Links Between Behavior Change Techniques and Mechanisms of Action: An Expert Consensus Study

Muslim Communities Learning About Second-hand Smoke in Bangladesh (MCLASS II): a combined evidence and theory-based plus partnership intervention development approach

Introduction

Deaths from second-hand smoke (SHS) exposure are increasing, but there is not sufficient evidence to recommend a particular SHS intervention or intervention development approach. Despite the available guidance on intervention reporting, and on the role and nature of pilot and feasibility studies, partial reporting of SHS interventions is common. The decision-making whilst developing such interventions is often under-reported. This paper describes the processes and decisions employed during transitioning from the aim of adapting an existing mosque-based intervention focused on public health messages, to the development of the content of novel community-based Smoke-Free Home (SFH) intervention. The intervention aims to promote smoke-free homes to reduce non-smokers’ exposure to SHS in the home via faith-based messages.

Methods

The development of the SFH intervention had four sequential phases: in-depth interviews with adults in households in Dhaka, identification of an intervention programme theory and content with Islamic scholars from the Bangladesh Islamic Foundation (BIF), user testing of candidate intervention content with adults, and iterative intervention development workshops with Imams and khatibs who trained at the BIF.

Results

It was judged inappropriately to take an intervention adaptation approach. Following the identification of an intervention programme theory and collaborating with stakeholders in an iterative and collaborative process to identify barriers, six potentially modifiable constructs were identified. These were targeted with a series of behaviour change techniques operationalised as Quranic verses with associated health messages to be used as the basis for Khutbahs. Following iterative user testing, acceptable intervention content was generated.

Conclusion

The potential of this community-based intervention to reduce SHS exposure at home and improve lung health among non-smokers in Bangladesh is the result of an iterative and collaborative process. It is the result of the integration of behaviour change evidence and theory and community stakeholder contributions to the production of the intervention content. This novel combination of intervention development frameworks demonstrates a flexible approach that could provide insights for intervention development in related contexts.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-01100-5.

Social cognition theories and behavior change in COVID-19: A conceptual review

The COVID-19 pandemic has had unprecedented health, economic, and social consequences worldwide. Although contact reductions and wearing face coverings have reduced infection rates, and vaccines have reduced illness severity, emergence of new variants of the coronavirus that causes COVID-19, and the shift from pandemic to endemic patterns of infection, highlights the importance of ongoing preventive behavior adherence to manage future outbreaks. Research applying social cognition theories may assist in explaining variance in these behaviors and inform the development of efficacious behavior change interventions to promote adherence. In the present article, we summarize research applying these theories to identify modifiable determinants of COVID-19 preventive behaviors and the mechanisms involved, and their utility in informing interventions. We identify limitations of these applications (e.g., overreliance on correlational data, lack of long-term behavioral follow-up), and suggest how they can be addressed. We demonstrate the virtue of augmenting theories with additional constructs (e.g., moral norms, anticipated regret) and processes (e.g., multiple action phases, automatic processes) to provide comprehensive, parsimonious behavioral explanations. We also outline how the theories contribute to testing mechanisms of action of behavioral interventions. Finally, we recommend future studies applying these theories to inform and test interventions to promote COVID-19 preventive behavior adherence.

Barriers to following imaging guidelines for the treatment and management of patients with low-back pain in primary care: a qualitative assessment guided by the Theoretical Domains Framework

Background

Low back pain (LBP) is a leading cause of disability and is among the top five reasons that patients visit their family doctors. Over-imaging for non-specific low back pain remains a problem in primary care. To inform a larger study to develop and evaluate a theory-based intervention to reduce inappropriate imaging, we completed an assessment of the barriers and facilitators to reducing unnecessary imaging for NSLBP among family doctors in Newfoundland and Labrador (NL).

Methods

This was an exploratory, qualitative study describing family doctors’ experiences and practices related to diagnostic imaging for non-specific LBP in NL, guided by the Theoretical Domains Framework (TDF). Data were collected using in-depth, semi-structured interviews. Transcripts were analyzed deductively (assigning text to one or more domains) and inductively (generating themes at each of the domains) before the results were examined to determine which domains should be targeted to reduce imaging.

Results

Nine family doctors (four males; five females) working in community (n = 4) and academic (n = 5) clinics in both rural (n = 6) and urban (n = 3) settings participated in this study. We found five barriers to reducing imaging for patients with NSLBP: 1) negative consequences, 2) patient demand 3) health system organization, 4) time, and 5) access to resources. These were related to the following domains: 1) beliefs about consequences, 2) beliefs about capabilities, 3) emotion, 4) reinforcement, 5) environmental context and resources, 6) social influences, and 7) behavioural regulation.

Conclusions

Family physicians a) fear that if they do not image they may miss something serious, b) face significant patient demand for imaging, c) are working in a system that encourages unnecessary imaging, d) don’t have enough time to counsel patients about why they don’t need imaging, and e) lack access to appropriate practitioners, community programs, and treatment modalities to prescribe to their patients. These barriers were related to seven TDF domains. Successfully reducing inappropriate imaging requires a comprehensive intervention that addresses these barriers using established behaviour change techniques. These techniques should be matched directly to relevant TDF domains. The results of our study represent the important first step of this process – identifying the contextual barriers and the domains to which they are related.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-022-01751-6.

Motivating Machines: The Potential of Modeling Motivation as MoA for Behavior Change Systems

The pathway through which behavior change techniques have an effect on the behavior of an individual is referred to as the Mechanism of Action (MoA). Digitally enabled behavior change interventions could potentially benefit from explicitly modelling the MoA to achieve more effective, adaptive, and personalized interventions. For example, if ‘motivation’ is proposed as the targeted construct in any behavior change intervention, how can a model of this construct be used to act as a mechanism of action, mediating the intervention effect using various behavior change techniques? This article discusses a computational model for motivation based on the neural reward pathway with the aim to make it act as a mediator between behavior change techniques and target behavior. This model’s formal description and parametrization are described from a neurocomputational sciences prospect and elaborated with the help of a sub-question, i.e., what parameters/processes of the model are crucial for the generation and maintenance of motivation. An intervention scenario is simulated to show how an explicit model of ‘motivation’ and its parameters can be used to achieve personalization and adaptivity. A computational representation of motivation as a mechanism of action may also further advance the design, evaluation, and effectiveness of personalized and adaptive digital behavior change interventions.

Maintenance of physical activity after cardiac rehabilitation (FAIR): study protocol for a feasibility trial

INTRODUCTION

To enhance health and prevent secondary consequences for patients with cardiovascular disease (CVD), maintenance of an active lifestyle following participation in cardiac rehabilitation (CR) is important. However, levels of physical activity often decrease after completion of a structured CR programme. Models that support long-term behaviour change with a sustained level of physical activity are imperative. The aim of this study is to evaluate the feasibility of a mobile health intervention based on the Health Action Process Approach theoretical model of behaviour change in patients with CVD for 3 months after completion of a CR programme.

METHODS AND ANALYSIS

In a feasibility trial design, we will recruit 40 participants from CR programmes at Slagelse Hospital, the City of Slagelse (municipality), or Holbæk Hospital. After completing the standard structured CR programme, each participant will create an action plan for physical activity together with a physiotherapist. Following that, participants are sent 2 weekly text messages for 3 months. The first text message prompts physical activity, and the second will check if the action plan has been followed. If requested by participants, a coordinator will call and guide the physical activities behaviour. The feasibility of this maintenance intervention is evaluated based on predefined progression criteria. Physical activity is measured with accelerometers at baseline and at 3 months follow-up.

ETHICS AND DISSEMINATION

Study approval was waived (EMN-2021-00020) by the Research Ethics Committee of Region Zealand, Denmark. Study results will be made public and findings disseminated to patients, health professionals, decision-makers, researchers and the public.

TRIAL REGISTRATION NUMBER

NCT05011994.

Investigating strategies to increase general education teachers' adherence to evidence-based social-emotional behavior practices: A meta-analysis of the single-case literature

Educational researchers have produced a variety of evidence-based practices (EBP) to address social, emotional, and behavioral (SEB) needs among students. Yet, these practices are often insufficiently adopted and implemented with fidelity by teachers to produce the beneficial outcomes associated with the EBP, leaving students at risk for developing SEB problems. If ignored, SEB problems can lead to other negative outcomes, such as academic failure. Therefore, implementation strategies (i.e., methods and procedures designed to promote implementation outcomes) are needed to improve teachers' uptake and delivery of EBPs with fidelity. This meta-analysis sought to examine the types and magnitude of effect of implementation strategies that have been designed and tested to improve teacher adherence to SEB EBPs. Included studies (a) used single case experimental designs, (b) employed at least one implementation strategy, (c) targeted general education teachers, and (d) evaluated adherence as a core dimension of fidelity related to the delivery of EBPs. In total, this study included 28 articles and evaluated 122 effect sizes. A total of 15 unique implementation strategies were categorized. Results indicated that, on average, implementation strategies were associated with increases in teacher adherence to EBPs above baseline and group-based pre-implementation trainings alone (g = 2.32, tau = 0.77). Moderator analysis also indicated that larger effects were associated with implementation strategies that used a greater number of unique behavior change techniques (p < .001). Implications and future directions for research and practice regarding use of implementation strategies for general education teachers are discussed.

