Systematic Review: Positive Psychological Interventions for Improving Health Behaviors

Positive psychological interventions (PPIs) aim to increase positive emotions, thoughts, and behaviors in people with or without psychopathology. In typical examples, individuals are asked to incorporate acts of kindness, gratitude for daily events, or self-affirmations into their daily lives to increase their focus on positive experiences.

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Emily H. Feig, PhD, a psychologist in the Department of Psychiatry at Massachusetts General Hospital, Bettina Hoeppner, PhD, MS, associate director of research at the Mass General Recovery Research Institute, and colleagues recently conducted the first systematic review of literature on PPIs that assessed health behavior outcomes.

Their report in Preventive Medicine concludes that although PPIs are well received and feasible for promoting health behavior change, there is no consensus on their efficacy for that purpose.

Methods

The reviewers searched the PubMed, PsycINFO and EMBASE databases from inception to December 2020 and the reference lists of the initial studies identified.

Because the topic is understudied, eligible studies included not only randomized controlled trials (RCTs) but also nonrandomized trials, single-arm trials without a control condition and studies in which a health behavior was a secondary outcome.

Study Characteristics

In the end, the team included 27 studies published between 2001 and 2020:

• Type of study—20 papers reviewed were RCTs and seven were single-arm studies measuring pre/post changes. The only studies powered to detect significantly significant intervention effects were 13 of the RCTs. The other 14 studies were designed as feasibility and/or pilot studies
• Health behaviors—The health behavior most frequently targeted was physical activity (20 studies) followed by medication adherence (eight studies), diet (seven studies) and smoking cessation (three studies). Eight studies targeted multiple health behaviors
• Interventions—Six RCTs sought to increase positive affect and self-affirmation by teaching participants to think of things they perceived as positive or were proud of. Ten studies taught a series of positive psychology skills aimed at enhancing gratitude, personal strengths and meaning in life. Other interventions focused specifically on enhancing resiliency, gratitude, optimism, happiness and/or social support
• Participants—21 studies included adults (mean age, 36–71), five targeted young adults (usually college students) specifically and one enrolled only adolescents

Intervention Effects Overall

PPIs appeared to hold promise:

• Across all studies, 19 showed improvement in at least one health behavior with medium or large effect size
• Of the 13 RCTs powered to detect significant effects, six found significant improvement in at least one health behavior
• The interventions were largely feasible, as judged from low withdrawal rates, and where acceptability was measured the ratings were high
• Studies that directly targeted a health behavior in combination with a PPI did not have consistently different effects than those that used PPIs alone

Intervention Effects by Health Behavior

Sample sizes, type and quality of outcome measurement, and content, duration and intensity of PPIs differed widely between studies, and the results for specific health behaviors reflected that variability:

• Physical activity—Studies of this behavior were the most likely to show significant improvements and/or large effect sizes of PPIs
• Medication adherence—Most studies did not find PPIs had significant effects
• Diet—Measurement was so variable across studies that no definitive conclusion could be drawn
• Smoking cessation—Conclusions could not be drawn, as only two of the three studies measured cigarette use comprehensively, and one of those studies was uncontrolled and had low power

Conclusion

Because of the heterogeneous literature and its preliminary nature, there is not yet a strong evidence base that PPIs consistently improve behavioral outcomes. More research using objectively measurement health behaviors and appropriate sample size is needed to determine how and for whom PPIs could affect meaningful health behavior change.

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