NC: Behavior Change Strategies (2007-2008)
The purposes of the study were
- To identify individuals who expressed a desire to improve their nutrition practices and examine their degree of success
- To examine the impact of goal-setting instruction on nutrition-related behaviors when the emphasis is on free goal choice.
- Enlisted military personnel working at Walter Reed Army Medical Center (e.g., private, corporal, specialist, sergeant)
- Answers on a Life-Style Assessment Questionaire identified individuals who desired to make one or more changes in dietary habits.
- Non-military personnel
- Army officers (initially recruited, but later excluded due to low response rate)
- Army weight control program participants
- Answers to Life-Style Assessment questionaire did not indicate desires to change any nutrition behaviors.
Study publicized via administrative meetings and classes and the Walter Reed Medical Center newspaper.
- Subjects were randomly assigned to three groups with different levels of intervention: Goal-Setting/Goal Attanment (GSGA) group, the Goal-Setting (GS) group and the Control group
- At the end of six months, change scores for nutrition-related goals were evaluated and the groups were compared.
- Participants knew that they were enrolled in an employee wellness study
- They were unaware that change in nutrition-related behaviors were the only things actually being studied
- Raters evaluated changes in all areas and were blinded to the fact that just nutrition changes were being studied.
- The GSGA group received eight group sessions and four individual sessions to learn goal-setting and goal-attainment techniques
- The GS group received one group session and one individual session to learn how to set goals (purpose was to evaluate the effects of goal-setting alone
- The control group received no intervention.
- The Statistical Package for the Social Sciences was used to data analysis
- Analysis included descriptive statistical information on the three treatment groups and analysis of variance (ANOVA) on mean Change Scores for the three groups
- Inter-rater reliability was also computed for a comparison of the subjects; self-scoring of the change with the raters' Change Scores.
Timing of Measurements
- Recruitment and screening took place over the first three months, the work-site health promotion program was administered in the following two months and evaluation occurred during the sixth month
- The screening questionaire was given to individuals as they were recruited during the first three months
- The follow-up questionaire was given during the sixth month (one month after the intervention ended).
Change score for nutrition-related behaviors
- -1: Behavior worse than before
- 0: No change
- +1: Expected level of success
- +2: More than expected success
- +3: Best anticipated success.
- Initial N: 77 (number of men and women not reported)
- Attrition (final N): 60 (42 women). Seven dropped out of the study and 10 did not complete final questionnaires.
- GSGA group: 25±4.7 years
- GS group: 24±6.2 years
- Control group: 24±3.8 years.
- Ethnicity: Not given
- Other relevant demographics: Not given
- Anthropometrics: Not given
- Location: Walter Reed Army Medical Center.
Statistical Significance of Group Difference
Nutrition Change Score Self-Rating
GSGA vs. Control: P<0.05
Nutrition Change Score Composite Rating (Average of Rater's and Counselor's Scores)
GSGA vs. Control: P<0.05
- The inter-rater reliability between change score ratings of the independent rater and counselor was 0.95, as was the reliability between the two raters. This indicates a high degree of consistency between raters as to what constitutes "desirable nutrition change."
- The composite change scores compared to the self-change scores showed a correlation coefficient of 0.55. This was due to self-ratings of what participants perceived as "improvements," but were considered undesirable by counselors and raters (e.g., one subject described as improvement, "I skip lunch; I work through the lunch break five times a week." Both counselor and rater agreed this was nutritionally undesirable and rated it -1).
- Frequency data indicate that dietary improvements were attained (change score of +2 or +3) by 84% of the GSGA group, 64% of the GS group and only 37% of the control group.
- If a patient chooses goals that he can see himself achieving, he is much more apt to be successful, rather than working toward a goal that a health professional set for himThe use of self-set goals in health promotion presents problems with evaluation, as there is not always a physiologic outcome to measure as an indicator of success
- For this study, the Goal Attainment Scaling system ("Change Scores") was quite flexible and relevant for evaluating nutrition-related behaviors
- The high level of agreement between the raters in this study suggests that the Goal Attainment Scaling tool is useful for quantifying and documenting diet-related behavioral change
- Further research into goal-setting, goal commitment and motivations, as it relates to goals, is necessary in order to refine our effectiveness as health and nutrition counselors
- The interpretation of these findings is limited because there was a small sample and the groups did not have the same frequency of contact
- The trends observed, however, suggest several interesting areas for future study:
- Further evaluation of various goal-setting approaches is recommended, as are further studies in the area of free goal choice
- Goal Attainment Scaling offers new possibilities for documenting and evaluating dietary change. The development and evaluation of Goal Attainment Scales in other research endeavors is encouraged.
- The comparison of Goal Attainment Scale ratings with corresponding physiological measures is recommended to examine associations between self-reports of behavior and physiological outcomes.
|University/Hospital:||University of Pittsburg, Virgina Commonwealth University, Pennsylvania State University|
- This is a simple study that shows that motivated individuals, who set their own nutrition goals and receive instruction in both goal-setting and goal attainment can be very successful
- The author points out the limitations of this particular study, which I think increases its value
- The findings of this 19-year-old study go along with later research in the area of motivational interviewing, which has been shown to be a very good method of helping individuals to establish and work toward health-related goals.
