As part of its mission to change how health is prescribed and help people get better, Fullscript developed the Treatment Adherence in Integrative Medicine report in 2021. In that report, Fullscript identified behavioral factors and interventions as key contributors to treatment adherence. Thus, the Behavioral Change (BC) Project was initiated to delve further into these factors to better support practitioners and their patients in changing and maintaining healthy behaviors.
Similar to Fullscript’s treatment adherence report, Fullscript’s Integrative Medical Advisory team has now produced a BC white paper. It is composed of a literature review and a patient survey, and focuses on the context of integrative medicine. The project sought to develop key recommendations, tools, and other resources for integrative practitioners looking to support their patients’ behavioral change journeys.
This article provides a high-level summary of the BC project’s main findings, but readers are encouraged to refer to the white paper for greater context and more information.
Defining behavioral change
Behavioral change can be defined by the reshaping of a person’s (health) behaviors. (1)(60) In the context of health promotion and medicine, BC typically implies some kind of sustained benefit to the well-being of the individual without further practitioner support. (53)
The Transtheoretical Model of Change below outlines that BC is made up of six stages:
- Pre-contemplation: The individual is (un)aware of a problematic or beneficial health behavior or is not yet considering change.
- Contemplation: The individual is considering change.
- Preparation (determination): The individual is planning to make change.
- Action: the individual initiates change by stopping a harmful behavior or starting a beneficial one, usually within six months.
- Maintenance: The behavior is continuously performed, usually past six months.
- Relapse/termination: The individual regresses back into any one of the prior stages or stops efforts to continue the behavior at any point in time (or not at all). (59)
Steps to supporting patients’ behavioral change journeys
You can follow five steps to better delivery behavioral change techniques (BCTs) and support their patients’ health journeys. (3)(45)(46)(58)
Step 1: Build awareness
Making yourself and your patients more aware of the importance of healthy behavioral and lifestyle changes is crucial to improving health outcomes.
The inability to change behavior or lifestyle habits is one of the top reasons why patients are unable to follow treatment recommendations long-term. When prolonged, unhealthy lifestyle and behavioral factors contribute to increasing chronic disease rates, (9)(38) which in turn may lead to 90% of the yearly spend ($4.1 trillion) on healthcare (10) and to 40 to 50% of deaths in the United States. (44)(49)
Conversely, adopting healthy behaviors can reduce high mortality rates.
Therefore, if practitioners learn to better support behavioral and lifestyle changes, patients will be more likely to achieve better health outcomes and be more satisfied with their care. The country will also experience reductions in chronic disease rates and the associated healthcare costs.
However, providing BC support can be challenging.
Fortunately, integrative medicine is well poised to support behavioral and lifestyle changes because it has a foundation in lifestyle medicine (73) and can intrinsically help with motivation and patient engagement.
Did you know? Using supplements motivated 16% of adults to exercise more frequently, 22% to eat healthier, 4.6% to reduce alcohol intake, and 5.6% to reduce smoking. (67)
Nonetheless, patients receiving integrative care can still require support from their practitioners, especially if they feel that some aspects of their treatment plan are harder to follow than others.
Did you know? 93% of Fullscript patients believed that at least some change was needed to improve their health. Physical activity, mindfulness, nutrition, and sleep recommendations were perceived to be harder to follow than using supplements, lab testing, and pharmaceuticals.
Step 2: Assess
Using a number of techniques to assess your patient’s individual behavioral change needs is critical to personalizing their path to wellness and improving the likelihood of treatment adherence.
Using open-ended questions from motivational interviewing (MI) techniques can be useful in eliciting what needs to occur to best support a patient with BC. (47)(48) Examples of open-ended questions you could ask include:
- How can I help you with…?
- Can you help me understand…?
- How are you feeling about…?
- What are your options?
- Tell me about your goals with…?
- What do you want to do next?
Evidence supports the behavioral change benefits of MI in multiple behaviors, including:
- Alcohol, smoking, and substance abuse (23)
- Dietary intake (65)
- Medication adherence (4)
- Physical activity (6)(52)
- Screening (11)
- Self-management of conditions (13)(18)(25)(43)(64)
- Weight management (24)(68)
For an official directory for MI resources and training, please refer to the MINT website.
