Move More for Life: Theory-and evidence-based development and process evaluation notes

Abstract

  • Title of the work: Theory-and evidence-based development and process evaluation of the Move More for Life program: a tailored-print intervention designed to promote physical activity among post-treatment breast cancer survivors.
  • Authors: Camille E Short, Erica L James, Ronald C Plotnikoff.
  • Objective: Describe theory-and evidence-based development of Move More for Life (a computer-tailored, print intervention) and exemplify theory-based applied research.
  • Methods: Used Kreuter et al.’s nine-step program planning model to develop the computer-tailored intervention; the tailoring guide by Kreuter et al. aided integration of theory and evidence-based practice.
  • Results: Tailoring guide useful for integrating theory and practice; participants generally rated tailored materials as attention-catching, personally relevant, and useful for changing behaviour, but considerable room for improvement.
  • Conclusion: Move More for Life is a low-cost, potentially sustainable approach to PA promotion grounded in Social Cognitive Theory (SCT); detailed development descriptions enable replication/adaption and guide future theory-based applied research in PA promotion among cancer survivors and distance-based PA promotion in other populations.
  • Trial: Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12611001061921.
  • Keywords: Physical activity, Intervention development, Social cognitive theory, Breast cancer survivors, Tailored-print.

Background

  • Breast cancer: highest incidence among women in many regions; improved survival with screening and adjuvant treatments leads to long-term survivors facing recurrence risk, metastases, and chronic comorbidity.
  • Population health goal: reduce survivor health deficits (lower QoL, reduced physical function, fatigue) via regular physical activity (PA).
  • Current situation: Most survivors are inactive or have difficulty maintaining activity; many trials show PA benefits, but PA promotion is not routine in cancer care.
  • Computer-tailored print interventions:
    • Provide messages matched to personal characteristics at relatively low cost with wide reach.
    • Shown to be more efficacious than non-tailored print approaches, but reporting on how interventions work (theoretical basis, techniques used, links between theory and techniques) is often lacking.
  • The “black box of tailoring”: tailor mechanisms often poorly described; comprehensive reporting standards for tailored interventions have been published to address this gap.
  • Aim of the current paper: Describe development and process evaluation of Move More for Life; align with reporting standards; enable replication/adaptation; discuss implications for researchers and for distance-based PA promotion.
  • Prior trial: Move More for Life evaluated in a large Australian RCT (n ≈ 330 post-treatment survivors).

Methods

  • Ethics: University of Newcastle Human Research Ethics Committee (H-2010-11-3).
  • Framework: 9-step program-planning model (Kreuter et al.) to guide tailoring and delivery.
    • Steps (brief):
      1) Analyzing the health problem; 2) Developing a program framework; 3) Developing tailoring assessment; 4) Designing feedback; 5) Writing tailored messages; 6) Creating tailored algorithms; 7) Automating the tailoring process; 8) Implementing the program; 9) Evaluating the program.
  • Theoretical basis: Selected Social Cognitive Theory (SCT) as the primary framework; reasons include:
    • SCT explains PA behaviour in survivors and demonstrates stronger explanatory power than the Theory of Planned Behaviour (TPB) for this context, largely due to self-efficacy.
    • Self-efficacy is a key SCT construct and a strong correlate of PA in survivors.
    • More SCT constructs in an intervention generally yield larger effect sizes.
    • Variability in SCT constructs among survivors supports tailoring.
    • SCT provides predictors and practical guidance for enabling health-promoting habit formation.
  • Comparison of theories: TPB vs SCT; SCT preferred for described reasons (self-efficacy predictive power, tailoring relevance, etc.).
  • Evidence synthesis: Reviewed determinants of PA in survivors to identify targets for segmentation and tailoring; summary of determinants (demographics, health status, SCT constructs) informed targeting and tailoring strategies.
  • Data collection and theory refinement: Conducted qualitative work with post-treatment survivors to understand how SCT constructs relate to PA and to inform operationalization of constructs and strategies; immediate PA benefits (weight loss, fatigue reduction) and knowledge gaps were identified as drivers for tailoring tone.
  • Tailoring approach: Mixed sources of evidence (demographics, health status, SCT constructs) plus actual PA behaviour to tailor messages; audience segmentation considered co-morbidity, disability, and other psycho-social factors.
  • Studies and reviews informing design: Literature and meta-analyses suggested that multi-contact, theory-based, and timely print delivery improve efficacy; tailored messages should be iterative and delivered within a short window after tailoring assessment.