Quality Criteria Checklist: Primary Research
|1.||Would implementing the studied intervention or procedure (if found successful) result in improved outcomes for the patients/clients/population group? (Not Applicable for some epidemiological studies)||Yes|
|2.||Did the authors study an outcome (dependent variable) or topic that the patients/clients/population group would care about?||Yes|
|3.||Is the focus of the intervention or procedure (independent variable) or topic of study a common issue of concern to dieteticspractice?||Yes|
|4.||Is the intervention or procedure feasible? (NA for some epidemiological studies)||Yes|
|1.||Was the research question clearly stated?||Yes|
|1.1.||Was (were) the specific intervention(s) or procedure(s) [independent variable(s)] identified?||Yes|
|1.2.||Was (were) the outcome(s) [dependent variable(s)] clearly indicated?||Yes|
|1.3.||Were the target population and setting specified?||Yes|
|2.||Was the selection of study subjects/patients free from bias?||Yes|
|2.1.||Were inclusion/exclusion criteria specified (e.g., risk, point in disease progression, diagnostic or prognosis criteria), and with sufficient detail and without omitting criteria critical to the study?||Yes|
|2.2.||Were criteria applied equally to all study groups?||Yes|
|2.3.||Were health, demographics, and other characteristics of subjects described?||N/A|
|2.4.||Were the subjects/patients a representative sample of the relevant population?||Yes|
|3.||Were study groups comparable?||Yes|
|3.1.||Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT)||Yes|
|3.2.||Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline?||N/A|
|3.3.||Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.)||Yes|
|3.4.||If cohort study or cross-sectional study, were groups comparable on important confounding factors and/or were preexisting differences accounted for by using appropriate adjustments in statistical analysis?||N/A|
|3.5.||If case control study, were potential confounding factors comparable for cases and controls? (If case series or trial with subjects serving as own control, this criterion is not applicable.)||N/A|
|3.6.||If diagnostic test, was there an independent blind comparison with an appropriate reference standard (e.g., "gold standard")?||N/A|
|4.||Was method of handling withdrawals described?||No|
|4.1.||Were follow-up methods described and the same for all groups?||Yes|
|4.2.||Was the number, characteristics of withdrawals (i.e., dropouts, lost to follow up, attrition rate) and/or response rate (cross-sectional studies) described for each group? (Follow up goal for a strong study is 80%.)||???|
|4.3.||Were all enrolled subjects/patients (in the original sample) accounted for?||No|
|4.4.||Were reasons for withdrawals similar across groups?||???|
|4.5.||If diagnostic test, was decision to perform reference test not dependent on results of test under study?||N/A|
|5.||Was blinding used to prevent introduction of bias?||Yes|
|5.1.||In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate?||Yes|
|5.2.||Were data collectors blinded for outcomes assessment? (If outcome is measured using an objective test, such as a lab value, this criterion is assumed to be met.)||Yes|
|5.3.||In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded?||N/A|
|5.4.||In case control study, was case definition explicit and case ascertainment not influenced by exposure status?||N/A|
|5.5.||In diagnostic study, were test results blinded to patient history and other test results?||N/A|
|6.||Were intervention/therapeutic regimens/exposure factor or procedure and any comparison(s) described in detail? Were interveningfactors described?||Yes|
|6.1.||In RCT or other intervention trial, were protocols described for all regimens studied?||Yes|
|6.2.||In observational study, were interventions, study settings, and clinicians/provider described?||N/A|
|6.3.||Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect?||Yes|
|6.4.||Was the amount of exposure and, if relevant, subject/patient compliance measured?||Yes|
|6.5.||Were co-interventions (e.g., ancillary treatments, other therapies) described?||N/A|
|6.6.||Were extra or unplanned treatments described?||N/A|
|6.7.||Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups?||N/A|
|6.8.||In diagnostic study, were details of test administration and replication sufficient?||N/A|
|7.||Were outcomes clearly defined and the measurements valid and reliable?||Yes|
|7.1.||Were primary and secondary endpoints described and relevant to the question?||Yes|
|7.2.||Were nutrition measures appropriate to question and outcomes of concern?||Yes|
|7.3.||Was the period of follow-up long enough for important outcome(s) to occur?||Yes|
|7.4.||Were the observations and measurements based on standard, valid, and reliable data collection instruments/tests/procedures?||Yes|
|7.5.||Was the measurement of effect at an appropriate level of precision?||Yes|
|7.6.||Were other factors accounted for (measured) that could affect outcomes?||No|
|7.7.||Were the measurements conducted consistently across groups?||Yes|
|8.||Was the statistical analysis appropriate for the study design and type of outcome indicators?||Yes|
|8.1.||Were statistical analyses adequately described and the results reported appropriately?||Yes|
|8.2.||Were correct statistical tests used and assumptions of test not violated?||Yes|
|8.3.||Were statistics reported with levels of significance and/or confidence intervals?||Yes|
|8.4.||Was "intent to treat" analysis of outcomes done (and as appropriate, was there an analysis of outcomes for those maximally exposed or a dose-response analysis)?||No|
|8.5.||Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)?||Yes|
|8.6.||Was clinical significance as well as statistical significance reported?||Yes|
|8.7.||If negative findings, was a power calculation reported to address type 2 error?||N/A|
|9.||Are conclusions supported by results with biases and limitations taken into consideration?||Yes|
|9.1.||Is there a discussion of findings?||Yes|
|9.2.||Are biases and study limitations identified and discussed?||Yes|
|10.||Is bias due to study's funding or sponsorship unlikely?||Yes|
|10.1.||Were sources of funding and investigators' affiliations described?||Yes|
|10.2.||Was the study free from apparent conflict of interest?||Yes|