Using validated tools that ask questions related to BC can also be helpful for you to understand what needs to happen to best support BC. Examples are found in the table below. Several other validated tools measuring self-control, impulsivity, cognitive flexibility, threat perception, self-affirmation, self-identity, and more (51) can be found in The National Institutes of Health (NIH)’s Science of Behavior Change database.
Step 3: Facilitate empowerment
Empowerment involves ensuring that both you and your patients both have the necessary information and tools at your disposal to support healthy behavioral changes.
Uncover the underlying barriers and reasons your patients may be having challenges with BC. The uptake and maintenance of healthy behaviors can be influenced by many factors including:
- Environmental restrictions (e.g., distance, location, safety)
- Financial cost
- Firmly established attitudes and behaviors
- Lack of access (e.g., transport, facilities, resources)
- Lack of knowledge
- Lack of time (e.g., due to life responsibilities)
- Low socioeconomic status (33)
The top BC barriers for Fullscript patients were:
1. Cost of treatment/appointments
3. Motivation, attitudes, and beliefs
Research now focuses on identifying the specific techniques that most effectively improve BC specific to the patient’s underlying needs or barriers. An interactive tool to identify appropriate techniques based on a patient’s given needs can be found here. (8)(30)
For example, providing instructions (a BC technique) might be helpful for a patient who lacks knowledge (the underlying mechanism of action), but might not be as helpful if they lack motivation. Rather, goal setting (a BC technique) would be more effective to boost motivation (the underlying mechanism of action) and would be more likely to lead to BC.
Step 4: Provide strategies
Based on your assessment and the directions of your empowerment focus, the strategies that you deliver should now be tailored to your patients needs.
Did you know? Fullscript patients felt that the most useful strategies were:
1. Receiving education or treatment plan simplification
2. Creating goals, action plans, and making commitments
3. Practitioner monitoring and feedback
There are a number of broadly applicable strategies that are relatively reliable for improving the likelihood of behavioral change across contexts. In a 2010 synthesis of 62 meta-analyses, BC interventions were shown to produce small effects on improving behaviors (d= 0.21). (29) However, even small effects can translate into meaningful outcomes. Examples of such techniques are provided below.
Step 5: Utilize technology
Whereas traditional BC interventions have been mainly conducted face-to-face, which allows for observation of a patient’s physical cues and the benefits of in-person social dynamics, technological interventions may provide other benefits. These benefits include accessibility, cost efficiency, and elimination of barriers that prevent patients from disengaging as a result of the need to be physically present for a consultation or intervention. (2)
Did you know? Most of Fullscript’s patients (82%) would consider using technology to support their BC wellness journeys.
The table below provides a summary of effects found across various digital health interventions. For a full list of evidence, please refer to the white paper.
One of the most important predictors of a patient’s willingness to adopt and use technology to support their BC journeys (and thus, its efficacy) is the extent to which the digital platform can engage the patient in its supportive interventions. (21)(40)(70)(75)
If opting to use technology to support BC, use the following list to identify specific features and factors that improve patient uptake and engagement:
- Available user guidance
- Embedded practitioner support
- Features to reduce cognitive load
- Goal setting
- Patient app literacy skills
- Patient awareness of the app
- Perceived utility of the app
To reiterate, the use of technologies that are helpful for engaging patients long-term is key. Fullscript patients tended to indicate that the longer they were working with their practitioners, the more likely they were to consider themselves as “acting” or “maintaining” their desired behavioral changes.
The bottom line
Through the steps of building awareness, assessing, facilitating empowerment, providing strategies, and utilizing technology, you can be better equipped to support long-term change and improved health outcomes for your patients. These steps may be particularly important for those patients who require added support in changing and maintaining healthy behaviors.
