Type 2 diabetes is a life-threatening condition, and it is rapidly growing in the world. If patients receive adequate education and support, they can manage their diabetes-related tasks effectively and reduce the severe complications of this disease. However, traditional self-management education and practices were not very effective in stimulating behaviour change and addressing patients’ diversified needs and expectations. Mobile text messaging is a promising method for type 2 diabetes self-management as it can provide continuous and customized support to these patients. However, there is a lack of knowledge about the optimal approach to designing and delivering mobile text messages. Hence, this dissertation aimed to define effective message strategies for mobile text messaging interventions targeting type 2 diabetes self-management. This manuscript-based dissertation consists of three complementary studies. The first manuscript includes a systematic review and a meta-analysis of tailored mobile text messaging interventions on type 2 diabetes self-management. It examines the tailoring strategies, message content, and structure and identifies the moderators of effectiveness in these interventions. The second manuscript includes a systematic review and a meta-synthesis of qualitative evidence on patients’ experiences and perspectives of mobile text messaging studies. The third manuscript consists of a prospective qualitative study to explore the text messaging design and delivery preferences of patients. In the first and second studies, the comprehensive search strategy included major electronic databases, key journal searches, and hand searches of the reference lists of related systematic reviews and meta-analyses. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and Cochrane Collaboration's guidelines and recommended tools were used for data extraction, risk of bias and critical appraisal assessments, data analysis and reporting. Within a social marketing framework, the third study included semi-structured interviews and a thematic analysis of the main findings. In the first manuscript, 13 eligible trials were included for the systematic review and 11 eligible trials were further analyzed in the meta-analysis. This study concluded that tailored mobile text messaging interventions could improve glycemic control in patients with type 2 diabetes. The subgroup analyses revealed the importance of some moderators such as message delivery, message direction, message frequency, and using multi-modalities. In the second manuscript, the systematic review included 14 eligible studies, and the thematic synthesis included 13 eligible studies. Patients emphasized the importance of tailored text message design and delivery. They felt “supported” by using text messaging and improved their communication with family/friends and care providers. Mobile text messaging increased patients’ self-awareness, knowledge and control of diabetes. The third study explored that mobile text messages could be more effective if they are gain-framed and written in a standard format. Patients favoured the text messages that included simple and direct tone and provided statistical evidence. The findings demonstrated patients’ needs and expectations for advanced tailoring strategies in both message content and delivery. Together, the manuscripts fill a significant gap and inform research and practice for the development of more effective message strategies that could lead to reducing the spread of type 2 diabetes worldwide. / Graduate / 2022-05-12

Background: The prevalence of disability increases with age; therefore with an aging population, interventions to reduce disability are crucial. This thesis adopts a behavioural conceptualisation of disability. The theoretical frameworks of the International Classification of Functioning, Disability and Health (ICF), the Theory of Planned Behaviour (TPB) and the integrated ICF/TPB model are applied to investigate disability and physical activity (PA) behaviours. The thesis aims to: (1) identify the factors involved in the prioritisation of patients for total joint replacement; (2) classify patient pre-operative expectations of total hip replacement (THR) and investigate the relationship between expectations and recovery after surgery, and; (3) test whether the TPB and theory-based interventions can predict and explain PA within individuals. Method: Five studies were conducted. In the first study, health professionals judged whether the items from two prioritisation tools measured each of the ICF constructs. In the second study, surgeons ranked patient vignettes, which differed by constructs from the integrated model, in order of priority for THR. In the third study, a large cohort of THR patients reported expectations of surgery pre-operatively. Health and functioning were also reported pre-operatively and 1-year post-operatively. The fourth and fifth studies were a series of experimental n-of-1 studies using diary methods assessing TPB cognitions and PA behaviours. Results: There is a lack of agreement between judges in relation to the content of many of the items from prioritisation tools. Behavioural and psychological factors can influence prioritisation for THR. The majority of patient expectations of THR addressed activities and social participation; however, the evidence for a relationship between expectations and recovery was limited. The TPB can predict PA within some individuals but the evidence in support of interventions to increase PA was limited. Discussion: The findings provide important clinical and theoretical implications for understanding disability and physical activity behaviours.

