Background: Recent empirical research and theoretical models acknowledge that impulsive processes, can often undermine peoples’ attempts to lose weight despite currently available and effective support (Chapter 2). Aim: To develop, deliver, and evaluate an impulse management intervention to support weight loss in adults. Methods: A systematic review was conducted to identify available impulse management techniques for influencing eating behaviour (Chapter 3). Intervention Mapping was used to develop the intervention (Chapter 4) which drew on various sources including the findings from the systematic review, stakeholder consultations, existing guidance, and qualitative interviews. A two-arm randomised controlled feasibility trial (Chapter 5), with nested mixed-methods process evaluation and two cycles of intervention delivery and data collection (Chapter 6), was conducted. This assessed the feasibility and acceptability of, and informed refinements to, both the intervention and trial procedures in preparation for a full-scale effectiveness evaluation. Weight was measured as the proposed primary outcome for a full-scale trial at baseline, one-month, and three-months of follow-up, app usage data were collected at both follow-up time points, and semi-structured interviews were conducted at one-month with a subsample of intervention group participants only. Results: The systematic review critically appraised and synthesised evidence on 17 identified techniques which were categorised as Impulse-focused or Reflective techniques. Promising changes in eating behaviour and craving were found for the techniques of visuospatial loading, physical activity, and implementation intentions. Intervention Mapping resulted in development of a novel smartphone app-based intervention (ImpulsePal) aimed to reduce unhealthy snacking, overeating, and alcoholic and sugary drink consumption using impulse management techniques identified in the systematic review. Eighty-eight adults with a Body Mass Index of ≥25kg/m2 and wishing to lose weight, were recruited and randomised in a 2:1 ratio to use ImpulsePal (n=58) or to a waiting list control (n=30) group. Data were available for 74 participants (84%) at one-month and 67 (76%) at three months. Exploratory analyses suggest that the ImpulsePal group (n=43) lost 1.03kg (95% CI 0.33 to 1.74) more than controls (n=26) at one-month, and 1.01kg (95% CI -0.45 to 2.47) more at three months. Participants reported high satisfaction with the intervention and trial procedures. The process evaluation suggests that ImpulsePal and the impulse management techniques are feasible to deliver and acceptable to users. Interviews with twenty-two participants suggest that they valued having access to in-the-moment support, felt more aware of their own eating behaviour and influences on it, and felt an increased ability to resist temptations. Conclusions: This work has developed a novel, theory- and evidence-informed, person-centred app which showed potential to improve impulse management, promote healthier eating, and support weight loss. ImpulsePal is acceptable to overweight and obese adults who want to lose weight and is now ready for evaluation in a full-scale trial. The thesis discusses theoretical, methodological, and practical implications for the future development, evaluation, and implementation of digital behaviour change interventions.

Context: The Western Cape Province's Department of Health, South Africa, implemented a complex intervention aimed at changing organisational culture across health facilities in the province called the C²AIR² club challenge, in phases, starting from August 2013 and was still ongoing in 2016 at the time of the research. A group of front-line staff from each participating health facility called C²AIR² club champions were capacitated to implement the intervention in their respective facilities. This study aimed to explored the process of introduction, diffusion, adoption and implementation of the C²AIR² club challenge in one of the primary health facilities where the challenge was implemented, using a diffusion of innovation lens. Methods: We examined the process of implementing the C²AIR² club and the contextual and other factors that constrained and enabled this process. Working in one primary health care facility selected as a representative case, we explored the experiences of the champions and other staff members of the C²AIR² club. Our methods included 21 in-depth interviews, informal conversations, document review, and non-participant observation. Results: Innovation-fit, leadership, champions, adopters' characteristics, and contextual issues were the main factors that influenced the spread of the C²AIR² club. Contextual issues particularly those related to resource constraints played a central role in determining the successful spread of the complex organisational culture change intervention. Sufficiently trained champions could successfully spread the intervention without onsite external change consultants' facilitation, however this took time and caution should be taken not to evaluate implementation success too early. Involvement of not only top leadership but of all other multi-levels and multi-disciplines facilitated the spread of the intervention. Conclusions: When introducing an innovation like the C²AIR² club challenge the impact of which is not immediate neither tangible, in an organisation where there are tangible problems such as lack of working space, staff shortages and shortages in working equipment, it is important that efforts are made to address these immediate challenges and where they cannot be addressed that this is openly acknowledged by the implementers and management. If this is not considered, organisational members are likely to acknowledge the innovation as a good initiative but one that they would not actively rally around as it does not speak to their problems.