Fullscript simplifies supplement dispensingCreate your dispensary today I'm a patient
- APA Dictionary of Psychology. (2022). APA Dictionary of Psychology. https://dictionary.apa.org/behavior-change
- Arigo, D., Jake-Schoffman, D. E., Wolin, K., Beckjord, E., Hekler, E. B., & Pagoto, S. L. (2019). The history and future of digital health in the field of behavioral medicine. Journal of Behavioral Medicine, 42(1), 67–83.
- Atkins, L., Francis, J., Islam, R., O’Connor, D., Patey, A., Ivers, N., Foy, R., Duncan, E. M., Colquhoun, H., Grimshaw, J. M., Lawton, R., & Michie, S. (2017). A guide to using the Theoretical Domains Framework of behaviour change to investigate implementation problems. Implementation Science, 12(1), 77.
- Aubeeluck, E., Al-Arkee, S., Finlay, K., & Jalal, Z. (2021). The impact of pharmacy care and motivational interviewing on improving medication adherence in patients with cardiovascular diseases: A systematic review of randomised controlled trials. International Journal of Clinical Practice, 75(11), e14457.
- Azcurra, D. J. L. (2014). Elders Health Empowerment Scale: Spanish adaptation and psychometric analysis. Colombia Medica, 45(4), 179–185.
- Barrett, S., Begg, S., O’Halloran, P., & Kingsley, M. (2018). Integrated motivational interviewing and cognitive behaviour therapy for lifestyle mediators of overweight and obesity in community-dwelling adults: A systematic review and meta-analyses. BMC Public Health, 18(1), 1160.
- Bishop, F. L., Lauche, R., Cramer, H., Pinto, J. W., Leung, B., Hall, H., Leach, M., Chung, V. C., Sundberg, T., Zhang, Y., Steel, A., Ward, L., Sibbritt, D., & Adams, J. (2019). Health behavior change and complementary medicine use: National Health Interview Survey 2012. Medicina, 55(10).
- Carey, R. N., Connell, L. E., Johnston, M., Rothman, A. J., de Bruin, M., Kelly, M. P., & Michie, S. (2019). Behavior change techniques and their mechanisms of action: A synthesis of links described in published intervention literature. Annals of Behavioral Medicine, 53(8), 693–707.
- CDC. (2022a). Chronic Diseases in America. https://www.cdc.gov/chronicdisease/resources/infographic/chronic-diseases.htm
- CDC. (2022b). Health and Economic Costs of Chronic Diseases. https://www.cdc.gov/chronicdisease/about/costs/index.htm
- Chan, D. N. S., & So, W. K. W. (2021). Effectiveness of motivational interviewing in enhancing cancer screening uptake amongst average-risk individuals: A systematic review. International Journal of Nursing Studies, 113, 103786.
- Chen, S.-H., Lai, H.-R., Chen, S.-R., Lin, P.-C., Chou, K.-R., & Lee, P.-H. (2019). Validity and reliability of a Chinese-language instrument for continuous assessment of exercise stages of change in adults. The Journal of Nursing Research, 27(4), e37.
- Chew, H. S. J., Cheng, H. Y., & Chair, S. Y. (2019). The suitability of motivational interviewing versus cognitive behavioural interventions on improving self-care in patients with heart failure: A literature review and discussion paper. Applied Nursing Research, 45, 17–22.
- Contreras-Yáñez, I., Ruiz-Medrano, E., Hernández, L. D. C. R., & Pascual-Ramos, V. (2018). Psychometric validation of an empowerment scale for Spanish-speaking patients with rheumatoid arthritis. Arthritis Research & Therapy, 20(1), 244.
- Curran, F., Blake, C., Cunningham, C., Perrotta, C., van der Ploeg, H., Matthews, J., & O’Donoghue, G. (2021). Efficacy, characteristics, behavioural models and behaviour change strategies, of non-workplace interventions specifically targeting sedentary behaviour; A systematic review and meta-analysis of randomised control trials in healthy ambulatory adults. PloS One, 16(9), e0256828.
- DiClemente, C. C., & Hughes, S. O. (1990). Stages of change profiles in outpatient alcoholism treatment. Journal of Substance Abuse, 2(2), 217–235.
