Dr Phillippa Lally

Introduction: After a cancer diagnosis, recommendations for those living with and beyond cancer (LWBC) are to maintain a BMI<25 and avoid weight gain. This study explored factors associated with receipt of, and interest in weight management advice as well as engagement in weight management programmes among people LWBC affected by overweight and obesity.Methods: 3,456 participants living with or beyond breast, prostate or colorectal cancer and affected by overweight and obesity completed our questionnaire. Participants reported advice received on losing weight, interest in receiving weight management advice, enrollment in a lifestyle programme, and their beliefs about maintaining a healthy weight to prevent cancer recurrence. Results: Logistic regression results suggested that those who received advice were more likely to be interested in advice (OR=1.68; 95%CI:1.30,2.18) and to be enrolled in a weight management programme (OR=1.60; 95%CI:1.07,2.40). The belief that maintaining a healthy weight could prevent cancer recurrence was associated with greater interest in weight management advice (OR=1.47; 95%CI:1.33,1.62) and enrollment in a programme (OR=1.57; 95%CI:1.25,1.99). Discussion: These results highlight that those who recall receiving weight management advice are more likely to be enrolled in a weight management programme suggesting that advice should be offered by healthcare professionals to all those patients affected by overweight and obesity. Conclusions: This suggests that the receipt of weight management advice may encourage people LWBC that are affected by overweight and obesity to engage with weight management programmes.

Writing in 1899, William James observed that ‘ninety-nine hundredths or, possibly, nine hundred and ninety-nine thousandths of our activity is purely automatic and habitual’ (James, Citation1899, pp. 65–66). Nearly 125 years later, the concept of habit continues to stimulate important research regarding the most useful definition of habit, and how to harness habit to understand, predict, and change health-related behaviour (e.g., Gardner, Citation2015; Verplanken, Citation2018; Wood & Runger, Citation2016). Phillips and Mullan (Citation2022) offer a thoughtful synthesis of theory and evidence regarding how habit can be applied to complex health behaviours. Their review addresses an important question that habit researchers are often asked: how credible is it to propose that learned cue-behaviour associations can underpin and sustain complicated real-world health behaviours? Drawing on a definition of complex behaviour as that which involves separable components and a greater number of sub-actions (or ‘steps’), Phillips and Mullan address this question by suggesting that the same concept – i.e., habit – can underpin both simple and complex behaviours. Significantly however, they argue that ‘complex habits’ should be theorised differently to ‘simple habits’, to better recognise the multiple components of complex habits and the rewards that Phillips and Mullan suggest are needed for complex habits to form. In this commentary, we expand discussion of two areas of Phillips and Mullan’s argument. First, we debate aspects of the definition of habit. Second, we highlight the importance of distinguishing between ‘habit’ and ‘habitual behaviour’ when considering behavioural complexity. We argue that conceptualisations of key terms have important implications for understanding, measuring and changing habit and habitual behaviour.

Background: Accessible self-management interventions are required to support people living with breast cancer. Objectives: This was an industry-academic partnership study that aimed to collect qualitative user experience data of a prototype app with built-in peer and coach support designed to support the management of health behaviors and weight in women living with breast cancer. Methods: Participants were aged ≥18 years, were diagnosed with breast cancer of any stage within the last 5 years, had completed active treatment, and were prescribed oral hormone therapy. Participants completed demographic surveys and were asked to use the app for 4 weeks. Following this, they took part in in-depth qualitative interviews about their experiences. These were analyzed using thematic analysis. Results: Eight participants (mean age, 45 years; mean time since diagnosis, 32 months) were included. Of the 8 participants, 7 (88%) were white, 6 (75%) had a graduate degree or above, and 6 (75%) had stage I-III breast cancer. Four overarching themes were identified: (1) Support for providing an app earlier in the care pathway; (2) Desire for more weight-focused content tailored to the breast cancer experience; (3) Tracking of health behaviors generally popular; and (4) High value of in-app social support. Conclusions: This early user experience work showed that women with breast cancer found an app with integrated social and psychological support appealing to receive support for behavior change and weight or self-management. However, many features were recommended for further development. This work is the first step in an academic-industry collaboration that would ultimately aim to develop and empirically test a supportive app that could be integrated into the cancer care pathway.

Introduction: Increased moderate to vigorous physical activity (MVPA) can improve clinical and psychosocial outcomes for people living with and beyond cancer (LWBC). This study aimed to assess the feasibility and acceptability of trial procedures in a pilot randomised controlled trial (RCT) of a theory-driven app-based intervention with behavioural support focused on promoting brisk walking (a form of MVPA) in people LWBC (APPROACH). Methods: Participants diagnosed with breast, prostate, or colorectal cancer were recruited from a single UK hospital site. Assessments at baseline and 3-months included online questionnaires, device-measured brisk walking (activPAL accelerometer) and self-reported weight and height. Participants were randomised to intervention or control (care as usual). The intervention comprised a non-cancer-specific app to promote brisk walking (National Health Service ‘Active 10’) augmented with print information about habit formation, a walking planner, and two behavioural support telephone calls. Feasibility and acceptability of trial procedures were explored. Initial estimates for physical activity informed a power calculation for a phase III RCT. A preliminary health economics analysis was conducted.Results: Of those medically eligible, 369/577 (64%) were willing to answer further eligibility questions and 90/148 (61%) of those eligible were enrolled. Feasibility outcomes, including retention (97%), assessment completion rates (>86%) and app download rates in the intervention group (96%), suggest that the trial procedures are acceptable, and that the intervention is feasible. The phase III RCT will require 472 participants to be randomised. As expected, the preliminary health economic analyses indicate a high level of uncertainty around the cost-effectiveness of the intervention.Conclusions: This pilot study demonstrates that a large trial of the brisk walking intervention with behavioural support is both feasible and acceptable to people LWBC. The results support progression onto a confirmatory phase III trial to determine the efficacy and cost-effectiveness of the intervention.

ObjectiveEvidence shows that higher depressive symptoms are associated with mortality among people living with and beyond cancer (LWBC). However, prior studies have not accounted for a wider range of potential confounders, and no study has explored whether socioeconomic position (SEP) moderates the association. This study aimed to examine the association between depressive symptoms and mortality among people LWBC, and moderation by SEP. MethodsParticipants from the English Longitudinal Study of Ageing (ELSA), diagnosed with cancer and with a measure of depressive symptoms within four years following their diagnosis were included. Elevated depressive symptoms were indicated by a score of ≥3 on the 8-item Center for Epidemiologic Studies Depression Scale (CES-D). Cox regression models examined associations with all-cause mortality. Competing risk regression examined associations with cancer mortality.  ResultsIn 1352 people LWBC (mean age = 69.6 years), elevated depressive symptoms were associated with a 93% increased risk of all-cause mortality (95% CI: 1.52-2.45) within the first four years of follow-up, and 48% increased risk within a four to eight year follow-up (95% CI: 1.02-2.13) after multivariable adjustment. Elevated depressive symptoms were associated with a 38% increased risk of cancer mortality, but not after excluding people who died within one year after baseline assessments. There were no interactions between depressive symptoms and SEP. ConclusionsElevated depressive symptoms are associated with a greater risk of all-cause mortality among people LWBC within an eight year follow-up period. Associations between depressive symptoms and cancer mortality might be due to reverse causality. 

Background: A cancer diagnosis and its treatment may be an especially isolating experience. Despite evidence that positive health behaviours can improve outcomes for people living with and beyond cancer (LWBC), no studies have examined associations between loneliness and different health behaviours in this population. This study aimed to describe the prevalence of loneliness in a large sample of UK adults LWBC and to explore whether loneliness was associated with multiple health behaviours.Methods: Participants were adults (aged >18 years) diagnosed with breast, prostate or colorectal cancer who completed the Health and Lifestyle After Cancer Survey. Loneliness was reported using the UCLA loneliness score, dichotomised into higher (>6) versus lower (<6) loneliness. Engagement in moderate-to-vigorous physical activity, dietary intake, smoking status, alcohol use, and self-reported height and weight were recorded. Behaviours were coded to reflect meeting or not meeting the World Cancer Research Fund recommendations for people LWBC. Logistic regression analyses explored associations between loneliness and health behaviours. Covariates were age, sex, ethnicity, education, marital status, living situation, cancer type, spread and treatment, time since treatment, time since diagnosis and number of comorbid conditions. Multiple imputation was used to account for missing data.Results: 5835 participants, mean age 67.4 (standard deviation=11.8) years, completed the survey. 56% were female (n=3266) and 44% (n=2553) male, and 48% (n=2786) were living with or beyond breast cancer, 32% (n=1839) prostate, and 21% (n=1210) colorectal. Of 5485 who completed the loneliness scale, 81% (n=4423) of participants reported lower and 19% (n=1035) higher loneliness. After adjustment for confounders, those reporting higher levels of loneliness had lower odds of meeting the WCRF recommendations for moderate-to-vigorous physical activity (Odds Ratio [OR] 0.78. 95% Confidence Internal [CI], 0.67, 0.97, p=.028), fruit and vegetable intake (OR 0.81, CI 0.67, 1.00, p=.046), and smoking (OR 0.62, 0.46, 0.84, p=0.003). No association was observed between loneliness and the other dietary behaviours, alcohol, or body mass index.Conclusions: Loneliness is relatively common in people LWBC and may represent an unmet need. People LWBC who experience higher levels of loneliness may need additional support to improve their health behaviours.