Objectives This thesis aimed to explore psychological factors associated with walking behaviour in patients with Peripheral Arterial Disease, within the framework of Leventhal et al’s (1998) Common-sense Model of Self-regulation of Health and Illness. The objective was to identify psychological factors which could be modified to increase walking behaviour in these patients. Method A series of three studies were conducted to achieve these aims. The first study was an exploratory qualitative study, to explore the illness and treatment beliefs and walking behaviour of patients with intermittent claudication. The second study was a cross-sectional postal questionnaire to a cohort of patients with intermittent claudication, which tested the influence of the psychological factors identified in the qualitative study, in a larger sample. The final study was a randomised controlled trial of a brief psychological intervention designed to modify the illness and walking beliefs of patients with intermittent claudication, in order to increase walking behaviour. Results Beliefs about intermittent claudication, and beliefs about walking were both found to be associated with walking behaviour in the qualitative study. The results from the cross-sectional postal questionnaire confirmed this relationship – taken as a set, illness and walking beliefs accurately predicted adherence to minimum walking levels for 93.4% of the sample. The brief psychological intervention successfully modified illness and treatment beliefs and increased walking behaviour in patients newly diagnosed with intermittent claudication. Conclusion This thesis highlights the importance of illness and walking beliefs to the walking behaviour of patients with intermittent claudication. The thesis has added to the body of knowledge about intermittent claudication, and the findings of this thesis have implications for the treatment of patients with intermittent claudication within the health service. Theoretical and clinical implications of this research are discussed.

This paper explores the usage of digital behavior change applied to veganism by applying various concepts from different behavior change models. These models are used as a basis to create several intervention posts that are presented to participants over a period of 8 days via the medium of Instagram. The transtheoretical model is used as a tool of measurement of how participants progress by placing them in distinct stages of change, based on interviews conducted before and after being exposed to the intervention posts. For this purpose, several behavior change interventions are designed with the help of the Behavior Change Wheel model. By measuring the rate of recollection of each intervention post we get an overview of how well different types of posts stick in memory. Of the intervention functions in the Behavior Change Wheel, Education was found to be the most important in our study, meaning that most participants found a lack of knowledge to be a limiting factor. The economical aspect of vegan food was also found to be a major aspect in our sample group of university students. Additionally it was observed that participants were communicating and recommending recipes to each other, it was found that this had a major influence on the behavior of our participants. / Den här rapporten utforskar användningen av digitala beteendeförändrings-metoder applicerat på veganism genom att använda koncept från två beteendeförändrings-modeller. Dessa modeller används som bas för att skapa flera interventions-inlägg som presenteras för deltagarna via Instagram under en period av 8 dagar. Intervjuer utförs före och efter studieperioden för att placera varje deltagare i en utav den Transteoretiska modellens skeden som används för att mäta hur interventions-inläggen påverkar dem. Genom att mäta vilka inlägg som deltagarna kom ihåg får vi en överblick av hur väl olika typer av inlägg fastna på minnet. Modellen Behavior Change Wheel används för att designa själva interventionerna och av dess interventions-funktioner så verkade Utbildning vara den viktigaste i vår studie då de flesta deltagarna ansåg att avsaknaden av kunskap var en begränsande faktor. Den ekonomiska aspekten av vegansk mat ansågs också vara en stor faktor i vår provgrupp som bestod av universitetsstudenter. Ytterligare så observerades det att deltagarna kommunicerade och rekommenderade recept till varandra vilket visade sig ha ett stort inflytande be deras beteende.

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Adults with intellectual disability (ID) have a higher rate of falls than the general population, and changing health behaviors through exercise program could enhance health and reduce falls in this population. However, the feasibility study of fall prevention based on the theoretical framework for adults with ID has not been explored to date. This study examined the feasibility of a home-based exercise intervention for people with ID living in a residential setting. We provided an 8 week intervention consisting of a training workshop for support workers and sessions for adults with ID devoted to behavior reward, education about fall prevention and exercise, and exercise training. Adults with ID (n = 33) and support workers, including caregivers (n = 3), staff (n = 8), and one administrator, participated in this study. Adults with ID significantly improved physical performance, self-efficacy for activity, fall efficacy, and support from friends and support workers. There were no significant changes in free-living PA. There was no adverse event during the intervention, and the average adherence rate was sufficient. Adults with ID, support workers, and an administrator were satisfied with the program and had the intention to continue the program. The intervention was feasible and perhaps efficacious for adults with ID living in group-homes.