Step 1: Analyzing the health problem

  • Theoretical frameworks reviewed: TPB and SCT; SCT chosen for multiple reasons (see above).
  • Rationale for SCT constructs in this population: self-efficacy as a central predictor; relevance of social support; ability of SCT to guide tailoring across multiple determinants.
  • Literature synthesis outcomes guiding planning: key demographics and health variables for audience segmentation (age, comorbidity, weight, PA history, etc.); key social-cognitive determinants (self-efficacy, social support, intention, outcome expectations).
  • Operationalization insight: intentions conceptualized as proximal goals within SCT; need to tailor messages to diverse survivor experiences and motivations.

Step 2: Developing the program framework

  • Program objectives (informed by PA guidelines and sedentary-risk evidence):
    • Primary: increase total minutes and days/week of health-enhancing PA (aerobic + resistance training).
    • Secondary: promote maintenance of regular PA; reduce sedentary time.
  • Program constraints: budget AUD 52,000; 3-year timeline.
  • Designing the framework based on evidence: Systematic review of computer-tailored PA interventions; findings highlighted multiple-contacts, theory-based design, and rapid tailoring after the assessment; two meta-analyses supported multiple-contact, iteratively tailored approaches; tailoring improves efficacy, particularly when combined with ongoing feedback.
  • Advisory input: Expert panel advised maximizing acceptability and materials given program constraints; guidance to collect direct participant input on acceptability and to maximize tailored outputs.
  • Acceptability study: Qualitative interviews (n=8 post-treatment survivors) showed:
    • General support for distance-based tailored PA advice.
    • Perceived benefits included exercise instruction clarity, access to more information, and monitoring.
    • Preferences varied on frequency (monthly vs weekly) and program length (3 months deemed appropriate).
    • Quotes illustrate motivation, monitoring value, and desire for feedback and accountability.
  • Program framework decisions: Three tailored newsletters delivered over 12 weeks (every 6 weeks); iterative tailoring via update cards at 4 and 8 weeks; mail-delivered, computer-tailored content.
  • Outcome focus: iterative tailoring to modify PA and sitting behaviour; alignment with SCT-based strategies.
  • Reference to additional materials: detailed program framework described in a separate publication.

Step 3: Developing a tailoring assessment questionnaire

  • Embedding: Tailoring assessment embedded within the baseline survey.
  • Measures: All SCT constructs assessed with validated measures where available; some adapted for breast cancer survivors.
  • Dual purpose measures: Prepared for both tailoring and mediation analyses in baseline and follow-up surveys; a balance was sought between measure comprehensiveness and survey length.
  • Update cards: Two short update cards for PA and goal-setting over the previous month used to provide iterative feedback in newsletters 2 and 3.
  • Tailoring inputs: Demographic, social-cognitive, health and behaviour variables used to tailor messages across all newsletters.

Step 4: Designing design templates

  • Collaboration with design firm Headjam; basing design on prior resources and survivor-focused materials.
  • Newsletter layout: Four A4 pages per issue; blocks include:
    • Welcome message
    • Targeted expert advice (non-tailored)
    • Feedback on PA behaviour and sitting time
    • Persuasive message tailored to SCT constructs
    • Action planning task
  • Content sequencing: Order of SCT constructs informed by literature and Bandura’s model (self-efficacy as a focal determinant with downstream effects on other constructs).
  • Branding: Move More for Life logo and a cohesive design using watercolour textures and hand-painted graphics for a personalised look.
  • Relevance to tailoring: A detailed description of each newsletter and tailoring variables provided elsewhere; design decisions aimed to support engagement and comprehension.