Background: Adults with intellectual disabilities (ID) are susceptible to multiple health risk behaviours such as alcohol consumption, smoking, low physical activity, sedentary behaviour, and poor diet. Lifestyle modification interventions can prevent or reduce negative health consequences caused by these behaviours. We aim to determine the effectiveness of lifestyle modification interventions and their components in targeting health risk behaviours in adults with IDs. Methods: A systematic review and meta-analysis were conducted. Electronic databases, clinical trial registries, grey literature, and citations of systematic reviews and included studies were searched in January 2021 (updated February 2022). Randomised controlled trials and non-randomised controlled trials targeting alcohol consumption, smoking, low physical activity, sedentary behaviours, and poor diet in adults (aged≥18 years) with ID were included. Meta-analysis was conducted at the intervention-level (pairwise and network meta-analysis) and the component-level (component network meta-analysis). Studies were coded using Michie’s 19-item theory coding scheme and 94-item behaviour change taxonomies. Risk of bias was assessed using the Cochrane Collaboration's Risk of Bias Assessment Tool (RoB Version 2) for RCTs and Risk of Bias in Non-randomised Studies - of Interventions (ROBINS-I) tool for non-RCTs. The study involved a Patient and Public Involvement (PPI) group, including people with lived experience, who contributed extensively by shaping the methodology, providing valuable insights in interpreting results, and organising of dissemination events. Results: Our literature search identified 12,180 articles, of which 80 studies with 4,805 participants were included in the review. The complexity of lifestyle modification intervention was dismantled by identifying six core components that influenced outcomes. Interventions targeting single or multiple health risk behaviours could have a single or combination of multiple core-components. Interventions (2 RCTS; 4 non-RCTs; 228 participants) targeting alcohol consumption and smoking behaviour were effective but based on limited evidence. Similarly, interventions targeting low physical activity only (16 RCTs; 17 non-RCTs; 1413 participants) or multiple behaviours (low physical activity only, sedentary behaviours, and poor diet) (17 RCTs; 24 non-RCTs; 3164 participants) yielded mixed effectiveness in outcomes. Most interventions targeting low physical activity only and multiple behaviours generated positive effects on various outcomes, while some interventions led to no change or worsened outcomes which could be attributed to the presence of a single core component or a combination of similar core components in interventions. The intervention-level meta-analysis for weight management outcomes showed that none of the interventions were associated with a statistically significant change in outcomes when compared to treatment-as-usual. Interventions with core-components combination of energy deficit diet, aerobic exercise and behaviour change techniques showed the highest weight loss (MD=-3.61,95% CrI -9.68 – 1.95) and those with core-components combination dietary advice and aerobic exercise showed a weight gain (MD 0.94, 95% CrI -3.93 to 4.91). Similar findings were found with the components network meta-analysis for which additional components were identified. Studies had a high and moderate risk of bias. Various theories and behaviour change techniques were used in intervention development and adaptation. Conclusion: Our systematic review is the first to comprehensively explore lifestyle modification interventions targeting a range of single and multiple health risk behaviours in adults with ID, co-produced with people with lived experience. It has practical implications for future research as it highlights the importance of mixed-methods research in understanding lifestyle modification interventions and the need for population-specific improvements in the field (e.g., tailored interventions, development of evaluation instruments or tools, use of rigorous research methodologies, and comprehensive reporting frameworks). Wide dissemination of related knowledge and the involvement of PPI groups, including people with lived experience, will help future researchers design interventions that consider the unique needs, desires, and abilities of people with ID.

Habit change is often seen as key to successful long-term behaviour change. Making ‘good’ behaviours habitual – i.e., ensuring a behaviour is prompted automatically on exposure to situational cues, based on cue-response associations learned through context-consistent repetition – is portrayed as a mechanism for sustaining such behaviours over time. Conversely, disrupting ‘bad’ habits is expected to terminate longstanding unwanted actions. Yet, some commentators have suggested that the role of habit in real-world behaviour and behaviour change has been overstated. Such critiques highlight a gap between habit theory and the reality of human behaviour ‘in the wild’. This state-of-the-field review aims to narrow this gap. Building on a core distinction between habit and habitual behaviour, our review seeks to offer interpretations of habit theory and evidence that will better manage intervention designers’ expectations regarding how modifying habit can realistically be expected to promote behaviour change. We emphasise that habit is just one potential influence on behaviour at any given moment, and highlight instances in which habit may dominate over intention, and in which intention may dominate over habit, in determining behaviour frequency. We suggest that, while it may assist behaviour maintenance, habit formation may be neither necessary nor sufficient to sustain real-world behaviour change. We draw attention to the various ways in which habit may be ‘broken’ (i.e., disrupted), and discern the implications of each habit disruption mechanism for long-term cessation of unwanted behaviours.

This study explored perceived changes in health behaviours and body weight following a cancer diagnosis and investigated related sociodemographic and clinical characteristics. Individuals living with and beyond breast, prostate, or colorectal cancer (N = 5835) completed the 'Health and Lifestyle After Cancer Survey' which explored their perceptions of health behaviour change following a cancer diagnosis. Multinomial logistic regressions were conducted with perceived changes as dependent variables, and sociodemographic and clinical characteristics as independent variables. Approximately half of the participants did not perceive changes in their physical activity, alcohol intake and body weight, and most did not perceive dietary changes. Less than a third of individuals perceived positive health behaviour changes (11.7% increased physical activity, 24.3% healthier diet, and 31.3% decreased alcohol intake), 35.9% perceived decreases in physical activity, and 27.0% perceived increases in body weight, whereas 19.2% perceived decreases in body weight. Individuals with no education, who were unmarried, and with anxiety/depression and pain/discomfort, were more likely to perceive changes in physical activity, body weight, and diet, but in different directions. Participants of younger age were more likely to perceive increases in their physical activity, a healthier diet, and increases in body weight. Following a diagnosis of cancer, a large proportion of individuals perceived that their health behaviours were unchanged. However, some groups of individuals were more likely to perceive positive changes, whereas others were more likely to perceive negative changes, with differences also observed according to the type of health behaviour. Participants with no education, who were unmarried, with anxiety/depression and pain/discomfort, may be more at risk of experiencing negative health behaviour changes post-diagnosis. Clinicians should consider targeting health behaviour support to prevent worse outcomes in the long term.

Adults with learning disabilities face increased risks of unhealthy lifestyle behaviours, including alcohol consumption, smoking, low physical activity, sedentary behaviour and poor diet. Lifestyle modification interventions that target health-risk behaviours can prevent or reduce their negative effects. The goal of this project was to investigate the effectiveness and underlying mechanisms of lifestyle modification interventions in adults with learning disabilities. A systematic review and meta-analysis were conducted to determine the effectiveness of lifestyle modification interventions and their components in targeting health risk behaviours in adults with learning disabilities. Major electronic databases, clinical trial registries, grey literature, and citations of systematic reviews and included studies were searched in January 2021 (updated in February 2022). We included randomised and non-randomised controlled trials targeting alcohol consumption, smoking, low physical activity only, sedentary behaviour and poor diet in adults (aged ≥ 18 years) with learning disabilities. Studies were also coded based on the extent of use of theories and behaviour change techniques in interventions. Risk of bias in studies was assessed using appropriate tools. A realist synthesis of qualitative, quantitative and mixed-methods literature was conducted to complement the systematic review findings by identifying key intervention mechanisms that are likely to improve the health of adults with learning disabilities. Data were synthesised in the form of a programme theory regarding complex causal mechanisms and how these interact with social context to produce outcomes. All findings were integrated into a logic model. A patient and public involvement group provided input and insights throughout the project. A total of 80 studies with 4805 participants were included in the systematic review. The complexity of lifestyle modification interventions was dismantled by identifying six core components that influenced outcomes. These components could be present in interventions targeting single or multiple health risk behaviors, either as individual elements or in various combinations. Interventions on alcohol and smoking behaviours were found to be effective, but this was based on limited evidence. The effectiveness of interventions targeting low physical activity only or multiple behaviours (low physical activity only, sedentary behaviours and poor diet) was mixed. All interventions had a varying level of statistical significance. The intervention-level network meta-analysis for weight management outcomes showed none of the interventions was associated with a statistically significant change in outcomes when compared to treatment as usual and each other. Similar findings were observed in the component network meta-analysis. A variety of theories and behaviour change techniques were employed in the development and adaptation of interventions. Most studies had a high and moderate risk of bias. A total of 79 studies, reporting the experiences of more than 3604 adults with intellectual disabilities and over 490 caregivers, were included in the realist synthesis. The resulting programme theory highlighted the contexts and mechanisms relating to support involvement, negotiating the balance between autonomy and behaviour change, fostering social connectedness and fun, the accessibility and suitability of intervention strategies and delivery, along with the broader behavioural pathways to lifestyle change. It also brought out the importance of working with people with lived experiences when developing and evaluating interventions. Our logic model, bringing together the findings of both syntheses, provides guidance on the design of future interventions. This study was the first comprehensive mixed-methods evidence synthesis to explore lifestyle modification interventions targeting multiple unhealthy lifestyle behaviours in adults with learning disabilities. We conclude that future research could benefit from codeveloping interventions and population-specific assessment frameworks with people with lived experiences. There is a need for more high-quality research with appropriate outcomes and a focus on qualitative and mixed-methods research to better understand what works for whom and why. This trial is registered as PROSPERO CRD 42020223290. This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR128755) and is published in full in ; Vol. 29, No. 4. See the NIHR Funding and Awards website for further award information.

Background: The APPROACH pilot study explored the feasibility and acceptability of an app (NHS Active 10) with brief, habit-based, behavioral support calls and print materials intended to increase brisk walking in people diagnosed with cancer. Objective: Following UK Medical Research Council guidelines, this study assessed the implementation of the intervention, examined the mechanisms of impact, and identified contextual factors influencing engagement. Methods: Adults (aged ≥18 y) with breast, prostate, or colorectal cancer who reported not meeting the UK guidelines for moderate-to-vigorous physical activity (≥150 min/wk) were recruited from a single hospital site in Yorkshire, United Kingdom. They were randomly assigned to the intervention or control (usual care) arm and assessed via quantitative surveys at baseline (time point 0 [T0]) and 3-month follow-up (time point 1 [T1]) and qualitative exit interviews (36/44, 82%) at T1. The process evaluation included intervention participants only (n=44). Implementation was assessed using data from the T1 questionnaire exploring the use of the intervention components. The perceived usefulness of the app, leaflet, and behavioral support call was rated from 0 to 5. Behavioral support calls were recorded, and the fidelity of delivery of 25 planned behavior change techniques was rated from 0 to 5 using an adapted Dreyfus scale. Mechanisms of impact were identified by examining T0 and T1 scores on the Self-Reported Behavioural Automaticity Index and feedback on the leaflet, app, call, and planner in the T1 questionnaire and qualitative interviews. Contextual factors influencing engagement were identified through qualitative interviews. Results: The implementation of the intervention was successful: 98% (43/44) of the participants received a behavioral support call, 78% (32/41) reported reading the leaflet, 95% (39/41) reported downloading the app, and 83% (34/41) reported using the planners. The mean perceived usefulness of the app was 4.3 (SD 0.8) in participants still using the app at T1 (n=33). Participants rated the leaflet (mean 3.9, SD 0.6) and the behavioral support call (mean 4.1, SD 1) as useful. The intended behavior change techniques in the behavioral support calls were proficiently delivered (overall mean 4.2, SD 1.2). Mechanisms of impact included habit formation, behavioral monitoring, and support and reassurance from the intervention facilitator. Contextual factors impacting engagement included barriers, such as the impact of cancer and its treatment, and facilitators, such as social support. Conclusions: The APPROACH intervention was successfully implemented and shows promise for increasing brisk walking, potentially through promoting habit formation and enabling self-monitoring. Contextual factors will be important to consider when interpreting outcomes in the larger APPROACH randomized controlled trial.

