Objectives: Obesity-related illnesses are a major public health concern. Although doctors are expected to discuss obesity and health-related behaviour change with patients, they report being unprepared by medical education to do this effectively. Healthcare settings provide an opportunity to help patients tackle unhealthy behaviours and make the necessary changes to improve their health and longevity. This programme of research aims to investigate and improve current obesity management education for medical students. It also aims to identify whether the existing evidence-base on behaviour change techniques has been used to inform educational interventions in this area. Five separate studies were conducted in order to investigate obesity management education for medical students, identify challenges and solutions to its integration within medical schools, and then design and test a novel educational intervention in this area. Methods: Two systematic reviews were conducted to investigate relevant educational interventions about obesity management in terms of a) their efficacy and b) their educational content. A qualitative study using semi-structured interviews with medical educators (n = 27) was conducted to explore key challenges to integrating this education into medical schools in Ireland and the UK. The final two studies involved designing and validating a communication tool based upon behaviour change techniques, and subsequently evaluating this within an educational intervention in a before-and-after feasibility study (n = 34 medical students). Results: Findings from the systematic reviews illustrated that educational interventions addressing obesity management for medical students are rare. Robust empirical evaluations are scarce, and on the whole authors report using little behaviour change theory or evidence to inform their interventions. Barriers to integrating obesity management education into medical schools may relate to the diverse and opportunistic manner in which it is currently delivered within medical schools; varied support for its inclusion, and varied medical student engagement in the topic. Taking into account these issues, findings of the feasibility study suggest that it is possible to deliver theory- and evidence-based obesity management education to medical students. This educational intervention was delivered consistently by clinical tutors, it was acceptable and valued by students, and results suggest that participants would go on to discuss obesity management with patients and use desired communication skills within such interactions.Conclusions: The available evidence-base on obesity management educational interventions for medical students is poor. However, it is possible to design and deliver this education within an existing undergraduate medical programme. Further research is required to investigate the efficacy and effectiveness of such an intervention in practice.

Background: Cystic fibrosis (CF) is a genetically inherited disease which adversely affects the respiratory and gastrointestinal systems. Malnutrition is a major clinical problem in individuals with the disease. Nutritional interventions are warranted as improvements in nutritional status could improve the rates of morbidity and mortality associated with the disease. The review of the literature indicated the need to develop a behavioural-based nutrition prevention program in order for children to achieve CF dietary requirements and appropriate pancreatic enzyme replacement therapy.Methods: The intervention program, Go and Grow with CF, and nutrition and pancreatic enzyme knowledge and self-management questionnaires were developed for children with CF and their carers as part of this thesis. Social learning theory constructs which particularly assist children in achieving desirable behaviours were applied during the development of the Go and Grow with CF program. The program consisted of workshops and a home-based course.Fifty eight children with cystic fibrosis, aged 2 to 11 years, and their carers participated in a clinical trial that was designed to assess the effects of the Go and Grow with CF pilot program on knowledge, self-management, behaviour, dietary intake and body composition, using anthropometry. Process evaluation was conducted on the pilot program and on the clinic-wide implementation of the revised Go and Grow with CF program. The revised program included the Australian Pancreatic Enzyme Replacement Therapy Guidelines and the effects of fat-based dosing were assessed with a cohort of 29 children with CF-related pancreatic insufficiency aged 1 to 13 years.Results: Similar to the process evaluation of the pilot program, 100% of carers who completed the revised home-based course indicated that they would recommend Go and Grow with CF to other families ++ / with a child who has CF. The 'objective assessment of knowledge indicated a significant m improvement in' children's knowledge in the short-term. There were no statistically significant improvements in any of the other parameters assessed. The lack of significant improvements in self-management, behaviour, dietary intake and anthropometry may have been because the program had no effect, the parameters assessed or the instruments used (particularly the questionnaires) were not sufficiently sensitive, the sample size (which was determined by the CF population available) was too small or the duration of the intervention and follow-up was too short.Conclusion: Carers' unanimous recommendation of Go and Grow with CF, together with high levels of perceived learning, reported increase in confidence and improvement in children's knowledge in the short-term, indicate the benefits of the program.Although there was no statistically significant improvement in the anthropometric measurements after the intervention, 'the extensive data obtained during this study suggest that measurements of height and weight may underestimate the presence of poor nutritional status. It is likely that comprehensive assessments of body composition of children with CF would be useful in detecting mild degrees of malnutrition and in providing information about the effects of nutritional status on morbidity and mortality associated with the disease.Fat-based pancreatic enzyme replacement therapy dosing warrants further investigation given that parents had a strong preference for this method and that fat absorption remains abnormal in the majority of individuals who have pancreatic insufficiency. Evaluation of all pancreatic enzyme replacement therapy dosing methods are needed and this research suggests that dose should be assessed on a meal and snack basis, rather than just on daily intake, in order ++ / for levels of adherence to be examined.The apparent absence of a long-term effect of a single exposure to the program on knowledge suggests that regular, ongoing education and counselling is required by families to reinforce aspects related to the child's current stage of development and disease status.

