Features of the Intervention and Its Delivery

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Generally, it is impossible to say whether interventions targeted to one specific behavioral component or behavior are more effective in addressing it than a more comprehensive intervention might be. When targeting physical activity in the worksite, less comprehensive interventions were not necessarily more effective. When addressing disease management, more comprehensive interventions were reportedly more effective. Many interventions were shown to have a positive effect on some lifestyle behaviors or clinical risk factors, while not affecting others. This strongly suggests that a number of interventions and delivery components are likely needed to address all aspects of behavior change related to preventing and managing a specific chronic disease such as CVD or diabetes. This is certainly the case at a population level, however, it is also likely to be the case at a more individual level as well. This view is more strongly supported by the evidence from the field of tobacco control (WHO, 2008) with further support coming from community intervention trials over the past 30 years

Table 62.2 Important issues arising from systematicreviews of interventions targeting lifestyle factors

1. Study design and measurement o Small, underpowered studies o Heterogeneity and lack of specificity in relation to participants:

- Socio-demographic characteristics

- Clinical characteristics o Heterogeneity in measurement

- Different outcomes

- Lack of key outcomes in relation to behavior, morbidity, mortality, cost-effectiveness

- Variability in the quality and type of measures used o Heterogeneity in length of follow-up

- Lack of long-term follow-up o Lack of implementation and process measurement o Difficulty in disentangling the effects of other factors

- Medication use

- Mediating and moderating factors

2. Features of the intervention and its delivery o Heterogeneity and lack of specificity in relation to:

- Content

- Setting

- Intensity

- Duration

- Delivery person/system o Intervention is a "black box," i.e., components are either undefined or impossible to separate from each other o Inadequate use and reporting of health behavior theory, including:

- Theoretical model for expected behavior changes and determinants

- Techniques to change behaviors

- Compliance by program users with techniques to change behaviors

- Systematic analysis of theory-based moderators and mediators

3. Intervention sustainability and future uptake o What were the necessary versus sufficient components? o Intensive interventions but small effects o Economic outcomes and costing data are lacking o Long-term outcomes are not established

(Sowden et al, 2003). It is further supported by more recent evidence in relation to interventions that focus on reducing absolute risk of a number of chronic diseases (Ebrahim et al, 2006; Goldstein et al, 2004; Pronk et al, 2004; WHO, 2002).

The fact that little particularly useful information was found in reviews in relation to settings for program delivery reflects the complexity of this issue as well. Clearly, some settings are likely to make recruitment, targeting, and tailoring of interventions easier than others. For example, schools and worksites are community settings where many people can easily be reached. When recruiting people for telephone interventions where no "natural" setting necessarily exists, recruitment was generally shown to be easier when conducted via a clinical setting (Eakin et al, 2007). Furthermore, as the review on exercise training among older adults showed (Ashworth et al, 2005), what works best setting wise might change over time as participants' needs change. Instead of thinking in terms of home-based versus center-based programs, maybe the ideal would be a program where the participant can choose from either or both and change back and forth between the options as their personal circumstances and needs change.

Intensity and duration are issues for which the reviews do provide some important findings. More intensive and longer interventions are generally more effective than less intensive and briefer interventions, and it is critically important that follow-up is included in an intervention in order to enhance maintenance and sustainability. However, there may be a trade-off between effectiveness and availability of resources, but this cannot be assessed without cost-effectiveness studies. Attrition can also be very problematic in long-lasting interventions. However, we do not know much about individual differences in relation to intervention intensity and duration. As the review on internet interventions showed (Strecher, 2007), if people get to choose for themselves, some will decide to be intensively involved for long periods of time while others only have very fleeting and brief contact with the intervention.

There is not much information in relation to which professionals are best able to delivery which kinds of lifestyle interventions. While physicians can deliver lifestyle advice and programs in an effective and durable fashion under certain circumstances, there are likely to be many other professionals who can do so much more cost-effectively. However, they do not necessarily have the same "window of opportunity" as physicians might have, particularly those in the primary care setting. There are also some interventions, such as dietary advice, which may be delivered quite effectively and efficiently through the use of information and communications technology. The delivery of such programs by lay leaders or peers (Dale et al, 2008; Foster et al, 2007) is another area that needs more investigation, particularly, when associated with management of a disease such as diabetes (Fisher etal, 2010).

Automated telephone programs and the internet also have great potential to supplement and support health-care settings and professionals as platforms for effective intervention delivery. The outcomes are by and large moderately positive on several measures (Dale et al, 2008; Eakin et al, 2007; Strecher, 2007). However, despite the burgeoning interest in internet-based interventions, the potential of the internet in interactivity - user navigation, collaborative filters, expert systems, and human-to-human interaction - is still poorly utilized and understood for the delivery of lifestyle change programs (Strecher, 2007). It is certainly the case that the internet provides tremendous opportunities for making use of the individual's characteristics as active ingredients for tailoring and delivery of programs. However, the ways these characteristics moderate the impact of interventions need to be explored first and then purposefully utilized. Furthermore, there are now tremendous opportunities to combine current knowledge with new interactive and mobile technologies, as well as with consumer and other (medical and public health) informatics systems (Strecher, 2007).

Probably more important than who or which system delivers an intervention per se is how well the intervention components and the system used to deliver these, properly address the participant's needs, and the extent to which these are related to their current knowledge, attitudes, skills or support, or most likely, a combination of all of these. The need for theory to inform more appropriately these issues as well as the development, implementation, and evaluation of lifestyle change programs is a really important issue which has received increasing attention in recent years and whole textbooks have been devoted to this issue (e.g. Bartholomew et al, 2006; Glanz et al, 2002). As already mentioned, few of the systematic reviews discussed in this chapter discuss in detail the importance of behavioral or other kinds of theories and only a couple of reviews actually analyzed the use of theory-based interventions. The Transtheoretical Model of Stages of Change (Prochaska and DiClemente, 1982) has been one of the most frequently cited theories in both smoking and telephone interventions in the reviews that have been considered in this chapter. Consequently, it is really the only theory with adequate data for recent evaluation. These data, however, only lend equivocal support to the theory. Abraham, among others, has critiqued stage models for oversimplifying "the cognitive architecture" by defining stage transitions by single determinants and for implying cognitive uniformity within stages (Abraham, 2008). Moreover, instead of stage-based interventions, he has suggested use of multi-determinant, multi-goal continuum approaches. Such an approach recognizes graded discontinuities throughout the development of action readiness from attitude formation to maintenance of behavior change as a process that is not linear and that includes movement in both directions (Abraham, 2008).

In addition to health behavior theories that help intervention designers to identify psychosocial determinants for behavior change and target and tailor interventions, the need for explicit use of theory-based health behavior techniques has also been acknowledged (Abraham and Michie, 2008). Reporting the use of these specific techniques in interventions would take the field forward and allow gathering of evidence for what works.

The approach advocated by Abraham is interesting, not just because of the perspective it provides on behavior change, but also because it provides a framework for conceptualizing a more menu-based approach to interventions. In other words, instead of providing one uniform or stage-specified intervention to all program participants, it is probably more appropriate to provide a menu of interventions from which potential program participants can then self-tailor a combination of interventions that best suit their personal needs and circumstances. Utilizing such an approach in relation to the interactive potential that different ICT and web-based systems can provide is likely to lead to a significant paradigm shift in the way in which lifestyle change interventions are provided to and accessed by the community over the next few years. This will lead to a shift away from the view of the individual/patient as an almost passive recipient of expert-driven interventions toward the individual becoming a much more active participant in deciding on their own needs and how to address these.

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