University of Groningen
Lifestyle change in adults with intellectual disabilities
Willems, Mariël
DOI:
10.33612/diss.102031521
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Publication date:
2019
Link to publication in University of Groningen/UMCG research database
Citation for published version (APA):
Willems, M. (2019). Lifestyle change in adults with intellectual disabilities: use and effectiveness of
behaviour change techniques. Rijksuniversiteit Groningen. https://doi.org/10.33612/diss.102031521
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Chapter 5
Behaviour change techniques used in lifestyle support of adults with mild
intellectual disabilities
Mariël Willems Johan de Jong Annelies Overwijk Thessa I.M. Hilgenkamp Cees P. Van der Schans Aly Waninge
120
ABSTRACT
Background: Professional caregivers are important in the daily support of lifestyle change in adults with mild
intellectual disabilities (ID). However, little is known about which behaviour change techniques (BCTs) they actually use in changing their lifestyle behaviour.
Aim: This study aims to get insight in the use of behaviour change techniques (BCTs) in daily support for lifestyle
behaviour of adults with mild ID, using video observations.
Methods: Professional caregivers (N=14) were observed in their daily work, supporting adults with mild ID. Videos
are analysed using the Coventry Aberdeen London Refined (CALO-RE) taxonomy and BCTs used were coded on a data report form.
Results: 21 out of 40 BCTs were used by professional caregivers. The BCTs “Information about others' approval”,
“Identification as role model”, “Rewards on successful behaviour”, “Review behavioural goals” and “Instructions on how to perform the behaviour” were mostly used.
Conclusion: Professional caregivers used BCTs to support lifestyle behaviour of adults with mild ID. However, the
most promising BCTs were rarely used by professional caregivers.
121
1
| INTRODUCTION
Adults with intellectual disabilities (ID) often demonstrate an unhealthy lifestyle (McGuire, Daly, & Smyth, 2007). They are often sedentary (Haveman et al., 2010), not physically active enough to gain substantial health benefits (Draheim, Williams, & McCubbin, 2002; Frey & Chow, 2006; Lahtinen, Rintala, & Malin, 2007; Temple, Frey, & Stanish, 2006), and they experience unhealthy dietary habits (Haveman et al., 2010; Hsieh, Rimmer, & Heller, 2014). Supporting lifestyle change for adults with intellectual disabilities is therefore important.
Lifestyle behaviour can be improved using behaviour change techniques (BCTs) in the general population (Bird et al. 2013, Greaves et al., 2011; Michie, Abraham, Whittington, McAteer, & Gupta, 2009; Olander et al., 2013; Williams & French, 2011). For adults with ID, we found frequent use of BCTs in lifestyle change interventions although mostly implicit (Willems, Hilgenkamp, Havik, Waninge, & Melville, 2017).
According to professionals (professional caregivers, behavioural scientists, health professionals, intellectual disability physicians) BCTs may be suitable to change lifestyle behaviour in adults with mild ID (Willems, Waninge, De Jong, Hilgenkamp, & Van der Schans, 2019). Professional caregivers and relatives play an important role in behaviour change for adults with ID (Alesi & Pepi, 2015; Davison, Jurkowski, Li, Kranz & Lawson, 2013; Grondhuis & Aman, 2014; Heller, McCubbin, Drum, & Peterson, 2011; Hithersay, Strydom, Moulster, & Buszewicz, 2014; James & Shireman, 2010; Melville, Hamilton, Hankey, Miller, & Boyle, 2007; Naaldenberg, Kuijken, van Dooren & De Valk, 2013; Stanish, Temple & Frey, 2006; Van Schijndel-Speet, Evenhuis, Van Wijck, & Echteld, 2014). BCTs that were considered most suitable were: “Barrier identification”, “Set graded tasks”, “Reward effort towards behaviour”, “Motivational interviewing”, and “Action planning” (Willems et al., 2019). The perceived suitability of BCTs was related to personal characteristics of adults with mild ID and the social support from others they receive. However, to date, there is no insight into the actual use or application of BCTs in the daily support that professional caregivers provide. This is instrumental knowledge for determining what BCT would be most effective to focus on in a training or education program. In order to investigate the gaps of knowledge and expertise, and to design meaningful support for professional caregivers, this observational study aims to observe and determine the use of BCTs by professional caregivers, assisting lifestyle behaviour of adults with mild ID using video observations. If BCTs are used by professional caregivers, this study will also investigate whether there is any relation between the BCTs used and characteristics of the users.
2
| METHODS
2.1 | Design
During this observational study, professional caregivers were observed during their daily work, supporting adults with mild ID. Between October 2018 and March 2019, data were collected in nine community-based living facilities where adults with all levels of ID were living and receiving support from professional caregivers. Observations of professional caregivers providing regular daily support to adults with mild ID took place on three random weekdays, on various moments of the day.
ABSTRACT
Background: Professional caregivers are important in the daily support of lifestyle change in adults with mild
intellectual disabilities (ID). However, little is known about which behaviour change techniques (BCTs) they actually use in changing their lifestyle behaviour.
Aim: This study aims to get insight in the use of behaviour change techniques (BCTs) in daily support for lifestyle
behaviour of adults with mild ID, using video observations.
Methods: Professional caregivers (N=14) were observed in their daily work, supporting adults with mild ID. Videos
are analysed using the Coventry Aberdeen London Refined (CALO-RE) taxonomy and BCTs used were coded on a data report form.
Results: 21 out of 40 BCTs were used by professional caregivers. The BCTs “Information about others' approval”,
“Identification as role model”, “Rewards on successful behaviour”, “Review behavioural goals” and “Instructions on how to perform the behaviour” were mostly used.
Conclusion: Professional caregivers used BCTs to support lifestyle behaviour of adults with mild ID. However, the
most promising BCTs were rarely used by professional caregivers.