- DiClemente, C. C., Schlundt, D., & Gemmell, L. (2004). Readiness and stages of change in addiction treatment. The American Journal on Addictions, 13(2), 103–119.
- Dorstyn, D. S., Mathias, J. L., Bombardier, C. H., & Osborn, A. J. (2020). Motivational interviewing to promote health outcomes and behaviour change in multiple sclerosis: A systematic review. Clinical Rehabilitation, 34(3), 299–309.
- Dounavi, K., & Tsoumani, O. (2019). Mobile health applications in weight management: A systematic literature review. American Journal of Preventive Medicine, 56(6), 894–903.
- Dozois, D. J. A., Westra, H. A., Collins, K. A., Fung, T. S., & Garry, J. K. F. (2004). Stages of change in anxiety: psychometric properties of the University of Rhode Island Change Assessment (URICA) scale. Behaviour Research and Therapy, 42(6), 711–729.
- Fernandes, L. G., Devan, H., Fioratti, I., Kamper, S. J., Williams, C. M., & Saragiotto, B. T. (2022). At my own pace, space, and place: A systematic review of qualitative studies of enablers and barriers to telehealth interventions for people with chronic pain. Pain, 163(2), e165–e181.
- Field, C. A., Adinoff, B., Harris, T. R., Ball, S. A., & Carroll, K. M. (2009). Construct, concurrent and predictive validity of the URICA: Data from two multi-site clinical trials. Drug and Alcohol Dependence, 101(1-2), 115–123.
- Frost, H., Campbell, P., Maxwell, M., O’Carroll, R. E., Dombrowski, S. U., Williams, B., Cheyne, H., Coles, E., & Pollock, A. (2018). Effectiveness of motivational interviewing on adult behaviour change in health and social care settings: A systematic review of reviews. PloS One, 13(10), e0204890.
- Gálvez Espinoza, P., Gómez San Carlos, N., Nicoletti Rojas, D., & Cerda Rioseco, R. (2019). Is the individual motivational interviewing effective in overweight and obesity treatment? A systematic review. Atencion primaria / Sociedad Espanola de Medicina de Familia y Comunitaria, 51(9), 548–561.
- Ghizzardi, G., Arrigoni, C., Dellafiore, F., Vellone, E., & Caruso, R. (2021). Efficacy of motivational interviewing on enhancing self-care behaviors among patients with chronic heart failure: A systematic review and meta-analysis of randomized controlled trials. Heart Failure Reviews.
- Henderson, M. J., Saules, K. K., & Galen, L. W. (2004). The predictive validity of the university of rhode island change assessment questionnaire in a heroin-addicted polysubstance abuse sample. Psychology of Addictive Behaviors: Journal of the Society of Psychologists in Addictive Behaviors, 18(2), 106–112.
- Jeminiwa, R., Hohmann, L., Qian, J., Garza, K., Hansen, R., & Fox, B. I. (2019). Impact of eHealth on medication adherence among patients with asthma: A systematic review and meta-analysis. Respiratory Medicine, 149, 59–68.
- Jerdén, L., Dalton, J., Johansson, H., Sorensen, J., Jenkins, P., & Weinehall, L. (2018). Lifestyle counseling in primary care in the United States and Sweden: A comparison of patients’ expectations and experiences. Global Health Action, 11(1), 1438238.
- Johnson, B. T., Scott-Sheldon, L. A. J., & Carey, M. P. (2010). Meta-synthesis of health behavior change meta-analyses. American Journal of Public Health, 100(11), 2193–2198.
- Johnston, M., Carey, R. N., Connell Bohlen, L. E., Johnston, D. W., Rothman, A. J., de Bruin, M., Kelly, M. P., Groarke, H., & Michie, S. (2021). Development of an online tool for linking behavior change techniques and mechanisms of action based on triangulation of findings from literature synthesis and expert consensus. Translational Behavioral Medicine, 11(5), 1049–1065.
