Incorporating Health Behavior Theory into mHealth: an Examination of Weight Loss, Dietary, and Physical Activity Interventions
- 19 Downloads
Health behavior interventions are effective for many modifiable lifestyle behaviors. In some cases, remotely-delivered behavioral interventions, particularly those that include some form of contact with a clinician and strong behavioral strategies, have been shown to be as effective as traditional in-person interventions; they are also more flexible, disseminable, and cost-effective. With ubiquitous increases in mobile phone use, opportunities for remote delivery of health interventions (mHealth) have grown exponentially, particularly in the use of behavioral smartphone applications. Despite research suggesting that mHealth interventions can be effective at initiating and maintaining behavior changes, many mHealth interventions are not theoretically-based, and evidence-based behavioral strategies are not often adapted into the mobile format. Thus, there is a need for clear summaries of behavioral change theories and examples of theoretically driven behavioral strategies to unify and improve the field of mHealth. The authors review the existing literature on theories of behavior change, intervention, and systems for evaluating theoretical content. Specifically, the authors briefly summarize both traditional and contemporary theories of behavior change, evidence-based behavioral strategies, and the methods for evaluating the degree to which they are included in existing mHealth behavioral interventions, with an emphasis on weight loss, dietary, and physical activity interventions. Authors also include examples of integration of theory into both research and clinical practice. This research highlights the importance of incorporation of theory into behavior change interventions. The authors suggest specific theoretical considerations for the development of mHealth interventions within collaborative, interdisciplinary environments, and recommend future research areas.
KeywordsmHealth Health behavior Lifestyle Technology Weight loss Physical activity
Dr. Martin – Aetna Foundation.
Compliance with Ethical Standards
Conflict of Interest
Dr. Martin is a founder of and holds equity in Corrie Health, which intends to further develop the platform. This arrangement has been reviewed and approved by the Johns Hopkins University in accordance with its conflict of interest policies. He has served on the scientific advisory boards of Amgen, Sanofi, Regeneron, Esperion, Novo Nordisk, Quest Diagnostics, and Akcea Therapeutics and reports grants from Apple, Google, iHealth, Nokia, the Maryland Innovation Initiative, American Heart Association, Aetna Foundation, PJ Schafer Memorial Fund, and David and June Trone Family Foundation.
- Appel, L. J., Clark, J. M., Yeh, H. C., Wang, N. Y., Coughlin, J. W., Daumit, G., & Brancati, F. L. (2011). Comparative effectiveness of weight-loss interventions in clinical practice. The New England Journal of Medicine, 365(21), 1959–1968. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/22085317. https://doi.org/10.1056/NEJMoa1108660.PubMedCrossRefGoogle Scholar
- Armstrong, M., Mottershead, T., Ronksley, P., Sigal, R., Campbell, T., & Hemmelgarn, B. (2011). Motivational interviewing to improve weight loss in overweight and/or obese patients: A systematic review and meta-analysis of randomized controlled trials. Obesity Reviews, 12, 709–723. https://doi.org/10.1111/j.1467-789X.2011.00892.x.CrossRefPubMedGoogle Scholar
- Azar, K. M., Lesser, L. I., Laing, B. Y., Stephens, J., Aurora, M. S., Burke, L. E., & Palaniappan, L. P. (2013). Mobile applications for weight management: Theory-based content analysis. American Journal of Preventive Medicine, 45(5), 583–589. https://doi.org/10.1016/j.amepre.2013.07.005.CrossRefPubMedGoogle Scholar
- Bandura, A. (1986). Social foundations of thought and action: A social cognitive theory. Prentice-Hall, Inc.Google Scholar
- Bandura, A. (1997). Self-efficacy: The exercise of control. New York: Freeman.Google Scholar
- Cowan, L. T., Van Wagenen, S. A., Brown, B. A., Hedin, R. J., Seino-Stephan, Y., Hall, P. C., & West, J. H. (2012). Apps of steel: Are exercise apps providing consumers with realistic expectations? A content analysis of exercise apps for presence of behavior change theory. Health Education & Behavior, 40(2), 133–139. https://doi.org/10.1177/1090198112452126.CrossRefGoogle Scholar
- Diabetes Prevention Program Research Group, et al. (2009). 10-year follow-up of diabetes incidence and weight loss in the diabetes Prevention program outcomes study. The Lancet, 374(9702), 1677–1686. https://doi.org/10.1016/S0140-6736(09)61457-4.