1
| INTRODUCTION
Adults with intellectual disabilities (ID) often demonstrate an unhealthy lifestyle (McGuire, Daly, & Smyth, 2007). They are often sedentary (Haveman et al., 2010), not physically active enough to gain substantial health benefits (Draheim, Williams, & McCubbin, 2002; Frey & Chow, 2006; Lahtinen, Rintala, & Malin, 2007; Temple, Frey, & Stanish, 2006), and they experience unhealthy dietary habits (Haveman et al., 2010; Hsieh, Rimmer, & Heller, 2014). Supporting lifestyle change for adults with intellectual disabilities is therefore important.
Lifestyle behaviour can be improved using behaviour change techniques (BCTs) in the general population (Bird et al. 2013, Greaves et al., 2011; Michie, Abraham, Whittington, McAteer, & Gupta, 2009; Olander et al., 2013; Williams & French, 2011). For adults with ID, we found frequent use of BCTs in lifestyle change interventions although mostly implicit (Willems, Hilgenkamp, Havik, Waninge, & Melville, 2017).
According to professionals (professional caregivers, behavioural scientists, health professionals, intellectual disability physicians) BCTs may be suitable to change lifestyle behaviour in adults with mild ID (Willems, Waninge, De Jong, Hilgenkamp, & Van der Schans, 2019). Professional caregivers and relatives play an important role in behaviour change for adults with ID (Alesi & Pepi, 2015; Davison, Jurkowski, Li, Kranz & Lawson, 2013; Grondhuis & Aman, 2014; Heller, McCubbin, Drum, & Peterson, 2011; Hithersay, Strydom, Moulster, & Buszewicz, 2014; James & Shireman, 2010; Melville, Hamilton, Hankey, Miller, & Boyle, 2007; Naaldenberg, Kuijken, van Dooren & De Valk, 2013; Stanish, Temple & Frey, 2006; Van Schijndel-Speet, Evenhuis, Van Wijck, & Echteld, 2014). BCTs that were considered most suitable were: “Barrier identification”, “Set graded tasks”, “Reward effort towards behaviour”, “Motivational interviewing”, and “Action planning” (Willems et al., 2019). The perceived suitability of BCTs was related to personal characteristics of adults with mild ID and the social support from others they receive. However, to date, there is no insight into the actual use or application of BCTs in the daily support that professional caregivers provide. This is instrumental knowledge for determining what BCT would be most effective to focus on in a training or education program. In order to investigate the gaps of knowledge and expertise, and to design meaningful support for professional caregivers, this observational study aims to observe and determine the use of BCTs by professional caregivers, assisting lifestyle behaviour of adults with mild ID using video observations. If BCTs are used by professional caregivers, this study will also investigate whether there is any relation between the BCTs used and characteristics of the users.
2
| METHODS
2.1 | Design
During this observational study, professional caregivers were observed during their daily work, supporting adults with mild ID. Between October 2018 and March 2019, data were collected in nine community-based living facilities where adults with all levels of ID were living and receiving support from professional caregivers. Observations of professional caregivers providing regular daily support to adults with mild ID took place on three random weekdays, on various moments of the day.
122
2.2 | Participants
Participants were professional caregivers working with adults with mild ID in ID care provider organizations in the Netherlands.
Inclusion criteria were: - Professional caregivers;
- Supporting adults with mild ID (>18 years) in daily living;
- Working on community-based living facility for adults with ID of Dutch ID care provider organizations; - Minimum of 6 months of working experience;
- Age ≥18 years.
Professional caregivers were approached through a consortium consisting of nine Dutch ID care provider organizations. These organizations support persons within the whole range of ID. Participants were recruited by contact persons of these organizations. Informed consent was asked for all participants (professional caregivers). Since adults with mild ID may also be recorded, informed consent was also given by involved adults with mild ID or their legal representatives.
2.3 | Ethical approval
Dispensation was obtained from the local medical ethical committee of the University Medical Centre Groningen (number: 201700241, Medical Ethics Committee, University Medical Centre Groningen, the Netherlands, METc UMCG) because this study did not concern medical scientific research in humans. Privacy of participants and adults with mild ID was secured, saving the recordings and personal characteristics separately.
2.4 | Data collection
The observations were made in community-based living facilities. They were made on three weekdays on different moments of the day, including an observation in the morning (e.g. during breakfast) and in the evening (e.g. during diner or evening activities). Each video recording moment lasted for two hours to reveal a reliable representation of the daily support of adults with mild ID. Professionals were asked to engage in their normal activities like there was no observer. Activities regarding personal hygiene (e.g. showering, bathing) were not recorded because of the privacy of the adults with mild ID.
The observations were of audio-visual nature, which means that the observations included both picture and sound. The observations were non-participative, since the observer did not or only minimally participate in the interaction between professional caregivers and the adults with mild ID they supported. The video recordings were collected by interns working at the included living facility. The deployment of interns reduced the infringement on the daily living of adults with mild ID, since the interns were already familiar. Interns were instructed about the methods of the observations by the first author (MW). Instructions included 1) technical instructions about how to use the camera 2) the observation method with information on how to film without participating or interpreting 3) registration of the video recording, e.g. notation of characteristics to recognize participants and adults with mild ID 4) bias registration, about possible forms of bias during filming and how to
123
register this when necessary 5) data storage instructions on how to store the video recordings safely after recording. Observations were made with high quality cameras. Before starting the observations, interns had to sign a declaration of confidentiality. The video camera was stored in a saved locker before, between and after the observations until the camera was collected by the first author (MW).
The protocol for filming and instruction of the filming procedure were optimized using the first pilot type of recordings. The latter were checked for correct placement of the camera, optimal visibility of the interaction between professional caregiver and adults with mild ID and whether relevant information about the environment and eventual special circumstances was provided by the interns making the video observations.
Before the video observations were made, professional caregivers were asked to complete a questionnaire about demographic characteristics: age, gender, education level, working experience, current position, number of colleagues, group size of the adults with mild ID and characteristics of the individuals with ID they were supporting (age, gender, level of ID, mobility, additional problems). Before starting the observations, the first author (MW) checked the questionnaires (about the general characteristics) for completeness.
