The Behaviour Change Technique Ontology: Transforming the Behaviour Change Technique Taxonomy v1

The DID-guide: A guide to developing digital mental health interventions

The opportunities technology offers for improving mental health have led to a surge in digital interventions. A pivotal step in the development of such interventions involves translating theoretical intervention techniques into specific technological features. However, practical guidelines on how to approach this translation are currently underdeveloped. To support efforts to develop digital mental health interventions, from theoretical inception to an actual digital intervention, we present the Digital Intervention Development Guide (DID-Guide). The DID-Guide is structured into two distinct phases. Phase 1 establishes the intervention's theoretical foundation, outlining the steps for developing a theoretical intervention framework. Phase 2 translates this theoretical framework into actionable technological features, that make up the intervention. We break down the DID-Guide's two phases into a series of actionable steps, accompanied by concrete examples from a recent intervention that can be delivered through both a smartphone app and Virtual Reality. The DID-Guide serves as a comprehensive resource for creating impactful digital mental health interventions, while also facilitating collaboration and communication among a diverse range of stakeholders, including researchers, clinicians, and software developers.

App-based interventions to improve cancer outcomes rely on informational support from professionals: a systematic review

The importance of social support for cancer patients is well-established, and mobile applications hold promise for implementation. This systematic review examines app-based interventions with social support components for cancer patients, investigating the use of different support functions from different sources and the impact on cancer-related symptoms and psychological outcomes. A systematic search across five databases (EMBASE, Scopus, PsycINFO, PubMed, Web of Science) yielded 449 records, of which 17 studies (12 controlled designs) were included. Two independent reviewers extracted data and assessed study quality, revealing a high risk of bias across studies. Social support was implemented through different app functions, including contact/chat functions (n = 9), automatic alerts based on app input (n = 6) and discussion forums (n = 5). Social support predominantly focused on informational support (n = 17), mostly from healthcare professionals. Emotional support was less common (n = 7). Results indicated some promising intervention effects for pain, fatigue, nausea/vomiting, insomnia, constipation and overall symptom distress, but heterogeneous effects for health-related quality of life. Overall, results were mixed, but indicate that mobile apps incorporating social support may hold promise for cancer patients. However, future studies should focus on measuring and reporting social support as an intervention mechanism to systematically investigate its specific impact and improve effectiveness.

The BSSO Foundry: A community of practice for ontologies in the behavioural and social sciences

There has been a rapid expansion in the quantity and complexity of data, information and knowledge created in the behavioural and social sciences, yet the field is not advancing understanding, practice or policy to the extent that the insights warrant. One challenge is that research often progresses in disciplinary silos and is reported using inconsistent and ambiguous terminology. This makes it difficult to integrate and aggregate findings to produce cumulative bodies of knowledge that can be translated to applied settings. Ontologies can address these challenges; their development and use have the potential to accelerate the behavioural and social sciences. Ontologies can facilitate communication through precise specification and dissemination of terms, and enable efficient data integration, sharing, comparison and analysis. The widespread use of ontologies in the biomedical and biological sciences has led to multiple successes. It is time now for the behavioural and social sciences to follow that lead. In recent years, a number of ontologies have been developed within the behavioural and social sciences; however, efforts have tended to be isolated, with limited resources to support developers and those who work (or would like to work) with and use ontologies. There is a need for coordination and exchange to reduce duplication of work and leverage the value of a community to support the interoperability of these ontologies (linking of entities across domains and datasets). We have therefore initiated the Behavioural and Social Sciences Ontology (BSSO) Foundry, a community of practice and online repository for the development, adoption and use of ontologies in the behavioural and social sciences. The BSSO Foundry aligns with and builds upon the model provided by the Open Biological and Biomedical Ontology Foundry. We describe this new initiative and how to join and contribute to the community of interoperable ontologies for the behavioural and social sciences.