Background: Adults with learning disabilities have an increased disposition to unhealthy lifestyle behaviours which often occur simultaneously. Existing studies focus on complex interventions targeting unhealthy diet, physical inactivity, sedentary behaviour, smoking, and alcohol use to reduce health risks experienced. It is essential to understand how well these interventions work, what works, for whom, in what context and why. This study aims to investigate the effectiveness and underlying mechanisms of lifestyle modification interventions for adults with learning disabilities. Methods: This is a mixed-methods systematic review consisting of a network meta-analysis (NMA) and realist synthesis. Electronic databases (ASSIA, CINAHL, EMBASE, MEDLINE, and PsycINFO) will be searched from inception to 14 January 2021 with no language restriction. Additionally, trial registries, grey literature databases and references lists will be searched. Studies related to lifestyle modification interventions on the adult population (>18 years) with learning disabilities will be eligible for inclusion. Two independent researchers will screen studies, extract data and assess its quality and risk of bias using the Cochrane Collaboration’s Risk of Bias Assessment Tool (RoB Version 2) and ROBINS-I. The strength of the body of evidence will be assessed based on the GRADE approach. The NMA will incorporate results from RCTs and quasi-experimental studies to estimate the effectiveness of various lifestyle interventions. Where appropriate, a component NMA (CNMA) will be used to estimate effectiveness. The realist synthesis will complement and explain the findings of NMA and CNMA by including additional qualitative and mixed-methods studies. Studies will be included based on their relevance to the programme theory and the rigour of their methods, as determined by quality appraisal tools appropriate to the study design. Results from both syntheses will be incorporated into a logic model.

This study aimed to examine whether psychological distress was cross-sectionally associated with meeting World Cancer Research Fund (WCRF) recommendations in people living with and beyond cancer. Participants were adults living with and beyond breast, prostate and colorectal cancer, participating in the baseline wave of the Advancing Survivorship after Cancer Outcomes Trial (ASCOT). Anxiety/depression was assessed using the EQ-5D-5L and dichotomised into any/no problems. WCRF recommendations were assessed via pedometers, 24-hour dietary recalls, self-reported alcohol intake (AUDIT-C), and self-reported smoking status.  Participants were categorised as meeting WCRF recommendations using the following cut-offs: average daily steps (≥10,000/day), average weekly aerobic steps (≥15,000/day), fruit and vegetables (≥400g/day), fibre (≥30g/day), red meat (<500g/week), processed meat (0g/day), high calorie food (fat ≤33% of total daily energy intake and free sugar ≤5% of total daily energy intake), alcohol (≤14 units/week) and smoking (non-smoking). A composite health behaviour risk index (CHBRI) was calculated by summing the number of WCRF recommendations met (range: 0-9).Among 1348 participants (mean age = 64 years (SD = 11.4)), 41.5% reported anxiety/depression problems. The mean CHBRI score was 4.4 (SD = 1.4). Anxiety/depression problems were associated with lower odds of meeting WCRF recommendations for average daily steps (odds ratio (OR) = 0.73; 95% CI: 0.55, 0.97), but not for any other health behaviour. Psychological distress is associated with lower adherence to WCRF recommendations for physical activity in people living with and beyond cancer. Physical activity may be a mechanism linking psychological distress and poorer outcomes among people living with and beyond cancer, and this should be explored in longitudinal studies.

Purpose: Physical activity is safe and feasible for individuals with metastatic cancer and may support symptom management. We investigated the extent to which individuals with metastatic cancer are meeting the World Health Organisation (WHO) moderate-vigorous physical activity (MVPA) guideline, factors associated with meeting the guideline, and perceptions about physical activity and receiving physical activity advice.Methods: Data were from UK adults with metastatic breast, prostate, or colorectal cancer who completed the Healthy Lifestyle After Cancer survey (N=588). Self-reported clinical, demographic, and physical activity (Godin Leisure-Time Exercise Questionnaire) data were collected. Logistic regression models assessed whether clinical and demographic factors were associated with meeting the MVPA guideline. Results: Most (59%) individuals with metastatic cancer were not meeting the WHO guideline of 150 minutes of MVPA per week. Adjusting for cancer type, the odds of meeting the MVPA guideline were lower for unemployed individuals (OR=0.47, 95% CI=0.23-0.77) and ethnic minorities (OR=0.44, 95% CI=0.22-0.89), but higher for those with a university education (OR = 1.89, 95% CI = 1.0-3.57). Most (63.5%) participants felt they should be doing more physical activity. However, 70.1% did not receive any physical activity advice or support, despite 73.6% wanting to receive it. Conclusion: People with metastatic cancer may need further support to address inadequate levels of physical activity. The differences observed between demographic sub-groups suggest this may be more beneficial for those less likely to engage in physical activity. Implications for Cancer Survivors: Individuals with metastatic cancer are likely to benefit from increased physical activity support, which considers the needs of diverse demographic groups.

Understanding the influence of habit on health behaviour, or the formation or disruption of health habits over time, requires reliable and valid measures of automaticity. The most used measure, the Self-Report Behavioural Automaticity Index (SRBAI; derived from the Self-Report Habit Index [SRHI]) comprises four items, which may be impractical in some research contexts. Responding to demand from fellow researchers, this study sought to identify whether and which single items from the SRBAI adequately detect hypothesised effects of automaticity, via secondary analysis of 16 datasets, incorporating 16,838 participants and seven different behaviours. We assessed construct validity through correlations between each item and the full SRBAI (and where possible, the SRHI) and predictive validity by examining correlations with behaviour. All four single-item measures independently met construct and predictive validity criteria. We recognise compelling conceptual and methodological arguments regarding why people should not attempt to assess automaticity via a single, self-report item. However, where circumstances require brief measures, three SRBAI items each offer a credible and practical one-item measure that can substitute for the SRBAI or SRHI. We recommend one item in particular – ‘Behaviour X is something I do automatically’ – because it tended to most closely replicate the effects of the four-item SRBAI.

The aim was to pilot an adapted manualised weight management programme for persons with mild-moderate intellectual disabilities affected by overweight or obesity ('Shape Up-LD'). Adults with intellectual disabilities were enrolled in a 6-month trial (3-month active intervention and 3-month follow-up) and were individually randomised to Shape Up-LD or a usual care control. Feasibility outcomes included recruitment, retention, initial effectiveness and cost. Fifty people were enrolled. Follow-up rates were 78% at 3 months and 74% at 6 months. At 3 and 6 months, controlling for baseline weight, no difference was observed between groups (3 months: β: -0.34, 95% confidence interval [CI]: -2.38, 1.69, 6 months: β: -0.55, 95%CI -4.34, 3.24). It may be possible to carry out a trial of Shape Up-LD, although barriers to recruitment, carer engagement and questionnaire completion need to be addressed, alongside refinements to the intervention.

Lifestyle modification interventions for adults with intellectual disabilities have had, to date, mixed effectiveness. This study aimed to understand how lifestyle modification interventions for adults with intellectual disabilities work, for whom they work and in what circumstances. A realist evidence synthesis was conducted that incorporated input from adults with intellectual disabilities and expert researchers. Following the development of an initial programme theory based on key literature and input from people with lived experience and academics working in this field, five major databases (MEDLINE, EMBASE, CINAHL, PsycINFO and ASSIA) and clinical trial repositories were systematically searched. Data from 79 studies were synthesised to develop context, mechanism and outcome configurations (CMOCs). The contexts and mechanisms identified related to the ability of adults with intellectual disabilities to actively take part in the intervention, which in turn contributes to what works, for whom and in what circumstances. The included CMOCs related to support involvement, negotiating the balance between autonomy and behaviour change, fostering social connectedness and fun, accessibility and suitability of intervention strategies and delivery and broader behavioural pathways to lifestyle change. It is also essential to work with people with lived experiences when developing and evaluating interventions. Future lifestyle interventions research should be participatory in nature, and accessible data collection methods should also be explored as a way of including people with severe and profound intellectual disabilities in research. More emphasis should be given to the broader benefits of lifestyle change, such as opportunities for social interaction and connectedness.

PurposePeople living with and beyond cancer (LWBC) are advised to achieve a body mass index (BMI) within the healthy range (>= 18.5 and < 25). Not perceiving a need for weight change may be a barrier to achieving a healthy weight. This study aimed to explore factors associated with perceived need for weight change among people LWBC.MethodsAdults diagnosed with breast, prostate, or colorectal cancer were recruited through National Health Service sites in Essex and London. Participants (N = 5835) completed the 'Health and Lifestyle After Cancer' survey, which included a question on perceived need to change weight. Associations between perceived need for weight change and BMI, and perceived need for weight change and health and demographic variables, were analyzed using chi-square tests and logistic regression, respectively.ResultsThe proportion of participants perceiving a need to lose weight differed according to BMI category: healthy weight (23%), overweight (64%), obese (85%) (P < 0.001). Having overweight or obesity but not perceiving a need to lose weight was associated with being older, male, non-white, not married or cohabiting, and having cancer that had spread, no formal qualifications, no comorbidities, and having received chemotherapy.ConclusionsPerceived need to lose weight is prevalent among people LWBC with obesity and overweight. This group may be interested in weight management support. Demographic and health factors were associated with having obesity or overweight but not perceiving a need to lose weight.Implications for cancer survivorsWeight loss interventions for people LWBC are needed. A subset of people LWBC with overweight and obesity may need additional information or motivators to engage with weight management.

OBJECTIVES Interventions promoting habitual fruit consumption have the potential to bring about long-term behaviour change. Assessing the effectiveness of such interventions requires adequate habit and behaviour measures. Habits are based on learned context-behaviour associations, so measures that incorporate context should be more sensitive to expected habit and behaviour changes than context-free measures. This study compared context-specific and context-free measures of fruit consumption habit and behaviour following a 3-week habit formation intervention. DESIGN Prospective online study (n = 58). METHODS Behaviour frequency was assessed across five timepoints, retrospectively (Time 1 [T1], T5) or via daily diary data (uploaded weekly at T2, T3 and T4). Habit strength was assessed before (T1) and immediately after the intervention (T4), and again 2 weeks later (T5). Analyses of variance were run, with time and context specificity as within-subject factors, and habit and behaviour frequency as dependent measures. RESULTS An interaction between time and context specificity was found in both analyses (habit: F(2,114) = 12.848, p < .001, part.η2 = .184; behaviour: F(2,114) = 6.714, p = .002, part.η2 = .105). Expected habit formation patterns 5 weeks post-baseline were only detected by the context-specific habit measure. Likewise, increased behaviour frequency was only found when the target context was specified (p's < .001). CONCLUSIONS Assessments of purposeful dietary habit and behaviour change attempts should incorporate context-specific measurement.

Purpose The present work investigated dietary changes amongst individuals living with and beyond cancer (LWBC) from before to during the pandemic. To identify those at greatest risk of unhealthy changes, it was further examined whether patterns varied by sociodemographic, health-related, and COVID-19-related characteristics. Methods This longitudinal cohort study analysed data from 716 individuals LWBC participating in the Advancing Survivorship Cancer Outcomes Trial (ASCOT). Using data provided before and during the pandemic, changes in fruit and vegetable, snack, and alcohol intake were tested using mixed-effect regression models. Results Fruit and vegetable (95%CI: − 0.30; − 0.04) and alcohol consumption (95%CI: − 1.25; − 0.31) decreased, whilst snacking increased (95%CI: 0.19; 0.53). Women and individuals with limited social contact were more likely to reduce fruit and vegetable intake during the pandemic. Women and individuals with poorer sleep quality, limited social contact, and shielding requirements and without higher education were more likely to increase snacking during the pandemic. Individuals with poorer sleep quality, poorer mental health, and regular social contact were more likely to decrease alcohol consumption during the pandemic. Conclusions Findings suggest decreased intake for fruit, vegetable, and alcohol consumption and increased snack intake in response to the pandemic amongst individuals LWBC. These changes appear to differ across various characteristics, suggesting the pandemic has not equally impacted everyone in this population. Findings highlight the need for targeted post-COVID strategies to support individuals LWBC most adversely affected by the pandemic, including women and socially isolated individuals. This encourages resources to be prioritised amongst these groups to prevent further negative impact of the pandemic. Whilst the findings are statistically significant, practically they appear less important. This is necessary to acknowledge when considering interventions and next steps.

