Yet another Behaviour Change Intervention

416 Pages·2016·6.11 MB·English

Yet another Behaviour Change Intervention:
The Feasibility of an autonomy-supportive
active lifestyle intervention in older adults

Liane S Lewis BSc Hons

PhD Thesis
University of East Anglia

School of Health Sciences
JULY 2015

"This copy of the thesis has been supplied on condition that anyone who consults it is understood to
recognise that its copyright rests with the author and that use of any information derived there from
must be in accordance with current UK Copyright Law. In addition, any quotation or extract must
include full attribution.”
Abstract
Background: Self-Determination Theory (SDT) has been used successfully as a
model for health behaviour change in weight loss programs buts its effectiveness
promoting physical activity (PA) behaviour change in an elderly population at
elevated risk of colon cancer has not been tested. This study investigated the
feasibility of implementing an SDT approach in this population and provides
preliminary evidence of its efficacy for modifying motivational regulation in the
short- and long-term. Furthermore, barriers to participation, and characteristics of
non-participators were explored. Trial design: This thesis consists of two
randomized controlled feasibility trials. Methods: Trial A was called ‘Physical
Activity and Risk of Colon Cancer’ (PARC) and trial B was called ‘MOtiVation for
Exercise- promoting an active lifestyle after Colorectal Cancer’ (MOVE). Participants
in PARC (n=31, mean age 69y [SD=4.9], BMI 29.3 [SD=5.1]) were patients diagnosed
with polyps after a screening colonoscopy. MOVE participants (n=28, mean age 65y
[SD=8.3], BMI=27.7 [SD=4.6]) were patients diagnosed with colorectal cancer after
completion of treatment. In both studies, participants were randomized to either
an active lifestyle programme (ALP) (PARC n=17, MOVE n=14) or the standard care
group (SC) (PARC n=14, MOVE n=14). ALP received supervised exercise sessions and
physical activity counselling workshops during the intervention and SC was
encouraged to continue with their usual lifestyle. For PARC the intervention was
6months with a 6 months follow-up and for MOVE the intervention was 3months
with 3 months follow-up. Randomization was carried out with a bespoke computer
software (nQuery). The intervention facilitator was not blinded to the group
allocation. Data were analysed with intention-to treat analysis. The primary
outcomes were the feasibility of the intervention in these populations. Secondary
outcomes were variables of behavioural regulation, physical activity behaviour,
physical capacity (fitness and strength), self-efficacy, intention to exercise, and
quality of life.
Results: PARC: Overall recruitment yield was 12.1% of eligible participants. Main
barriers for participation for time commitment and distance to research site.
Attrition post-intervention was 29% and at follow-up 43%. Attendance at the
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supervised exercise sessions was 62% and at the workshops was 53%. Post-
intervention, ALP had lower amotivation (P<.01), and higher levels of identification
(P<.01), intrinsic regulation (P<.001), relative autonomy index (P<.01), and intention
to exercise (P<0.05) compared to SC. Total leisure time activity was higher in ALP
compared to SC with a mean group difference of 84 min per week (P= 0.08). At
follow-up the differences in behavioural regulation were not maintained. ALP did
more physical activity at follow-up than SC, with a difference in mean change for
leisure-time PA of 170min (P< 0.05). There were no adverse events during the
intervention.
MOVE: Overall recruitment rate was 58.3% of eligible participants. The main
barriers to participation for time commitment and the travel distance to the
research site. Attrition at 3months was 14% and 29% at 6months follow-up.
Attendance at supervised exercise sessions was 79% and at physical activity
counselling workshops 71%. Post-intervention, ALP was engaging in 98min more
walking time physical activity (P< 0.05). Group differences were also observed for
body composition with a reduction in body weight (-1.6kg), BMI (-0.04 kg/m2) and
body fat (-1.4%) in ALP compared to an increase in these parameters in SC (+1.1kg,
+0.5 kg/m2, +0.3%) (P< 0.05). At follow-up differences in PA and body composition
were maintained (P< 0.05). No differences were observed for behavioural
regulation, self-efficacy, intention to exercise, and quality of life at any time-point.
Exercise was deemed safe and there were no adverse events throughout the
intervention.
Conclusion: Recruitment rates of both trials were poor, but other trials have
reported similar low recruitment rates in studies with an elderly population. These
are the first studies based on SDT in this population to demonstrate increased
physical activity behaviour post-intervention and at long-term follow-up. The
findings also suggest that 6months of intervention is successful at evoking changes
in behavioural regulation. These findings are comparable to other studies using this
model. Larger RCTs are needed to substantiate these findings.
The studies were sponsored by the University of East Anglia, Norwich, United
Kingdom.
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Contents
Abstract ........................................................................................................... i
Tables and figures ....................................................................................... viii
Appendices .................................................................................................... ix
List of Abbreviations ..................................................................................... x
Acknowledgements ...................................................................................... xii
Chapter 1 ...................................................................................................... 13
An Introduction to the thesis ........................................................................ 13
Chapter structure and aims ................................................................................ 14
Chapter 2 ...................................................................................................... 17
CRC: A globally growing Malady which can be reduced with more PA .... 17
2.1. CRC Incidence and Mortality ........................................................................ 18
2.2. A biography of CRC ...................................................................................... 19
2.2.1. Causes of CRC ........................................................................................ 19
2.2.2. Pathogenesis ......................................................................................... 20
2.3. Risk factors of CRC and its precursors .......................................................... 21
2.3.1. Diet ........................................................................................................ 21
2.3.2. Body composition ................................................................................. 22
2.3.3. PA: a definition of terms ....................................................................... 23
2.4. Primary prevention: The effects of PA on the prevention of adenomas and
CRC ...................................................................................................................... 25
2.4.1. What is the evidence of an inverse relationship between PA and
adenoma prevalence? ..................................................................................... 25
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2.4.2. What is the evidence of an inverse relationship between PA and CRC?
........................................................................................................................ 27
2.4.3. What type, duration, frequency, and intensity of PA is associated with
the lowest risk of CRC ..................................................................................... 31
2.4.4. Conclusion ............................................................................................. 39
2.4.5. How much is enough? ........................................................................... 40
2.5. Secondary prevention: The effects of pre and post diagnosis PA on cancer
mortality .............................................................................................................. 41
2.6. Conclusion .................................................................................................... 46
2.7. Implications on the development of an exercise interventions and
