abstract: Many individual-level behavioral interventions improve health and well-being. However, most interventions exhibit considerable heterogeneity in response. Put differently, what might be effective on average might not be effective for specific individuals. From an individual’s perspective, many healthy behaviors exist that seem to have a positive impact. However, few existing tools support people in identifying interventions that work for them, personally. One approach to support such personalization is via self-experimentation using single-case designs. ‘Hack Your Health’ is a tool that guides individuals through an 18-day self-experiment to test if an intervention they choose (e.g., meditation, gratitude journaling) improves their own psychological well-being (e.g., stress, happiness), whether it fits in their routine, and whether they enjoy it. The purpose of this work was to conduct a formative evaluation of Hack Your Health to examine user burden, adherence, and to evaluate its usefulness in supporting decision-making about a health intervention. A mixed-methods approach was used, and two versions of the tool were tested via two waves of participants (Wave 1, N=20; Wave 2, N=8). Participants completed their self-experiments and provided feedback via follow-up surveys (n=26) and interviews (n=20). Findings indicated that the tool had high usability and low burden overall. Average survey completion rate was 91%, and compliance to protocol was 72%. Overall, participants found the experience useful to test if their chosen intervention helped them. However, there were discrepancies between participants’ intuition about intervention effect and results from analyses. Participants often relied on intuition/lived experience over results for decision-making. This suggested that the usefulness of Hack Your Health in its current form might be through the structure, accountability, and means for self-reflection it provided rather than the specific experimental design/results. Additionally, situations where performing interventions within a rigorous/restrictive experimental set-up may not be appropriate (e.g., when goal is to assess intervention enjoyment) were uncovered. Plausible design implications include: longer experimental and phase durations, accounting for non-compliance, missingness, and proximal/acute effects, and exploring strategies to complement quantitative data with participants’ lived experiences with interventions to effectively support decision-making. Future work should explore ways to balance scientific rigor with participants’ needs for such decision-making. / Dissertation/Thesis / Doctoral Dissertation Exercise and Nutritional Sciences 2019

The ability of direct care staff members to carry out behavior programs, specific protocols written by a behavior analyst, or recommendations made after completion of a functional behavioral assessment is an essential tool needed for such documents to actually be meaningful to patients. Since direct care staff members spend the most time directly working with patients, it is imperative that they carry out intervention procedures with reliability and fidelity. This study evaluated the effectiveness of staff training procedures as well as organizational behavior management techniques used to ensure that staff members are equipped with the tools they need and are properly motivated to carry out the proposed intervention procedures. Staff members received training on the Tools for Positive Behavior Change curriculum developed by the Behavior Analysis Services Program at the University of South Florida using a myriad of training techniques. Then, organizational behavior management techniques were implemented in order to maintain tool implementation and positive interactions with patients over time. Effectiveness of these procedures was measured using a concurrent multiple baseline across participant research design. Results showed that participants did not increase, or only slightly increased, tool use and positive interactions after being trained. However, tool use and positive interactions showed a more substantial increase for most participants after the implementation of organizational behavior management procedures.

Background. CRC risk can be reduced though lifestyle modification and regular screenings. Providing CRC risk feedback that promotes preventive behaviors to those at average risk has the potential to significantly reduce CRC morbidity and mortality. Purpose. The purpose of this dissertation was to examine the impact of CRC risk assessment feedback among adults aged 50-75 with no personal or family history of the disease. The specific aims were to: (1a) test personalized (vs. generic) risk assessment feedback on individuals’ risk perceptions and intentions to engage in three risk-reducing behaviors (e.g., physical activity, diet, and screening); (1b) determine if the provision of CRC risk information influences breast cancer risk perceptions and mammography intentions; (2a) examine individuals’ accuracy of perceived lifetime risk of CRC; (2b) assess whether improved accuracy following risk assessment was associated with changes in behavioral intentions; and finally, (3) evaluate the use of a unique sampling procedure designed to increase diversity of survey respondents. Methods. A pre-post parallel, two arm randomized controlled trial examined the effects of providing CRC risk assessment feedback that included lifetime risk estimates and information about CRC risk factors that was either personalized (treatment) or generic (control). N=419 average risk adults between the ages of 50-75 were recruited from a commercial online panel. Results. There were no differences in risk perception between study arms. Overall participants, perceived lifetime risk of CRC lowered at post-test and seemingly produced a spillover effect in lowered perceived lifetime risk of breast cancer among females. CRC screening intentions increased in both study arms and mammography intentions increased in the control arm. Accuracy of lifetime risk improved at post-test, but was not associated with changes in intentions to perform risk reducing behaviors. Quota sampling acquired a targeted and diverse sample quickly and efficiently. Conclusion. Communicating CRC risk information to average risk adults can improve CRC risk perception accuracy and enhance colorectal and mammography screening intentions. Risk assessment feedback did not consistently influence intentions to improve diet and physical activity.