Step 5: Writing tailored messages

  • Message concept booklets: For each newsletter, outlining intended message location, objective, message parameters, tailoring variables, and feedback variables.
  • Writing and review: CS wrote messages; subset reviewed by EJ; copy-editing to ensure quality and appropriateness.

Step 6: Creating tailored algorithms

  • Purpose: Link tailoring assessment items/responses to tailored messages via logic statements (if this, then that).
  • Data components:
    • Raw variables: Participant responses from the tailoring assessment (Table 4 example).
    • Intermediate variables: New variables derived from raw data (e.g., whether meeting PA guidelines using aerobic and resistance data; age, BMI, SCT measures).
    • Feedback variables: Definitions that determine which PA messages to deliver based on raw/intermediate data (Table 6 example).
  • Example structure: An intermediate variable describing meeting aerobic guidelines is combined with raw variables to determine PA messages.

Step 7: Automating the tailoring process

  • Implementation tech stack: HTML, CSS, Java (web-based tailored newsletters).
  • Development stages:
    • Style: PDF print styling via CSS; multi-column rendering issues resolved by choosing Firefox as the best browser for rendering.
    • User interface: Online interface to input baseline data and generate PDFs.
    • Scripts: JavaScript rules to activate/deactivate message blocks based on data (if/else-if/else).
    • Output: All newsletters embedded in a single HTML document with inlined scripts and messages.
  • Development cost and time: Tailoring system cost AUD $14,000; total program development cost AUD $21,580; development took 8 months (plus some steps).
  • Team: Primarily CS with EJ and RP providing guidance.
  • Cost details (per stage): Step 1 qualitative research; Steps 2–7 newsletter design; copy-editing; programming; Step 8 production; Step 9 evaluation materials; full cost table provided in publication.

Step 8: Implementing the program

  • Recruitment: 109 post-treatment survivors recruited from across Australia via community and setting-based methods (cancer organizations; health professionals; breast cancer beacons).
  • Response rate to tailoring: Newsletter generation complicated by printing protocol; final feedback generation took time.
  • Newsletter generation timeline:
    • Newsletter 1: Tailoring assessment mailed; return within 10 days; average return time 19 days (SD 6.2).
    • Newsletter production: PDFs created within ~3.17 days (SD 2.5) after data receipt; printing/delivery took about 25 days (SD 4.9) due to external printer batching.
    • Newsletter 2 and 3: If update cards not returned within 2 weeks, iterative feedback was not provided.
  • Update card return rates: 70% (newsletter 1), 60% (newsletter 2); 49% returned both cards; 15% did not return any card.
  • Output: Three newsletters plus an exemplar exercise poster and activity planner; delivery occurred via postal mail.