After completion of the observations, the video camera with recordings was collected by the first author (MW). The recordings were saved on two separate external hard disks, secured with different passwords. The passwords were saved separately, in a file that was accessible by the researchers involved only. Afterwards, the memory cards in the video cameras were formatted to erase all data. Names and characteristics of adults with mild ID were extracted from the online questionnaire filled in by participants to determine which persons on the video’s had given informed consent and to avoid that parts of the recordings were analysed where someone else was accidentally filmed. Before data analyses, the first author (MW) checked the recordings for quality of the videos.
2.5 | Data analyses
The Coventry Aberdeen London Refined (CALO-RE) taxonomy (Michie et al., 2011) was used for deductive coding of the BCTs. A data report form was designed and pilot tested by two authors (MW, AO), using the recordings from the pilot test observations. No changes were made during pilot testing. The BCTs were coded per video recording moment on use or non-use, frequency of use was not coded in a video recording moment.
Recordings were scored separately by two trained research assistants, which were instructed for scoring by the first author (MW). After instruction, the two research assistants and the first author (MW) scored a sample of 2 recordings, including approximately 20 minutes of video material. The sample included recordings from different observation moments and included a physical activity moment and a nutrition moment. Scorings were compared and disagreements were solved by consensus discussion. Next, the researchers and first author (MW) scored another sample of recordings of approximately 20 minutes of video material and interrater reliability was calculated, disagreements were solved by consensus discussion. Interrater reliability after instruction for first author and two research assistants (RA1 and RA2) was calculated. One research assistant (RA1) scored the videos of twelve participants of the sample, whereas the other research assistant (RA2) scored the videos of two participants. When scorings were halfway, research assistant (RA1) and first author (MW) scored a sample of recordings (approximately 20 minutes of video material) to check interrater reliability again and solve
2.2 | Participants
Participants were professional caregivers working with adults with mild ID in ID care provider organizations in the Netherlands.
Inclusion criteria were: - Professional caregivers;
- Supporting adults with mild ID (>18 years) in daily living;
- Working on community-based living facility for adults with ID of Dutch ID care provider organizations; - Minimum of 6 months of working experience;
- Age ≥18 years.
Professional caregivers were approached through a consortium consisting of nine Dutch ID care provider organizations. These organizations support persons within the whole range of ID. Participants were recruited by contact persons of these organizations. Informed consent was asked for all participants (professional caregivers). Since adults with mild ID may also be recorded, informed consent was also given by involved adults with mild ID or their legal representatives.
2.3 | Ethical approval
Dispensation was obtained from the local medical ethical committee of the University Medical Centre Groningen (number: 201700241, Medical Ethics Committee, University Medical Centre Groningen, the Netherlands, METc UMCG) because this study did not concern medical scientific research in humans. Privacy of participants and adults with mild ID was secured, saving the recordings and personal characteristics separately.
2.4 | Data collection
The observations were made in community-based living facilities. They were made on three weekdays on different moments of the day, including an observation in the morning (e.g. during breakfast) and in the evening (e.g. during diner or evening activities). Each video recording moment lasted for two hours to reveal a reliable representation of the daily support of adults with mild ID. Professionals were asked to engage in their normal activities like there was no observer. Activities regarding personal hygiene (e.g. showering, bathing) were not recorded because of the privacy of the adults with mild ID.
The observations were of audio-visual nature, which means that the observations included both picture and sound. The observations were non-participative, since the observer did not or only minimally participate in the interaction between professional caregivers and the adults with mild ID they supported. The video recordings were collected by interns working at the included living facility. The deployment of interns reduced the infringement on the daily living of adults with mild ID, since the interns were already familiar. Interns were instructed about the methods of the observations by the first author (MW). Instructions included 1) technical instructions about how to use the camera 2) the observation method with information on how to film without participating or interpreting 3) registration of the video recording, e.g. notation of characteristics to recognize participants and adults with mild ID 4) bias registration, about possible forms of bias during filming and how to
register this when necessary 5) data storage instructions on how to store the video recordings safely after recording. Observations were made with high quality cameras. Before starting the observations, interns had to sign a declaration of confidentiality. The video camera was stored in a saved locker before, between and after the observations until the camera was collected by the first author (MW).
The protocol for filming and instruction of the filming procedure were optimized using the first pilot type of recordings. The latter were checked for correct placement of the camera, optimal visibility of the interaction between professional caregiver and adults with mild ID and whether relevant information about the environment and eventual special circumstances was provided by the interns making the video observations.
Before the video observations were made, professional caregivers were asked to complete a questionnaire about demographic characteristics: age, gender, education level, working experience, current position, number of colleagues, group size of the adults with mild ID and characteristics of the individuals with ID they were supporting (age, gender, level of ID, mobility, additional problems). Before starting the observations, the first author (MW) checked the questionnaires (about the general characteristics) for completeness.
After completion of the observations, the video camera with recordings was collected by the first author (MW). The recordings were saved on two separate external hard disks, secured with different passwords. The passwords were saved separately, in a file that was accessible by the researchers involved only. Afterwards, the memory cards in the video cameras were formatted to erase all data. Names and characteristics of adults with mild ID were extracted from the online questionnaire filled in by participants to determine which persons on the video’s had given informed consent and to avoid that parts of the recordings were analysed where someone else was accidentally filmed. Before data analyses, the first author (MW) checked the recordings for quality of the videos.
2.5 | Data analyses
The Coventry Aberdeen London Refined (CALO-RE) taxonomy (Michie et al., 2011) was used for deductive coding of the BCTs. A data report form was designed and pilot tested by two authors (MW, AO), using the recordings from the pilot test observations. No changes were made during pilot testing. The BCTs were coded per video recording moment on use or non-use, frequency of use was not coded in a video recording moment.