For decades, the Department of Defense has been plagued by persistent cost, schedule, and performance problems in defense acquisition programs. Recent changes in Department of Defense acquisition policy were intended to improve efficiency and are demonstrating some improvement in terms of overall cost improvements, yet little is understood about whether training efforts related to the new policies are producing policy-compliant behavior on the job. Using Edgar Schein's 'Onion Model' of organizational change as the theoretical construct, the purpose of this study was to examine through an ex post facto, cross-sectional longitudinal study whether there is a significant relationship between learning achieved from Defense Acquisition University (DAU) training in acquisition policy and application of learned policy-compliant behavior, as represented by the variables learning achieved and applied training. Data were obtained from DAU that spanned 19 months and over 334,000 training events separated into 40 course-type subgroups. These data were analyzed through hierarchical regression analysis to test whether concepts learned in policy training predicted policy compliance. The findings confirmed that the independent variable of 'learning achieved' is predictive of policy compliance.

Alzheimer’s disease is a growing public health concern with the current number afflicted of 5 million in the US expected to triple by 2050. Since there is currently no cure or preventive pharmacological treatment, AD prevention research is now recognized as an important enterprise, with a goal to identify modifiable lifestyle factors that can reduce AD risk or delay its onset. Among these, increased physical activity, healthier food choices, more cognitive stimulation, better sleep quality, stress management, and social engagement have been identified as reasonable targets for behavioral intervention. A smartphone application-based behavioral intervention targeting these six behavioral domains was recently developed and a six-month randomized controlled trial was conducted, both to determine feasibility and compliance with technology usage and to test its efficacy. This study, titled the Gray Matters Study, was conducted in Cache County, Utah, enrolling a sample of 146 middle-aged participants (aged 40 to 64 years) randomized to treatment or control condition. Under the Health Belief Model, individuals who perceive a greater susceptibility to a particular health condition are hypothesized to be more likely to engage in more positive behaviors to reduce disease risk. Following this model, perceived threat of AD (operationalized by fear of AD, family history of AD, and metacognitive concerns) was examined for prediction of behavioral change over the six-month Gray Matters intervention period in these same six behavioral domains. Persons with a moderate level of fear of AD made significantly greater improvements in physical activity than those with low or high levels of fear. Family history was not a significant predictor of health-related behavioral change. However, persons with a moderate level of metacognitive concerns made significantly greater improvements in both physical activity and food quality than those with low or high levels of concerns. This is the first study to examine these psychological constructs related to AD risk and the extent to which they predict health-related behavior change. Future studies should extend the length of follow-up to at least one full year, include a more diverse sample of participants to expand generalizability, and build upon these findings to personalize supportive behavioral change interventions in order to be sensitive to these psychological factors.

Cognitive behavioral violence prevention (CB-VP) parenting groups are commonly used for the primary and secondary prevention of violence. These groups use persuasive messages that target violence-related attitudes and cognitions, with the expectation that this will result in behavior change. Despite their frequent use as family violence prevention strategies, little is known about the actual messages being exchanged in CB-VP groups and how participants perceive and recall these messages. This study analyzes messages aimed at changing behaviors as recalled by Hispanic participants in federally funded Fatherhood groups in Miami, Florida. Applying concepts from violence prevention, behavior change messages were classified by topic, type of behavior targeted, compliance gaining strategies (Marwell & Schmitt, 1967), and sources of influence Wheeless, Baraclough & Stewart, 1983). The most common topics reported by participants included parenting role, discipline, communication content and spending time with children. Over a third of the appeals targeted behaviors that were not observable actions, but rather cognitive acts such as thinking, reflecting, and paying attention. Reward and punishment were the most frequently used compliance gaining strategies, followed by moral and expertise strategies. Most appeals were based on the expected outcomes of the proposed behaviors as the main source of influence. The results of this study provide a greater understanding of the motivations used to support behavior change messages in violence prevention parenting groups.

Improved weight loss interventions are needed to help reduce obesity. One dietary factor that has been effective in increasing weight loss is increased dietary structure. One method for increasing dietary structure is prescribing the frequency in which eating bouts (meals and snacks) occur. Eating frequency (EF) has been inversely related to body mass index (BMI) but the impact of EF on weight loss is unclear. This randomized controlled trial examined the effect of EF on hunger, the relative-reinforcing value of food, energy intake (EI), and weight loss during a 6 month behavioral weight loss intervention. Participants (age: 51.0 ± 9.9 yrs, BMI: 35.5 ± 4.8 kg/m2, 57.8% female, 94.1% white) were randomized to one of two EF prescriptions: 1) Three Meal (n=25): three eating bouts/day; or 2) Grazing (n=26): eat at least 100 kcals every 2-3 hrs. Both groups attended 20 sessions and had identical dietary (1200–1500 kcals/day, < 30% kcals from fat) and physical activity (200 minutes/wk) goals. Hunger, relative-reinforcing value of food, diet, and anthropometric data were collected at 0 and 6 months. Using intent-to-treat analyses, Grazing reported a greater EF (eating bouts in which > 25 kcals were eaten/day) than Three Meal at 6 months (5.8 ± 1.1 eating bouts vs. 3.2 ± 0.6 eating bouts, p<0.001). On a 100-mm visual analogue scale Grazing reported significantly less hunger at 6 months as compared to 0 months (47.9 ± 18.5 mm vs. 56.3 ± 15.7 mm, p<0.05), while Three Meal did not report any changes. There were no significant differences in the relative-reinforcing value of food between groups or over time. EI and BMI were significantly (p<0.001) reduced from 0 to 6 months (EI: 0 months = 2198 ± 692 kcals/day vs. 6 months = 1266 ± 353 kcals/day; BMI: 0 months = 35.5 ± 4.8 kg/m2 vs. 6 months = 30.6 ± 4.9 kg/m2). There were no significant differences in EI or BMI between the groups. An EF of approximately six eating bouts/day may decrease hunger more so than an EF of three meals/day while consuming a low-kcal diet during a behavioral weight loss intervention.