Thesis (MPhil (Sociology and Social Anthropology))--University of Stellenbosch, 2010. / ENGLISH ABSTRACT: The study examines the implementation of an intervention aimed at stopping alcohol consumption during pregnancy in order to decrease Foetal Alcohol Spectrum Disorder (FASD) and how this affected changes in alcohol consumption. FASD is a growing concern in South Africa where the prevalence rate is almost 12/100 at some schools in the Western Cape; the highest reported FASD rate in the world. FASD is caused by alcohol consumption during pregnancy and it is an irreversible mental and physical disability in children. FASD is preventable through abstinence from alcohol consumption during pregnancy. The intervention study (referred to as the Ceres Intervention Study), utilised a cluster-randomised trial design, with a control and intervention group, where the control arm of the study received basic screening and information on FASD, while the intervention arm of the study received a more comprehensive intervention, consisting of a variety of screening and counselling techniques. The study took place during 2007/2008 in the Witzenberg sub-district in Ceres in the Western Cape Province of South Africa. The Study used research techniques combined with therapeutic methods and techniques to mediate behaviour change in pregnant women. From the Ceres Intervention Study it was found that 60% of pregnant women changed their drinking behaviour, which led to questions around how this behaviour change took place. The main aim of this study therefore is to examine how pregnant women changed their drinking behaviour during this intervention and also what facilitated the change that was observed. In order to examine the behaviour change, data from the intervention arm and control arm of the study was analysed and a profile of the women was developed. A focus on the intervention arm of the study resulted in distinguishing further between two sub-groups within the intervention arm, namely, the change and no-change groups. Mainly quantitative data was obtained with the use of various tools, however from the comments and experiences of participants, qualitative data could be used as complementary to quantitative data to provide more clarity as to how behaviour change was facilitated in the study. Results from the study suggest that there is a dialectical interplay between client and counsellor which facilitate generative mechanisms that may lead to behaviour change. / AFRIKAANSE OPSOMMING: Hierdie studie lig die implementering van 'n intervensie toe met die doel om die gebruik van alkohol gedurende swangerskap te stop teneinde Fetale Alkohol Spektrum Afwyking (FASD) te verminder en die gepaardgaande gedragsverandering by swanger vroue te ondersoek. FASD is 'n groeiende probleem in Suid-Afrika waar die voorkoms van FASD by 12/100 kinders by sommige skole in die Weskaap gerapporteer is. FASD word veroorsaak deur alkohol-gebruik tydens swangerskap en kan permanente verstandelike en fisiese gestremdheid by kinders veroorsaak. FASD kan voorkom word deur geen alkohol tydens swangerskap te gebruik nie. Die intervensie (of die Ceres Intervensie-studie) maak gebruik van 'n kliniese ontwerp met 'n kontrole en 'n intervensie groep, waar die kontrole arm van die studie basiese assessering asook inligting oor FASD ontvang het, terwyl die intervensie arm 'n meer omvattende intervensie bestaande uit 'n verskeidenheid assesserings sessies en beradingstegnieke ontvang het. Die studie is gedurende 2007/2008 in die Witzenberg sub-distrik in Ceres in die Weskaap, Suid-Afrika, geïmplementeer. Die studie maak gebruik van navorsingstegnieke gekombineer met wetenskaplik gebaseerde intervensie metodes en tegnieke om gedragsverandering by swanger vroue te onderhandel. In die Ceres Intervensie-studie is bevind dat 60% van die swanger vroue hul alkohol-gebruik gedrag verander het. Dit het aanleiding gegee tot vrae rondom hoe hierdie gedragsverandering plaasgevind het. Die hoofdoel van hierdie studie is dus om te kyk na hoe swanger vroue hul alkohol-gebruik verander het gedurende die intervensie asook wat hierdie verandering in gedrag moontlik gemaak het. Om hierdie gedragsverandering te ondersoek is data van die intervensie arm en kontrole arm ontleed en is 'n profiel van die vroue saamgestel. Die fokus op die intervensie arm van die studie het aanleiding gegee tot die verdere onderskeiding tussen twee sub-groepe binne die intervensie arm, naamlik, die groep wat verander het en die groep wat nie verander het nie. Kwantitatiewe data is hoofsaaklik ingesamel, alhoewel kwalitatiewe data wat verkry is uit opmerkings en ondervindings van deelnemers as aanvullende inligting tot die kwantitatiewe data gebruik is teneinde die gedragsverandering wat plaasgevind het toe te lig. Bevindinge uit die studie dui op 'n dialektiese verhouding tussen klient en berader wat skeppende meganismes teweeg bring en sodoende moontlike gedragsverandering bevorder.

