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Self-control training to bolster effectiveness

Especially in people with severe mental illness (SMI), improving physical activity (PA) can prevent a broad range of negative consequences for physical and mental health. While existing PA interventions show fairly positive effects, there is room for improvement. Amongst other things, existing interventions are time consuming and are based predominantly on cognitive models. These cognitively underpinned interventions suffer from the behaviour-intention gap and rely on a fairly high level of cognitive skills such as attention, goal-setting and writing, which people with SMI often do not fully possess. Self-control training (SCT) is an evidence-based method that has much potential to address these concerns. In SCT, participants are asked to perform a task that requires self-control for a pre-specified period of time, often two weeks. An example is using one’s non-dominant hand for daily tasks. SCT can bridge the intention-behaviour gap, and can thus be added to existing, cognitively underpinned interventions to bolster their effectiveness. However, while SCT has been proven to be effective in improving multiple types of behaviour, it has not been applied to improving PA in people with SMI, highlighting the need for evaluation studies in context. Consequently, in this project, an existing, functioning prototype of an SCT app will be re-designed to fit psychiatric inpatients with SMI via participatory development. This SCT app will be added to Google Fit, an existing, evidence-based intervention, in order to increase PA in people with SMI.

 

New research designs

In order to study the effectiveness of SCT in a field that is dominated by interventions with a cognitive focus, other methods than the classical randomized controlled trial are required. Consequently, two different single-case experimental designs (SCEDs) will be used. SCEDs allow for high-quality experimental research and are able to overcome practical limitations such as difficulties with sampling and the heterogeneity of the target group. SCEDs are used to study a limited number of patients by means of repeated measurements and are very suitable to conduct research in real-life settings. SCEDs will not only yield evidence for SCT’s effectiveness, but also provide more insight into the extent to which SCT can improve effectiveness of existing interventions; how long SCT should be received to be most effective; and for how long its effects remain. SCEDs are a very suitable way to evaluate these types of interventions in practice, but there is an urgent need for more knowledge on how to apply these types of designs in e-health evaluation with vulnerable, complex target groups.

 

Methods

The goal of this project is to develop and evaluate a self-control training (SCT) app that can bolster the effects of existing e-health interventions. The first research question aims to elicit requirements for the development of an SCT app based on the non-dominant hand training. This app will be based on a functioning prototype of such an app that was developed in a project funded by Stichting Vrienden van Oldenkotte. Through multiple rounds of focus groups and interviews with patients, staff and developers, requirements will be elicited and an app will be developed.

Two SCEDs will be used in this project: an introduction/withdrawal design (ABAB) and a multiple-baseline design. In each SCED, six inpatients from two large mental healthcare organizations (Dimence Groep & GGz Centraal) will be closely monitored for 12 weeks to determine if using the SCT has a positive impact on PA (measured by an accelerometer) and self-control (measured by a questionnaire). The introduction/withdrawal SCED will provide insights into whether adding SCT to Google Fit increases its effectiveness. In this design, six participants will first only use Google Fit (A) and after two weeks, SCT will be added (B), which is expected to result in an increase in PA and self-control. After two weeks, SCT will be withdrawn and only Google Fit will be used for two weeks (A), after which SCT will again be added (B). The multiple-baseline SCED will offer more insight into how long SCT should be administered and for how long its effects on PA and self-control remain. Again, six patients will be regularly monitored. Each participant will receive a different version of the intervention in terms of time: participants will either start with the intervention after two or four weeks of baseline measurements, and will use it for either one, two or four weeks.

 

This project will contribute to research and practice in two major ways. First, the to-be-developed SCT app can be used to bolster the effectiveness of a broad range of existing preventive interventions, and is a very suitable way to engage vulnerable, hard-to-reach populations. Second, knowledge will be generated about the application of SCEDs to evaluate e-health in complex settings and vulnerable populations.

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