Recordings were scored separately by two trained research assistants, which were instructed for scoring by the first author (MW). After instruction, the two research assistants and the first author (MW) scored a sample of 2 recordings, including approximately 20 minutes of video material. The sample included recordings from different observation moments and included a physical activity moment and a nutrition moment. Scorings were compared and disagreements were solved by consensus discussion. Next, the researchers and first author (MW) scored another sample of recordings of approximately 20 minutes of video material and interrater reliability was calculated, disagreements were solved by consensus discussion. Interrater reliability after instruction for first author and two research assistants (RA1 and RA2) was calculated. One research assistant (RA1) scored the videos of twelve participants of the sample, whereas the other research assistant (RA2) scored the videos of two participants. When scorings were halfway, research assistant (RA1) and first author (MW) scored a sample of recordings (approximately 20 minutes of video material) to check interrater reliability again and solve
124
disagreements by consensus discussion. A sample of recording (approximately 20 minutes) was scored again for calculating the intra-rater reliability.
For the characteristics of participants, means and standard deviations were calculated. The outcomes of the frequency of usage of top 5 of BCTs used out of a total of 3 are binomial distributed. Therefore, a generalized linear modelling analysis was performed using the logit link for binomial regression with the explanative variables sex, age, work years, education, additional lifestyle training and policies.
3
| RESULTS
3.1 | General characteristics
Fourteen professional caregivers participated in the study who supported adults with mild ID in a community based living facility (N=6), and were filmed during daily support work. Participants had a mean age of 41.9 (SD 12.1) years and their mean working experience was 17.4 (SD 10.1, range 3-35) years. Baseline characteristics of participants were shown in Table 1. Informed consent was given for 30 adults with mild ID, whereas 12 adults where supported by 2 participants during the observations. Mean age of adults with mild ID was 51.5 years (SD 18.0). Participants (N=4) dropped out for several reasons: they left the organization during observation period (n=1), ran out of time to perform the video observation (n=2) or the adults with ID involved did not have mild ID (N=1). In total, 33:15:47 (h:m:s) film material was obtained and total observation time ranged from 00:13:10 to 04:38:59 per participant. Most participants (N=8) were filmed two moments (n=6) or one moment (n=2) or instead of three moments, due to scheduling issues. For one participant, videos from two measurements had to be erased as informed consent for an adult with mild ID was withdrawn. Interrater reliability after instruction was 82.5% (MW-RA1), 85% (MW, RA2) and 87.5% (RA1-RA2) respectively. Interrater reliability halfway data analysis for 2 measurements was 92.5% and 90% (MW-RA1). Intra-rater reliability was 97.5%, calculated as percentage of absolute agreement.
Table 1: General characteristics of participants
Professional caregivers (N=14)
Age, mean (SD) 41.9 (12.1)
sex (% Female) 85.7
Working experience mean (SD) years 17.4
Mean years working in organization 15 (SD 7.5)
Mean working hours per week 18.6 (SD 7.2)
Education level Higher=6, Vocational=8
Supplemental lifestyle training No=9, Yes=5
Lifestyle policy in ID care organization Very little: 0, Little: 1, Not much/not little: 4, Much: 8, Very much: 1
Mean no. of clients per group 12.9 (SD 6.1)
Mean no. of professionals for clients 2.3 (SD 1.0)
125
3.2 | Behaviour change techniques in lifestyle support
A total of 21 BCTs was used by professional caregivers, supporting lifestyle behaviour of adults with mild ID. The BCTs mostly used were: “Information about others' approval” (N=15), “Identification as role model” (N=15), “Rewards on successful behaviour” (N=11), “Review behavioural goals” (N=9) and “Instructions on how to perform the behaviour” (N=8). A total of nine BCTs was used by only two (N=1) or one (N=8) participants, and 19 BCTs were not used at all. See Table 2 for an overview of the frequencies for BCTs used.
Univariate binomial regression analysis were performed on frequency of use of the five mostly used BCTs (“Information about others' approval”, “Identification as role model”, “Rewards on successful behaviour”, “Review behavioural goals” and “Instructions on how to perform the behaviour”) one for each characteristic of the 14 professional caregivers, including: sex, age, work years, education, additional lifestyle training and policies. A significant effect was found for policies on the BCT “Identification as a role model” (odds ratio 0.04906, 95% CI [0.00241, 0.2920]), whereas an increase in reported organization policies gives an increase in the BCT used. For “Instructions on how to perform the behaviour”, an increase in reported policies gave a significant decrease as well (odds ratio 0.2991; 95% CI [0.07762, 0.9102]). No significant effects were found for other participant characteristics.
disagreements by consensus discussion. A sample of recording (approximately 20 minutes) was scored again for calculating the intra-rater reliability.
For the characteristics of participants, means and standard deviations were calculated. The outcomes of the frequency of usage of top 5 of BCTs used out of a total of 3 are binomial distributed. Therefore, a generalized linear modelling analysis was performed using the logit link for binomial regression with the explanative variables sex, age, work years, education, additional lifestyle training and policies.
3
| RESULTS
3.1 | General characteristics
Fourteen professional caregivers participated in the study who supported adults with mild ID in a community based living facility (N=6), and were filmed during daily support work. Participants had a mean age of 41.9 (SD 12.1) years and their mean working experience was 17.4 (SD 10.1, range 3-35) years. Baseline characteristics of participants were shown in Table 1. Informed consent was given for 30 adults with mild ID, whereas 12 adults where supported by 2 participants during the observations. Mean age of adults with mild ID was 51.5 years (SD 18.0). Participants (N=4) dropped out for several reasons: they left the organization during observation period (n=1), ran out of time to perform the video observation (n=2) or the adults with ID involved did not have mild ID (N=1). In total, 33:15:47 (h:m:s) film material was obtained and total observation time ranged from 00:13:10 to 04:38:59 per participant. Most participants (N=8) were filmed two moments (n=6) or one moment (n=2) or instead of three moments, due to scheduling issues. For one participant, videos from two measurements had to be erased as informed consent for an adult with mild ID was withdrawn. Interrater reliability after instruction was 82.5% (MW-RA1), 85% (MW, RA2) and 87.5% (RA1-RA2) respectively. Interrater reliability halfway data analysis for 2 measurements was 92.5% and 90% (MW-RA1). Intra-rater reliability was 97.5%, calculated as percentage of absolute agreement.