- Direito, A., Dale, L. P., Shields, E., Dobson, R., Wittaker, R., & Maddison, R. (2014). Do physical activity and dietary smartphone applications incorporate evidence-based behaviour change techniques? BMC Public Health, 14.Google Scholar
- Duggan, M. (2013). Cell phone activities 2013. Cell. Google Scholar
- Fischer, H. H., Fischer, I. P., Pereira, R. I., Furniss, A. L., Rozwadowski, J. M., Moore, S. L., & Havranek, E. P. (2016). Text message support for weight loss in patients with prediabetes: A randomized clinical trial. Diabetes Care, dc152137.Google Scholar
- Fogg, B. (2009). A Behavior Model for Persuasive Design. Paper presented at the proceedings of the 4th international conference on persuasive technology. Claremont, CA.Google Scholar
- Kelders, S. M., Kok, R. N., Ossebaard, H. C., & Van Gemert-Pijnen, J. E. W. C. (2012). Persuasive system design does matter: A systematic review of adherence to web-based interventions. Journal of Medical Internet Research, 14(6), e152. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3510730/. doi: https://doi.org/10.2196/jmir.2104.PubMedPubMedCentralCrossRefGoogle Scholar
- Lee, H. Y., Koopmeiners, J. S., Rhee, T. G., Raveis, V. H., & Ahluwalia, J. S. (2014). Mobile phone text messaging intervention for cervical cancer screening: Changes in knowledge and behavior pre-post intervention. Journal of Medical Internet Research, 16(8), e196.PubMedPubMedCentralCrossRefGoogle Scholar
- Lim, S. S., Vos, T., Flaxman, A. D., Danaei, G., Shibuya, K., Adair-Rohani, H., & Andrews, K. G. (2013). A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. The lancet, 380(9859), 2224–2260.CrossRefGoogle Scholar
- Look AHEAD Research Group & Wing, R. R. (2010). Long term effects of a lifestyle intervention on weight and cardiovascular risk factors in individuals with type 2 diabetes: Four year results of the look AHEAD trial. Archives of Internal Medicine, 170(17), 1566–1575.Google Scholar
- Lundahl, B., Moleni, T., Burke, B. L., Butters, R., Tollefson, D., Butler, C., & Rollnick, S. (2013). Motivational interviewing in medical care settings: A systematic review and meta-analysis of randomized controlled trials. Patient Education and Counseling, 93(2), 157–168. https://doi.org/10.1016/j.pec.2013.07.012.CrossRefPubMedGoogle Scholar
- Mastellos, N., Gunn, L. H., Felix, L. M., Car, J., & Majeed, A. (2014). Transtheoretical model stages of change for dietary and physical exercise modification in weight loss management for overweight and obese adults. The Cochrane Library, Transtheoretical model stages of change for dietary and physical exercise modification in weight loss management for overweight and obese adults.Google Scholar
- McConnon, A., Raats, M., Astrup, A., Bajzová, M., Handjieva-Darlenska, T., Lindroos, A. K., & Pfeiffer, A. (2012). Application of the theory of planned behaviour to weight control in an overweight cohort. Results from a pan-European dietary intervention trial (DiOGenes). Appetite, 58(1), 313–318.PubMedCrossRefGoogle Scholar
- Michie, S., van Stralen, M. M., & West, R. (2011). The behaviour change wheel: A new method for characterising and designing behaviour change interventions. Implementation Science, 6(1). https://doi.org/10.1186/1748-5908-6-42.
- Michie, S., Richardson, M., Johnston, M., Abraham, C., Francis, J., Hardeman, W., & Wood, C. E. (2013). The behavior change technique taxonomy (v1) of 93 hierarchically clustered techniques: Building an international consensus for the reporting of behavior change interventions. Annals of Behavioral Medicine, 46, 81–95. https://doi.org/10.1007/s12160-013-9486-6.CrossRefPubMedGoogle Scholar
- Middelweerd, A., Mollee, J. S., van der Wal, C. N., Brug, J., & te Velde, S. J. (2014). Apps to promote physical activity among adults: A review and content analysis. International Journal of Behavioral Nutrition and Physical Activity, 11.Google Scholar
- Militello, L., Melnyk, B. M., Hekler, E. B., Small, L., & Jacobson, D. (2016). Automated behavioral text messaging and face-to-face intervention for parents of overweight or obese preschool children: Results from a pilot study. JMIR mHealth and uHealth, 4(1), e21.PubMedPubMedCentralCrossRefGoogle Scholar
- Mohr, D. C., Schueller, S. M., Montague, E., Burns, M. N., & Rashidi, P. (2014). The behavioral intervention technology model: An integrated conceptual and technological framework for eHealth and mHealth interventions. Journal of Medical Internet Research, 16(6), e146. https://doi.org/10.2196/jmir.3077.CrossRefPubMedPubMedCentralGoogle Scholar
- Morton, K., Sutton, S., Hardeman, W., Troughton, J., Yates, T., Griffin, S., & Eborall, H. (2015). A text-messaging and pedometer program to promote physical activity in people at high risk of type 2 diabetes: The development of the PROPELS follow-on support program. JMIR mHealth and uHealth, 3(4), e105.PubMedPubMedCentralCrossRefGoogle Scholar