Background: Prompting employees to swap their usual lunches for lower-energy alternatives may help align energy intake with public health recommendations. We tested the effect of offering lower-energy swaps with and without physical activity calorie equivalent (PACE) information on the energy of lunches pre-ordered in an online hypothetical workplace canteen. Methods: UK employed adults (n = 2,150) were invited to hypothetically pre-order their lunch from the canteen through a custom-made online platform. They were randomised 1:1:1 to: (i) control: no swaps offered; (ii) lowerenergy swaps offered; or (iii) lower-energy swaps offered with PACE information. The primary outcome was the total energy ordered using analysis of covariance and controlling for the energy content of the initial items ordered. Secondary outcomes were swap acceptance rate and intervention acceptability. Results: Participants were 54% female, had a mean age of 36.8 (SD= 11.6) and a BMI of 26.3 (SD = 5.6). Compared with an average 819 kcal energy ordered in the control, both the swaps and swaps + PACE interventions significantly reduced average energy ordered by 47 kcal (95% CI: -82 to -13, p = 0.003) and 66 kcal (95% CI: -100 to -31, p

The purpose of this study was to understand breast, prostate and colorectal cancer clinical nurse specialists' (CNSs) perspectives on physical activity (PA) promotion and the role of smartphone apps to support PA promotion in cancer care. CNSs working in breast, prostate or colorectal cancer were recruited via advertisements distributed by professional organizations. In-depth semi-structured telephone interviews were conducted and analysed using thematic analysis. Nineteen CNSs participated. The analysis resulted in 4 themes regarding CNSs' perspectives of PA promotion within cancer care: (i) policy changes in survivorship care have influenced CNSs' promotion of PA; (ii) CNSs recognize their role in supporting PA but sit within a wider system necessary for effective PA promotion; (iii) CNSs use several techniques to promote PA within their consultations; (iv) remaining challenges in PA promotion. The analysis resulted in 3 themes regarding CNSs' perspectives on the use of apps to promote PA within cancer care: (i) the influence of apps on access to PA support; (ii) the role of apps in self-directed PA; (iii) implementing apps in cancer care. The results of this study provide valuable insight into the CNS role and provide a number of important considerations for the development and implementation of PA interventions within cancer care, with a specific focus on smartphone-based interventions. CNSs play an important role in PA promotion in cancer care and this research can inform the development of PA interventions delivered via smartphone app for people affected by cancer.

The COVID-19 pandemic saw promotion of novel virus transmission-reduction behaviours, and discouragement of familiar transmission-conducive behaviours. Understanding changes in the automatic nature of such behaviours is important, because habitual behaviours may be more easily reactivated in future outbreaks and disrupting old habits may discontinue unwanted behaviours. A repeated-measures, multi-national design tracked virus-transmission habits and behaviour fortnightly over six months (Apr-Sept 2020) among 517 participants (age M = 42 ± 16y, 79% female). Within-participant habit trajectories across all timepoints, and engagement in transmission-reduction behaviours (handwashing when entering home; handwashing with soap for 20 seconds; physical distancing) and transmission-conducive behaviours (coughing/sneezing into hands; making physical contact) summed over the final two timepoints. Three habit trajectory types were observed. Habits that remained strong ('stable strong habit') and habits that strengthened ('habit formation') were most common for transmission-reduction behaviours. Erosion of initially strong habits ('habit degradation') was most common for transmission-conducive behaviours. Regression analyses showed 'habit formation' and 'stable strong habit' trajectories were associated with greater behavioural engagement at later timepoints. Participants typically maintained or formed transmission-reduction habits, which encouraged later performance, and degraded transmission-conducive habits, which decreased performance. Findings suggest COVID-19-preventive habits may be recoverable in future virus outbreaks.

Many individuals living with and beyond cancer (LWBC) have ongoing quality of life (QoL) issues, including fatigue. The World Cancer Research Fund (WCRF) provides health behaviour recommendations for people LWBC, and there is some evidence linking adherence to these with improved QoL. Adults LWBC (specifically breast, colorectal or prostate cancer) completed a survey covering health behaviours (diet, physical activity, alcohol consumption and smoking), fatigue (FACIT-Fatigue Scale, version 4) and a broad measure of QoL (EQ-5D-5L descriptive scale). Participants were categorised as meeting/not meeting WCRF recommendations, using the following cut-offs classified as meeting the guidelines: ≥150 min physical activity/week, fruit and vegetables (≥5 portions/day), fibre (≥30 g fibre per day), free sugar (

BACKGROUND: There are multiple health benefits from participating in physical activity after a cancer diagnosis, but many people living with and beyond cancer (LWBC) are not meeting physical activity guidelines. App-based interventions offer a promising platform for intervention delivery. This trial aims to pilot a theory-driven, app-based intervention that promotes brisk walking among people living with and beyond cancer. The primary aim is to investigate the feasibility and acceptability of study procedures before conducting a larger randomised controlled trial (RCT). METHODS: This is an individually randomised, two-armed pilot RCT. Patients with localised or metastatic breast, prostate, or colorectal cancer, who are aged 16 years or over, will be recruited from a single hospital site in South Yorkshire in the UK. The intervention includes an app designed to encourage brisk walking (Active 10) supplemented with habit-based behavioural support in the form of two brief telephone/video calls, an information leaflet, and walking planners. The primary outcomes will be feasibility and acceptability of the study procedures. Demographic and medical characteristics will be collected at baseline, through self-report and hospital records. Secondary outcomes for the pilot (assessed at 0 and 3 months) will be accelerometer measured and self-reported physical activity, body mass index (BMI) and waist circumference, and patient-reported outcomes of quality of life, fatigue, sleep, anxiety, depression, self-efficacy, and habit strength for walking. Qualitative interviews will explore experiences of participating or reasons for declining to participate. Parameters for the intended primary outcome measure (accelerometer measured average daily minutes of brisk walking (≥ 100 steps/min)) will inform a sample size calculation for the future RCT and a preliminary economic evaluation will be conducted. DISCUSSION: This pilot study will inform the design of a larger RCT to investigate the efficacy and cost-effectiveness of this intervention in people LWBC.

Purpose Positive health behaviours (sufficient exercise, healthy diet, limiting alcohol, and not smoking) can improve multiple outcomes after a cancer diagnosis. Observational studies suggest that health behaviours were negatively impacted for some but not all individuals living with and beyond cancer. The aim of this study was to qualitatively explore the impact of the pandemic on health behaviours of people in this population. Methods Thirty participants were purposively sampled for characteristics including diagnostic group (breast, prostate, and colorectal cancers), gender, time since diagnosis, and age. Semi-structured interviews were conducted to discuss the impact of the pandemic on health behaviours. Thematic analysis and a secondary Ideal Types analysis were conducted. Results Five themes covered changes in food, weight management, relationship to alcohol, and exercise. Five "types" were identified, representing orientations to health behaviours. The "gift of time" provided by the pandemic had an impact on health behaviours, with trends towards increases in drinking, eating unhealthy food, and exercising less. Conclusions The COVID-19 pandemic impacted engagement in positive health behaviours among participants in this study. Strict restrictions and changes in routines resulted in individuals adjusting how they managed their diet, alcohol intake, and exercise behaviours. The typology identified within this study helps to define how different orientation to health behaviours could underpin the responses of individual people LWBC. Implications for cancer survivors Alongside providing an understanding of the experiences of people LWBC during the COVID-19 pandemic, the proposed typology suggests how, with further development, future health behaviour interventions in this group could be targeted based on individual orientations to health, rather than demographic or clinical variables.

ObjectivesIn the last decade, there has been a rapid expansion of physical activity (PA) promotion programmes and interventions targeting people living with and beyond cancer (LWBC). The impact that these initiatives have on long-term maintenance of PA remains under-researched. This study sought to explore the experiences of participants in order to characterise those who have and have not successfully sustained increases in PA following participation in a PA intervention after a diagnosis of gastrointestinal (GI) cancer, and identify barriers and facilitators of this behaviour.DesignCross-sectional qualitative study. Semi-structured interviews with participants who had previously taken part in a PA programme in the UK, explored current and past PA behaviour and factors that promoted or inhibited regular PA participation. Interviews were audio-recorded, transcribed verbatim and analysed using thematic analysis. Themes and subthemes were identified. Differences between individuals were recognised and a typology of PA engagement was developed.ParticipantsTwenty-seven individuals (n=15 male, mean age=66.3 years) with a diagnosis of GI cancer who had participated in one of four interventions designed to encourage PA participation.SettingUK.ResultsSeven themes were identified: disease processes, the role of ageing, emotion and psychological well-being, incorporating PA into everyday life, social interaction, support and self-monitoring and competing demands. A typology with three types describing long-term PA engagement was generated: (1) maintained PA, (2) intermittent PA, (3) low activity. Findings indicate that identifying an enjoyable activity that is appropriate to an individual’s level of physical functioning and is highly valued is key to supporting long-term PA engagement.ConclusionThe typology described here can be used to guide stratified and personalised intervention development and support sustained PA engagement by people LWBC.

Background: Health behaviour models typically neglect habitual action. The Self-Report Habit Index (SRHI) permits synthesis of evidence of the influence of habit on behaviour. Purpose: The purpose of this study is to review evidence around mean habit strength, habit-behaviour correlations, and habit × intention interactions, from applications of the SRHI to dietary, physical activity, and active travel behaviour. Method: Electronic database searches identified 126 potentially relevant papers. Twenty-two papers (21 datasets) passed eligibility screening. Mean scores and correlations were meta-analysed using fixed, random and mixed effects, and interactions were synthesised via narrative review. Results: Twenty-three habit-behaviour correlations and nine habit × intention interaction tests were found. Typical habit strength was located around the SRHI midpoint. Weighted habit-behaviour effects were medium-to-strong (fixed: r = 0.44; random: r = 0.46). Eight tests found that habit moderated the intention-behaviour relation. Conclusion: More comprehensive understanding of nutrition and activity behaviours will be achieved by accounting for habitual responses to contextual cues.