challenges of monitoring exercise behaviour to encourage changes in physical
activity ................................................................................................................. 47
Chapter 3 ...................................................................................................... 52
PA as the target in behaviour change interventions: A rationale for Self-
Determination Theory ...................................................................... 52
3.1. Who is meeting the PA Guidelines? ............................................................. 53
3.2. The challenges of measuring free-living PA ................................................. 53
3.3. The problem of long-term adherence to PA ................................................ 55
3.4. Are interventions based on common sense or evidence? ........................... 57
3.5. The search for a theory ................................................................................ 59
3.6. Self-Determination Theory to inform a PA intervention ............................. 63
3.6.1. Intrinsic and extrinsic motivation ......................................................... 64
3.6.2. The sub-theories of Self-Determination Theory ................................... 65
3.7. Why is SDT a promising model for behaviour change in the PA domain? ... 71
3.8. Application of Self-Determination theory in PA interventions .................... 73
3.9. A final comment- why Self-Determination Theory stands out from other
theories ............................................................................................................... 75
3.10. Summary .................................................................................................... 76
Chapter 4 ...................................................................................................... 78
Evidence-based instead of evidence-inspired: A description of a PA
intervention for people at increased risk of and recovering from
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CRC .................................................................................................. 78
4.1. Introduction ................................................................................................. 79
4.2. Aim ............................................................................................................... 81
4.3. From theory to practice ............................................................................... 83
4.4. A general overview of the intervention ....................................................... 88
Chapter 5 ...................................................................................................... 99
A Feasibility study to investigate the long-term effects of an autonomy-
supportive intervention on PA Behaviour in people at increased risk
of CRC: a randomized controlled trial ............................................. 99
5.1. Abstract ...................................................................................................... 100
5.2. Introduction ............................................................................................... 102
5.3. Aims ............................................................................................................ 104
5.4. Methods ..................................................................................................... 105
5.5. Results ........................................................................................................ 120
5.6. Discussion ................................................................................................... 140
5.7. Conclusion .................................................................................................. 147
Chapter 6 .................................................................................................... 148
A feasibility study of an autonomous supportive intervention in people
recovering from with CRC: a randomised controlled trial............. 148
6.1. Abstract ................................................................................................. 149
6.2. Introduction .......................................................................................... 151
6.3. Methods ................................................................................................ 154
6.4. Results ................................................................................................... 167
6.5. Discussion .............................................................................................. 182
6.6. Conclusion .................................................................................................. 187
Chapter 7 .................................................................................................... 188
The effectiveness of different recruitment strategies in people at elevated
risk of and recovering from CRC ................................................... 188
7.1. Abstract ...................................................................................................... 189
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7.2. Introduction ............................................................................................... 190
7.3. Design ......................................................................................................... 192
7.4. Methods ..................................................................................................... 192
7.5. Part A: PARC ............................................................................................... 194
7.5.1. Results ................................................................................................. 198
7.6. Part B: MOVE.............................................................................................. 208
7.6.1. Results ................................................................................................ 208
7.7. Discussion ................................................................................................... 214
7.8. Conclusion .................................................................................................. 220
Chapter 8 .................................................................................................... 221
Validation of the International PA Questionnaire against different
accelerometer cut-points in an elderly population at elevated risk of
CRC ................................................................................................ 221
8.1. Abstract ...................................................................................................... 222
8.2. Introduction ............................................................................................... 223
8.3. Methods ..................................................................................................... 226
8.4. Results ........................................................................................................ 229
8.5. Discussion ................................................................................................... 234
Chapter 9 .................................................................................................... 240
Discussion .................................................................................................. 240
9.1. Overview .................................................................................................... 241
9.2. Summary of the main findings ................................................................... 241
9.3. Feasibility of recruitment into MOVE and PARC ........................................ 243
9.4. Considerations of the Intervention ............................................................ 246
9.5. Other considerations of feasibility ............................................................. 250
9.6. Final comments about the intervention’s practicality ............................... 253
9.7. Design of potential RCTs based on the feasibility findings ........................ 254
9.8. General directions ...................................................................................... 262
9.9. Future directions ........................................................................................ 265
9.10. Conclusion ................................................................................................ 266
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10. References ............................................................................................ 268
11. Appendices ................................................................................. cclxxxvii