Pain management in hospitalized infants in the Neonatal Intensive Care Unit continues to be substandard despite the development and availability of evidence-based guidelines. The Evidence-based Practice Identification and Change (Lee et al., 2009) strategy is a multifaceted tailored intervention that has been used to promote evidence-based practice. However, the process of delivering the components of the intervention is not well understood and no valid measure for evaluating the fidelity of intervention implementation exists. The overall objective was to develop and determine the face validity, content validity, construct validity, feasibility, and clinical utility of the Process Evaluation Checklist. Three prospective studies were conducted. In Study 1, the face and content validity of the Process Evaluation Checklist was determined. In Study 2, the construct validity of the Process Evaluation Checklist was examined by assessing the fidelity of implementing the Evidence-based Practice Identification and Change intervention in a clinical setting. In Study 3, the feasibility and clinical utility of the Process Evaluation Checklist was determined. Overall, the face and content validity of the Process Evaluation Checklist was achieved. The intervention was implemented with high fidelity, supporting the construct validity of the measure. A Research Practice Council, with assistance from an external facilitator and internal facilitators, implemented multifaceted knowledge translation strategies in the form of constant reminders to improve sucrose administration practices. Post intervention admission orders were significantly more likely to include sucrose, and odds of being administered sucrose were 13 times greater compared to baseline. Beginning support was provided for the content and construct validity, feasibility, and clinical utility of the Process Evaluation Checklist for use with complex interventions. Using this measure to monitor intervention fidelity in different contexts and with different users over longer periods of time will provide additional support to the validity of the Process Evaluation Checklist.

Pain management in hospitalized infants in the Neonatal Intensive Care Unit continues to be substandard despite the development and availability of evidence-based guidelines. The Evidence-based Practice Identification and Change (Lee et al., 2009) strategy is a multifaceted tailored intervention that has been used to promote evidence-based practice. However, the process of delivering the components of the intervention is not well understood and no valid measure for evaluating the fidelity of intervention implementation exists. The overall objective was to develop and determine the face validity, content validity, construct validity, feasibility, and clinical utility of the Process Evaluation Checklist. Three prospective studies were conducted. In Study 1, the face and content validity of the Process Evaluation Checklist was determined. In Study 2, the construct validity of the Process Evaluation Checklist was examined by assessing the fidelity of implementing the Evidence-based Practice Identification and Change intervention in a clinical setting. In Study 3, the feasibility and clinical utility of the Process Evaluation Checklist was determined. Overall, the face and content validity of the Process Evaluation Checklist was achieved. The intervention was implemented with high fidelity, supporting the construct validity of the measure. A Research Practice Council, with assistance from an external facilitator and internal facilitators, implemented multifaceted knowledge translation strategies in the form of constant reminders to improve sucrose administration practices. Post intervention admission orders were significantly more likely to include sucrose, and odds of being administered sucrose were 13 times greater compared to baseline. Beginning support was provided for the content and construct validity, feasibility, and clinical utility of the Process Evaluation Checklist for use with complex interventions. Using this measure to monitor intervention fidelity in different contexts and with different users over longer periods of time will provide additional support to the validity of the Process Evaluation Checklist.

Overview: Pregnant women living with obesity are at increased risk of pregnancy complications, with risks rising as Body Mass Index (BMI) increases. Midwives are willing to support women with managing their gestational weight gain but lack confidence and access to supporting resources. In the UK there are no interventions that aim to change the intention and behaviour of midwives, to support women with managing their gestational weight gain. The Theory of Planned Behaviour (TPB) (Ajzen, 1985) was utilised to frame the design of a behaviour change intervention for midwives. This three-phase study conducted a qualitative needs assessment, intervention design, and a quantitative study of, intervention testing. Methods: Phase One: Interview data were thematically analysed and the TPB utilised to elicit participants’ salient beliefs, to inform intervention design. Phase Two: The design of the intervention, and the TPB scale, were informed by Phase One data. Midwives reviewed the intervention and participated in a pilot test of the scale. Phase Three: The intervention was tested in a before-and-after controlled trial, utilising the refined TPB scale. Results: Phase One: 4 key themes emerged: 1)The current state of affairs 2) Perspectives on an intervention: what may work 3) Influences on uptake and successful weight control 4) Taking things forward. Phase Two: An intervention to facilitate the involvement of community midwives in supporting weight management for pregnant women living with obesity; a booklet about weight management in pregnancy; and a TPB scale were designed. Recommendations from midwives were integrated into the final intervention resource, and pilot testing of the scale led to refinement for use in phase 3. Phase Three: Midwives in the intervention group increased their intention to offer weight management support to pregnant women living with obesity. Furthermore, midwives in the intervention group increased actual weight management support for pregnant women living with obesity, after participating in the intervention. Conclusions: This study made a unique contribution to new knowledge by developing and testing a novel intervention that was underpinned by health psychology theory, which increased the intention and behaviour of community midwives to support pregnant women living with obesity, with managing their gestational weight gain.