Objectives Habit formation has been identified as one of the key determinants of behaviour change. To initiate habit formation, self-regulation interventions can support individuals to form a cue-behaviour plan and to repeatedly enact the plan in the same context. This randomized controlled trial aimed to model habit formation of an everyday nutrition behaviour and examined whether habit formation and plan enactment differ when individuals plan to enact their behaviour in response to a routine-based versus time-based cue. Design Following a baseline assessment, N = 192 adults (aged 18-77 years) were randomly assigned to a routine-based cue or a time-based cue planning intervention, in which they selected an everyday nutrition behaviour and linked it to a daily routine or a time cue. Methods Participants responded to daily questionnaires over 84 days assessing plan enactment and the behaviour's automaticity (as an indicator of habit formation). Multilevel models with days nested in participants were fitted. Results As indicated by asymptotic curves, it took a median of 59 days for participants who successfully formed habits to reach peak automaticity. Group-level analyses revealed that both routine-based and time-based cue planning led to increases in automaticity and plan enactment, but no between-condition differences were found. Repeated plan enactment was a key predictor for automaticity. Conclusions Linking one's nutrition behaviour to a daily routine or a specific time was similarly effective for habit formation. Interventions should encourage persons to repeatedly carry out their planned behaviour in response to the planned cue to facilitate habit formation.

Objective: Misperception of social norms may result in normalising unhealthy behaviours. The present study tested the hypothesis that parents overestimate both the frequency of unhealthy snacking in pre-school children other than their own (descriptive norms) and its acceptability to other parents (injunctive norms). Design: A cross-sectional, self-report community survey. Questions assessed the frequency with which respondents' own child ate unhealthy snacks and their beliefs about the appropriate frequency for children to snack. Perceived descriptive norms were assessed by asking parents to estimate how often other 2-4 year-old children in their area ate snacks. Perceived injunctive norms were assessed by asking them about other parents' beliefs regarding the appropriate frequency for snacks. Misperceptions were assessed from (i) the difference between the prevalence of daily snacking and parents' perceived prevalence and (ii) the difference between acceptability of daily snacking and parents' beliefs about its acceptability to others. Setting: Pre-schools and children's centres in one borough of London, UK. Subjects: Parents (n 432) of children age 2-4 years. Results: On average, parents believed that more than half of 'other' children had snacks at least daily, while prevalence data indicated this occurred in only 10% of families. The same discrepancy was observed for perceived injunctive norms: parents overestimated other parents' acceptance of frequent snacking, with two-thirds of parents having a self v. others discrepancy. Conclusions: Misperceptions were identified for descriptive and injunctive norms for children's snacking. Accurate information could create less permissive norms and motivate parents to limit their child's intake of unhealthy snacks.

Background Dietary supplements (DSs) are not recommended for the prevention of cancer recurrence. Although DS use is common in individuals living with and beyond cancer, its associations with beliefs about reduced cancer recurrence risk and demographic and health behaviors are unclear. Methods Adults (18 years old or older) who had been diagnosed with breast, prostate, or colorectal cancer were recruited through National Health Service sites in Essex and London. Participants completed a mailed survey and telephone or online 24-hour dietary recalls (MyFood24). Supplement use was collected during the dietary recalls. Associations between DS use and demographics, health behaviors, and beliefs about DSs and cancer were explored. Results Nineteen percent of 1049 individuals believed that DSs were important for the reduction of cancer recurrence risk, and 40% of individuals reported DS use. DS use was positively associated with being female (odds ratio [OR], 2.48; confidence interval [CI], 1.72-3.56), meeting 5-a-day fruit and vegetable recommendations (OR, 1.36; CI, 1.02-1.82), and believing that DSs were important for reducing cancer recurrence risk (OR, 3.13; CI, 2.35-4.18). DS use was negatively associated with having obesity (OR, 0.58; CI, 0.38-0.87). The most commonly taken DSs overall were fish oils (taken by 13%). Calcium with or without vitamin D was the most common DS taken by individuals with breast cancer (15%). Conclusions DS use by individuals living with and beyond cancer is associated with demographic factors and health behaviors. A belief that DSs reduce the risk of cancer recurrence is common and positively associated with DS use. There is a need for health care professionals to provide advice about DS use and cancer recurrence risk.

Self-completed 24 h dietary recalls (24-HRs) are increasingly used for research and national dietary surveillance. It is unclear how difficulties with self-completion affect response rates and sample characteristics. This study identified factors associated with being unable to self-complete an online 24-HR but willing to do so with an interviewer. Baseline 24-HRs from the ASCOT Trial were analysed ( = 1224). Adults who had been diagnosed with cancer in the past seven years and completed treatment, were invited to self-complete 24-HRs online using myfood24 . Non-completers were offered an interviewer-administered 24-HR. One third of participants willing to provide dietary data, were unable to self-complete a 24-HR. This was associated with being older, non-white and not educated to degree level. Compared to interviewer-administered 24-HRs, self-completed 24-HRs included 25% fewer items and reported lower intakes of energy, fat, saturated fat and sugar. This study highlights how collection of dietary data via online self-completed 24-HRs, without the provision of an alternative method, contributes to sampling bias. As dietary surveys are used for service and policy planning it is essential to widen inclusion. Optimisation of 24-HR tools might increase usability but interviewer-administered 24-HRs may be the only suitable option for some individuals.

Online systems that allow employees to pre-order their lunch may help reduce energy intake. We investigated the acceptability of a pre-ordering website for a workplace canteen that prompts customers to swap to lower-energy swaps and the factors influencing swap acceptance. Employees (n = 30) placed a hypothetical lunch order through a pre-ordering website designed for their canteen while thinking aloud. Semi-structured interview questions supported data collection. Data were analysed using thematic analysis. Acceptability was generally high, but potentially context dependent. Practical considerations, such as reminders to pre-order, user-friendliness, provision of images of menu items and energy information while browsing, an ability to reserve pre-ordered meals, and a swift collection service facilitated acceptability. The restrictive timeframe within which orders could be placed, a lack of opportunity to see foods before ordering, and prompts to swap being perceived as threatening autonomy were barriers to acceptability. Swap acceptance was facilitated by the provision of physical activity calorie equivalents (PACE) information, and swap similarity in terms of taste, texture, and expected satiety as well as the perception that alternatives provided meaningful energy savings. Online canteen pre-ordering systems that prompt lower-energy swaps may be an acceptable approach to help reduce energy intake in the workplace.

A vegan diet, which excludes all animal-derived products, has been associated with some improvements in health, while also conferring environmental benefits. Understanding the psychological determinants of successfully switching to a vegan diet will help to inform the design of interventions supporting long-term dietary change. Studies to date have tended to focus on reasoned motives underlying the decision to initiate such a dietary shift. Yet, focusing on reasons for switching may overlook the importance of a broader range of psychological factors that may help or hinder attempts to maintain a vegan diet. This qualitative interview study, the timing of which coincided with UK Covid-19 lockdowns, documented experiences of 20 young adults (17 female; mean age 22y) who attempted to adopt a vegan diet in the past nine months and had or had not successfully maintained this change. Reflexive Thematic Analysis identified five themes surrounding initiation and maintenance. A theme of ‘motives, expectations and cues to switching’ showed that switching was motivated by ethical or health concerns, and cued by Veganuary, lockdown or health issues. ‘The effortfulness of switching’ captured experiences of the perceived burden imposed by adhering to the diet due to, for example, a perceived lack of accessible vegan options. The ‘flexibility of dietary rules’ theme showed that many found the ‘no animal products’ rule clear but restrictive, so allowed themselves occasional non-meat animal products. ‘Social acceptability concerns’ captured the importance of acceptance from vegan and non-vegan family and friends, and ‘satisfaction with the switch’ described the perceived benefits that sustained maintenance for many. Our findings suggest that interventions should seek to support people to overcome potentially unforeseen practical and social challenges to adhering to a vegan diet.

Background Adults with learning disabilities have an increased disposition to unhealthy lifestyle behaviours which often occur simultaneously. Existing studies focus on complex interventions targeting unhealthy diet, physical inactivity, sedentary behaviour, smoking, and alcohol use to reduce health risks experienced. It is essential to understand how well these interventions work, what works, for whom, in what context and why. This study aims to investigate the effectiveness and underlying mechanisms of lifestyle modification interventions for adults with learning disabilities. Methods This is a mixed-methods systematic review consisting of a network meta-analysis (NMA) and realist synthesis. Electronic databases (ASSIA, CINAHL, EMBASE, MEDLINE, and PsycINFO) will be searched from inception to 14 January 2021 with no language restriction. Additionally, trial registries, grey literature databases and references lists will be searched. Studies related to lifestyle modification interventions on the adult population (>18 years) with learning disabilities will be eligible for inclusion. Two independent researchers will screen studies, extract data and assess its quality and risk of bias using the Cochrane Collaboration’s Risk of Bias Assessment Tool (RoB Version 2) and ROBINS-I. The strength of the body of evidence will be assessed based on the GRADE approach. The NMA will incorporate results from RCTs and quasi-experimental studies to estimate the effectiveness of various lifestyle interventions. Where appropriate, a component NMA (CNMA) will be used to estimate effectiveness. The realist synthesis will complement and explain the findings of NMA and CNMA by including additional qualitative and mixed-methods studies. Studies will be included based on their relevance to the programme theory and the rigour of their methods, as determined by quality appraisal tools appropriate to the study design. Results from both syntheses will be incorporated into a logic model. Discussion The paucity of population-specific lifestyle interventions contributes to the challenges of behaviour change in adults with learning disabilities. This study will provide an evidence-base from which various stakeholders can develop effective interventions for adults with learning disabilities. The evidence will also help prioritise and inform research recommendations for future primary research so that people with learning disabilities live happier, healthier and longer lives.

What are the psychological mechanisms that trigger habits in daily life? Two studies reveal that strong habits are influenced by context cues associated with past performance (e.g., locations) but are relatively unaffected by current goals. Specifically, performance contexts but not goals automatically triggered strongly habitual behaviors in memory (Experiment 1) and triggered overt habit performance (Experiment 2). Nonetheless, habits sometimes appear to be linked to goals because people self-perceive their habits to be guided by goals. Furthermore, habits of moderate strength are automatically influenced by goals, yielding a curvilinear, U-shaped relation between habit strength and actual goal influence. Thus, research that taps self-perceptions or moderately strong habits may find habits to be linked to goals. (C) 2011 Elsevier Inc. All rights reserved.

Objective: To evaluate the efficacy of a simple weight loss intervention, based on principles of habit formation. Design: An exploratory trial in which overweight and obese adults were randomized either to a habit- based intervention condition ( with two subgroups given weekly vs monthly weighing; n = 33, n = 36) or to a waiting- list control condition ( n = 35) over 8 weeks. Intervention participants were followed up for 8 months. Participants: A total of 104 adults ( 35 men, 69 women) with an average BMI of 30.9 kgm(-2). Intervention: Intervention participants were given a leaflet containing advice on habit formation and simple recommendations for eating and activity behaviours promoting negative energy balance, together with a self- monitoring checklist. Main outcome measures: Weight change over 8 weeks in the intervention condition compared with the control condition and weight loss maintenance over 32 weeks in the intervention condition. Results: At 8 weeks, people in the intervention condition had lost significantly more weight ( mean = 2.0 kg) than those in the control condition ( 0.4 kg), with no difference between weekly and monthly weighing subgroups. At 32 weeks, those who remained in the study had lost an average of 3.8 kg, with 54% losing 5% or more of their body weight. An intention- to- treat analysis ( based on last- observation- carried- forward) reduced this to 2.6 kg, with 26% achieving a 5% weight loss. Conclusions: This easily disseminable, low- cost, simple intervention produced clinically significant weight loss. In limited resource settings it has potential as a tool for obesity management.