A framework to guide storytelling as a knowledge translation intervention for health-promoting behaviour change

BACKGROUND

Stories can be a powerful tool to increase uptake of health information, a key goal of knowledge translation (KT). Systematic reviews demonstrate that storytelling (i.e. sharing stories) can be effective in changing health-promoting behaviours. Though an attractive KT strategy, storytelling is a complex approach requiring careful planning and consideration of multiple factors. We sought to develop a framework to assist KT researchers and practitioners in health contexts to consider and develop effective KT interventions that include stories or storytelling.

METHODS

We conducted a broad search of the literature to identify studies that used storytelling as a KT intervention across different disciplines: health research, education, policy development, anthropology, organizational development, technology research, and media. We extracted purposes, theories, models, mechanisms, and outcomes and then mapped the theoretical and practical considerations from the literature onto the Medical Research Council guidance for complex interventions. The theoretical and practical considerations uncovered comprised the basis of the storytelling framework development. Through discussion and consensus, methodological experts refined and revised the framework for completeness, accuracy, nuance, and usability.

RESULTS

We used a complex intervention lens paired with existing behaviour change techniques to guide appropriate theory-based intervention planning and practical choices. An intentional approach to the development of story-based KT interventions should involve three phases. The theory phase specifies the goal of the intervention, mechanisms of action, and behaviour change techniques that will achieve the intended effects. The modelling phase involves development and testing using an iterative approach, multiple methods and engagement of end-users. Finally, formal evaluation using multiple methods helps determine whether the intervention is having its intended effects and value added.

CONCLUSIONS

This framework provides practical guidance for designing story-based KT interventions. The framework was designed to make explicit the requisite considerations when determining the appropriateness and/or feasibility of storytelling KT, clarify intervention goals and audience, and subsequently, support the development and testing of storytelling interventions. The framework presents considerations as opposed to being prescriptive. The framework also offers an opportunity to further develop theory and the KT community's understanding of effectiveness and mechanisms of action in storytelling interventions.

A mobile phone application intervention to promote healthy salt intake among adults: Protocol for a randomized controlled study (Preprint)

Background

There is sound evidence associating high salt intake and a greater risk of cardiovascular and noncardiovascular diseases. High salt intake has been observed in several populations worldwide. Therefore, promoting healthier salt consumption has been encouraged as a low-cost strategy to reduce this risk factor. However, these strategies need to be sound, built on theoretical and methodological bases, and consider the target population’s context.

Objective

This protocol aims to describe a mobile phone app intervention to promote healthy salt intake among adults.

Methods

This is an experimental and longitudinal study protocol conducted in three modules. Module 1 refers to the planning of the intervention based on the Behaviour Change Wheel framework. Module 2 is the development of the mobile phone app intervention based on the date of module 1. In module 3, the intervention will be evaluated using a randomized controlled study, with three steps of data collection in a 2-month follow-up in a sample of 86 adults (43 participants for each group: the control group and intervention group) recruited from the primary health care centers of a Brazilian town. The discretionary salt intake questionnaire will assess salt consumption, the app usability will be assessed using the System Usability Scale, and psychosocial variables (habit, intention, and self-efficacy) will also be measured.

Results

Recruitment began in October 2021, and the follow-up will end in August 2022. The results of this study are expected to be published in 2023.

Conclusions

Results from this study will help people to control salt intake when cooking at home, will stimulate self-care, will work as an alternative or supportive method in the relationship between health care professionals and patients, and will contribute to implementing the app intervention to promote healthy salt intake on a large scale.

Trial Registration

The Brazilian Clinical Trials Registry RBR-4s8qyyq; https://ensaiosclinicos.gov.br/rg/RBR-4s8qyyq

International Registered Report Identifier (IRRID)

DERR1-10.2196/37853

Identifying ways to improve diabetes management during cancer treatments (INDICATE): protocol for a qualitative interview study with patients and clinicians

INTRODUCTION

A large and growing number of patients with cancer have comorbid diabetes. Cancer and its treatment can adversely impact glycaemic management and control, and there is accumulating evidence that suboptimal glycaemic control during cancer treatment is a contributory driver of worse cancer-related outcomes in patients with comorbid diabetes. Little research has sought to understand, from the perspective of patients and clinicians, how and why different aspects of cancer care and diabetes care can complicate or facilitate each other, which is key to informing interventions to improve diabetes management during cancer treatments. This study aims to identify and elucidate barriers and enablers to effective diabetes management and control during cancer treatments, and potential intervention targets and strategies to address and harness these, respectively.

METHODS AND ANALYSIS

Qualitative interviews will be conducted with people with diabetes and comorbid cancer (n=30-40) and a range of clinicians (n=30-40) involved in caring for this patient group (eg, oncologists, diabetologists, specialist nurses, general practitioners). Semistructured interviews will examine participants' experiences of and perspectives on diabetes management and control during cancer treatments. Data will be analysed using framework analysis. Data collection and analysis will be informed by the Theoretical Domains Framework, and related Theory and Techniques Tool and Behaviour Change Wheel, to facilitate examination of a comprehensive range of barriers and enablers and support identification of pertinent and feasible intervention approaches. Study dates: January 2021-January 2023.

ETHICS AND DISSEMINATION

The study has approval from National Health Service (NHS) West Midlands-Edgbaston Research Ethics Committee. Findings will be presented to lay, clinical, academic and NHS and charity service-provider audiences via dissemination of written summaries and presentations, and published in peer-reviewed journals. Findings will be used to inform development and implementation of clinical, health services and patient-management intervention strategies to optimise diabetes management and control during cancer treatments.

Employing the theory of planned behaviour to design an e-cigarette education resource for use in secondary schools

Background

An extended version of the theory of planned behaviour (TPB) was used to inform the design of a framework for an educational resource around e-cigarette use in young people.

Methods

A sequential exploratory design was employed. In Phase 1, elicited behavioural, normative and control beliefs, via 7 focus groups with 51 participants, aged 11–16 years, identified salient beliefs around e-cigarette use. These were used to construct a questionnaire administered to 1511 young people aged 11–16 years, which determined predictors of e-cigarette use and ever use. In Phase 2, sociodemographic variables, e-cigarette knowledge, access, use, marketing and purchasing of e-cigarettes and smoking behaviour were also gathered. The composite findings from Phase 1 and 2 informed the design of a post primary educational resource in Phase 3 around e-cigarette use.

Results

Current e-cigarette use was 4%, with almost 23% reporting ever use, suggesting current use is stable but experimentation may be increasing in this cohort. Sociodemographic variables, knowledge of e-cigarettes, smoking behaviour and TPB variables (direct and indirect measures of attitudes, subjective norm, and perceived behavioural control) accounted for 17% of the variance in current e-cigarette use, with higher intentions to use e-cigarettes within the next month, having the strongest impact on use (p < 0.001), followed by self-efficacy (p = 0.016). Sociodemographic and TPB variables accounted for 65% of the variance in intentions to use e-cigarettes in the next month; current e-cigarette use (p < 0.001), more positive attitudes (p < 0.001), stronger social influence (p < 0.001), higher self-efficacy (p < 0.001), higher control beliefs (p < 0.001) and greater motivation to use e-cigarettes (p < 0.001) were the main predictors of intentions. Phases 1 and 2 informed the mapping of key predictors of intentions and use of e-cigarettes onto the Theoretical Domains Framework, which identified appropriate intervention functions and behaviour change techniques.

Conclusions

This paper is the first to bridge the theoretical-practice gap in an area of significant public health importance through the development of a framework for a novel theory driven school-based educational resource aimed at reducing experimentation and uptake of e-cigarette use in young people.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-12674-3.

Exploring barriers and facilitators for mental health professionals delivering behavioural activation to young people with depression: qualitative study using the Theoretical Domains Framework

BACKGROUND

Depression prevalence among young people is increasing, with growing pressures on specialist mental health services. Manualised behavioural activation therapy may be effective for young people, and can be delivered by a range of mental health professionals (MHPs). This study explored clinician perspectives of barriers and facilitators to implementing behavioural activation with young people in routine practice.

AIMS

We conducted a qualitative study with individual semi-structured interviews with MHPs, as part of a wider feasibility study.

METHOD

Participants were mental health professionals (therapists and supervisors) from two UK NHS sites delivering manualised behavioural activation for young people. Data were analysed with an inductive followed by deductive approach, applying the Theoretical Domains Framework (TDF) to understand key influences on practice change. Identified domains were mapped onto possible behaviour change techniques (BCTs) to support implementation, using the Theory and Techniques Tool (TTT).

RESULTS

Nine MHPs were interviewed. Thirteen of fourteen TDF domains were relevant, including perceived professional identity, beliefs about own capabilities and perceived positive or negative consequences of using manualised behavioural activation, social influences, memory and attention, and environmental resources. Fourteen theory-linked BCTs were identified as possible strategies to help clinicians overcome barriers (e.g. integrating behavioural practice/rehearsal, prompts and persuasive communications within training, and supervision).

CONCLUSIONS

Behavioural science approaches (TDF, TTT) helped conceptualise key barriers and facilitators for MHPs delivering manualised behavioural activation with young people. Interventions using BCTs to address identified barriers could help the implementation of new therapies into routine practice, working to bridge the research-practice gap in clinical psychology.

