part due to the lack of a practicable conceptual framework that can be applied to better describe and assess these interventions. We propose a framework for describing or categorising interventions to change health behaviour by the degree to which their effects may be considered non-conscious. Potential practical issues with applying such a framework are discussed, as are the implications for further research to inform the testing and development of interventions. A pragmatic means of conceptualising interventions targeted at non-conscious processes is a necessary prelude to testing the potency of such interventions. This can ultimately inform the development of interventions with the potential to shape healthier behaviours across populations.

Downsizing: policy options to reduce portion sizes to help tackle obesity.

Larger portions of food increase consumption. Theresa Marteau and colleagues suggest ways to reduce their size, availability, and appeal

Public Acceptability in the UK and USA of Nudging to Reduce Obesity: The Example of Reducing Sugar-Sweetened Beverages Consumption

Background “Nudging”—modifying environments to change people’s behavior, often without their conscious awareness—can improve health, but public acceptability of nudging is largely unknown. Methods We compared acceptability, in the United Kingdom (UK) and the United States of America (USA), of government interventions to reduce consumption of sugar-sweetened beverages. Three nudge interventions were assessed: i. reducing portion Size, ii. changing the Shape of the drink containers, iii. changing their shelf Location; alongside two traditional interventions: iv. Taxation and v. Education. We also tested the hypothesis that describing interventions as working through non-conscious processes decreases their acceptability. Predictors of acceptability, including perceived intervention effectiveness, were also assessed. Participants (n = 1093 UK and n = 1082 USA) received a description of each of the five interventions which varied, by randomisation, in how the interventions were said to affect behaviour: (a) via conscious processes; (b) via non-conscious processes; or (c) no process stated. Acceptability was derived from responses to three items. Results Levels of acceptability for four of the five interventions did not differ significantly between the UK and US samples; reducing portion size was less accepted by the US sample. Within each country, Education was rated as most acceptable and Taxation the least, with the three nudge-type interventions rated between these. There was no evidence to support the study hypothesis: i.e. stating that interventions worked via non-conscious processes did not decrease their acceptability in either the UK or US samples. Perceived effectiveness was the strongest predictor of acceptability for all interventions across the two samples. Conclusion In conclusion, nudge interventions to reduce consumption of sugar-sweetened beverages seem similarly acceptable in the UK and USA, being more acceptable than taxation, but less acceptable than education. Contrary to prediction, we found no evidence that highlighting the non-conscious processes by which nudge interventions may work decreases their acceptability. However, highlighting the effectiveness of all interventions has the potential to increase their acceptability.

Priming healthy eating. You can't prime all the people all of the time

Highlights • Mock adverts were used to prime healthy eating in two studies.• The primes increased fruit preference in more educated and hungry individuals.• Priming did not alter fruit preference in less educated or non-hungry individuals.• The mechanism of prime action may be dependent on participant characteristics.• Primes effective in some participants cannot be assumed to be effective in others.