Regular physical activity (PA) participation and fruit and vegetable (FV) consumption confers numerous positive health outcomes for cancer survivors, including prevention of cancer recurrence, second primary cancers, and other non-communicable chronic diseases. Rural-living young adult cancer survivors (YAs) possess unique barriers and concerns that influence their ability to participate in traditional face-to-face behaviour change interventions. Few researchers have explored alternative means for delivering behaviour change interventions grounded in theory utilizing a mixed-methods approach to assess processes of change and behavioural outcomes. To fill this gap and provide recommendations for future interventions and services focused on positive health behaviours in this population, the objective of the research presented in this thesis was to explore the feasibility and acceptability of a 12-week theory-based telehealth behaviour change intervention aiming to improve PA and FV consumption using a single-arm, mixed methods pilot trial. Over a 7-month period, 14 YAs self-referred. Of these 14, 5 were eligible and consented to participate with 3 completing the study. Retention to the study was 73% and adherence to the health coaching program ranged from 66.67-100% with a 40% attrition rate. Inquiry into the acceptability of the intervention offered insight into participants experiences, which was summarized within five themes: (1) the more time the better, (2) the human factor, (3) supporting access, (4) influencing the basic psychological needs, and (5) finding motivation. Collectively, the findings suggest the methods used require minor modifications before being deemed feasible despite the general acceptability of the intervention. Importantly, they highlight the necessity of more expansive recruitment strategies and a need to explore participants’ underlying intentions for participating in behaviour change interventions. Further, recommendations are made based on the findings to improve this style of intervention, including testing stepped down models of support because it may help some YAs maintain behaviour change post-intervention.

<div>Growing automobile dependency and usage continue to exacerbate traffic congestion, air pollution, and physical inactivity in metropolitan areas. Extensive efforts have been made to leverage advanced technology and related policies to influence short- (within-day and day-to-day) and long-term (mobility and lifestyle) travel decisions to address these issues from the system operator and individual traveler perspectives. However, most studies have yet to address system operator and individual traveler needs together; provide sufficient understanding of the impacts of such technologies on safety and health; and consider the impacts of distinctive regional and political characteristics on responses to different policies among population subgroups.</div><div>This dissertation seeks to facilitate the leveraging of information technologies and related policies to influence short- and long-term travel decisions by: (1) developing a framework for apps that integrate augmented reality, gamification, and social component to influence travel decisions that address multiple user- and system-level goals, (2) understanding the safety and health impacts of these apps, (3) developing strategies to influence residential location decision-making to foster sustainable post-relocation travel behavior, (4) investigating the impacts of economic and legal policies on travel decisions by considering distinctive regional and political characteristics.</div><div>This dissertation can provide insights to system operators for designing a new generation of apps to dynamically manage traffic in real-time, promote long-term mode shifts from single-occupancy driving to carpooling, public transit use, walking and cycling, and address individual traveler needs. The dissertation also presents app mechanisms for providing feedback to legislators and app developers for designing policies and apps geared towards safe usage and promoting the physical and mental health of its users. </div><div>In addition, by considering the impacts of distinctive regional and political characteristics on population subgroups in terms of their responses to information technologies and economic and legal policies, additional measures can be deployed to support and facilitate the implementation of such technologies and policies.</div><div><br></div>