Background: There currently exists a vast amount of literature concerning chronic illness self-management, however the developmental patterns and sustainability of self-management over time remain largely unknown. This paper aims to describe the patterns by which different chronic illness self-management behaviors develop and are maintained over time. Method: Twenty-one individuals newly diagnosed with chronic illnesses (e.g., diabetes, rheumatism, ischemic heart disease, multiple sclerosis, chronic renal disease, inflammatory bowel disease) were repeatedly interviewed over two-and-a-half years. The interviews were conducted in Sweden from 2006 to 2008. A total of 81 narrative interviews were analyzed with an interpretive description approach. Results: The participants’ self-management behaviors could be described in four different developmental patterns: consistent, episodic, on demand, and transitional. The developmental patterns were related to specific self-management behaviors. Most participants took long-term medications in a consistent pattern, whereas exercise was often performed according to an episodic pattern. Participants managed health crises (e.g., angina, pain episodes) according to an on demand pattern and everyday changes due to illness (e.g., adaptation of work and household activities) according to a transitional pattern. All of the participants used more than one self-management pattern. Conclusion: The findings show that self-management does not develop as one uniform pattern. Instead different self-management behaviors are enacted in different patterns. Therefore, it is likely that self-management activities require support strategies tailored to each behavior’s developmental pattern. / Exploring individuals’ conceptions as a way to understand self-management among people living with long term medical conditions

As an effect of increased living standards and improved health care, life expectancy has risen in many parts of the world. At the same time, welfare diseases such as diabetes and obesity increases. As the number of elderly and long-term sick rises, so will the medical care needs. E-health applications are often presented as a way to meet future medical and doing so within the scope of existing resources. By facilitating health communication and widen access to health services by offering them online, e-health applications encourages people to become more engaged in their own health, thus working proactively towards a healthier population. However, e-health applications often fail to reach their full potential. The purpose of this study is to explore how health care providers and health care recipients perceives e-health applications and their usefulness and thus being able to identify factors significant for successful introduction and use of e-health services. Two e-health applications have been analysed and six important aspects have been identified and discussed. In order to be successful, an e-health application must facilitate behaviour change and be integrated in the everyday life of the user. Substantial and adequate evaluation is essential to make sure that the application meet the requirements from both health care providers and health care recipients. An understanding of the possibilities technology has to offer is needed in order to fully exploit the potential of e-health applications in health care. Instructions for health care providers on how to use the applications are essential not only to ensure their proper usage but also to make sure that applications are being presented to recipients in a satisfactory way and that care providers can offer the support and help recipients may need. Finally, when discussing e-health applications it is important to remember that there are people who does not want to get involved and that there is still a demand for face-to-face interaction in health care. Therefore, e-health services must be complemented with alternatives providing different types of interaction opportunities.

This thesis studied four CEMUS courses offered in spring 2011. The purpose of this study was: 1) to measure CEMUS students‘ self-reported behavior and action as well as behavior intention towards sustainable development; 2) to analyze different factors and barriers to their behavior and action; 3) to analyze course coordinators‘ knowledge and perspectives about behavior change and action towards sustainable development; and 4) to analyze each course‘s impact on students. Finally, this thesis discusses how education can be improved to foster behavior and action towards sustainable development. This study used both qualitative and quantitative methods. According to the results, most CEMUS students were willing to recycle; to switch off electricity when it‘s not needed; and to travel by bicycle or public transportation instead of by car. On the other hand, fewer students had a willingness to pay for environmental costs and to cut down water consumption and waste. Among the opportunities for indirect action, it was political participation and working within the field of sustainable development (SD) that were most preferred. In contrast, much fewer students were willing to avoid purchasing products from companies with poor track records on CSR, to participate in voluntary work related to SD and to donate money for social or environmental causes. The two most frequently perceived constraints for behavior change among students were a lack of money and obstructive social norms. As a course outcome, four out of six coordinators expect students to take action afterwards but there is a lack of knowledge on how to encourage students to behave and act more sustainably. Based on the results, this thesis discussed what kinds of learning methods can be applied in CEMUS and ESD. It was concluded that education should focus on a specific domain and a small spatial scale, and assign project assignments in which students communicate and interact with stakeholders. Such an approach will help to approach the goals of Education for Sustainable Development (ESD). CEMUS could also implement the theory of locus of control, emotional involvement and four different kinds of knowledge in their education in order to improve the effectiveness of CEMUS courses when it comes to promoting behavior and action towards sustainable development.