- Kaner, E. F., Beyer, F. R., Garnett, C., Crane, D., Brown, J., Muirhead, C., Redmore, J., O’Donnell, A., Newham, J. J., de Vocht, F., Hickman, M., Brown, H., Maniatopoulos, G., & Michie, S. (2017). Personalised digital interventions for reducing hazardous and harmful alcohol consumption in community-dwelling populations. Cochrane Database of Systematic Reviews, 9, CD011479.
- Karabulutlu, E. Y., Turan, G. B., & Oruç, F. G. (2021). Elders health empowerment scale: Turkish translation and psychometric testing. Perspectives in Psychiatric Care, 57(2), 550–557.
- Kelly, S., Martin, S., Kuhn, I., Cowan, A., Brayne, C., & Lafortune, L. (2016). Barriers and facilitators to the uptake and maintenance of healthy behaviours by people at mid-life: A rapid systematic review. PloS One, 11(1), e0145074.
- Keyworth, C., Epton, T., Goldthorpe, J., Calam, R., & Armitage, C. J. (2020). Delivering opportunistic behavior change interventions: A systematic review of systematic reviews. Prevention Science: The Official Journal of the Society for Prevention Research, 21(3), 319–331.
- Keyworth, C., Epton, T., Goldthorpe, J., Calam, R., & Armitage, C. J. (2021). Patients’ experiences of behaviour change interventions delivered by general practitioners during routine consultations: A nationally representative survey. Health Expectations: An International Journal of Public Participation in Health Care and Health Policy, 24(3), 819–832.
- Krachler, B., Jerdén, L., Tönnesen, H., & Lindén, C. (2021). Medical licensing examinations in both Sweden and the US favor pharmacology over lifestyle. Preventive Medicine Reports, 23, 101453.
- Lerdal, A., Moe, B., Digre, E., Harding, T., Kristensen, F., Grov, E. K., Bakken, L. N., Eklund, M. L., Ruud, I., & Rossi, J. S. (2009). Stages of change–Continuous measure (URICA-E2): Psychometrics of a Norwegian version. Journal of Advanced Nursing, 65(1), 193–202.
- Liu, Y., Croft, J. B., Wheaton, A. G., Kanny, D., Cunningham, T. J., Lu, H., Onufrak, S., Malarcher, A. M., Greenlund, K. J., & Giles, W. H. (2016). Clustering of five health-related behaviors for chronic disease prevention among adults, United States, 2013. Preventing Chronic Disease, 13, E70.
- Loef, M., & Walach, H. (2012). The combined effects of healthy lifestyle behaviors on all cause mortality: A systematic review and meta-analysis. Preventive Medicine, 55(3), 163–170.
- Martinez-Millana, A., Jarones, E., Fernandez-Llatas, C., Hartvigsen, G., & Traver, V. (2018). App features for type 1 diabetes support and patient empowerment: Systematic literature review and benchmark comparison. JMIR mHealth and uHealth, 6(11), e12237.
- McConnaughy, E. A., Prochaska, J. O., & Velicer, W. F. (1983). Stages of change in psychotherapy: Measurement and sample profiles. Group Dynamics: Theory, Research, and Practice, 20(3), 368–375.
- McCrabb, S., Baker, A. L., Attia, J., Skelton, E., Twyman, L., Palazzi, K., McCarter, K., Ku, D., & Bonevski, B. (2019). Internet-based programs incorporating behavior change techniques are associated with increased smoking cessation in the general population: A systematic review and meta-analysis. Annals of Behavioral Medicine, 53(2), 180–195.
- McDaniel, C. C., Kavookjian, J., & Whitley, H. P. (2022). Telehealth delivery of motivational interviewing for diabetes management: A systematic review of randomized controlled trials. Patient Education and Counseling, 105(4), 805–820.
- McGinnis, J. M., & Foege, W. H. (1993). Actual causes of death in the United States. The Journal of the American Medical Association, 270(18), 2207–2212.
- Michie, S., Richardson, M., Johnston, M., Abraham, C., Francis, J., Hardeman, W., Eccles, M. P., Cane, J., & Wood, C. E. (2013). The behavior change technique taxonomy (v1) of 93 hierarchically clustered techniques: Building an international consensus for the reporting of behavior change interventions. Annals of Behavioral Medicine, 46(1), 81–95.