Table 1: General characteristics of participants
Professional caregivers (N=14)
Age, mean (SD) 41.9 (12.1)
sex (% Female) 85.7
Working experience mean (SD) years 17.4
Mean years working in organization 15 (SD 7.5)
Mean working hours per week 18.6 (SD 7.2)
Education level Higher=6, Vocational=8
Supplemental lifestyle training No=9, Yes=5
Lifestyle policy in ID care organization Very little: 0, Little: 1, Not much/not little: 4, Much: 8, Very much: 1
Mean no. of clients per group 12.9 (SD 6.1)
Mean no. of professionals for clients 2.3 (SD 1.0)
3.2 | Behaviour change techniques in lifestyle support
A total of 21 BCTs was used by professional caregivers, supporting lifestyle behaviour of adults with mild ID. The BCTs mostly used were: “Information about others' approval” (N=15), “Identification as role model” (N=15), “Rewards on successful behaviour” (N=11), “Review behavioural goals” (N=9) and “Instructions on how to perform the behaviour” (N=8). A total of nine BCTs was used by only two (N=1) or one (N=8) participants, and 19 BCTs were not used at all. See Table 2 for an overview of the frequencies for BCTs used.
Univariate binomial regression analysis were performed on frequency of use of the five mostly used BCTs (“Information about others' approval”, “Identification as role model”, “Rewards on successful behaviour”, “Review behavioural goals” and “Instructions on how to perform the behaviour”) one for each characteristic of the 14 professional caregivers, including: sex, age, work years, education, additional lifestyle training and policies. A significant effect was found for policies on the BCT “Identification as a role model” (odds ratio 0.04906, 95% CI [0.00241, 0.2920]), whereas an increase in reported organization policies gives an increase in the BCT used. For “Instructions on how to perform the behaviour”, an increase in reported policies gave a significant decrease as well (odds ratio 0.2991; 95% CI [0.07762, 0.9102]). No significant effects were found for other participant characteristics.
126 126 Tabl e 2 : F re qu en cy ta bl e o f u sed BCT s p er p ar tici pa nt, r an ke d b y m ost u sed B CT s. Par tic ip an ts A B C E F G I K L M N O P Q Su m of used BCTs BCT s No . of m ea su remen ts per pr of es sio na l ca reg iver 3 3 1 2 2 3 2 1 2 3 3 2 2 2 #3 In fo rm ati on a bo ut ot he rs ' app ro val 1 1 1 0 1 1 1 1 2 3 2 0 1 0 15 #30 Id en tifi ca tio n a s ro le mo del 0 1 1 2 0 1 0 1 1 3 3 1 1 0 15 #13 R ew ar ds o n su cc essfu l b eh av io ur 0 0 1 2 0 1 0 1 2 0 1 0 2 1 11 #1 0 R ev ie w b eh av io ur al g oa ls 0 0 1 1 0 1 2 1 1 2 0 0 0 0 9 #21 In st ru ct io ns on h ow to p er fo rm th e be hav io ur 0 2 0 1 0 1 0 0 1 3 0 0 0 0 8 #16 Se lf-m oni to ring o f b eh av io ur 0 1 1 0 0 0 2 1 0 0 0 1 1 0 7 #1 9 F ee dbac k o n p er fo rm anc e 0 2 1 0 0 1 0 0 0 3 0 0 0 0 7 #22 Mo del / d emo nst ra te b eh av io ur 0 0 0 1 0 2 0 0 1 1 0 0 1 1 7 #8 Ba rr ier id en tifi ca tio n 0 1 1 0 0 0 1 0 0 1 1 0 0 0 5 #1 2 R ew ar d e ffo rt to w ar ds b ehav io ur 0 0 0 0 0 0 2 0 1 2 0 0 0 0 5 #2 0 In fo rm at io n w he re a nd w he n t o pe rf or m be hav io ur 1 0 1 1 0 0 0 0 1 1 0 0 0 0 5 #7 A ct io n p lanni ng 0 0 0 0 0 0 1 0 0 1 0 1 0 0 3 #37 Mo tiv ati on al in ter vi ew in g 0 0 0 0 0 0 0 0 0 0 3 0 0 0 3 #6 G oa l sett in g ( ou tc om e) 0 0 1 0 0 0 0 0 0 0 1 0 0 0 2 #1 In fo rm at io n o n c ons eque nc es in g ene ral 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 #2 In fo rm ati on to th e i nd iv id ua l 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 #9 G ra ded ta sk s 0 0 0 0 0 0 1 0 0 0 0 0 0 0 1 #1 1 R ev ie w ou tc om e g oa ls 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 #28 F aci lita te so cia l co m pa riso n 0 0 0 0 0 0 1 0 0 0 0 0 0 0 1 #29 P la n so cia l su pp or t/ so cia l ch an ge 0 0 0 0 0 0 1 0 0 0 0 0 0 0 1 #33 Se lf-ta lk 0 0 0 0 0 0 1 0 0 0 0 0 0 0 1 #4 N or m at ive in fo rm at ion ot he rs ' b eh avi ou r 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 127 #5 G oal se tt ing ( be hav io ur ) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 #14 Sh ap in g 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 #1 5 G en eral izat io n o f b ehav io ur 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 #17 Se lf-m oni to ring o f o ut co m e 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 #18 F ocu s o n p ast su cc ess 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 #23 T ea ch to u se p ro m pts /c ues 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 #24 E nv iro nm en ta l r estru ct ur in g 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 #25 Be ha vi ou ra l co ntra ct 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 #26 P ro m pt p ra ct ice 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 #27 Us e o f f ol lo w -up p ro m pt s 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 #31 P ro m pt a nti cip ated reg ret 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 #32 F ea r a ro usa l 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 #34 Us e o f i m ag er y 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 #3 5 R el aps e p re ve nt io n/ co pi ng p lanni ng 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 #36 Str ess m an ag emen t /em oti on al co ntro l tr ain in g 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 #3 8 Ti m e m anage m ent 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 #39 G en er al co m m un ica tio n sk ill s tra in in g 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 #40 Sti m ul ate a nti cip ati on o f f utu re r ew ar ds 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 No. of (uni que ly ) u sed BCT s pe r p ro fe ss io nal 2 6 10 7 1 7 10 5 8 11 6 3 5 2 21