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Tables and figures
Figure 1 Continuum of human motivation (Ryan and Deci, 2000) ......................... 70
Figure 2 Treatment effects of an autonomy supportive intervention on need
satisfaction and behavioural regulation. Solid lines indicate significant effects, and
dashed lines non-significant effects. Strength of positive (+) and negative (-) are
indicated. MVAP=moderate to vigorous intensity PA ............................................ 83
Figure 3 Cost-benefit grid. The responses are examples from a group session ..... 97
Figure 4 Flow of recruitment-related amendments that were implemented
throughout the study ............................................................................................ 111
Figure 5 Flow of participants through the study .................................................. 119
Figure 6 Overview of the key findings in motivational regulation and leisure time
physical activity. Data points are means of the change at each time-point, error
bars present the standard error of the means ..................................................... 139
Figure 7 CONSORT diagramme of patient recruitment and retention throughout
the study ............................................................................................................... 166
Figure 8 Overview of key outcomes for motivational regulation and changes in
physical activity behaviour from self-report. Error bars are the standard error of
the means. ............................................................................................................ 181
Figure 9 Flow diagram of patient recruitment. NBCS=National Bowel Cancer
Screening Nurse .................................................................................................... 205
`Figure 10 MOVE recruitment ............................................................................... 210
Figure 11. Overview of recruitment processes of both studies. NBCS = National
Bowel Cancer Screening Nurse ............................................................................. 213
Figure 12 A, B, and C show Bland-Altman plots for the difference between A) total
IPAQ and total accelerometer time, B) total IPAQ and time spent in Freedson
bouts and C) Total IPAQ and time spent in Matthews bouts. D, E, and F show the
Bland-Altman plots for % difference between D) total IPAQ and total
accelerometer time, E) total IPAQ and time spent in Freedson bouts and F) Total
IPAQ and time spent in Freedson bouts ............................................................... 233

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Appendices
Appendix 1- Borg Scale.................................................................................. cclxxxvii
Appendix 2- Workshop topics ...................................................................... cclxxxviii
Appendix 3- BREQ-2 ............................................................................................ ccxc
Appendix 4- Intention to Exercise ..................................................................... ccxci
Appendix 5- Self-efficacy to exercise ................................................................. ccxci
Appendix 6- SF-36 (Quality of Life) .................................................................... ccxcii
Appendix 7- International Physical Activity Questionnaire- long version ...... ccxcvi
Appendix 8- Functional Assessment for Cancer Therapy ................................. ccciii
Appendix 9- Psychological Needs Satisfaction for Exercise .............................. cccvi
Appendix 10- Bruce protocol ............................................................................ cccvii
Appendix 11-Survey questionnaires ................................................................. cccviii
Appendix 12- Study Protocol PARC- Version 1 .................................................. cccxi
Appendix 13- Summary of amendments PARC ............................................ cccxxxiii
Appendix 14- PARC Study approval from Research Ethics Committee ....... cccxxxiv
Appendix 15- Approval letters for amendments (PARC) ........................... cccxxxviii
Appendix 16- PARC NHS Research and Development study approval ............ cccliv
Appendix 17- PARC supportive documents ...................................................... ccclvi
Appendix 18- MOVE study protocol version 1 ............................................... ccclxvii
Appendix 19- MOVE Research Ethics Committee Approval Letter ............... ccclxxx
Appendix 20-MOVE NHS Research and Development Approval ................ ccclxxxiv
Appendix 21- MOVE supportive study documents ..................................... ccclxxxvi
Appendix 22 ..................................................................................................... cccxcvi
Appendix 23-TDier Checklist and CONSORT checklist ......................................... cdi
Appendix 24 Study reports to participants- End of Study report ....................... cdix

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