Many patient-level barriers to more effective post-fracture osteoporosis (OP) management are associated with patients’ perceptions of their bone health and the link between their fracture and OP. These barriers could be addressed by interventions which account for the role of patients’ perceptions, such as those based on theories of behaviour change. This thesis had two objectives: to review the literature and determine whether these theories have been integrated in post-fracture OP management and to examine patients’ awareness of the OP-fracture link. The results showed that theories of behaviour change have not been integrated into post-fracture interventions, that most patients do not perceive the OP-fracture link even after a baseline intervention and that two baseline factors predict who is less likely to make the OP-fracture link at follow up. Based on these findings, modifications to current OP interventions were proposed and guidance that could help create new, patient-centered interventions was provided.

Many patient-level barriers to more effective post-fracture osteoporosis (OP) management are associated with patients’ perceptions of their bone health and the link between their fracture and OP. These barriers could be addressed by interventions which account for the role of patients’ perceptions, such as those based on theories of behaviour change. This thesis had two objectives: to review the literature and determine whether these theories have been integrated in post-fracture OP management and to examine patients’ awareness of the OP-fracture link. The results showed that theories of behaviour change have not been integrated into post-fracture interventions, that most patients do not perceive the OP-fracture link even after a baseline intervention and that two baseline factors predict who is less likely to make the OP-fracture link at follow up. Based on these findings, modifications to current OP interventions were proposed and guidance that could help create new, patient-centered interventions was provided.

This thesis aimed at developing and evaluating a tailored behavioural sleep medicine intervention for enhanced physical activity and healthy eating in patients with obstructive sleep apnea syndrome (OSAS) and overweight. Participants with moderate or severe OSAS (apnea-hypopnea index ≥15) and obesity (Studies I-II) or overweight (Studies III-IV), treated with continuous positive airway pressure (CPAP) (Studies I-II) or admitted to CPAP treatment (Studies III-IV), were recruited from the sleep clinic at Uppsala University Hospital, Sweden. Semi-structured individual interviews were analysed using qualitative content analysis (Study I). Data on moderate-to-vigorous physical activity (MVPA) and sedentary time were collected with three measurement methods and analysed regarding the level of measurement agreement (Study II). Potential disease-related and psychological correlates for the amount of MVPA, daily steps and sedentary time were explored using multiple linear regression (Study III). Physical activity and eating behaviour changes were examined after a six month behaviour change trial (Study IV). A tailored behavioural sleep medicine intervention targeting physical activity and healthy eating in combination with first- time CPAP treatment was compared with CPAP treatment and advice on the association between weight and OSAS. According to participants’ conceptions, a strong incentive is needed for a change in physical activity and bodily symptoms, external circumstances and thoughts and feelings influence physical activity engagement (Study I). Compared with accelerometry, the participants overestimated the level of MVPA and underestimated sedentary time when using self-reports (Study II). The participants spent 11 hours 45 minutes (71.6% of waking hours) while sedentary. Fear of movement contributed to the variation in steps and sedentary time. Body mass index was positively correlated to MVPA (Study III). The experimental group increased intake of fruit and fish and reduced more weight and waist circumference compared with controls. There were no changes in physical activity (Study IV). The novel tailored behavioural sleep medicine intervention combined with first-time CPAP facilitated eating behaviour change, with subsequent effects on anthropometrics, but it had no effects on physical activity and sedentary time. Fear of movement may be a salient determinant of sedentary time, which has to be further explored in this population. The results confirm sedentary being a construct necessary to separate from the lower end of a physical activity continuum and highlight the need of developing interventions targeting sedentary behaviours specifically.