127 #5 G oal se tt ing ( be hav io ur ) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 #14 Sh ap in g 0 0 0 0 0 0 0 0 0 0 0 0 0 0 #1 5 G en eral izat io n o f b ehav io ur 0 0 0 0 0 0 0 0 0 0 0 0 0 0 #17 Se lf-m oni to ring o f o ut co m e 0 0 0 0 0 0 0 0 0 0 0 0 0 0 #18 F ocu s o n p ast su cc ess 0 0 0 0 0 0 0 0 0 0 0 0 0 0 #23 T ea ch to u se p ro m pts /c ues 0 0 0 0 0 0 0 0 0 0 0 0 0 0 #24 E nv iro nm en ta l r estru ct ur in g 0 0 0 0 0 0 0 0 0 0 0 0 0 0 #25 Be ha vi ou ra l co ntra ct 0 0 0 0 0 0 0 0 0 0 0 0 0 0 #26 P ro m pt p ra ct ice 0 0 0 0 0 0 0 0 0 0 0 0 0 0 #27 Us e o f f ol lo w -up p ro m pt s 0 0 0 0 0 0 0 0 0 0 0 0 0 0 #31 P ro m pt a nti cip ated reg ret 0 0 0 0 0 0 0 0 0 0 0 0 0 0 #32 F ea r a ro usa l 0 0 0 0 0 0 0 0 0 0 0 0 0 0 #34 Us e o f i m ag er y 0 0 0 0 0 0 0 0 0 0 0 0 0 0 #3 5 R el aps e p re ve nt io n/ co pi ng p lanni ng 0 0 0 0 0 0 0 0 0 0 0 0 0 0 #36 Str ess m an ag emen t /em oti on al co ntro l tr ain in g 0 0 0 0 0 0 0 0 0 0 0 0 0 0 #3 8 Ti m e m anage m ent 0 0 0 0 0 0 0 0 0 0 0 0 0 0 #39 G en er al co m m un ica tio n sk ill s tra in in g 0 0 0 0 0 0 0 0 0 0 0 0 0 0 #40 Sti m ul ate a nti cip ati on o f f utu re r ew ar ds 0 0 0 0 0 0 0 0 0 0 0 0 0 0 No. of (uni que ly ) u sed BCT s pe r p ro fe ss io nal 2 6 10 7 1 7 10 5 8 11 6 3 5 2
128
4
| DISCUSSION
4.1 | Main findings
This observation study showed that professional caregivers used BCTs to support lifestyle behaviour of adults with mild ID. The BCTs “Information about others' approval”, “Identification as role model”, “Rewards on successful behaviour”, “Review behavioural goals” and “Instructions on how to perform the behaviour” were mostly used. Only reported organization policies significantly decreased the frequency of use of “Identification as a role model” and “Instructions on how to perform the behaviour”. No other significant effects were found for characteristics of professional caregivers on the frequency of use of the five most frequently used BCTs. The use of BCTs by professional caregivers is important and innovative knowledge, since it was unknown to which extend professional caregivers used BCTs or whether they used any BCTs at all. However, the effectiveness of the BCTs used was not researched in this study. Also, it is still unknown whether there is a relation between effect of BCTs and the characteristics of adults with mild ID (e.g. qualities and disabilities). For example, adults with mild ID have often issues regarding planning and executive functioning (American Psychiatric Association, 2013), which implies that BCTs targeting planning like “Action planning”, “Barrier identification/problem solving” and “Set graded tasks” may support them to change lifestyle behaviour. These BCTs were all used by professional caregivers, but were not used mostly. Also, social and emotional development of adults with mild ID are important to take into account (WHO, 1992) and may lead to use BCTs like “Provide information about others’ approval”, “Facilitate social comparison”, “General communication skills training” as well as “Prompt rewards contingent on effort or progress towards behaviour” or “Provide rewards contingent on successful behaviour”. Most of these BCTs were used by professional caregivers, with exception of “General communication skills training”. The BCTs “Provide information about others' approval” and “Provide rewards contingent on successful behaviour” were applied most frequently, which implicated that professional caregivers might take social and emotional development of adults with mild ID into account. To further investigate the tailoring of used BCTs in relation to the social and emotional characteristics of an adult with mild ID, future research could focus on the effects of BCTs used to improve lifestyle behaviour change in adults with mild ID.
The BCTs “Information about others' approval”, “Rewards on successful behaviour”, “Review behavioural goals”, “Instructions on how to perform the behaviour” and “Identification as role model” were often used by professional caregivers. In our previous research, the first four BCTs were considered to be suitable BCTs in changing lifestyle behaviour of adults with mild ID also (Willems et al., 2019). This means that professional caregivers already use suitable BCTs, which is good news for clinical practice and professional caregivers. However, the effects of using BCTs were not measured in this study so it is not clear if the BCTs used indeed changed the lifestyle of adults with mild ID. The BCT “Identification as role model” was often used by professional caregivers. However, this BCT was unsuitable according to a panel of behaviour scientists, but suitable according to a panel of professional caregivers (Willems et al., 2019). This phenomenon is also known as the scientist-practitioner split (Hoshmand & Polkinghorne, 1992). This finding is important because behavioural scientists are trained to support professional caregivers about behaviour change, but professional caregivers still use a BCT
129
that is not suitable according to behavioural scientists. An explanation could be that behavioural scientists interpret this BCT in another way than professional caregivers did. For example: behavioural scientists might think that role modelling does not fit social and emotional development of adults with mild ID, whereas professional caregivers did use the BCT in a way that the client is a role model for the professional caregiver on that specific moment.