A Systematic Review of Nudge Interventions to Optimize Medication Prescribing

Background: The benefits of medication optimization are largely uncontroversial but difficult to achieve. Behavior change interventions aiming to optimize prescriber medication-related decisions, which do not forbid any option and that do not significantly change financial incentives, offer a promising way forward. These interventions are often referred to as nudges.

Objective: The current systematic literature review characterizes published studies describing nudge interventions to optimize medication prescribing by the behavioral determinants they intend to influence and the techniques they apply.

Methods: Four databases were searched (MEDLINE, Embase, PsychINFO, and CINAHL) to identify studies with nudge-type interventions aiming to optimize prescribing decisions. To describe the behavioral determinants that interventionists aimed to influence, data were extracted according to the Theoretical Domains Framework (TDF). To describe intervention techniques applied, data were extracted according to the Behavior Change Techniques (BCT) Taxonomy version 1 and MINDSPACE. Next, the recommended TDF-BCT mappings were used to appraise whether each intervention applied a sufficient array of techniques to influence all identified behavioral determinants.

Results: The current review located 15 studies comprised of 20 interventions. Of the 20 interventions, 16 interventions (80%) were effective. The behavior change techniques most often applied involved prompts (n = 13). The MINDSPACE contextual influencer most often applied involved defaults (n = 10). According to the recommended TDF-BCT mappings, only two interventions applied a sufficient array of behavior change techniques to address the behavioral determinants the interventionists aimed to influence.

Conclusion: The fact that so many interventions successfully changed prescriber behavior encourages the development of future behavior change interventions to optimize prescribing without mandates or financial incentives. The current review encourages interventionists to understand the behavioral determinants they are trying to affect, before the selection and application of techniques to change prescribing behaviors.

Systematic Review Registration: [https://www.crd.york.ac.uk/prospero/], identifier [CRD42020168006].

Game Plan-a Brief Web-Based Intervention to Improve Uptake and Use of HIV Pre-exposure Prophylaxis (PrEP) and Reduce Alcohol Use Among Gay and Bisexual Men: Content Analysis

Background

HIV pre-exposure prophylaxis (PrEP) has considerable potential for reducing incidence among high-risk groups, such as gay, bisexual, and other men who have sex with men (GBM). However, PrEP’s effectiveness is closely linked with consistent use, and a variety of individual-level barriers, including alcohol use, could impede optimal uptake and use. Web-based interventions can encourage medication adherence, HIV prevention behaviors, and responsible drinking and may help support PrEP care, particularly in resource-limited settings.

Objective

We previously developed a web application called Game Plan that was designed to encourage heavy drinking GBM to use HIV prevention methods and reduce their alcohol use and was inspired by brief motivational interventions. This paper aims to describe the web-based content we designed for integration into Game Plan to help encourage PrEP uptake and consistent use among GBM. In this paper, we also aim to describe this content and its rationale.

Methods

Similar to the original site, these components were developed iteratively, guided by a thorough user-centered design process involving consultation with subject-matter experts, usability interviews and surveys, and user experience surveys.

Results

In addition to Game Plan’s pre-existing content, the additional PrEP components provide specific, personal, and digestible feedback to users about their level of risk for HIV without PrEP and illustrate how much consistent PrEP use could reduce it; personal feedback about their risk for common sexually transmitted infections to address low-risk perceptions; content challenging common beliefs and misconceptions about PrEP to reduce stigma; content confronting familiar PrEP and alcohol beliefs; and a change planning module that allows users to select specific goals for starting and strategies for consistent PrEP use. Users can opt into a weekly 2-way SMS text messaging program that provides similar feedback over a 12-week period after using Game Plan and follows up on the goals they set.

Conclusions

Research preliminarily testing the efficacy of these components in improving PrEP outcomes, including uptake, adherence, sexually transmitted infection rates, and alcohol use, is currently ongoing. If supported, these components could provide a scalable tool that can be used in resource-limited settings in which face-to-face intervention is difficult.

Barriers and Facilitators to Implementation of a Preschool Outcome Measure: An Interview Study with Speech-Language Pathologists

INTRODUCTION

The Preschool Speech and Language Program in Ontario, Canada implemented the Focus on the Outcomes of Communication Under Six (FOCUS), an outcome measure, in 2012. This study aimed to investigate commonly experienced facilitators of and barriers to implementing the FOCUS in clinical practice from the perspectives of speech-language pathologists (SLPs).

METHODS

Thirty-seven SLPs participated in semi-structured interviews to share their experiences adopting the FOCUS in clinical practice. A deductive content analysis of interview transcripts was conducted using the Theoretical Domains Framework (TDF), followed by an inductive analysis to identify sub-themes within each domain.

RESULTS

SLPs frequently encountered barriers within three TDF domains: Environmental Context and Resources (e.g., difficulties integrating the FOCUS into assessment sessions and intervention schedules), Beliefs about Consequences (e.g., beliefs that data collected using the FOCUS lack relevance to clinical practice), and Social Influences (e.g., administration of the FOCUS harmed rapport with families). Commonly reported facilitators were found in the Behavioural Regulation (e.g., reminder system) and Environmental Context and Resources (e.g., availability of administrative personnel and technology support) domains.

CONCLUSIONS

SLPs identified barriers and facilitators to implementing an evidence-based outcome measure into practice. Insights drawn from SLPs' perspectives will support the design of new methods to improve the implementation of functional outcome measurement tools within programs.

Tailoring implementation interventions of different order in infection prevention and control: A cascadic logic model (IPC-CASCADE)

Implementation interventions in infection prevention and control (IPC) differ by recipients. The two target groups are healthcare workers directly involved in patient care ("frontline") and IPC professionals as proxy agents, that is, implementation support practitioners. While both types of implementation interventions aim to promote compliance with clinical interventions to prevent healthcare-associated infections (HAI), their tailoring may be vastly different, for example, due to different behavioural outcomes. Additionally, IPC teams, as recipients of empowering tailored interventions, are under-researched. To overcome this gap and improve conceptual clarity, we proposed a cascadic logic model for tailored IPC interventions (IPC-CASCADE). In the model, we distinguished between interventions by IPC professionals targeting clinicians and those targeting IPC professionals (first- and second-order implementation interventions, respectively). Tailoring implies selecting behaviour change techniques matched to prospectively-assessed determinants of either clinician compliance (in first-order interventions) or interventions by IPC professionals for frontline workers (in second-order interventions). This interventional cascade is embedded in the prevailing healthcare system. IPC-CASCADE is horizontally structured over time and vertically structured by hierarchy or leadership roles. IPC-CASCADE aims to highlight the potential of increasing the impact of tailored interventions by IPC professionals for clinicians (to improve their compliance) via tailored interventions for IPC professionals (to improve their work as proxy agents). It underlines the links that IPC professionals define between macro contexts (healthcare and hospitals) and frontline workers in HAI prevention. It is specific, i.e., "tailored" to IPC, and expected to assist implementation science to better conceptualise tailoring.

A review of the quality and content of mobile apps to support lifestyle modifications following a transient ischaemic attack or 'minor' stroke

Objective

Secondary prevention is recommended to reduce cardiovascular risk after transient ischaemic attack (TIA) or ‘minor’ stroke. Mobile health interventions can provide accessible, cost-effective approaches to address modifiable risk factors, such as physical inactivity, hypertension and being overweight. The objective of this study was to evaluate the quality of apps for supporting lifestyle change following a TIA or ‘minor’ stroke.

Methods

Systematic searches of Google Play and the Apple Store were carried out to identify mobile apps released between 1 November 2019 and 1 October 2021. Keywords were used including stroke, TIA, lifestyle, prevention and recovery. Quality was assessed using the Mobile Application Rating Scale (MARS). Common components were identified with the Behaviour Change Technique (BCT) Taxonomy. Descriptive statistics were used to summarize the performance results for each app.

Results

Searches identified 2545 potential apps. Thirty remained after removing duplicates and screening titles and descriptions. Six were eligible after full review of their content. All apps included at least one BCT (range: 1–16 BCTs). The most frequent BCTs included ‘information about health consequences’ (n = 5/6), ‘verbal or visual communication from a credible source’ (n = 4/6) and ‘action planning’ (n = 4/6). The mean MARS score was 2.57/5 (SD: 0.51; range: 1.78–3.36). No apps were of ‘good’ overall quality (scoring more than 4/5).

Conclusions

This is the first review of mobile health interventions for this population. Only a small number of apps were available. None were targeted specifically at people with a TIA or ‘minor’ stroke. Overall quality was low. Further work is needed to develop and test accessible, user designed, and evidence-informed digital interventions in this population.

The Physical Activity Messaging Framework (PAMF) and Checklist (PAMC): International consensus statement and user guide

Effective physical activity messaging plays an important role in the pathway towards changing physical activity behaviour at a population level. The Physical Activity Messaging Framework (PAMF) and Checklist (PAMC) are outputs from a recent modified Delphi study. This sought consensus from an international expert panel on how to aid the creation and evaluation of physical activity messages. In this paper, we (1) present an overview of the various concepts within the PAMF and PAMC, (2) discuss in detail how the PAMF and PAMC can be used to create physical activity messages, plan evaluation of messages, and aid understanding and categorisation of existing messages, and (3) highlight areas for future development and research. If adopted, we propose that the PAMF and PAMC could improve physical activity messaging practice by encouraging evidence-based and target population-focused messages with clearly stated aims and consideration of potential working pathways. They could also enhance the physical activity messaging research base by harmonising key messaging terminologies, improving quality of reporting, and aiding collation and synthesis of the evidence.