Exploring factors influencing late evening eating and barriers and enablers to changing to earlier eating patterns in adults with overweight and obesity

Late evening eating is a potential risk factor for overconsumption and weight gain. However, there is limited qualitative research investigating the complex factors that influence late evening eating in adults living with obesity. Identifying the factors that influence late evening eating can inform interventions to reduce late evening eating and associated health risks. Therefore, this study aimed to: i) explore factors that contribute to eating late, and ii) apply the Capability, Opportunity, and Motivation Behaviour (COM-B) model to understand the barriers and enablers to changing to earlier food intake timings in UK adults who report eating late. Semi-structured interviews with seventeen participants [32.47 ± 6.65 years; 34.68 ± 7.10 kg/m2; 71% female (n = 12); 41% White (n = 7)] investigated reasons for late evening eating and the potential barriers and enablers to changing to earlier eating patterns. Thematic analysis identified four main contributors to late evening eating: 1) internal signals (e.g., feeling hungry in the evening); 2) external and situational factors (e.g., work schedules and the food-rich environment); 3) social factors (e.g., interactions with family) and 4) behavioural and emotional factors (e.g., personal preferences and negative feelings in the evening). Time constraints and work schedules were identified as main barriers to changing to earlier eating patterns. Whereas, having high motivation (e.g., contentment with eating earlier in the evening) and interpersonal support were identified as main enablers to eating earlier. This study provides in-depth insights into the psychological, social, and environmental factors contributing to late evening eating. The findings highlight potential targets for future interventions to facilitate earlier eating times in individuals at risk of overweight and obesity.

Understanding the mechanisms of change in social norms around tobacco use: A systematic review and meta-analysis of interventions

BACKGROUND AND AIMS

Tobacco use spreads through social networks influencing social norms around tobacco use. However, the social norms scholarship is extremely diverse and occasionally conflicting, complicating efforts to understand how best to leverage social norms to reduce tobacco use. This study systematically reviewed and meta-analyzed this vast terrain by focusing on social norms measurement and mechanism, and intervention effectiveness and modality aimed at changing social norms around tobacco use and actual tobacco use.

METHODS

We searched Scopus, PubMed, PsycInfo, Clinicaltrials.gov, ProQuest Dissertations, the Cochrane Trial Registry, as well as the websites of the Society for Research on Nicotine and Tobacco, the Open Science Framework, medrXiv and the Truth Initiative for experimental and quasi-experimental evaluation studies of interventions designed to shift tobacco use. We included studies written in English from inception to 30 May 2024. We only included studies which noted social norms or social influence as part of the intervention design or set of measured variables. We excluded studies with only one time point, without an intervention being evaluated and those not published in English. Study screening followed the PRISMA 2020 guidelines, and was conducted by at least two independent reviewers who resolved discrepancies through discussion and consensus. All included studies were analyzed in a narrative synthesis, and those providing sufficient statistics for tobacco and social norms outcomes were included in meta-analyses, which were performed separately for tobacco outcomes and social norms outcomes. Study outcomes were transformed into a standardized mean difference (Hedges' g) and several meta-regressions were fit to explore sources of heterogeneity using a robust variance estimation specification to handle effect size dependency.

RESULTS

A total of 95 studies met inclusion criteria for the narrative synthesis, 200 effect sizes from 86 studies were included in the tobacco outcomes meta-analysis, and 66 effect sizes from 29 studies were included in the social norms outcomes meta-analysis. Nearly 90% of included studies were conducted in high-income settings, with the remainder conducted in middle-income settings. No studies were conducted in Latin America or on the African continent. Social norms change interventions had a statistically significant effect on reducing tobacco use and pro-tobacco social normative perceptions [g = 0.233, 95% confidence interval (CI) = 0.166, 0.301, P < 0.001 and g = 0.292, 95% CI = 0.090, 0.494, P = 0.007, respectively]. Interventions were commonly conducted among schoolchildren in classrooms through multicomponent education sessions, often coupled with regular 'booster' sessions over time. Among adult populations, motivational interviewing and other counselling approaches were used in some cases, and few interventions leveraged digital technologies to change social norms.

CONCLUSIONS

Social norms change interventions appear to be effective for reducing tobacco use and pro-tobacco social normative perceptions. In particular, leveraging role models appears to be the most effective social norms change mechanisms for tobacco control.

Feasibility and Engagement of a Mobile App Preparation Program (Kwit) for Smoking Cessation in an Ecological Context: Quantitative Study

BACKGROUND

Mobile health apps can facilitate access to effective treatment and therapeutic information services. However, the real-world effectiveness of mobile apps for smoking cessation and their potential impact in everyday settings remain unclear.

OBJECTIVE

In an ecological context, this study aimed to estimate the engagement rate of a mobile app-based smoking cessation preparation program and its potential impact on users' willingness, ability, and readiness to quit smoking.