Background Individuals living with and beyond cancer are at heightened risk of adverse psychological and social outcomes and experiences. In March 2020, the COVID-19 global pandemic presented a unique set of social circumstances with the potential to exacerbate the challenges faced by this population. The purpose of this study was to investigate the experiences of people living with and beyond cancer during the first year of the COVID-19 pandemic and assess the impact on psychological and social aspects of their lives. Methods From a pool of participants from a larger health behaviours study thirty participants were purposively sampled for characteristics including: diagnostic group (breast, prostate and colorectal cancers), gender, time since diagnosis and age. Semi-structured interviews were conducted via telephone to discuss their experience of living through the pandemic. A thematic analysis was conducted using a needs-based approach to detail the fundamental needs expressed by this population in relation to their mental health and quality of life during the pandemic. Results Three fundamental needs underpinned the experiences expressed by participants: the need to feel safe; particularly in relation to risk of contracting COVID-19 and their ongoing cancer monitoring; the need to feel connected; to the people, places, activities and practices of everyday life; and the need to make the most out of life; specifically in context of having already endured cancer and cancer treatment. Participant experiences are described in relation to how they impacted each of these three needs. Conclusions People living with and beyond cancer have past and ongoing experiences that make them vulnerable to adverse psychosocial reactions and outcomes. Support for this population needs to provide greater clarity of risk, clearer guidelines specific to their personal circumstances, and regular updates on scheduling of important follow up care and monitoring.

•Estimates of the percentage of cancer patient that are meeting physical activity guidelines vary widely between pedometer and self-report data.•Using either pedometer or self-report data an association is found between meeting physical activity guidelines and not experiencing severe fatigue, in cancer patients.•Associations, in cancer patients, between meeting physical activity guidelines and experiencing no quality of life issues or good sleep quality varied depending on the measure of activity used. Greater physical activity is associated with improved outcomes in people living with and beyond cancer. However, most studies in exercise oncology use self-reported measures of physical activity. Few have explored agreement between self-reported and device-based measures of physical activity in people living with and beyond cancer. This study aimed to describe physical activity in adults affected by cancer across self-reported and device-assessed activity, to explore levels of agreement between these measures in terms of their utility for categorizing participants as meeting/not meeting physical activity guidelines, and to explore whether meeting guidelines is associated with fatigue, quality of life, and sleep quality. A total of 1348 adults living with and beyond cancer from the Advancing Survivorship Cancer Outcomes Trial completed a survey assessing fatigue, quality of life, sleep quality, and physical activity. The Godin-Shephard Leisure-Time Physical Activity Questionnaire was used to calculate a Leisure Score Index (LSI) and an estimate of moderate-to-vigorous physical activity (MVPA). Average daily steps and weekly aerobic steps were derived from pedometers worn by participants. The percentage of individuals meeting physical activity guidelines was 44.3% using LSI, 49.5% using MVPA, 10.8% using average daily steps, and 28.5% using weekly aerobic steps. Agreement (Cohen's κ) between self-reported and pedometer measures ranged from 0.13 (LSI vs. average daily steps) to 0.60 (LSI vs. MVPA). After adjusting for sociodemographic and health-related covariates, meeting activity guidelines using all measures was associated with not experiencing severe fatigue (odds ratios (ORs): 1.43–1.97). Meeting guidelines using MVPA was associated with no quality-of-life issues (OR = 1.53). Meeting guidelines using both self-reported measures were associated with good sleep quality (ORs: 1.33–1.40). Less than half of all adults affected by cancer are meeting physical activity guidelines, regardless of measure. Meeting guidelines is associated with lower fatigue across all measures. Associations with quality of life and sleep differ depending on measure. Future research should consider the impact of physical activity measure on findings, and where possible, use multiple measures. [Display omitted]

In 2015, Tesco Express convenience stores implemented a healthy checkouts initiative; products high in fat, salt or sugar were removed from in-queue areas. We compare purchasing of less healthy foods before and after its introduction. Tesco provided store-level sales data (n = 1151) for Express stores in England over two 8-week periods, May-July 2014 and 2015. Paired t-tests examined if spending on less healthy foods (biscuits, cakes, crisps and confectionery), as a proportion of total spend, changed between 2015 and 2014. Analyses were repeated for the quantity of less healthy products sold. Compliance was measured through unannounced store visits (n = 41). Complete sales data were available for 1101 stores (96%). Mean overall spend increased in 2015 compared with 2014 (666 pound 079.70 [SD 406 385.00] vs. 653 pound 786.59 [SD 447 580.77]; p < 0.001). The proportion of total spend from less healthy foods decreased in 2015 versus 2014 (8.03% [SD 2.07] vs. 8.21% [SD 2.17]; p < 0.001). Confectionery accounted for the largest proportion of less healthy product spend, showing the biggest reduction (3.91% [SD 1.16] in 2015 vs. 4.12% [SD 1.24] in 2014; p < 0.001). Results were similar for quantity of less healthy products sold. Like-for-like sales data from major supermarkets revealed spend on less healthy products rose across the UK over this period. Thirty-nine per cent of stores were fully compliant. In conclusion, following implementation of Tesco's healthier checkouts initiative, there was a small reduction in sales of less healthy foods, largely accounted for by confectionery products. These findings suggest that removal of less healthy products from checkouts might lead to healthier purchasing behaviour. However, store compliance was poor, suggesting scope for improvement.

Purpose Social support facilitated healthy behaviours in people living with and beyond cancer (LWBC) before the COVID-19 pandemic. Little is known about how social support impacted their health behaviours during the pandemic when social restrictions were imposed. The aim of this study was to qualitatively explore how social support was perceived to impact the health behaviours of people LWBC during the COVID-19 pandemic. Methods Semi-structured interviews were conducted via telephone with 24 adults living with and beyond breast, prostate and colorectal cancer. Inductive and deductive framework analysis was used to analyse the data. Results Five themes developed. These were (1) Companionship and accountability as motivators for physical activity, (2) Social influences on alcohol consumption, (3) Instrumental support in food practices, (4) Informational support as important for behaviour change and (5) Validation of health behaviours from immediate social networks. Conclusion This study described how companionship, social influence, instrumental support, informational support and validation were perceived to impact the health behaviours of people LWBC during the COVID-19 pandemic. Interventions for people LWBC could recommend co-participation in exercise with friends and family; promote the formation of collaborative implementation intentions with family to reduce alcohol consumption; and encourage supportive communication between partners about health behaviours. These interventions would be useful during pandemics and at other times. Government policies to help support clinically extremely vulnerable groups of people LWBC during pandemics should focus on providing access to healthier foods.

Background:There are multiple benefits to being physically active after a cancer diagnosis, but many people living with and beyond cancer (LWBC) require support to increase their activity levels. App-based interventions offer a promising platform for intervention delivery. This trial aims to pilot a theory-driven, app-based intervention that promotes brisk walking among people LWBC. Aims: The primary aim of the pilot is to investigate the feasibility and acceptability of study procedures before conducting a larger randomised controlled trial (RCT). Methods: This is an individually randomised, two-armed pilot RCT. Patients with localised or metastatic breast, prostate, or colorectal cancer, who are aged 16 years or over will be recruited from a single hospital site in South Yorkshire. The intervention includes an app designed to encourage brisk walking (Active 10) supplemented with behavioural support in the form of two brief telephone/video calls, an information leaflet and walking planners. The primary outcomes will be feasibility and acceptability of the study procedures (e.g. recruitment/retention rate, acceptability of randomisation/intervention/outcome assessments). Demographic and medicalcharacteristics will be collected at baseline, through self-report and hospital records. Secondary outcomes for the pilot (assessed at 0 and 3 months) include accelerometer-measured and self-reported physical activity, as well as several other behavioural/quality of life outcomes. Qualitative interviews will explore experiences of participating or reasons for declining to participate. Parameters for the intended primary outcome measure (accelerometer measured average daily minutes of brisk walking (>100 steps/minute)) will inform a sample size calculation for the future RCT and a preliminary economic evaluation will be conducted. Results/Conclusion:To date, 39 participants have been recruited out of the target pilot sample of 90.This pilot study will inform the design of a larger RCT to investigate the efficacy and cost-effectiveness of this intervention in people LWBC.

Removing unhealthy products from checkouts will arguably reduce impulse purchasing, but evidence is lacking. In 2015, Tesco Express stores implemented so-called healthy checkouts; products high in sugar, fat, or salt (defined by national Nutrient Profiling Model criteria) were removed from in-queue areas. We aimed to compare the purchasing of unhealthy foods before and after its introduction. Tesco provided store-level sales data for 1151 Tesco Express stores in England over two 8 week periods (May–July in 2014 and 2015). We used paired t tests to examine whether spend on unhealthy foods (biscuits, cakes, crisps, confectionary) as a proportion of total spend changed in 2015 versus 2014. Analyses were repeated for the quantity of unhealthy products sold. Unannounced store visits (n=41) were conducted by three researchers (in London, the South East, the North West, and Yorkshire and Humber) to measure compliance (ie, whether prohibited products were displayed in-queue). Complete sales data were available for 1101 stores (96%). Mean overall spend increased in 2015 compared with 2014 (£666 079·70 [SD 406 385·00] vs £653 786·59 [SD 447 580·77], p

Finding effective ways to increase acceptance of lower-energy swaps offered for snacks and non-alcoholic drinks may reduce population energy intake. We examined whether incrementally increasing the tangibility of information accompanying swaps offered increased their acceptance. UK adults (n = 3481) selected a sweet snack, a savoury snack, and a drink in an experimental online canteen after being equally randomised to receive one of four messages when swaps were offered; a control message providing no specific information, a vague calorie message, an exact numeric-calories message or, a physical activity calorie equivalent (PACE). Primary outcomes were the between-group differences in (i) the odds that a sweet, savoury, or drink swap would be accepted and (ii) the energy content for each type of item ordered. Compared with control, the numeric-calories and PACE messages significantly increased the odds of accepting a sweet snack swap. All interventions significantly increased the odds of accepting savoury swaps compared with control. Only the PACE message significantly increased the odds of drink swap acceptance. The numeric-calories and PACE messages significantly reduced the energy content of sweet snacks. All interventions significantly reduced the energy content of savoury snacks. None of the intervention messages significantly reduced the energy content of drinks compared with control. Increasing the tangibility of information provided when offering swaps increased swap acceptance. PACE messaging was the most promising.