A Low-Glucose Eating Pattern Improves Biomarkers of Postmenopausal Breast Cancer Risk: An Exploratory Secondary Analysis of a Randomized Feasibility Trial

Postmenopausal breast cancer is the most common obesity-related cancer death among women in the U.S. Insulin resistance, which worsens in the setting of obesity, is associated with higher breast cancer incidence and mortality. Maladaptive eating patterns driving insulin resistance represent a key modifiable risk factor for breast cancer. Emerging evidence suggests that time-restricted feeding paradigms (TRF) improve cancer-related metabolic risk factors; however, more flexible approaches could be more feasible and effective. In this exploratory, secondary analysis, we identified participants following a low-glucose eating pattern (LGEP), defined as consuming energy when glucose levels are at or below average fasting levels, as an alternative to TRF. Results show that following an LGEP regimen for at least 40% of reported eating events improves insulin resistance (HOMA-IR) and other cancer-related serum biomarkers. The magnitude of serum biomarkers changes observed here has previously been shown to favorably modulate benign breast tissue in women with overweight and obesity who are at risk for postmenopausal breast cancer. By comparison, the observed effects of LGEP were similar to results from previously published TRF studies in similar populations. These preliminary findings support further testing of LGEP as an alternative to TRF and a postmenopausal breast cancer prevention strategy. However, results should be interpreted with caution, given the exploratory nature of analyses.

The Brief Attitudes Survey for Interprofessional Collaborative Learning: The Design, Reliability, and Validation of a New Instrument

This paper describes the development and validation of a new questionnaire designed to measure and investigate attitudes towards interprofessional education (IPE) among health professions students. After a thorough literature review and survey of prior instruments, we created an instrument built around a single construct domain: attitudes toward interprofessional collaborative learning. Through a rigorous design methodology rooted in behavior change theory and an iterative question development process, we launched the 11-item "Brief Attitudes Survey for Interprofessional Collaborative Learning" (BASIC-L). Implemented as part of a "toolbox" for assessing the progress of learners in IPE, the questionnaire was then administered to a large cohort of medical and nursing students. Its reliability, validity, and fit with our one-domain model were evaluated via thorough psychometric analysis, including computation of reliability coefficients and a Rasch analysis. These analyses indicate strong reliability, validity, and fit of the questions with our one-domain model. The analyses also included assessment for any sources of measurement error, which were not significant. The BASIC-L appears to be a useful, valid, and reliable instrument for the assessment of attitudes toward interprofessional collaborative learning among students in the health professions, especially as part of a larger multidimensional assessment process.

Do Combinations of Behavior Change Techniques That Occur Frequently in Interventions Reflect Underlying Theory?

BACKGROUND

Behavioral interventions typically include multiple behavior change techniques (BCTs). The theory informing the selection of BCTs for an intervention may be stated explicitly or remain unreported, thus impeding the identification of links between theory and behavior change outcomes.

PURPOSE

This study aimed to identify groups of BCTs commonly occurring together in behavior change interventions and examine whether behavior change theories underlying these groups could be identified.

METHODS

The study involved three phases: (a) a factor analysis to identify groups of co-occurring BCTs from 277 behavior change intervention reports; (b) examining expert consensus (n = 25) about links between BCT groups and behavioral theories; (c) a comparison of the expert-linked theories with theories explicitly mentioned by authors of the 277 intervention reports.

RESULTS

Five groups of co-occurring BCTs (range: 3-13 BCTs per group) were identified through factor analysis. Experts agreed on five links (≥80% of experts), comprising three BCT groups and five behavior change theories. Four of the five BCT group-theory links agreed by experts were also stated by study authors in intervention reports using similar groups of BCTs.

CONCLUSIONS

It is possible to identify groups of BCTs frequently used together in interventions. Experts made shared inferences about behavior change theory underlying these BCT groups, suggesting that it may be possible to propose a theoretical basis for interventions where authors do not explicitly put forward a theory. These results advance our understanding of theory use in multicomponent interventions and build the evidence base for further understanding theory-based intervention development and evaluation.

Efficacy, characteristics, behavioural models and behaviour change strategies, of non-workplace interventions specifically targeting sedentary behaviour; a systematic review and meta-analysis of randomised control trials in healthy ambulatory adults

BACKGROUND

Sedentary behaviour (SB) research has grown exponentially but efficacy for interventions to reduce sedentary behaviour is often contaminated by interventions primarily or co-targeting other behaviours and outcomes. The primary aim of this research therefore, was to systematically review the efficacy of interventions specifically targeting sedentary behaviour reduction, as a sole primary outcome, from randomised control trials in healthy ambulatory adults. This research also sought to identify the successful interventions characteristics, behaviour change techniques (BCT's) and underlying theories, and their relation to intervention effectiveness.

METHODS

We followed PRISMA reporting guidelines for this systematic review. Six electronic databases were searched and a grey literature review conducted. Only randomised or cluster randomised controlled trials, from 2000 to 2020, in adult populations with a sole primary outcome of change in sedentary behaviour were included. Data codebooks were developed, data were extracted, and a narrative synthesis and meta-analysis was conducted using mixed methods random effects models.

RESULTS

Of 5589 studies identified, 7 studies met the inclusion criteria. Six studies reported activPAL3 measures of mean daily sitting time, and four reported mean daily standing time, stepping time and number of sedentary breaks. Pooled analysis of weighted mean differences revealed a reduction in mean daily sitting time of -32.4mins CI (-50.3, -14.4), an increase in mean daily standing time of 31.75mins CI (13.7, 49.8), and mean daily stepping time of 9.5mins CI (2.8, 16.3), and an increase in rate of sedentary breaks per day of 3.6 (CI 1.6, 5.6). BCTs used exclusively in two of the three most effective interventions are 'feedback on behaviour' and 'goal setting behaviour' whilst all three most effective interventions included 'instruction on how to perform the behaviour' and 'adding objects to the environment', BCTs which were also used in less effective interventions.

CONCLUSIONS

Although limited by small sample sizes and short follow up periods, this review suggests that interventions specifically designed to change sedentary behaviour, reduce overall daily sitting time by half an hour, with an equivalent increase in standing time, in the short to medium term. Effective characteristics and behaviour change strategies are identified for future development of high quality interventions targeting change in sedentary behaviour.

PROSPERO REGISTRATION

PROSPERO 2020 CRD42020172457 Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020172457.

Behavior change factors and retention in dietary interventions for older adults: scoping review

BACKGROUND AND OBJECTIVES

Although poor diet is a major driver of morbidity and mortality in people 60 and older, few dietary interventions are widely implemented for this population. We mapped behavior change theories, agents, and techniques in dietary interventions for adults 60+ and explored relationships between these factors and ability to retain at least 80% of the study participants.

RESEARCH DESIGN AND METHODS

We conducted a scoping review using MEDLINE, CINAHL, and Web of Science through April 2021 for dietary interventions in adults 60 and older. We collated, summarized, and calculated frequency distributions of behavior change theories, behavior change agents, and behavior change techniques (BCTs) using BCTv1 taxonomy with regard to participant retention across 43 studies.

RESULTS

Only 49% and 30% of the studies reported behavior theory and change agents respectively. Of the studies reporting on theory and agents, the most common were social cognitive theory and the related mechanism of self-efficacy. The most common BCTv1 were "shaping knowledge" and "goals and planning." Several BCTv1 such as "antecedents" and "reward and threat" and evidence for concordance between BCTs and change agents were more common in interventions with higher retention rates.

DISCUSSION AND IMPLICATIONS

Mechanistically concordant studies with BCTs that involve resource allocation and positive reinforcement through rewards may be advantageous for retention in dietary intervention for older adults. Future studies should continue developing theory and mechanism-oriented research. Furthermore, future studies should consider diversifying the portfolio of currently deployed BCTs and strengthening a concordance between BCTs and mechanisms of change.

A modified Delphi study to enhance and gain international consensus on the Physical Activity Messaging Framework (PAMF) and Checklist (PAMC)

INTRODUCTION

Physical activity messaging is an important step in the pathway towards improving population physical activity levels, but best practice is not yet understood. A gap in the literature exists for a physical activity messaging framework to help guide creation and evaluation of messages. This study aimed to further develop and improve, and gain international expert consensus on, a standardised Physical Activity Messaging Framework and Checklist.

METHODS

A modified Delphi study consisting of three online survey rounds was conducted. Each survey gathered feedback from an international expert panel using quantitative and qualitative methods. The framework and checklist were amended between each round based on survey results until consensus (defined a priori as 80% agreement) was reached.

RESULTS

The final expert panel (n = 40, 55% female) came from nine countries and comprised academics (55%), healthcare and other professionals (22.5%) and government officials or policymakers (22.5%). Consensus was reached in survey 3 with 85 and 87.5% agreement on the framework and checklist, respectively.

CONCLUSION

This study presents an expert- and evidence-informed framework and checklist for physical activity messaging. If used consistently, the Physical Activity Messaging Framework and Checklist may improve practice by encouraging evidence-based and target audience-focused messages, as well as enhance the research base on physical activity messaging by harmonising key terminologies and improving quality of reporting. Key next steps include further refining the Physical Activity Messaging Framework and Checklist based on their use in real-world settings.