Some BCTs that were rarely used by professional caregivers, were considered suitable by health care professionals. These BCTS were “Barrier identification/problem solving”, “Set graded tasks”, “Prompt rewards contingent on effort or progress towards behaviour”, “Motivational interviewing” and “Action planning”. This may imply that clinical practice might take advantage from BCTs that are still unknown by professional caregivers. Training of professional caregivers in promising BCTs for changing lifestyle behaviour of adults with mild ID was recommended.
4.2 | Strengths and limitations
Observations were performed using video cameras which increased reliability of the data. Video observation made it possible to check and recheck the data and coding of the data. This method was independent of self-report and opinions of participants, as is the case with questionnaires and other self-self-report methods. An eventual drawback of video observation was external validity, since participants and adults with mild ID may have behaved different because of the camera. Observations lasted for two hours, which gave participants the opportunity to get used to the camera each measurement. However, observations took often less than the scheduled two hours, which gave participants less time to get used and this might have influenced the study results since less time could be analysed than was intended. However, this was the first-time clinical practice was observed with video analysis to investigate the use of BCTs which gives guidance for future lifestyle behaviour change research. Another strength of this study was the use of a structured taxonomy of BCTs, the CALO-RE taxonomy (Michie et al., 2011). The systematic coding of BCTs was also used in literature about lifestyle change interventions for adults with ID (Willems et al., 2017), but never in video observations. Since the taxonomy was not designed for adults with mild ID, we used an adjusted version used before in a Delphi study about suitable BCTs for adults with mild ID (Willems et al., 2019). This method gave insight in the use of BCTs in daily support of lifestyle change for adults with mild ID. However, we did not research whether the use of BCTs was implicit or explicit. Also, the way in which BCTs were used was not measured, for example whether healthy or even unhealthy behaviour was supported. The BCTs were only coded as used or not-used instead of the frequency of use per observation moment, which made differences between participants in time observed of less influence, also known as selection bias.
Next to the BCTs used according to the CALO-RE taxonomy, we could not code all techniques used to change behaviour. “Performing lifestyle behaviour together”, “Expressing confidence in one another” and “Checking on lifestyle behaviour” were some techniques we could not code according to the existing taxonomy. A newer taxonomy of BCTs, ‘Taxonomy v1’ (Michie et al., 2013), consisting of 93 BCTs was not used in this study because
4
| DISCUSSION
4.1 | Main findings
This observation study showed that professional caregivers used BCTs to support lifestyle behaviour of adults with mild ID. The BCTs “Information about others' approval”, “Identification as role model”, “Rewards on successful behaviour”, “Review behavioural goals” and “Instructions on how to perform the behaviour” were mostly used. Only reported organization policies significantly decreased the frequency of use of “Identification as a role model” and “Instructions on how to perform the behaviour”. No other significant effects were found for characteristics of professional caregivers on the frequency of use of the five most frequently used BCTs. The use of BCTs by professional caregivers is important and innovative knowledge, since it was unknown to which extend professional caregivers used BCTs or whether they used any BCTs at all. However, the effectiveness of the BCTs used was not researched in this study. Also, it is still unknown whether there is a relation between effect of BCTs and the characteristics of adults with mild ID (e.g. qualities and disabilities). For example, adults with mild ID have often issues regarding planning and executive functioning (American Psychiatric Association, 2013), which implies that BCTs targeting planning like “Action planning”, “Barrier identification/problem solving” and “Set graded tasks” may support them to change lifestyle behaviour. These BCTs were all used by professional caregivers, but were not used mostly. Also, social and emotional development of adults with mild ID are important to take into account (WHO, 1992) and may lead to use BCTs like “Provide information about others’ approval”, “Facilitate social comparison”, “General communication skills training” as well as “Prompt rewards contingent on effort or progress towards behaviour” or “Provide rewards contingent on successful behaviour”. Most of these BCTs were used by professional caregivers, with exception of “General communication skills training”. The BCTs “Provide information about others' approval” and “Provide rewards contingent on successful behaviour” were applied most frequently, which implicated that professional caregivers might take social and emotional development of adults with mild ID into account. To further investigate the tailoring of used BCTs in relation to the social and emotional characteristics of an adult with mild ID, future research could focus on the effects of BCTs used to improve lifestyle behaviour change in adults with mild ID.
The BCTs “Information about others' approval”, “Rewards on successful behaviour”, “Review behavioural goals”, “Instructions on how to perform the behaviour” and “Identification as role model” were often used by professional caregivers. In our previous research, the first four BCTs were considered to be suitable BCTs in changing lifestyle behaviour of adults with mild ID also (Willems et al., 2019). This means that professional caregivers already use suitable BCTs, which is good news for clinical practice and professional caregivers. However, the effects of using BCTs were not measured in this study so it is not clear if the BCTs used indeed changed the lifestyle of adults with mild ID. The BCT “Identification as role model” was often used by professional caregivers. However, this BCT was unsuitable according to a panel of behaviour scientists, but suitable according to a panel of professional caregivers (Willems et al., 2019). This phenomenon is also known as the scientist-practitioner split (Hoshmand & Polkinghorne, 1992). This finding is important because behavioural scientists are trained to support professional caregivers about behaviour change, but professional caregivers still use a BCT
that is not suitable according to behavioural scientists. An explanation could be that behavioural scientists interpret this BCT in another way than professional caregivers did. For example: behavioural scientists might think that role modelling does not fit social and emotional development of adults with mild ID, whereas professional caregivers did use the BCT in a way that the client is a role model for the professional caregiver on that specific moment.