Objectives Understanding changes in moderate to vigorous aerobic physical activity (MVPA) and muscle-strengthening activity (MSA) at the start of the COVID-19 pandemic and their correlates (socio-demographics, health characteristics, living and exercise conditions and pre-pandemic MVPA/MSA) can inform interventions. Design A cross-sectional analysis of retrospective and concurrent data on MVPA/MSA. Setting An online survey in the UK. Participants 2657 adults (weighted n=2442, 53.6% women) participating in the baseline survey (29 April 2020-14 June 2020) of the HEalth BEhaviours during the COVID-19 pandemic (HEBECO) study. Primary and secondary outcome measures Meeting WHO-recommended levels for MVPA/MSA/both (vs meeting neither) during the first lockdown and changes in MVPA/MSA from before to since the COVID-19 pandemic following stratification for pre-pandemic MVPA/MSA. Results A third of adults maintained (30.4%), decreased (36.2%) or increased (33.4%) MVPA. For MSA, the percentages were 61.6%, 18.2% and 20.2%, respectively. MVPA increased or decreased by an average of 150 min/week and 219 min/week, respectively, and MSA by 2 days/week. Meeting both MSA+MVPA recommendations since COVID-19 (vs meeting neither) was positively associated with meeting MVPA+MSA before COVID-19 (adjusted OR (aOR)=16.11, 95% CI 11.24 to 23.07) and education: post-16 years of age (aOR=1.57, 95% CI 1.14 to 2.17), and negatively associated with having obesity (aOR=0.49, 95% CI 0.33 to 0.73), older age (65+ years vs

We hypothesized that adolescents misperceive social norms for food consumption, and aimed to test this, and examine associations between perceived norms and dietary behaviours. School pupils (n = 264) in the UK, aged 16-19 years, completed a questionnaire about their own attitudes to, and intake of, fruits and vegetables, unhealthy snacks and sugar-sweetened drinks, and their perceptions of their peers' attitudes to (injunctive norms), and intake of (descriptive norms), the same foods. Misperceptions were calculated from differences between perceived norms and median self-reports of peer groups. Respondents overestimated their peers' intake of snacks by 1.8 portions a week, and sugar-sweetened drinks by 5.2 portions, and overestimated how positive their peers' attitudes were towards these behaviours. They underestimated their peers' consumption of fruits and vegetables by 3.2 portions per week and how positive their peers' attitudes were towards fruit and vegetables. Descriptive norms were strongly associated with intake of fruit and vegetables, sugar-sweetened drinks, and unhealthy snacks, explaining between 17% and 22% of the variance in consumption. There was no association between injunctive norms and intake. Descriptive norms indicated that misperceptions of peers' food intake were associated with respondents' own intake. Interventions to correct misperceptions have the potential to improve adolescents' diets. (C) 2011 Elsevier Ltd. All rights reserved.

The present study aimed to quantify the level of sleep problems in 5835 breast, prostate, and colorectal cancer survivors, and explore a number of potential determinants of poor sleep quality in the present sample. BMI, diet, and physical activity were of particular interest as potential determinants. Participants who completed the 'Health and Lifestyle after Cancer' survey were adults who had been diagnosed with breast, prostate, or colorectal cancer (mean time since cancer diagnosis was 35.5 months, SD=13.56). Sleep quality was assessed using the Pittsburgh Sleep Quality Index. BMI was calculated from self-reported height and weight. Participants were categorised as meeting/not meeting the World Cancer Research Fund (WCRF) recommendations for fibre, fruit and vegetables, added sugar, red meat, processed meat, fat, alcohol, and physical activity. Analyses accounted for demographic and clinical factors. Fifty-seven percent of those with sleep data were classified as poor sleepers (response rate 79%). Being female, having a higher number of cancer treatments, more comorbid conditions, and being more anxious/depressed increased the odds of being a poor sleeper. After adjustment for these factors, there were no associations between diet/alcohol/physical activity and sleep. However, BMI was associated with sleep. Individuals in the overweight and obese categories had 22% and 79% higher odds of being poor sleepers than individuals in the underweight/healthy weight category, respectively. The findings suggest that there may be a need to develop sleep quality interventions for cancer survivors with obesity. Even after adjustment for multiple clinical and demographic factors, BMI (particularly obesity) was associated with poor sleep. Thus, researchers and health professionals should find ways to support individuals with overweight and obesity to improve their sleep quality. The present findings highlight that poor sleep is a common issue in cancer survivors. Interventions seeking to improve outcomes for cancer survivors over the longer term should consider sleep quality.

Background Many people living with and beyond cancer (LWBC) do not meet dietary recommendations. To implement a healthier diet, people LWBC must perceive a need to improve their diet. Methods Participants included people diagnosed with breast, prostate or colorectal cancer in the UK. Two binary logistic regression models were conducted with perceived need for dietary change as the outcome (need to improve vs. no need). Predictor variables included demographic and clinical characteristics, receipt of dietary advice, and either body mass index (BMI) or adherence to seven relevant World Cancer Research Fund (WCRF) dietary recommendations. Results The sample included 5835 responses. Only 31% perceived a need to improve their diet. Being younger (odds ratio [OR] 0.95, 95% confidence interval [CI] = 94–0.95), female (OR = 1.33, 95% CI = 1.15–1.53), not of white ethnicity (OR = 1.8, 95% CI = 1.48–2.27), not married/cohabiting (OR = 1.32, 95% CI = 1.16–1.52) and having received dietary advice (OR = 1.36, 95% CI = 1.43–1.86) was associated with an increased odds of perceiving a need to improve diet. This association was also seen for participants with two or more comorbidities (OR = 1.31, 95% CI = 1.09–1.57), those not meeting the recommendations for fruit and vegetables (OR = 0.47, 95% CI = 0.41–0.55), fat (OR = 0.67, 95% CI = 0.58–0.77), and sugar (OR = 0.86, 95% CI = 0.75–0.98) in the dietary components model and those who had a higher BMI (OR = 1.53, 95% CI = 1.32–1.77) in the BMI model. Conclusions Most of this sample of people LWBC did not perceive a need to improve their diet. More research is needed to understand the reasons for this and to target these reasons in dietary interventions.

Maintaining weight loss requires long-term behaviour change. Theory and evidence around habitual behaviour ? i.e., action triggered by impulses that are automatically activated upon exposure to cues, due to learned cueaction associations ? can aid development of interventions to support weight loss maintenance. Specifically, weight loss is more likely to be sustained where people develop new habits that support weight management, and break old habits that may undermine such efforts. Interventions seeking to break ?bad? weight-related habits have focused on inhibiting unwanted impulses or avoiding cues. This paper draws attention to the possibility that while such approaches may discontinue habitual behaviour, underlying habit associations may remain. We use evidence from existing qualitative studies to demonstrate that, left unchecked, unwanted habit associations can render people prone to lapsing into old patterns of unhealthy behaviours when motivation or willpower is momentarily weakened, or when returning to familiar settings following temporarily discontinued exposure. We highlight six behaviour change techniques especially suited to disrupting habit associations, but show that these techniques have been underused in weight loss maintenance interventions to date. We call for intervention developers and practitioners to adopt techniques conducive to forming new habit associations to directly override old habits, and to use the persistence of unwanted habit associations as a potential indicator of longterm weight loss intervention effectiveness.

Habitual behaviours are elicited when a familiar context activates cue-behaviour associations that have been learned through previous performance. A core hypothesis within habit theory is that, by virtue of its automaticity, habit weakens the impact of intention on action, such that in facilitating conditions, action will be guided more by habit than momentary intentions. This has led to recommendations that habit formation be harnessed as a mechanism for sustaining desirable behaviour over time, when people would otherwise relapse due to loss of motivation. This article reviews theory and evidence around the hypothesized interaction between habit and intention as determinants of behaviour. We first qualify the hypothesis by clarifying that it pertains only to determinants of the instigation of action, rather than execution. Next, drawing on a systematic review of 52 behaviour-prediction studies, we highlight mixed empirical support for the interaction. We argue that ostensibly inconsistent findings can be reconciled by recognizing the distinction between the direction and strength of intention, and identifying the "facilitating conditions" that may determine the relative influence of habit and intention on behaviour. Evidence demonstrates that when self-control is diminished, people act habitually regardless of intention direction or strength. When people possess self-control, habits can help people to act on favourable but weakened intentions, but intentions that oppose habitual tendencies can override habitual influence. This has important implications for behaviour change: even if habit has formed, a minimal level of favourable conscious motivation may be required to sustain behaviours over time. Social psychology might fruitfully move beyond askingwhetherhabit moderates the intention-behaviour relationship, and instead probehowandin which conditionshabits and intentions interact.

Hagger (2019) offers an insightful synthesis of recent theoretical and empirical developments in understanding of habit and its relevance to physical activity. This commentary extends coverage of one such advance, namely the distinction between two manifestations of habit in physical activity: habitually ‘deciding’ to engage in activity (i.e. habitual instigation), and habitually ‘doing’ the activity (habitual execution). We explore the rationale for this distinction and argue that most contemporary theory and evidence around habitual physical activity – and by extension, Hagger’s review – implicitly focuses on instigation and neglects execution. We offer hypotheses around the potential roles that habitual execution may play in physical activity. Broadening the scope of inquiry within the field to more fully encompass habitual performance would achieve a more comprehensive and informative account that incorporates concepts of skill acquisition and mastery.

Habitual behaviours are learned responses that are triggered automatically by associated environmental cues. The unvarying nature of most workplace settings makes workplace physical activity a prime candidate for a habitual behaviour, yet the role of habit strength in occupational physical activity has not been investigated. Aims of the present study were to: (i) document occupational physical activity habit strength; and (ii) investigate associations between occupational activity habit strength and occupational physical activity levels. A sample of UK office-based workers (n = 116; 53% female, median age 40 years, SD 10.52) was fitted with activPAL accelerometers worn for 24 h on five consecutive days, providing an objective measure of occupational step counts, stepping time, sitting time, standing time and sit-to-stand transitions. A self-report index measured the automaticity of two occupational physical activities (being active (e.g., walking to printers and coffee machines) and stair climbing). Adjusted linear regression models investigated the association between occupational activity habit strength and objectively-measured occupational step counts, stepping time, sitting time, standing time and sit-to-stand transitions. Eighty-one per cent of the sample reported habits for being active, and 62% reported habits for stair climbing. In adjusted models, reported habit strength for being active were positively associated with average occupational sit-to-stand transitions per hour (B = 0.340, 95% CI: 0.053 to 0.627, p = 0.021). Stair climbing habit strength was unexpectedly negatively associated with average hourly stepping time (B = -0.01, 95% CI: -0.01 to -0.00, p = 0.006) and average hourly occupational step count (B = -38.34, 95% CI: -72.81 to -3.88, p = 0.030), which may reflect that people with stronger stair-climbing habits compensate by walking fewer steps overall. Results suggest that stair-climbing and office-based occupational activity can be habitual. Interventions might fruitfully promote habitual workplace activity, although, in light of potential compensation effects, such interventions should perhaps focus on promoting moderate-intensity activity.