- Michie, S., van Stralen, M. M., & West, R. (2011). The behaviour change wheel: A new method for characterising and designing behaviour change interventions. Implementation Science: IS, 6, 42.
- Miller, W. R. (1983). Motivational interviewing with problem drinkers. Behavioural Psychotherapy, 11(2), 147–172.
- Miller, W. R., & Rollnick, S. (2012). Motivational Interviewing: Helping People Change. Guilford Press. https://play.google.com/store/books/details?id=o1-ZpM7QqVQC
- Mokdad, A. H., Marks, J. S., Stroup, D. F., & Gerberding, J. L. (2004). Actual causes of death in the United States, 2000. The Journal of the American Medical Association, 291(10), 1238–1245.
- Munson, S. O., Barabasz, A. F., & Barabasz, M. (2018). Ability of hypnosis to facilitate movement through stages of change for smoking cessation. The International Journal of Clinical and Experimental Hypnosis, 66(1), 56–82.
- Nielsen, L., Riddle, M., King, J. W., NIH Science of Behavior Change Implementation Team, Aklin, W. M., Chen, W., Clark, D., Collier, E., Czajkowski, S., Esposito, L., Ferrer, R., Green, P., Hunter, C., Kehl, K., King, R., Onken, L., Simmons, J. M., Stoeckel, L., Stoney, C., … Weber, W. (2018). The NIH Science of Behavior Change Program: Transforming the science through a focus on mechanisms of change. Behaviour Research and Therapy, 101, 3–11.
- Nuss, K., Moore, K., Nelson, T., & Li, K. (2021). Effects of motivational interviewing and wearable fitness trackers on motivation and physical activity: A systematic review. American Journal of Health Promotion, 35(2), 226–235.
- Ory, M. G., Lee Smith, M., Mier, N., & Wernicke, M. M. (2010). The science of sustaining health behavior change: The health maintenance consortium. American Journal of Health Behavior, 34(6), 647–659.
- Pantalon, M. V., Nich, C., Frankforter, T., Carroll, K. M., & University of Rhode Island Change Assessment. (2002). The URICA as a measure of motivation to change among treatment-seeking individuals with concurrent alcohol and cocaine problems. Journal of the Society of Psychologists in Addictive Behaviors, 16(4), 299–307.
- Park, C., & Park, Y.-H. (2013). Validity and reliability of Korean version of health empowerment scale (K-HES) for older adults. Asian Nursing Research, 7(3), 142–148.
- Peng, Y., Wang, H., Fang, Q., Xie, L., Shu, L., Sun, W., & Liu, Q. (2020). Effectiveness of mobile applications on medication adherence in adults with chronic diseases: A systematic review and meta-analysis. Journal of Managed Care & Specialty Pharmacy, 26(4), 550–561.
- Pietrabissa, G., Sorgente, A., Rossi, A., Simpson, S., Riva, G., Manzoni, G. M., Prochaska, J. O., Prochaska, J. M., Cattivelli, R., & Castelnuovo, G. (2017). Stages of change in obesity and weight management: Factorial structure of the Italian version of the University of Rhode Island Change Assessment Scale. Eating and Weight Disorders, 22(2), 361–367.
- Presseau, J., Byrne-Davis, L. M. T., Hotham, S., Lorencatto, F., Potthoff, S., Atkinson, L., Bull, E. R., Dima, A. L., van Dongen, A., French, D., Hankonen, N., Hart, J., Ten Hoor, G. A., Hudson, K., Kwasnicka, D., van Lieshout, S., McSharry, J., Olander, E. K., Powell, R., … Byrne, M. (2022). Enhancing the translation of health behaviour change research into practice: A selective conceptual review of the synergy between implementation science and health psychology. Health Psychology Review, 16(1), 22–49.
- Prochaska, J. O., & Velicer, W. F. (1997). The transtheoretical model of health behavior change. American Journal of Health Promotion, 12(1), 38–48.