Step 9: Evaluating the program

  • Study sample and response: 109 received newsletters; 92 completed feedback questionnaires (84% response rate); no differences between responders and non-responders on key demographics.
  • Baseline characteristics (n=92):
    • Mean age: 56 years (range 34–74)
    • Marital status: ~80% married or de facto
    • Education: ~47% completed university
    • Income: ~38% > AUD 1000/week
    • Remote/regional: ~51%
    • BMI: mean 26.6 (SD 5.11)
    • Months post active treatment: mean ~41 (SD 39)
    • Disease stage distribution: various stages (0–4) with some unknowns
    • Treatments received: Surgery ~93%; Chemotherapy ~71%; Radiotherapy ~68%; Hormone therapy ~56%
    • PA status at baseline: 23% aerobic >150 min/wk; 15% resistance >6 exercises/wk
  • Process evaluation: Likert-scale feedback on materials
    • Materials caught attention: 74% rated 3–5 (some to very much); mean 3.6 (SD 0.88)
    • Personally relevant: 73% rated 3–5; mean 3.7 (SD 0.96)
    • Helpful for behaviour change: 63.2% rated 3–5; mean 3.2 (SD 1.11)
    • Note: ~25% did not find personally relevant; ~33% did not find helpful for changing behaviour, despite tailoring intent.
  • Qualitative feedback (open-ended): Mostly positive comments on design (eye-catching, easy to read, colorful; useful charts for stretches). Some concerns:
    • Newsletter size felt unwieldy; desire for smaller or alternative formats (e.g., app, wallet-sized diary).
    • Some participants felt exercises were not suitable for post-surgery recovery; recommended gradual progression and more emphasis on progression of weights/reps.
    • Some perceived goal setting as unrealistic given personal time constraints.
  • Quantitative analyses to explore heterogeneity of tailoring effects:
    • Ordinal logistic regression examined associations between baseline characteristics and ratings of intervention relevance and usefulness.
    • Key predictors of personal relevance:
    • Higher sitting time; higher behavioural control (knowledge/skill for PA); greater observational learning; not working; no history of radiotherapy.
    • Key predictors of usefulness:
    • Higher sitting time; higher knowledge/skill; unmarried status; higher task self-efficacy.
    • Additional results (Table 9) indicate: higher resistance training, living in a major city, higher aerobic activity, more positive outcome expectations, and higher quality of life associated with higher odds of rating materials as personally relevant or useful.
  • Mediation and efficacy: Randomized controlled trial findings on immediate/mid-term outcomes and mediators forthcoming; related analyses published elsewhere.
  • Theoretical interpretation: Tailoring effectiveness linked to information processing theories (e.g., elaboration likelihood model) suggesting personally relevant information is more elaborately processed and thus more persuasive.
  • Overall interpretation: Messages were generally well-received and tailored, but mismatches occurred for certain psycho-social profiles and resource-poor participants; there is a need to refine tailoring to address heterogeneity.

Cost and development timeline summary

  • Development timeline: 8 months for design and development (steps 1–7; plus some steps overlapped with step 8).
  • Total development cost: AUD $21,580 (not including salaries).
  • Tailoring system cost: AUD $14,000 (programmer cost for HTML/CSS/Java/JAVA integration).
  • Step 1–7 development costs (example): Qualitative research $1,800; design/copy-editing $2,400; programming $14,000; other design-related costs.
  • Step 8 production costs: Printed newsletters; update cards; posters; total shown in Table 7 of the paper (not including salaries).
  • Participant reach and enrollment: 109 enrolled; 92 completed feedback (84% response rate).

Design and delivery considerations

  • Design features aligned with SCT and behavior change techniques: action planning, specific instructions, feedback on past behaviour, progress monitoring, social support strategies, and vicarious experiences through testimonials and expert sections.
  • Techniques mapped to SCT constructs (Table 2):
    • Self-efficacy: action planning, specific instructions, progress feedback, vicarious experiences.
    • Environment: social support, practical coping with barriers, community PA resources.
    • Behavioural capability: PA guidelines, activity demonstrations.
    • Expectations: benefits of PA, social comparisons.
    • Self-control: goal setting, self-monitoring, problem solving, self-reward.
    • Observational learning: role models, survivor testimonials, expert advice.
  • Output components: Newsletters 1–3, exemplar exercise poster, update card, activity planner; all designed to support progressive engagement and planning.
  • Delivery mode: Print newsletters delivered by post, chosen for older-to-middle-aged survivor population; acceptability of print vs. online modes discussed; majority reported internet access but delivery mode might be revisited for future work.
  • Ethical and methodological considerations: Emphasized transparent reporting for tailored interventions and links between theory and techniques; plan for mediation and moderation analyses to unpack mechanisms of action.

Lessons learned and next steps

  • Timeliness of feedback: Printing/logistics caused delays; in-house printing could substantially reduce delivery time and improve uniformity of feedback timing.
  • Delivery mode considerations: Although print was chosen for demographic reasons, most survivors had internet access; future work should compare print vs web/mobile delivery using RE-AIM to assess reach, efficacy, adoption, implementation, and maintenance.
  • Tailoring heterogeneity: Some participants did not perceive relevance or usefulness; recommend developing tailoring that captures message heterogeneity and tracks delivered messages more precisely to understand heterogeneity.
  • Future research directions: Efficacy vs comparator intervention and standard care; SCT mediators of effects at long-term follow-up; moderator analyses to identify who benefits most; more detailed reporting on working mechanisms to inform replication/adaptation.
  • Practical implications: The study offers a replicable, theory-guided approach to developing computer-tailored interventions and can inform distance-based PA promotion strategies for cancer survivors and other populations.