Background: The twelve-item Self-Report Habit Index (SRHI) is the most popular measure of energy-balance related habits. This measure characterises habit by automatic activation, behavioural frequency, and relevance to self-identity. Previous empirical research suggests that the SRHI may be abbreviated with no losses in reliability or predictive utility. Drawing on recent theorising suggesting that automaticity is the 'active ingredient' of habit-behaviour relationships, we tested whether an automaticity-specific SRHI subscale could capture habit-based behaviour patterns in self-report data. Methods: A content validity task was undertaken to identify a subset of automaticity indicators within the SRHI. The reliability, convergent validity and predictive validity of the automaticity item subset was subsequently tested in secondary analyses of all previous SRHI applications, identified via systematic review, and in primary analyses of four raw datasets relating to energy-balance relevant behaviours (inactive travel, active travel, snacking, and alcohol consumption). Results: A four-item automaticity subscale (the 'Self-Report Behavioural Automaticity Index'; 'SRBAI') was found to be reliable and sensitive to two hypothesised effects of habit on behaviour: a habit-behaviour correlation, and a moderating effect of habit on the intention-behaviour relationship. Conclusion: The SRBAI offers a parsimonious measure that adequately captures habitual behaviour patterns. The SRBAI may be of particular utility in predicting future behaviour and in studies tracking habit formation or disruption.

Objectives. Repeated action can lead to the formation of habits and identification as the kind of person that performs the behaviour. This has led to the suggestion that identity-relevance is a facet of habit. This study explores conceptual overlap between habit and identity, and examines where the two constructs fit into an extended Theory of Planned Behaviour (TPB) model of binge-drinking among university students. Design. Prospective, questionnaire-based correlational design. Methods. A total of 167 UK university students completed baseline measures of past behaviour, self-identity, the Self-Report Habit Index (SRHI), and TPB constructs. One week later, 128 participants completed a follow-up behaviour measure. Results. Factor analyses of the SRHI and four identity items revealed two correlated but distinct factors, relating to habit and identity, respectively. Hierarchical regression analyses of intention and behaviour showed that identity contributed over and above TPB constructs to the prediction of intention, whereas habit predicted behaviour directly, and interacted with intentions in predicting behaviour. Habits unexpectedly strengthened the intentionbehaviour relation, such that strong intenders were more likely to binge-drink where they also had strong habits. Conclusions. Identity and habit are conceptually discrete and impact differently on binge-drinking. Findings have implications for habit theory and measurement. Recommendations for student alcohol consumption reduction initiatives are offered.

Background Health behaviour models typically neglect habitual action. The Self-Report Habit Index (SRHI) permits synthesis of evidence of the influence of habit on behaviour. Purpose The purpose of this study is to review evidence around mean habit strength, habit–behaviour correlations, and habit × intention interactions, from applications of the SRHI to dietary, physical activity, and active travel behaviour. Method Electronic database searches identified 126 potentially relevant papers. Twenty-two papers (21 datasets) passed eligibility screening. Mean scores and correlations were meta-analysed using fixed, random and mixed effects, and interactions were synthesised via narrative review. Results Twenty-three habit–behaviour correlations and nine habit × intention interaction tests were found. Typical habit strength was located around the SRHI midpoint. Weighted habit–behaviour effects were medium-to-strong (fixed: r+ = 0.44; random: r+ = 0.46). Eight tests found that habit moderated the intention–behaviour relation. Conclusion More comprehensive understanding of nutrition and activity behaviours will be achieved by accounting for habitual responses to contextual cues.

Habitual actions are elicited automatically in associated settings, bypassing conscious motivation. This has prompted interest in habit formation as a mechanism for sustaining behaviour change when conscious motivation erodes. Promoting habit depends on understanding how habit develops. This chapter reviews theory and evidence around the habit formation process. First, we describe the few, recent studies that have explicitly sought to study habit development for meaningful activities in humans. Next, we outline a framework for understanding the habit formation process, and narratively review evidence regarding the factors that may directly facilitate or impede habit development, generating hypotheses for future studies. We offer practical suggestions for optimal modelling of habit formation and its determinants.

Translating research evidence into clinical practice to improve care involves healthcare professionals adopting new behaviours and changing or stopping their existing behaviours. However, changing healthcare professional behaviour can be difficult, particularly when it involves changing repetitive, ingrained ways of providing care. There is an increasing focus on understanding healthcare professional behaviour in terms of non-reflective processes, such as habits and routines, in addition to the more often studied deliberative processes. Theories of habit and routine provide two complementary lenses for understanding healthcare professional behaviour, although to date, each perspective has only been applied in isolation. To combine theories of habit and routine to generate a broader understanding of healthcare professional behaviour and how it might be changed. Sixteen experts met for a two-day multidisciplinary workshop on how to advance implementation science by developing greater understanding of non-reflective processes. From a psychological perspective ‘habit’ is understood as a process that maintains ingrained behaviour through a learned link between contextual cues and behaviours that have become associated with those cues. Theories of habit are useful for understanding the individual's role in developing and maintaining specific ways of working. Theories of routine add to this perspective by describing how clinical practices are formed, adapted, reinforced and discontinued in and through interactions with colleagues, systems and organisational procedures. We suggest a selection of theory-based strategies to advance understanding of healthcare professionals' habits and routines and how to change them. Combining theories of habit and routines has the potential to advance implementation science by providing a fuller understanding of the range of factors, operating at multiple levels of analysis, which can impact on the behaviours of healthcare professionals, and so quality of care provision. •Improving the quality of care involves changing healthcare professional behaviour.•Professional behaviour is driven by both reflective and non-reflective processes.•Changing non-reflective, habitual, or routine clinical behaviours is difficult.•Theory-based strategies can help address non-reflective clinical behaviours.•Future directions for research on non-reflective clinical behaviour are provided.

Habitual behaviours are triggered automatically, with little conscious forethought. Theory suggests that making healthy behaviours habitual, and breaking the habits that underpin many ingrained unhealthy behaviours, promotes long-term behaviour change. This has prompted interest in incorporating habit formation and disruption strategies into behaviour change interventions. Yet, notable research gaps limit understanding of how to harness habit to change real-world behaviours. Discussions among health psychology researchers and practitioners, at the 2019 European Health Psychology Society 'Synergy Expert Meeting', generated pertinent questions to guide further research into habit and health behaviour. In line with the four topics discussed at the meeting, 21 questions were identified, concerning: how habit manifests in health behaviour (3 questions); how to form healthy habits (5 questions); how to break unhealthy habits (4 questions); and how to develop and evaluate habit-based behaviour change interventions (9 questions). While our questions transcend research contexts, accumulating knowledge across studies of specific health behaviours, settings, and populations will build a broader understanding of habit change principles and how they may be embedded into interventions. We encourage researchers and practitioners to prioritise these questions, to further theory and evidence around how to create long-lasting health behaviour change.

Advances in understanding how habit forms can help people change their behaviour in ways that make them happier and healthier. Making behaviour habitual, such that people automatically act in associated contexts due to learned context-response associations, offers a mechanism for maintaining new, desirable behaviours even when conscious motivation wanes. This has prompted interest in understanding how habit forms in the real world. To reliably inform intervention design, habit formation studies must be conceptually and methodologically sound. This paper proposes methodological criteria for studies tracking real-world habit formation, or potential moderators of the effect of repetition on formation. A narrative review of habit theory was undertaken to extract essential and desirable criteria for modelling how habit forms in naturalistic settings, and factors that influence the relationship between repetition and formation. Next, a methodological review identified exemplary real-world habit formation studies according to these criteria. Fourteen methodological criteria, capturing study design (four criteria), measurement (six criteria), and analysis and interpretation (four criteria), were derived from the narrative review. Five extant studies were found to meet our criteria. Adherence to these criteria should increase the likelihood that studies will offer revealing conclusions about how habits develop in real-world settings.

Habits are automatic behavioural responses to environmental cues, thought to develop through repetition of behaviour in consistent contexts. When habit is strong, deliberate intentions have been shown to have a reduced influence on behaviour. The habit concept may provide a mechanism for establishing new behaviours, and so healthy habit formation is a desired outcome for many interventions. Habits also however represent a potential challenge for changing ingrained unhealthy behaviours, which may be resistant to motivational shifts. This review aims to provide intervention developers with tools to help establish target behaviours as habits, based on theoretical and empirical insights. We discuss evidence-based techniques for forming new healthy habits and breaking existing unhealthy habits. To promote habit formation we focus on strategies to initiate a new behaviour, support context-dependent repetition of this behaviour, and facilitate the development of automaticity. We discuss techniques for disrupting existing unwanted habits, which relate to restructuring the personal environment and enabling alternative responses to situational cues.

Physical distancing remains an important initiative to curb COVID-19, and virus transmission more broadly. This exploratory study investigated how physical distancing behaviour changed during the COVID-19 pandemic and whether it was associated with identity with virus transmission avoidance and physical distancing habit strength. In a longitudinal, multinational study with fortnightly repeated-assessments, associations and moderation effects were considered for both overall (person-level means) and occasion-specific deviations in habit and identity. Participants (N=586, M age = 42, 79% female) self-reported physical distancing behavioural frequency, physical distancing habit strength, and identity with avoiding virus transmission. Physical distancing followed a cubic trajectory, with initial high engagement decreasing rapidly before increasing again near study end. Physical distancing was associated with both overall and occasion-specific virus transmission avoidant identity and physical distancing habit strength. People with strong virus transmission avoidant identity engaged in physical distancing frequently regardless of fluctuations in habit strength. However, for those with weaker virus transmission avoidant identity, physical distancing was strongly aligned with fluctuations in habit strength. To enhance engagement in physical distancing, public health messaging might fruitfully target greater or more salient virus-transmission avoidance identity, and stronger physical distancing habit.

Habit formation is thought to aid maintenance of physical activity, but little research is available into determinants of habit strength aside from repeated performance. Previous work has shown that intrinsically motivated physical activity, underpinned by inherent satisfaction derived from activity, is more likely to be sustained. We explored whether this might reflect a tendency for self-determined activity to become more strongly habitual. A sample of 192 adults aged 18-30 completed measures of motivational regulation, intention, behaviour, and habit strength. Results showed that self-determined regulation interacted with past behaviour in predicting habit strength: prior action was more predictive of habit strength among more autonomously motivated participants. There was an unexpected direct effect of self-determined regulation on habit strength, independently of past behaviour. Findings offer possible directions for future habit formation work.

Habit formation is an important goal for behaviour change interventions because habitual behaviours are elicited automatically and are therefore likely to be maintained. This study documented experiences of habit development in 10 participants enrolled on a weight loss intervention explicitly based on habit-formation principles. Thematic analysis revealed three themes: Strategies used to support initial engagement in a novel behaviour; development of behavioural automaticity; and selecting effective cues to support repeated behaviour. Results showed that behaviour change was initially experienced as cognitively effortful but as automaticity increased, enactment became easier. Habits were typically formed in work-based contexts. Weekends and vacations temporarily disrupted performance due to absence of associated cues, but habits were reinstated on return to work. Implications for theory and practice are discussed.