METHODS

A total of 2331 "organic users" (ie, users who discover and install a mobile app on their own, without any prompts) chose 1 of 2 program versions of the mobile app (Kwit): the basic version or the premium version. Both versions were identical in design, with 4 more evidence-based content items and strategies in the premium version. Outcomes were analyzed based on automated data registered in the app (engagement rate, motivation to quit, motivation type, motivation levels, and satisfaction level). Mann-Whitney and χ2 tests were used to compare the results of both groups.

RESULTS

As expected, in the ecological context, a high dropout rate was observed at different moments. A significant difference was observed between the 2 versions (n=2331; χ21=5.4; P=.02), with a proportionally higher engagement rate in the premium version (premium=4.7% vs basic=2%). Likewise, differences were also observed between the 2 groups in terms of reasons to quit (n=2331; χ24=19; P≤.001; V=0.08), motivation type (n=2331; χ27=14.7; P=.04), and motivation level. Users of the app's premium version more frequently reported "well-being" (23.3% vs 17.9%) and "planning a pregnancy" (7.4% vs 4.4%) as their primary reasons for quitting smoking compared to those with the basic version. Moreover, they reported being more likely to be driven in the smoking cessation process by intrinsic motivation (premium=28% vs basic=20.4%), as well as feeling significantly more willing (z score=156,055; P≤.001; Cohen d=0.15), able (z score=172,905; P=.04; Cohen d=0.09), and ready (z score=166,390; P=.005; Cohen d=0.12) to stop smoking than users who had the basic version before completion of the preparation program. Among participants who finished each version of the program (premium: 9/189, 4.8%; basic: 47/2142, 2.19%), significant improvements in motivation levels were observed in both groups, although in different areas for each group (willingness levels for the premium group and ability for the basic group).

CONCLUSIONS

These results suggest that even in ecological contexts where engagement rates are meager, the Kwit preparation program can address ambivalence by increasing willingness to change, self-confidence, and readiness to quit among its users, especially those who feel less able to do so. Further development and evaluations are needed to better understand determinants for regular mobile health apps.

Supporting General Practitioners and people with hypertension to maximise medication use to control blood pressure: the contribution of Collective Intelligence to the development of the 'Maximising Adherence, Minimising Inertia' (MIAMI) intervention

Background

Hypertension remains one of the most important modifiable risk factors for stroke and heart disease. Anti-hypertensive medications are effective, but are often not used to maximum benefit. Sub-optimal dosing by prescribers and challenges with medication-taking for patients remain barriers to effective blood pressure control.

Objectives

We aimed to systematically develop a theory-based complex intervention to support General Practitioners (GPs) and people with hypertension to maximise medication use to control blood pressure.

Methods

We used the three-phase Behaviour Change Wheel (BCW) as the overarching intervention development framework. Collective Intelligence methodology was used to operationalise the stakeholder input to Phases 2 and 3 of the BCW. This took the form of a Collective Intelligence workshop with 19 stakeholders from diverse backgrounds including lived experience, general practice, nursing, pharmacy and health psychology. Techniques such as barrier identification, idea-writing and scenario-based design were used to generate possible intervention options. Intervention options were then selected and refined using the Acceptability, Practicability, Effectiveness, Affordability, Side-effects and Equity (APEASE) criteria and guidance from the MIAMI Public and Patient Involvement Panel.

Results

The finalised MIAMI intervention consists of both GP and patient supports. GP supports include a 30-minute online training, information booklet and consultation guide (drop-down menu) embedded within the patient electronic health system. Patient supports include a pre-consultation plan, website, and a structured GP consultation with results from an Ambulatory Blood Pressure Monitor and urine chemical adherence test. The intervention components have been mapped to the intervention functions of the BCW and Behaviour Change Technique Ontology.

Conclusion

Collective Intelligence offered a novel method to operationalise stakeholder input to Phases 2 and 3 of the BCW. The MIAMI intervention is now at pilot evaluation stage.