Additional references and links cited in the paper (highlights)

  • Frameworks and theories:
    • Theory of Planned Behavior (Ajzen, 1991)
    • Social Cognitive Theory (Bandura, 1977; 2004)
    • Transtheoretical Model (Prochaska & Velicer, 1997)
  • Tailoring and reporting standards:
    • Kreuter et al. (2000) tailoring health messages
    • Michie et al. (2009, 2010) and Harrington & Noar (2012) on reporting and linking theory to techniques
    • RE-AIM framework (Glasgow et al., 1999)
  • Key measures and determinants (selected): self-efficacy, social support, intention, outcome expectations, observational learning, behavioural control, demographics, PA history, BMI, QoL, fatigue.
  • Related work and context: FRESH-START trial (diet and exercise), various cancer survivor PA studies, and methodological papers on mediation and moderation analyses in theory-based interventions.

Summary takeaways

  • The Move More for Life program demonstrates a rigorous, theory-driven process for developing a tailored-print PA intervention for breast cancer survivors, anchored in SCT and enhanced by a structured 9-step planning framework.
  • The program achieved generally positive acceptability, with evidence of heterogeneity in perceived relevance and usefulness related to participant characteristics and psychosocial factors.
  • Key operational insights include the importance of timely feedback, consideration of delivery mode, and the need to refine tailoring to address heterogeneity and magnetic engagement across diverse survivor profiles.
  • The documented development process and cost/timeline data provide a useful blueprint for replication, adaptation, and further methodological work in tailored PA interventions for cancer survivors and other populations.

Glossary of acronyms used

  • SCT: Social Cognitive Theory
  • TPB: Theory of Planned Behavior
  • PA: physical activity
  • RCT: randomized controlled trial
  • ANZCTR: Australian New Zealand Clinical Trials Registry
  • ICT: information and communication technology (implicit in the computer-tailored approach)
  • RE-AIM: Reach, Efficacy, Adoption, Implementation, Maintenance

References to tables/figures (as cited in the transcript)

  • Table 1: Nine-step tailoring process (Kreuter et al.)
  • Table 2: Correspondence between SCT constructs and behavioural techniques used in Move More for Life
  • Table 3: Summary of literature on determinants/predictors of PA among breast cancer survivors
  • Table 4: Sample raw variable table (example variables for tailoring assessment)
  • Table 5: Sample intermediate variable (e.g., PA guideline attainment calculation)
  • Table 6: Sample feedback variable (algorithm examples for messages)
  • Table 7: Cost per development stage
  • Table 8: Participant characteristics (n = 92)
  • Table 9: Factors associated with ratings of intervention personal relevance and usefulness
  • Figure 1: Newsletters 1–3, exemplar exercise poster, update card and activity planner

Notes on practical implementation for exams

  • Be able to explain how Kreuter’s nine steps guide the development of tailored health messages and why each step matters.
  • Understand why SCT was chosen over TPB for this PA intervention in cancer survivors and how SCT constructs map onto specific tailoring techniques.
  • Describe how the tailoring assessment, intermediate variables, and feedback variables form the backbone of the automated tailoring system.
  • Discuss the balance and trade-offs between print-based delivery and digital delivery for tailored interventions, including considerations for reach, cost, timeliness, and user preferences.
  • Be able to summarize the main process evaluation findings (acceptability, perceived relevance, usefulness) and the key factors associated with varying ratings of relevance/usefulness as shown in the regression results.
  • Recognize the practical implications of the lessons learned (e.g., in-house printing to reduce turnaround, potential for web/mobile delivery, and the need to address heterogeneity in tailoring).
  • Recall the core quantitative data: sample size (109 enrolled, 92 completed feedback), basic demographics (mean age ~56), response rates (84%), program length (3 newsletters over 12 weeks), and update card return rates (70% and 60% for newsletters 1 and 2).