- Psychology Dictionary. (2013). What is behavior change? Psychology Dictionary. https://psychologydictionary.org/behavior-change/
- Rhodes, A., Smith, A. D., Chadwick, P., Croker, H., & Llewellyn, C. H. (2020). Exclusively digital health interventions targeting diet, physical activity, and weight gain in pregnant women: Systematic review and meta-analysis. JMIR mHealth and uHealth, 8(7), e18255.
- Shah, R., Watson, J., & Free, C. (2019). A systematic review and meta-analysis in the effectiveness of mobile phone interventions used to improve adherence to antiretroviral therapy in HIV infection. BMC Public Health, 19(1), 915.
- Sharpe, E. E., Karasouli, E., & Meyer, C. (2017). Examining factors of engagement with digital interventions for weight management: Rapid review. JMIR Research Protocols, 6(10), e205.
- Sokalski, T., Hayden, K. A., Raffin Bouchal, S., Singh, P., & King-Shier, K. (2020). Motivational interviewing and self-care practices in adult patients with heart failure: A systematic review and narrative synthesis. The Journal of Cardiovascular Nursing, 35(2), 107–115.
- Stallings, D. T., & Kraenzle Schneider, J. (2018). Motivational interviewing and fat consumption in older adults: A meta-analysis. Journal of Gerontological Nursing, 44(11), 33–43.
- Stephenson, A., McDonough, S. M., Murphy, M. H., Nugent, C. D., & Mair, J. L. (2017). Using computer, mobile and wearable technology enhanced interventions to reduce sedentary behaviour: A systematic review and meta-analysis. The International Journal of Behavioral Nutrition and Physical Activity, 14(1), 105.
- Stussman, B. J., Black, L. I., Barnes, P. M., Clarke, Ttallin. C., & Nahin, R. L. (2015). Wellness-related Use of Common Complementary Health Approaches Among Adults: United States, 2012. National health statistics reports, (85), 1–12.
- Suire, K. B., Kavookjian, J., Feiss, R., & Wadsworth, D. D. (2021). Motivational interviewing for weight management among women: A meta-analysis and systematic review of RCTs. International Journal of Behavioral Medicine, 28(4), 403–416.
- Szinay, D., Jones, A., Chadborn, T., Brown, J., & Naughton, F. (2020). Influences on the uptake of and engagement with health and well-being smartphone apps: Systematic review. Journal of Medical Internet Research, 22(5), e17572.
- Tighe, S. A., Ball, K., Kensing, F., Kayser, L., Rawstorn, J. C., & Maddison, R. (2020). Toward a digital platform for the self-management of noncommunicable disease: Systematic review of platform-like interventions. Journal of Medical Internet Research, 22(10), e16774.
- Villinger, K., Wahl, D. R., Boeing, H., Schupp, H. T., & Renner, B. (2019). The effectiveness of app-based mobile interventions on nutrition behaviours and nutrition-related health outcomes: A systematic review and meta-analysis. Obesity Reviews, 20(10), 1465–1484.
- Wang, Z., Zhu, Y., Cui, L., & Qu, B. (2019). Electronic health interventions to improve adherence to antiretroviral therapy in people living with hiv: Systematic review and meta-analysis. JMIR mHealth and uHealth, 7(10), e14404.
- Willoughby, F. W., & Edens, J. F. (1996). Construct validity and predictive utility of the stages of change scale for alcoholics. Journal of Substance Abuse, 8(3), 275–291.
- Wolever, R. Q., Caldwell, K. L., McKernan, L. C., & Hillinger, M. G. (2017). Integrative medicine strategies for changing health behaviors: support for primary care. Primary Care, 44(2), 229–245.
- Xie, L. F., Itzkovitz, A., Roy-Fleming, A., Da Costa, D., & Brazeau, A.-S. (2020). Understanding self-guided web-based educational interventions for patients with chronic health conditions: Systematic review of intervention features and adherence. Journal of Medical Internet Research, 22(8), e18355.
- Xu, H., & Long, H. (2020). The effect of smartphone app-based interventions for patients with hypertension: Systematic review and meta-analysis. JMIR mHealth and uHealth, 8(10), e21759.