Development of an online tool for linking behavior change techniques and mechanisms of action based on triangulation of findings from literature synthesis and expert consensus

Researchers, practitioners, and policymakers develop interventions to change behavior based on their understanding of how behavior change techniques (BCTs) impact the determinants of behavior. A transparent, systematic, and accessible method of linking BCTs with the processes through which they change behavior (i.e., their mechanisms of action [MoAs]) would advance the understanding of intervention effects and improve theory and intervention development. The purpose of this study is to triangulate evidence for hypothesized BCT–MoA links obtained in two previous studies and present the results in an interactive, online tool. Two previous studies generated evidence on links between 56 BCTs and 26 MoAs based on their frequency in literature synthesis and on expert consensus. Concordance between the findings of the two studies was examined using multilevel modeling. Uncertainties and differences between the two studies were reconciled by 16 behavior change experts using consensus development methods. The resulting evidence was used to generate an online tool. The two studies showed concordance for 25 of the 26 MoAs and agreement for 37 links and for 460 “nonlinks.” A further 55 links were resolved by consensus (total of 92 [37 + 55] hypothesized BCT–MoA links). Full data on 1,456 possible links was incorporated into the online interactive Theory and Technique Tool (https://theoryandtechniquetool.humanbehaviourchange.org/). This triangulation of two distinct sources of evidence provides guidance on how BCTs may affect the mechanisms that change behavior and is available as a resource for behavior change intervention designers, researchers and theorists, supporting intervention design, research synthesis, and collaborative research.

Efficacy, Use, and Acceptability of a Web-Based Self-management Intervention Designed to Maximize Sexual Well-being in Men Living With Prostate Cancer: Single-Arm Experimental Study

BACKGROUND

Sexual dysfunction is a frequent side effect associated with different prostate cancer treatment approaches. It can have a substantial impact on men and their partners and is associated with increased psychological morbidity. Despite this, sexual concerns are often not adequately addressed in routine practice. Evidence-based web-based interventions have the potential to provide ongoing information and sexual well-being support throughout all stages of care.

OBJECTIVE

The aim of this study is to examine the efficacy of a web-based self-management intervention designed to maximize sexual well-being in men living with prostate cancer and explore user perspectives on usability and acceptability.

METHODS

We used a single-arm study design, and participants were provided with access to the 5-step intervention for a period of 3 months. The intervention content was tailored based on responses to brief screening questions on treatment type, relationship status, and sexual orientation. Efficacy was assessed by using two-tailed, paired sample t tests for comparing the mean differences between pre- and postintervention measurements for exploring the participants' self-reported knowledge and understanding, sexual satisfaction, and comfort in discussing sexual issues. Usability and acceptability were determined based on the program use data and a postintervention survey for exploring perceived usefulness.

RESULTS

A total of 109 participants were recruited for this study. Significant postintervention improvements at follow-up were observed in the total scores (out of 20) from the survey (mean 12.23/20 points, SD 2.46 vs mean 13.62/20, SD 2.31; t₈₈=9.570; P=.001) as well as in individual item scores on the extent to which the participants agreed that they had sufficient information to manage the impact that prostate cancer had on their sex life (mean 2.31/4 points, SD 0.86 vs mean 2.57/4, SD 0.85; t₈₈=3.660; P=.001) and had the potential to have a satisfying sex life following treatment (mean 2.38/4 points, SD 0.79 vs mean 3.17/4, SD 0.78; t₈₈=7.643; P=.001). The median number of intervention sessions was 3 (range 1-11), and intervention sessions had a median duration of 22 minutes (range 8-77). Acceptable usability scores were reported, with the highest result observed for the question on the extent to which the intervention provided relevant information.

CONCLUSIONS

This study provides evidence on the efficacy of a tailored web-based intervention for maximizing sexual well-being in men living with prostate cancer. The results indicate that the intervention may improve one's self-perceived knowledge and understanding of how to manage sexual issues and increase self-efficacy or the belief that a satisfactory sex life could be achieved following treatment. The findings will be used to refine the intervention content before testing as part of a larger longitudinal study for examining its effectiveness.

Content analysis of behaviour change techniques in government physical distancing communications for the reopening of schools during the COVID-19 pandemic in Ireland

Background: Effective government communications and leadership are central to the management of pandemics. Behavioural science can offer important insight into the development of such communications strategies. The extent to which established behaviour-change science is reflected in current government messaging campaigns to promote adherence to physical distancing measures in the context of the coronavirus disease 2019 (COVID-19) pandemic is unclear. The current study aimed to describe the behaviour-change content of a set of government-issued poster communications for the reopening of schools in Ireland during the COVID-19 pandemic in September 2020. Methods: Posters targeting physical distancing behaviours in school settings were retrieved from the Government of Ireland website for analysis. Posters were independently coded for behaviour change techniques (BCTs) using the BCT Taxonomy Version 1, a hierarchically clustered taxonomy of 93 distinct BCTs across 16 groups. The Theories and Techniques tool was used to identify mechanisms of action (MoAs) linked to each of the identified BCTs. Eight posters were independently content-analysed by two members of the research team for BCTs and linked MoAs. Results: Eight unique BCTs from six unique groups were identified in at least one poster. These BCTs were linked with 11 unique MoAs through which behaviour change is theorised to occur. Several theoretically important groups of BCTs, such as Natural Consequences, Social Support, Shaping Knowledge, and Comparison of Behaviour, were underutilised or not included in any of the posters. Conclusion: Future poster communications could benefit from including additional BCTs from key groups, particularly Natural Consequences. This article provides proof-of-concept evidence for future evaluations of government public health communications for behaviour-change content using existing taxonomies and tools.

What behaviour change techniques have been used to improve adherence to evidence-based low back pain imaging?

Background

Despite international guideline recommendations, low back pain (LBP) imaging rates have been increasing over the last 20 years. Previous systematic reviews report limited effectiveness of implementation interventions aimed at reducing unnecessary LBP imaging. No previous reviews have analysed these implementation interventions to ascertain what behaviour change techniques (BCTs) have been used in this field. Understanding what techniques have been implemented in this field is an essential first step before exploring intervention effectiveness.

Methods

We searched EMBASE, Ovid (Medline), CINAHL and Cochrane CENTRAL from inception to February 1, 2021, as well as and hand-searched 6 relevant systematic reviews and conducted citation tracking of included studies. Two authors independently screened titles, abstracts, and full texts for eligibility and extracted data on study and intervention characteristics. Study interventions were qualitatively analysed by three coders to identify BCTs, which were mapped to mechanisms of action from the theoretical domains framework (TDF) using the Theory and Techniques Tool.

Results

We identified 36 eligible studies from 1984 citations in our electronic search and a further 2 studies from hand-searching resulting in 38 studies that targeted physician behaviour to reduce unnecessary LBP imaging. The studies were conducted in 6 countries in primary (n = 31) or emergency care (n = 7) settings. Thirty-four studies were included in our BCT synthesis which found the most frequently used BCTs were ‘4.1 instruction on how to perform the behaviour’ (e.g. Active/passive guideline dissemination and/or educational seminars/workshops), followed by ‘9.1 credible source’, ‘2.2 feedback on behaviour’ (e.g. electronic feedback reports on physicians’ image ordering) and 7.1 prompts and cues (electronic decision support or hard-copy posters/booklets for the office). This review highlighted that the majority of studies used education and/or feedback on behaviour to target the domains of knowledge and in some cases also skills and beliefs about capabilities to bring about a change in LBP imaging behaviour. Additionally, we found there to be a growing use of electronic or hard copy reminders to target the domains of memory and environmental context and resources.

Conclusions

This is the first study to identify what BCTs have been used to target a reduction in physician image ordering behaviour. The majority of included studies lacked the use of theory to inform their intervention design and failed to target known physician-reported barriers to following LBP imaging guidelines.

Protocol Registation

PROSPERO CRD42017072518

Supplementary Information

The online version contains supplementary material available at 10.1186/s13012-021-01136-w.

Environmental Issues Are Health Issues

Abstract. Increasing demands on ecosystems, decreasing biodiversity, and climate change are among the most pressing environmental issues of our time. As changing weather conditions are leading to increased vector-borne diseases and heat- and flood-related deaths, it is entering collective consciousness: environmental issues are human health issues. In public health, the field addressing these issues is known as environmental health. This field addresses both the effects people have on their environment as well as the effects of the environment on people. Psychology, as a discipline concerned with explaining, predicting, and changing behavior has much to contribute to these issues because human behavior is key in promoting environmental health. To date, however, an integrative view of environmental health in psychology is lacking, hampering urgently needed progress. In this paper, we review how the environment and human health are intertwined, and that much can be gained through a systemic view of environmental health in psychology. Based on a review of the literature, we suggest that psychologists unite efforts to promote an integrative science and practice of environmental health psychology, and jointly address environmental-health related behavior. The research agenda for this field will include integrating behavior change theory and intervention approaches. Thereby, psychology can potentially make an important contribution to sustained environmental health for generations to come.

Feasibility of Reducing and Breaking Up University Students' Sedentary Behaviour: Pilot Trial and Process Evaluation

Background: Accumulating high levels of sedentary behaviour has been linked to poor health outcomes. This study examined the feasibility and preliminary, short-term effects of a theory-based intervention aimed at reducing total and prolonged sedentary behaviour in University students.