- Murray, C. J., Vos, T., Lozano, R., Naghavi, M., Flaxman, A. D., Michaud, C., & Abdalla, S. (2013). Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. The lancet, (9859), 380, 2197–2223.Google Scholar
- Nguyen, M. N., Potvin, L., & Otis, J. (1997). Regular exercise in 30-to 60-year-old men: Combining the stages-of-change model and the theory of planned behavior to identify determinants for targeting heart health interventions. Journal of Community Health, 22(4), 233–246.PubMedCrossRefGoogle Scholar
- O'Halloran, P. D., Blackstock, F., Shields, N., Holland, A., Iles, R., Kingsley, M., & Taylor, N. F. (2014). Motivational interviewing to increase physical activity in people with chronic health conditions: A systematic review and meta-analysis. Clinical Rehabilitation, 28(1), 1159–1171. https://doi.org/10.1177/0269215514536210.CrossRefPubMedGoogle Scholar
- Oinas-Kukkonen, H., & Harjumaa , M. (2008). A Systematic Framework for Designing and Evaluating Persuasive Systems paper presented at the international conference on persuasive technology.Google Scholar
- Olander, E. K., Fletcher, H., Williams, S., Atkinson, L., Turner, A., & French, D. P. (2013). What are the most effective techniques in changing obese individuals’ physical activity self-efficacy and behaviour: A systematic review and meta-analysis. International Journal of Behavioral Nutrition and Physical Activity, 10(1), 1.CrossRefGoogle Scholar
- Palmeira, A. L., Teixeira, P. J., Branco, T. L., Martins, S. S., Minderico, C. S., Barata, J. T., & Sardinha, L. B. (2007). Predicting short-term weight loss using four leading health behavior change theories. International Journal of Behavioral Nutrition and Physical Activity, 4(1), 1.CrossRefGoogle Scholar
- Parsons, J. T., Golub, S. A., Rosof, E., & Holder, C. (2007). Motivational interviewing and cognitive-behavioral intervention to improve HIV medication adherence among hazardous drinkers: A randomized controlled trial. Journal of Acquired Immune Deficiency Syndromes (1999), 46(4), 443–450.CrossRefGoogle Scholar
- Prevention, C. f. D. C. a. (2004). The burden of chronic diseases and their risk factors: National and state perspectives.Google Scholar
- Prochaska, J. O. (2013). Transtheoretical model of behavior change. In Encyclopedia of behavioral medicine (pp. 1997–2000). Springer.Google Scholar
- Prochaska, J. O., & Norcross, J. C. (2010). Systems of psychotherapy: A transtheoretical analysis (Seventh Edition ed.): Brooks/Cole Cengage Learning.Google Scholar
- Prochaska, J. O., Redding, C. A., & Evers, K. E. (2008). The Transtheoretical model and stages of change in. In K. Glanz, B. K. Rimer, & K. Viswanath (Eds.), Health behavior and health education: Theory, research, practice (4th ed., pp. 97–122). San Fransisco: Wiley.Google Scholar
- Roth, W. R., Vilardaga, R., Wolfe, N., Bricker, J. B., & McDonell, M. G. (2014). Practical considerations in the design and development of smartphone apps for behavior change. Journal of Contextual Behavioral Science, 3(4), 269–272. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4254717/. https://doi.org/10.1016/j.jcbs.2014.08.006.CrossRefPubMedPubMedCentralGoogle Scholar
- Sacks, F., Svetkey, L., Vollmer, W., Appel, L., Bray, G., Harsha, D., . . . Cutler, J. A. (2001). Effects on blood pressure of reduced dietary sodium and the dietary approaches to stop hypertension (DASH) diet. The New England Journal of Medicine, 344(1), 3–10. doi: https://doi.org/10.1056/NEJM200101043440101.CrossRefPubMedGoogle Scholar
- Stacey, F. G., James, E. L., Chapman, K., Courneya, K. S., & Lubans, D. R. (2015). A systematic review and meta-analysis of social cognitive theory-based physical activity and/or nutrition behavior change interventions for cancer survivors. Journal of Cancer Survivorship, 9(2), 305–338.PubMedCrossRefGoogle Scholar
- Vandelanotte, C., Muller, A. M., Short, C. E., Hingle, M., Nathan, N., Williams, S. L., & Maher, C. A. (2016). Past, present, and future of eHealth and mHealth research to improve physical activity and dietary behaviors. Journal of Nutrition Education and Behavior, 48(3), 219–228. https://doi.org/10.1016/j.jneb.2015.12.006.CrossRefPubMedGoogle Scholar
- Webb, T., Joseph, J., Yardley, L., & Michie, S. (2010). Using the internet to promote health behavior change: A systematic review and meta-analysis of the impact of theoretical basis, use of behavior change techniques, and mode of delivery on efficacy. Journal of Medical Internet Research, 12(1), e4.PubMedPubMedCentralCrossRefGoogle Scholar
- Whittaker, R., McRobbie, H., Bullen, C., Rodgers, A., & Gu, Y. (2016). Mobile phone-Ba sed interve ntions for smoking cessation. The Cochrane Library, 4. https://doi.org/10.1002/14651858.CD006611.pub4.