Some BCTs that were rarely used by professional caregivers, were considered suitable by health care professionals. These BCTS were “Barrier identification/problem solving”, “Set graded tasks”, “Prompt rewards contingent on effort or progress towards behaviour”, “Motivational interviewing” and “Action planning”. This may imply that clinical practice might take advantage from BCTs that are still unknown by professional caregivers. Training of professional caregivers in promising BCTs for changing lifestyle behaviour of adults with mild ID was recommended.
4.2 | Strengths and limitations
Observations were performed using video cameras which increased reliability of the data. Video observation made it possible to check and recheck the data and coding of the data. This method was independent of self-report and opinions of participants, as is the case with questionnaires and other self-self-report methods. An eventual drawback of video observation was external validity, since participants and adults with mild ID may have behaved different because of the camera. Observations lasted for two hours, which gave participants the opportunity to get used to the camera each measurement. However, observations took often less than the scheduled two hours, which gave participants less time to get used and this might have influenced the study results since less time could be analysed than was intended. However, this was the first-time clinical practice was observed with video analysis to investigate the use of BCTs which gives guidance for future lifestyle behaviour change research. Another strength of this study was the use of a structured taxonomy of BCTs, the CALO-RE taxonomy (Michie et al., 2011). The systematic coding of BCTs was also used in literature about lifestyle change interventions for adults with ID (Willems et al., 2017), but never in video observations. Since the taxonomy was not designed for adults with mild ID, we used an adjusted version used before in a Delphi study about suitable BCTs for adults with mild ID (Willems et al., 2019). This method gave insight in the use of BCTs in daily support of lifestyle change for adults with mild ID. However, we did not research whether the use of BCTs was implicit or explicit. Also, the way in which BCTs were used was not measured, for example whether healthy or even unhealthy behaviour was supported. The BCTs were only coded as used or not-used instead of the frequency of use per observation moment, which made differences between participants in time observed of less influence, also known as selection bias.
Next to the BCTs used according to the CALO-RE taxonomy, we could not code all techniques used to change behaviour. “Performing lifestyle behaviour together”, “Expressing confidence in one another” and “Checking on lifestyle behaviour” were some techniques we could not code according to the existing taxonomy. A newer taxonomy of BCTs, ‘Taxonomy v1’ (Michie et al., 2013), consisting of 93 BCTs was not used in this study because
130
of its extensiveness and thus low feasibility. The development of a practical, complete and tailored taxonomy specific for changing lifestyle behaviour for adults with mild ID is recommended.
4.3 | Implications for future research
This observation study gives insight in BCTs used in lifestyle change for adults with mild ID by professional caregivers. A logical next step in research would be to determine effective BCTs in changing lifestyle behaviour. Research into the competencies of professional caregivers in changing lifestyle behaviour as well as training of professional caregivers in suitable BCTs can give some further insights in changing lifestyle behaviour of adults with mild ID.
4.4 | Conclusions
Professional caregivers used BCTs to change lifestyle behaviour of adults with mild ID. Most used BCTs were “Information about others' approval”, “Identification as role model”, “Rewards on successful behaviour”, “Review behavioural goals” and “Instructions on how to perform the behaviour”. Promising BCTs according to previous research, were used only a few times. Clinical practice could benefit from the use of these suitable BCTs to improve lifestyle behaviour of adults with mild ID.
CONFLICT OF INTEREST
The authors declare that they have no competing interests.
131
REFERENCES
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Ed.). Washington, DC: Author.
Bird, E. L., Baker, G., Mutrie, N., Ogilvie, D., Sahlqvist, S., & Powell, J. (2013). Behaviour change techniques used to promote walking and cycling: A systematic review. Health Psychology, 32(8), 829.
Davison, K. K., Jurkowski, J. M., Li, K., Kranz, S., & Lawson, H. A. (2013). A childhood obesity intervention developed by families for families: results from a pilot study. International Journal of Behavioural
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Draheim, C. C., Williams, D. P., & McCubbin, J. A. (2002). Prevalence of physical inactivity and recommended physical activity in community-based adults with mental retardation. Mental Retardation, 40(6), 436-444.
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4.3 | Implications for future research
This observation study gives insight in BCTs used in lifestyle change for adults with mild ID by professional caregivers. A logical next step in research would be to determine effective BCTs in changing lifestyle behaviour. Research into the competencies of professional caregivers in changing lifestyle behaviour as well as training of professional caregivers in suitable BCTs can give some further insights in changing lifestyle behaviour of adults with mild ID.
4.4 | Conclusions
Professional caregivers used BCTs to change lifestyle behaviour of adults with mild ID. Most used BCTs were “Information about others' approval”, “Identification as role model”, “Rewards on successful behaviour”, “Review behavioural goals” and “Instructions on how to perform the behaviour”. Promising BCTs according to previous research, were used only a few times. Clinical practice could benefit from the use of these suitable BCTs to improve lifestyle behaviour of adults with mild ID.
CONFLICT OF INTEREST
The authors declare that they have no competing interests.
REFERENCES
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Ed.). Washington, DC: Author.
Bird, E. L., Baker, G., Mutrie, N., Ogilvie, D., Sahlqvist, S., & Powell, J. (2013). Behaviour change techniques used to promote walking and cycling: A systematic review. Health Psychology, 32(8), 829.
Davison, K. K., Jurkowski, J. M., Li, K., Kranz, S., & Lawson, H. A. (2013). A childhood obesity intervention developed by families for families: results from a pilot study. International Journal of Behavioural
Nutrition and Physical Activity, 10(3), 10-1186.
Draheim, C. C., Williams, D. P., & McCubbin, J. A. (2002). Prevalence of physical inactivity and recommended physical activity in community-based adults with mental retardation. Mental Retardation, 40(6), 436-444.
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