Design: A quasi-experimental (pre-post) pilot study. Methods: Nine ambulatory undergraduate students (Mean age = 22 ± 2.32) participated in a one-on-one session, including an educational component around the health effects of sedentary behaviour and three distinct activities (feedback, “pros and cons” exercise, and suggested behaviour change strategies). In addition, automated daily text messages targeting sedentary behaviour were sent for 6 days (four messages per day at fixed intervals). The Behaviour Change Wheel framework guided the intervention design process. Outcomes were assessed over 6 days in pre- and post-intervention periods and included accelerometer-based (activPAL) and self-reported (Nightly-Week-U) total sedentary time, as well as accelerometer-based number of steps and prolonged sedentary time. Students completed a process evaluation interview upon completing the trial.

Results: From pre- to post-intervention, there was a significant reduction in accelerometer-based total and prolonged sedentary time during weekend days. In addition, there was a significant increase in accelerometer-based standing time and stepping during weekend days. There were no statistically significant changes in accelerometer-based sedentary time, standing time or number of steps during weekdays. Process evaluation results indicated that the intervention and its assessment is feasible. Reductions in sedentary time were likely to be mediated by positive changes in the student's reflective and automatic motivation.

Conclusions: Findings from this small, short-term intervention suggest that a single one-on-one session, together with automated text messages, may help University students reduce sedentary behaviour and enhance movement during weekend days. Additional strategies to maximise the intervention effects are discussed (e.g., establishing a collaboration with University staff, introducing sit-to-stand desks, and/or facilitating social support). A randomised control trial assessing sedentary behaviour over a longer period is needed to adequately study the intervention's effectiveness.

Efficacy of interventions to increase physical activity for people with heart failure: a meta-analysis

Objectives

This meta-analysis aims to (1) evaluate the efficacy of physical activity interventions in heart failure and (2) to identify intervention characteristics significantly associated with the interventions’ efficacy.

Methods

Randomised controlled trials reporting intervention effects on physical activity in heart failure were combined in a meta-analysis using a random-effect model. Exploratory meta-analysis was performed by specifying the general approach (eg, cardiac rehabilitation), strategies used (eg, action planning), setting (eg, centre based), mode of delivery (eg, face to face or online), facilitator (eg, nurse), contact time and behavioural change theory use as predictors in the random-effect model.

Results

Interventions (n=21) had a significant overall effect (SMD=0.54, 95% CI (0.13 to 0.95), p<0.0005). Combining an exercise programme with behavioural change intervention was found efficacious (SMD=1.26, 95% CI (0.26 to 2.26), p<0.05). Centre-based (SMD=0.98, 95% CI (0.35 to 1.62), and group-based (SMD=0.89, 95% CI (0.29 to 1.50),) delivery by a physiotherapist (SMD=0.84, 95% CI (0.03 to 1.65),) were significantly associated with efficacy. The following strategies were identified efficacious: prompts/cues (SMD=3.29, 95% CI (1.97 to 4.62)), credible source (standardised mean difference, SMD=2.08, 95% CI (0.95;3.22)), adding objects to the environment (SMD=1.47, 95% CI (0.41 to 2.53)), generalisation of the target behaviour SMD=1.32, 95% CI (0.22 to 2.41)), monitoring of behaviour by others without feedback (SMD=1.02, 95% CI (0.05 to 1.98)), self-monitoring of outcome(s) of behaviour (SMD=0.79, 95% CI (0.06 to 1.52), graded tasks (SMD=0.73, 95% CI (0.22 to 1.24)), behavioural practice/rehearsal (SMD=0.72, 95% CI (0.26 to 1.18)), action planning (SMD=0.62, 95% CI (0.03 to 1.21)) and goal setting (behaviour) (SMD=0.56, 95% CI (0.03 to 1.08)).

Conclusion

The meta-analysis suggests intervention characteristics that may be suitable for promoting physical activity in heart failure. There is moderate evidence in support of an exercise programme combined with a behavioural change intervention delivered by a physiotherapist in a group-based and centre-based settings.

PROSPERO registeration

CRD42015015280.

Identifying Content-Based Engagement Patterns in a Smoking Cessation Website and Associations With User Characteristics and Cessation Outcomes: A Sequence and Cluster Analysis

Introduction

Using WebQuit as a case study, a smoking cessation website grounded in Acceptance and Commitment Therapy, we aimed to identify sequence clusters of content usage and examine their associations with baseline characteristics, change to a key mechanism of action, and smoking cessation.

Methods

Participants were adult smokers allocated to the WebQuit arm in a randomized controlled trial (n = 1,313). WebQuit contains theory-informed content including goal setting, self-monitoring and feedback, and values- and acceptance-based exercises. Sequence analysis was used to temporally order 30-s website usage segments for each participant. Similarities between sequences were assessed with the optimal matching distance algorithm and used as input in an agglomerative hierarchical clustering analysis. Associations between sequence clusters and baseline characteristics, acceptance of cravings at 3 months and self-reported 30-day point prevalence abstinence at 12 months were examined with linear and logistic regression.

Results

Three qualitatively different sequence clusters were identified. “Disengagers” (576/1,313) almost exclusively used the goal-setting feature. “Tryers” (375/1,313) used goal setting and two of the values- and acceptance-based components (“Be Aware,” “Be Willing”). “Committers” (362/1,313) primarily used two of the values- and acceptance-based components (“Be Willing,” “Be Inspired”), goal setting, and self-monitoring and feedback. Compared with Disengagers, Committers demonstrated greater increases in acceptance of cravings (p = .01) and 64% greater odds of quit success (OR_adj = 1.64, 95% CI = 1.18, 2.29, p = .003).

Discussion

WebQuit users were categorized into Disengagers, Tryers, and Committers based on their qualitatively different content usage patterns. Committers saw increases in a key mechanism of action and greater odds of quit success.

Implications

This case study demonstrates how employing sequence and cluster analysis of usage data can help researchers and practitioners gain a better understanding of how users engage with a given eHealth intervention over time and use findings to test theory and/or to improve future iterations to the intervention. Future WebQuit users may benefit from being directed to the values- and acceptance-based and the self-monitoring and feedback components via reminders over the course of the program.

Development of a Digital Lifestyle Modification Intervention for Use after Transient Ischaemic Attack or Minor Stroke: A Person-Based Approach

This paper describes the development of the ‘Brain-Fit’ app, a digital secondary prevention intervention designed for use in the early phase after transient ischaemic attack (TIA) or minor stroke. The aim of the study was to explore perceptions on usability and relevance of the app in order to maximise user engagement and sustainability. Using the theory- and evidence-informed person-based approach, initial planning included a scoping review of qualitative evidence to identify barriers and facilitators to use of digital interventions in people with cardiovascular conditions and two focus groups exploring experiences and support needs of people (N = 32) with a history of TIA or minor stroke. The scoping review and focus group data were analysed thematically and findings were used to produce guiding principles, a behavioural analysis and explanatory logic model for the intervention. Optimisation included an additional focus group (N = 12) and individual think-aloud interviews (N = 8) to explore perspectives on content and usability of a prototype app. Overall, thematic analysis highlighted uncertainty about increasing physical activity and concerns that fatigue might limit participation. Realistic goals and progressive increases in activity were seen as important to improving self-confidence and personal control. The app was seen as a useful and flexible resource. Participant feedback from the optimisation phase was used to make modifications to the app to maximise engagement, including simplification of the goal setting and daily data entry sections. Further studies are required to examine efficacy and cost-effectiveness of this novel digital intervention.

Evidence-Based Digital Tools for Weight Loss Maintenance: The NoHoW Project

BACKGROUND

Effective interventions and commercial programmes for weight loss (WL) are widely available, but most people regain weight. Few effective WL maintenance (WLM) solutions exist. The most promising evidence-based behaviour change techniques for WLM are self-monitoring, goal setting, action planning and control, building self-efficacy, and techniques that promote autonomous motivation (e.g., provide choice). Stress management and emotion regulation techniques show potential for prevention of relapse and weight regain. Digital technologies (including networked-wireless tracking technologies, online tools and smartphone apps, multimedia resources, and internet-based support) offer attractive tools for teaching and supporting long-term behaviour change techniques. However, many digital offerings for weight management tend not to include evidence-based content and the evidence base is still limited. The Project: First, the project examined why, when, and how many European citizens make WL and WLM attempts and how successful they are. Second, the project employed the most up-to-date behavioural science research to develop a digital toolkit for WLM based on 2 key conditions, i.e., self-management (self-regulation and motivation) of behaviour and self-management of emotional responses for WLM. Then, the NoHoW trial tested the efficacy of this digital toolkit in adults who achieved clinically significant (≥5%) WL in the previous 12 months (initial BMI ≥25). The primary outcome was change in weight (kg) at 12 months from baseline. Secondary outcomes included biological, psychological, and behavioural moderators and mediators of long-term energy balance (EB) behaviours, and user experience, acceptability, and cost-effectiveness.

IMPACT

The project will directly feed results from studies on European consumer behaviour, design and evaluation of digital toolkits self-management of EB behaviours into development of new products and services for WLM and digital health. The project has developed a framework and digital architecture for interventions in the context of EB tracking and will generate results that will help inform the next generation of personalised interventions for effective self-management of weight and health.

Mechanisms of Action in a Behavioral Weight-Management Program: Latent Growth Curve Analysis

Background

A greater understanding of the mechanisms of action of weight-management interventions is needed to inform the design of effective interventions.