The purpose of this study was to understand the factors that encourage midlife women to make exercise and dietary changes, the prevalence of those changes, the process by which women make them, the factors that support or impede them, and how we can enhance women’s capacity to make health behaviour changes in midlife. Since the literature highlighted the importance of self-efficacy in changing health behaviour, and of health-related quality of life as a widely recognized measure of women’s mental and physical wellbeing, the study sought to understand the relationship between exercise and dietary self-efficacy, health behaviour change and health-related quality of life (SF-36), by testing a modified version of Bandura’s 1977 and 2002/2004b models of self-efficacy. The methodology involved postal surveys as well as semi-structured interviews with a subsample of the women who completed the survey. Surveys were sent to 866 women aged 51-66 years from rural and urban locations in Queensland, Australia. Five hundred and sixty-four (69%) were completed and returned. Survey data was analysed using descriptive and bivariate statistics and structural equation modeling. Thematic analysis was used to analyse interviews. The results confirmed that midlife is a significant time for women to make positive health behaviour changes. Almost 40% of women made a change to their exercise and around 60% made a dietary change since turning 40. The main exercise change was doing more walking and the most common dietary change was reducing fat intake. Self-efficacy was shown to be a key influence on whether women made positive changes to their health in midlife. In the relationship between health behaviour change and health-related quality of life, making a positive change to exercise was significantly related to physical but not mental health, and making a dietary change was not related to either physical or mental health. Body mass index was shown to be an important influence on both self-efficacy and health-related quality of life (particularly physical health). Interviews were conducted with 29 of the participants. Interview data reinforced that the main motivations to make a positive health behaviour change among midlife women were being overweight, having an injury or being diagnosed with an illness or health condition. Witnessing the hardship experienced by others with a degenerative disease could also prompt a positive behaviour change. Successful changes mainly involved modifying existing practices and repeating new behaviours until they became part of the daily routine. The main facilitators of health behaviour change were having positive role models, having more time due to retirement, and having support from significant others (such as husbands), health professionals and organizations such as Weight Watchers. The main obstacles to making changes were work, care giving, illness and injury. Bandura’s (1977, 2000/2004b) model was partially supported, but the cross-sectional nature of the study may have been a limitation in demonstrating all aspects of the self-efficacy process. In summary, women are willing to make positive health behaviour changes in midlife, but they need education and support to have those changes be effective. It is anticipated that this research will lead to a greater understanding of the significance of midlife as a time for making healthy lifestyle changes that have the potential to improve women’s health and quality of life in later years.

The current PhD thesis aimed to cross-culturally investigate the effectiveness of gain- and loss-framed physical activity messages among the university students in Turkey and the UK. This study sought to test the impact of the physical activity messages focusing on stress-related effects on physical activity intentions, attitudes and behaviours of the target group. The messages were developed based on the findings of a series of preliminary studies targeting to determine the characteristics and needs of the target groups, and identify the barriers to engage in physical activity. Two quasi-experimental studies were conducted with 309 university students from the two countries (200 participants from Turkey and 109 participants from the UK) to test the effects of framed messages on intentions and attitudes towards physical activity, and physical activity behaviour change in two weeks after message exposure. Results showed that immediate effects of both gain- and loss-framed messages on physical activity intentions and attitudes were significant in Turkey and the UK. However, these effects could not be maintained in the two weeks following the message exposure. Moreover, the loss-framed message led to a message reactance in the UK, and physical activity intensity of the participants in the loss-framed group were significantly decreased compared to their baseline physical activity levels. The present study was the first message framing study comparing Turkey and the UK in terms of the impact of gain- and loss-framed framed physical activity messages. Therefore, this study contributes to the literature through providing evidence on the effects of message framing interventions which are developed and implemented in different cultures. Recommendations for future message framing research include measuring physical activity behaviour through objective methods, and examining the impact of the tailored messages through using different dissemination methods in larger samples.