This thesis is an investigation of the self-reported health behaviour changes made by adults in the Canadian Community Health Survey 2007, categorized by BMI category. Descriptive analyses and forward stepwise regression were performed to determine variables associated with HBC. The final sample n = 111,449. Overall, 58% of individuals had made a HBC in the past year. Increased exercise was the most common HBC (29%), followed by improved eating habits (10%) and losing weight (7%). Only 51% experienced barriers to HBC; lack of will power was most commonly cited. Overweight and obese individuals were more likely to undertake HBC. In the regression model, opinion of own weight was the strongest predictor of HBC, followed by fruit and vegetable consumption, number of consultations with doctor, smoking status, and perceived health.

The oil and gas industry is a vital contributor to the global economy and a key source of employment within oil-producing countries. Oil production is largely dependent on a skilled population who are adept in coping with the demands of an offshore environment. Due to the high risk nature of work offshore, it is a requisite that personnel engage in health promoting behaviours. The research aimed to identify aspects of offshore workers self care which required behaviour change and the behavioural determinants which were associated with engagement in self care. A mixed methods design was utilised to generate novel data and original findings. Phase 1 used a quantitative cross-sectional online survey to assess offshore workers’ (n=352, 53.6% response rate) health, quality of life, mental wellbeing and self care status. The findings highlighted key areas of concern, as indicated by negative scoring across measures, relating to: overweight/obesity; medication adherence; absenteeism (with regard to travelling offshore); medical evacuation; lack of adherence to 5-a-day fruit and vegetable guidelines; physical activity; smoking; hazardous alcohol use, and insomnia. Phase 2 used qualitative theory-based telephone interviews to explore self care behaviours from the perspective of offshore workers (n=16). Offshore workers who had completed a survey and indicated they would like to receive further information on the interviews were invited to participate. Both the interview schedule and data analysis were informed by the Theoretical Domains Framework (TDF). Healthy eating and physical activity were the behaviours most frequently discussed by offshore workers and identified as areas requiring behaviour change. TDF domains representing both behaviours included: beliefs about capabilities; beliefs about consequences; intentions; goals; memory, attention and decision processes; environmental context and resources; social influences; emotion, and behavioural regulation. Phase 3 used qualitative theory-based telephone interviews to explore offshore workers’ (n=13) self care behaviours from the perspective of remote healthcare practitioners. Both the interview schedule and data analysis were informed by TDF. Healthy eating and harmful/hazardous alcohol use were the behaviours most frequently discussed by remote healthcare practitioners and identified as areas requiring behaviour change. TDF domains representing both behaviours included: knowledge; environmental context and resources; social influences; emotion, and behavioural regulation. The findings, when triangulated suggest that offshore workers may benefit from the implementation of a self care intervention which targets healthy eating, physical activity and alcohol consumption. It is advised that the intervention target multiple self care behaviours and that development is underpinned by behaviour change theory to ensure effectiveness. The intervention may be tailored in accordance with the TDF domains identified in this research as determinants of healthy eating, physical activity and alcohol use behaviours.

Yes / Automated tools to speed up the process of evidence synthesis are increasingly apparent within health behaviour research, however, frameworks to evaluate the development and implementation of such tools are not routinely used. This commentary explores the potential of the Non-adoption, Abandonment, Scale-up, Spread and Sustainability framework (NASSS; Greenhalgh et al., 2017) for supporting automated evidence synthesis in health behaviour change by applying it to the ongoing Human Behaviour-Change Project, which aims to revolutionise evidence synthesis within behaviour change intervention research. To increase the relevance of NASSS for health behaviour change, we recommend i) terminology changes (‘condition’ to ‘behaviour’ and ‘patient’ to ‘end user’) and ii) a that it is used prospectively so that complexities can be addressed iteratively. We draw three conclusions about i) the need to specify the organisations that will use the technology, ii) identifying what to do if interdependencies fail and iii) even though we have focused on automated evidence synthesis, NASSS would arguably be beneficial for technology developments in health behaviour change more generally, particularly for invention development (e.g. for a behaviour change app).