Purpose

To investigate whether dietary restraint, habit strength, or diet self-regulation mediated the impact of a behavioral weight-management intervention on weight loss and weight loss maintenance.

Methods

Latent growth curve analysis (LGCA) was conducted on trial data in which adults (N = 1,267) with a body mass index (BMI) ≥28 kg/m² were randomized to either a brief intervention (booklet on losing weight), a 12 week weight-management program or the same program for 52 weeks. LGCA estimated the trajectory of the variables over four time points (baseline and 3, 12 and 24 months) to assess whether potential mechanisms of action mediated the impact of the weight-management program on BMI.

Results

Participants randomized to the 12 and 52 week programs had a significantly greater decrease in BMI than the brief intervention. This direct effect became nonsignificant when dietary restraint, habit strength, and autonomous diet self-regulation were controlled for. The total indirect effect was significant for both the 12 (estimate = −1.33, standard error [SE] = 0.41, p = .001) and 52 week (estimate = −2.13, SE = 0.52, p < .001) program. Only the individual indirect effect for dietary restraint was significant for the 12 week intervention, whereas all three indirect effects were significant for the 52 week intervention.

Conclusions

Behavior change techniques that target dietary restraint, habit strength, and autonomous diet self-regulation should be considered when designing weight loss and weight loss maintenance interventions. Longer interventions may need to target both deliberative and automatic control processes to support successful weight management.

A step toward understanding the mechanism of action of audit and feedback: a qualitative study of implementation strategies

Background

Audit and feedback (A&F) is a widely used implementation strategy. Understanding mechanisms of action of A&F increases the likelihood that the strategy will lead to implementation of an evidence-based practice. We therefore sought to understand one hospital’s experience selecting and implementing an A&F intervention, to determine the implementation strategies that were used by staff and to specify the mechanism of action of those implementation strategies using causal pathway models, with the ultimate goal of improving acute stroke treatment practices.

Methods

We selected an A&F strategy in a hospital, initially based on implementation determinants and staff consideration of their performance on acute stroke treatment measures. After 7 months of A&F, we conducted semi-structured interviews of hospital providers and administrative staff to understand how it contributed to implementing guideline-concordant acute stroke treatment (medication named tissue plasminogen activator). We coded the interviews to identify the implementation strategies that staff used following A&F and to assess their mechanisms of action.

Results

We identified five implementation strategies that staff used following the feedback intervention. These included (1) creating folders containing the acute stroke treatment protocol for the emergency department, (2) educating providers about the protocol for acute stroke, (3) obtaining computed tomography imaging of stroke patients immediately upon emergency department arrival, (4) increasing access to acute stroke medical treatment in the emergency department, and (5) providing additional staff support for implementation of the protocol in the emergency department. We identified enablement, training, and environmental restructuring as mechanisms of action through which the implementation strategies acted to improve guideline-concordant and timely acute stroke treatment.

Conclusions

A&F of a hospital’s acute stroke treatment practices generated additional implementation strategies that acted through various mechanisms of action. Future studies should focus on how initial implementation strategies can be amplified through internal mechanisms.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13012-021-01102-6.

How leisure activities affect health: a narrative review and multi-level theoretical framework of mechanisms of action

There is a large and growing body of evidence on the health benefits of engagement in leisure activities (voluntary, enjoyable non-work activities, such as hobbies, arts, volunteering, community group membership, sports, and socialising). However, there is no unifying framework explaining how leisure activities affect health: what the mechanisms of action are by which engagement with leisure activities leads to the prevention, management, or treatment of mental and physical illness. In this Review, we identify and map over 600 mechanisms of action. These mechanisms can be categorised as psychological, biological, social, and behavioural processes that operate at individual (micro), group (meso), and societal (macro) levels, and are synthesised into a new theoretical framework: the Multi-level Leisure Mechanisms Framework. This framework situates understanding of leisure activities within the theoretical lens of complex adaptive systems and aims to support the design of more theory-driven, cross-disciplinary studies.

System Architecture for "Support Through Mobile Messaging and Digital Health Technology for Diabetes" (SuMMiT-D): Design and Performance in Pilot and Randomized Controlled Feasibility Studies

Background

Diabetes is a highly prevalent long-term condition with high morbidity and mortality rates. People with diabetes commonly worry about their diabetes medicines and do not always take them regularly as prescribed. This can lead to poor diabetes control. The Support Through Mobile Messaging and Digital Health Technology for Diabetes (SuMMiT-D) study aims to deliver brief messages as tailored interventions to support people with type 2 diabetes in better use of their diabetes medicines and to improve treatment adherence and health outcomes.

Objective

This paper describes the overall architecture of a tailored intervention delivery system used in the pilot and randomized controlled feasibility studies of SuMMiT-D and reports its performance.

Methods

The SuMMiT-D system includes several platforms and resources to recruit participants and deliver messages as tailored interventions. Its core component is called the clinical system and is responsible for interacting with the participants by receiving and sending SMS text messages from and to them. The personalization and tailoring of brief messages for each participant is based on a list of built-in commands that they can use.

Results

For the pilot study, a total of 48 participants were recruited; they had a median age of 64 years (first quartile, third quartile [Q₁, Q₃: 54.5, 69]). For the feasibility study, a total of 209 participants were recruited and randomly assigned to either the control or intervention group; they had a median age of 65 years (Q₁, Q₃: 56, 71), with 41.1% (86/209) being female. The participants used the SuMMiT-D system for up to 6 months (26 weeks) and had a wide range of different interactions with the SuMMiT-D system while tailored interventions were being delivered. For both studies, we had low withdrawal rates: only 4.2% and 5.3% for the pilot and feasibility studies, respectively.

Conclusions

A system was developed to successfully deliver brief messages as tailored health interventions to more than 250 people with type 2 diabetes via SMS text messages. On the basis of the low withdrawal rates and positive feedback received, it can be inferred that the SuMMiT-D system is robust, user-friendly, useful, and positive for most participants. From the two studies, we found that online recruitment was more efficient than recruitment via postal mail; a regular SMS text reminder (eg, every 4 weeks) can potentially increase the participants’ interactions with the system.

Trial Registration

ISRCTN Registry ISRCTN13404264; http://www.isrctn.com/ISRCTN13404264

Why and how to engage expert stakeholders in ontology development: insights from social and behavioural sciences

BACKGROUND

Incorporating the feedback of expert stakeholders in ontology development is important to ensure content is appropriate, comprehensive, meets community needs and is interoperable with other ontologies and classification systems. However, domain experts are often not formally engaged in ontology development, and there is little available guidance on how this involvement should best be conducted and managed. Social and behavioural science studies often involve expert feedback in the development of tools and classification systems but have had little engagement with ontology development. This paper aims to (i) demonstrate how expert feedback can enhance ontology development, and (ii) provide practical recommendations on how to conduct expert feedback in ontology development using methodologies from the social and behavioural sciences.

MAIN BODY

Considerations for selecting methods for engaging stakeholders are presented. Mailing lists and issue trackers as existing methods used frequently in ontology development are discussed. Advisory boards and working groups, feedback tasks, consensus exercises, discussions and workshops are presented as potential methods from social and behavioural sciences to incorporate in ontology development.

CONCLUSIONS

A variety of methods from the social and behavioural sciences exist to enable feedback from expert stakeholders in ontology development. Engaging domain experts in ontology development enables depth and clarity in ontology development, whilst also establishing advocates for an ontology upon its completion.

Delivering Behaviour Change Interventions: Development of a Mode of Delivery Ontology

Background: Investigating and improving the effects of behaviour change interventions requires detailed and consistent specification of all aspects of interventions. An important feature of interventions is the way in which these are delivered, i.e. their mode of delivery. This paper describes an ontology for specifying the mode of delivery of interventions, which forms part of the Behaviour Change Intervention Ontology, currently being developed in the Wellcome Trust funded Human Behaviour-Change Project. Methods: The Mode of Delivery Ontology was developed in an iterative process of annotating behaviour change interventions evaluation reports, and consulting with expert stakeholders. It consisted of seven steps: 1) annotation of 110 intervention reports to develop a preliminary classification of modes of delivery; 2) open review from international experts (n=25); 3) second round of annotations with 55 reports to test inter-rater reliability and identify limitations; 4) second round of expert review feedback (n=16); 5) final round of testing of the refined ontology by two annotators familiar and two annotators unfamiliar with the ontology; 6) specification of ontological relationships between entities; and 7) transformation into a machine-readable format using the Web Ontology Language (OWL) and publishing online. Results: The resulting ontology is a four-level hierarchical structure comprising 65 unique modes of delivery, organised by 15 upper-level classes: Informational , Environmental change, Somatic, Somatic alteration, Individual-based/ Pair-based /Group-based, Uni-directional/Interactional, Synchronous/ Asynchronous, Push/ Pull, Gamification, Arts feature. Relationships between entities consist of is_a. Inter-rater reliability of the Mode of Delivery Ontology for annotating intervention evaluation reports was a=0.80 (very good) for those familiar with the ontology and a= 0.58 (acceptable) for those unfamiliar with it. Conclusion: The ontology can be used for both annotating and writing behaviour change intervention evaluation reports in a consistent and coherent manner, thereby improving evidence comparison, synthesis, replication, and implementation of effective interventions.

Utilising the perspectives of patients with lower-limb osteoarthritis on prescribed physical activity to develop a theoretically informed physiotherapy intervention

BACKGROUND

Lower-limb osteoarthritis (OA) causes high levels of pain and disability. Physiotherapists are the primary healthcare provider of non-pharmacological treatments, and incorporate strategies to optimise physical activity (PA) to aid patients with lower-limb OA to moderate their clinical symptoms. However, patients with lower-limb OA have low adherence to PA recommendations both during treatment and after discharge. This study aimed to use knowledge of identified barriers and facilitators to physiotherapy prescribed PA (during treatment and post-discharge) to develop a theoretically informed intervention to optimise adherence to PA for patients with lower-limb OA during treatment and post-discharge.

METHODS

1) A purposive sample of 13 patients with lower-limb OA participated in semi-structured interviews following physiotherapy treatment. Inductive analysis identified themes/subthemes reflecting barriers and facilitators to physiotherapist prescribed PA, which were organised deductively according to personal factors, treatment and post-discharge phases. 2) Themes/subthemes were mapped onto the theoretical domains framework (TDF). 3) Behaviour change techniques (BCTs) were coded from the key identified domains and a theoretically informed physiotherapy intervention addressing barriers and using facilitators, was developed.

RESULTS

Themes of patient confidence, mind-set, motivation, OA symptoms and PA experiences were primary personal factors that influenced PA adherence; with the TDF domain 'Beliefs about capabilities' most important to target. During treatment, the theme of routine formation was the major driver of personal factors; and primarily influenced by developing a positive physiotherapist-patient relationship. Post-discharge, physical factors, psychosocial factors and ongoing access to resources were important themes influencing PA maintenance. 'Environmental context and resources' and 'social influences' emerged as the key TDF domains to target during treatment and post-discharge. The proposed theoretically informed intervention included 26 BCTs delivered across conceptual phases of adoption, routine formation, and maintenance.

CONCLUSION

A theoretically informed physiotherapy intervention was proposed to optimise PA adherence in patients with lower-limb OA. The included BCTs primarily target patients' perceived beliefs about their capabilities, by developing a PA routine during treatment and facilitating appropriate psychosocial support and access to resources for PA maintenance post-discharge. The feasibility of delivering the intervention in clinical practice will now be evaluated.

Behavior Change Techniques in Physical Activity Interventions for Multiple Sclerosis

OBJECTIVE

To identify and summarize the behavior change techniques (BCTs) included in behavior change interventions for promoting physical activity in persons with multiple sclerosis (MS).

DATA SOURCES

PubMed, PsycINFO, Cumulative Index to Nursing and Allied Health Complete, Scopus, and Embase were initially searched in November 2019, and data extraction began in June 2020.

STUDY SELECTION

The inclusion criteria for studies were: adults older than 18 years with diagnosed MS, English language, clinical trial designs (ie, pre-post or randomized controlled trials), group or individual interventions, and home or community-based settings wherein physical activity was defined as a primary or secondary outcome. Exclusion criteria for studies included protocol manuscripts pending results, case studies, studies focused on populations with multiple chronic diseases, and interventions targeting multiple behaviors. Two researchers completed screening for study selection, and a third researcher served as a referee. Of the initially identified 8681 studies, 54 studies met selection criteria.

DATA EXTRACTION

Data extraction was completed by 3 researchers. Each article was coded by 2 of the 3 researchers, and a fourth researcher resolved discrepancies. Data extracted from each paper included study title, authors, country, year, sample size, study design, intervention details, physical activity outcomes, and BCTs.

DATA SYNTHESIS

Thirty-eight unique behavior change interventions were identified, and 53 of the 93 possible BCTs were included across the studies. The mean number of BCTs per study was 15, and studies and effect sizes across studies ranged from 0.04-1.49.

CONCLUSIONS

This review provides a comprehensive overview of BCTs as the active ingredients in behavior change interventions targeting physical activity in MS. Results from this study provide a compendium for future intervention development for increasing physical activity and improving overall health in MS.

Comparison of barriers and facilitators of MIND diet uptake among adults from Northern Ireland and Italy

Background

The aim of the study was to identify and compare components of the COM-B (capability, opportunity, motivation and behaviour) model, that influences behaviour to modify dietary patterns in 40–55-year olds living in Northern Ireland (NI) and Italy, in order to reduce the risk of cognitive decline in later life.

Methods

This was a qualitative study examining factors influencing Mediterranean-DASH (Dietary Approaches to Stop Hypertension) Intervention for Neurodegenerative Delay (MIND) diet behaviour. This study further elaborated the COM-B components into the 14 domains of the Theoretical Domains Framework to further understand behaviour. Twenty-five Northern Irish and Italian participants were recruited onto the study, to take part in either a focus group or an interview. Participants were both male and female aged between 40 and 55 years.

Results

Thematic analysis revealed that the main barriers to the uptake of the MIND diet were; time, work environment (opportunity), taste preference and convenience (motivation). Culture (motivation), seasonal foods and lack of family support (opportunity) to be a barrier to the Italian sample only. The main facilitators reported were; improved health, memory, planning and organisation (motivation) and access to good quality food (opportunity). Cooking skills, knowledge (capability) and heathy work lunch (opportunity) reported as a facilitator to the Italian sample only.

Conclusions

Cross-cultural differences in relation to psychosocial barriers and facilitators were found in both samples. More barriers than facilitators towards uptake of the MIND diet were found. There is a need for interventions that increase capability, opportunity, and motivation to aid behaviour change. The findings from this study will be used to design a behaviour change intervention using the subsequent steps from the Behaviour Change Wheel.

Behavioral and Physical Activity Interventions for HAND

Approximately 30-50% of persons living with HIV manifest some degree of neurocognitive impairment. Even mild-to-moderate forms of HIV-associated neurocognitive disorders (HAND) can result in difficulties with everyday functioning, such as suboptimal medication adherence and impaired driving. Despite the pervasive presence and consequences of HAND, there is a significant unmet need to develop effective behavioral strategies to reduce the incidence and consequences of HAND. Although there is an absence of evidence-based behavioral interventions specific to HAND, the literature reviewed in this chapter suggest the following modifiable lifestyle factors as intervention targets: physical activity, diet, sleep, and antiretroviral medication adherence. Adoption and maintenance of these healthy lifestyle factors may reduce inflammation and oxidative stress, which, in turn, may reduce the incidence and/or severity of HAND.

Developing an evidence-based online method of linking behaviour change techniques and theoretical mechanisms of action: a multiple methods study

Background

Many global health challenges may be targeted by changing people’s behaviour. Behaviours including cigarette smoking, physical inactivity and alcohol misuse, as well as certain dietary behaviours, contribute to deaths and disability by increasing the risk of cancers, cardiovascular diseases and diabetes. Interventions have been designed to change these health behaviours with a view to reducing these health risks. However, the effectiveness of these interventions has been quite variable and further information is needed to enhance their success. More information is needed about the specific processes that underlie the effectiveness of intervention strategies.

Aim

Researchers have developed a taxonomy of 93 behaviour change techniques (i.e. the active components of an intervention that bring about behavioural change), but little is known regarding their potential mechanisms of action (i.e. the processes through which a behaviour change technique affects behaviour). We therefore aimed to examine links between behaviour change techniques and mechanisms of action.

Method

First, we conducted a literature synthesis study of 277 behaviour change intervention studies, from which we extracted information on links, described by authors, between behaviour change techniques and mechanisms of action, and identified an average of 10 links per intervention report. Second, behaviour change experts (n = 105) were engaged in a three-round consensus study in which they discussed and rated their confidence in the presence/absence of ‘links’ and ‘non-links’ between commonly used behaviour change techniques (n = 61) and a set of mechanisms of action (n = 26). Ninety links and 460 ‘non-links’ reached the pre-set threshold of 80% agreement. To enhance the validity of these results, a third study was conducted that triangulated the findings of the first two studies. Discrepancies and uncertainties between the studies were included in a reconciliation consensus study with a new group of experts (n = 25). The final results identified 92 definite behaviour change technique–mechanism of action links and 465 definite non-links. In a fourth study, we examined whether or not groups of behaviour change techniques used together frequently across interventions revealed shared theoretical underpinnings. We found that experts agreed on the underlying theory for three groups of behaviour change techniques.

Results

Our results are potentially useful to policy-makers and practitioners in selecting behaviour change techniques to include in behaviour change interventions. However, our data do not demonstrate that the behaviour change techniques are effective in targeting the mechanism of action; rather, the links identified may be the ‘best bets’ for interventions that are effective in changing mechanisms of action, and the non-links are unlikely to be effective. Researchers examining effectiveness of interventions in either primary studies or evidence syntheses may consider these links for further investigation.

Conclusion

To make our results usable by researchers, practitioners and policy-makers, they are available in an online interactive tool, which enables discussion and collaboration (https://theoryandtechniquetool.humanbehaviourchange.org/); accessed 1 March 2020. This work, building on previous work to develop the behaviour change technique taxonomy, is part of an ongoing programme of work: the Human Behaviour Change Project (www.humanbehaviourchange.org/; accessed 1 March 2020).

Funding

This project was funded by the Medical Research Council via its Methodology Panel: ‘Developing methodology for designing and evaluating theory-based complex interventions: an ontology for linking behaviour change techniques to theory’ (reference MR/L011115/1).