A research agenda to advance the study of implementation mechanisms

BACKGROUND

Implementation science scholars have made significant progress identifying factors that enable or obstruct the implementation of evidence-based interventions, and testing strategies that may modify those factors. However, little research sheds light on how or why strategies work, in what contexts, and for whom. Studying implementation mechanisms-the processes responsible for change-is crucial for advancing the field of implementation science and enhancing its value in facilitating equitable policy and practice change. The Agency for Healthcare Research and Quality funded a conference series to achieve two aims: (1) develop a research agenda on implementation mechanisms, and (2) actively disseminate the research agenda to research, policy, and practice audiences. This article presents the resulting research agenda, including priorities and actions to encourage its execution.

METHOD

Building on prior concept mapping work, in a semi-structured, 3-day, in-person working meeting, 23 US-based researchers used a modified nominal group process to generate priorities and actions for addressing challenges to studying implementation mechanisms. During each of the three 120-min sessions, small groups responded to the prompt: "What actions need to be taken to move this research forward?" The groups brainstormed actions, which were then shared with the full group and discussed with the support of facilitators trained in structured group processes. Facilitators grouped critical and novel ideas into themes. Attendees voted on six themes they prioritized to discuss in a fourth, 120-min session, during which small groups operationalized prioritized actions. Subsequently, all ideas were collated, combined, and revised for clarity by a subset of the authorship team.

RESULTS

From this multistep process, 150 actions emerged across 10 priority areas, which together constitute the research agenda. Actions included discrete activities, projects, or products, and ways to shift how research is conducted to strengthen the study of implementation mechanisms.

CONCLUSIONS

This research agenda elevates actions to guide the selection, design, and evaluation of implementation mechanisms. By delineating recommended actions to address the challenges of studying implementation mechanisms, this research agenda facilitates expanding the field of implementation science, beyond studying what works to how and why strategies work, in what contexts, for whom, and with which interventions.

Shared characteristics of intervention techniques for oral vocabulary and speech comprehensibility in preschool children with co-occurring features of developmental language disorder and speech sound disorder: a systematic review with narrative synthesis

OBJECTIVES

To descriptively compare and contrast intervention techniques for preschool children with features of developmental language disorder (outcome: oral vocabulary) and speech sound disorder (outcome: speech comprehensibility) and analyse them in relation to effectiveness and theory.

DESIGN

This is a systematic review with narrative synthesis. The process was supported by an expert steering group consisting of relevant professionals and people with lived experience.

DATA SOURCES

Ovid Emcare, MEDLINE Complete, CINAHL, APA PsycINFO, ERIC, and Communication Source from January 2012 were searched. Relevant studies were obtained from an initial published review (up to January 2012).

ELIGIBILITY CRITERIA

Interventions for preschool children (80% aged 2:0-5:11 years) with idiopathic speech or language needs; outcomes relating to either oral vocabulary or speech comprehensibility.

DATA EXTRACTION AND SYNTHESIS

Searches were conducted on 27 January 2023. Two independent researchers screened at abstract and full-text levels. Data regarding intervention content (eg, techniques) and format/delivery (eg, dosage, location) were extracted. Data were synthesised narratively according to the methods of Campbell et al.

RESULTS

24 studies were included: 18 for oral vocabulary and 6 for speech comprehensibility. There were 11 randomised controlled trials, 2 cohort studies and 11 case series. Similarities included a focus on input-related techniques and similar therapy activities. Speech studies were more likely to be professional-led and clinic-led, rather than at home and through a parent. Analysis was restricted by heterogeneity in study design and terminology, as well as gaps within intervention reporting. Information deemed important to the expert steering group was missing.

CONCLUSIONS

Similarities and differences between intervention techniques for oral vocabulary and speech comprehensibility have been identified and synthesised. However, analysis of effectiveness was limited due to issues with study design and heterogeneity within studies. This has implications for the progression of the evidence base within the field.

PROSPERO REGISTRATION NUMBER

CRD42022373931.

Behavior Change Techniques Within Digital Interventions for the Treatment of Eating Disorders: Systematic Review and Meta-Analysis

BACKGROUND

Previous systematic reviews of digital eating disorder interventions have demonstrated effectiveness at improving symptoms of eating disorders; however, our understanding of how these interventions work and what contributes to their effectiveness is limited. Understanding the behavior change techniques (BCTs) that are most commonly included within effective interventions may provide valuable information for researchers and developers. Establishing whether these techniques have been informed by theory will identify whether they target those mechanisms of action that have been identified as core to changing eating disorder behaviors. It will also evaluate the importance of a theoretical approach to digital intervention design.

OBJECTIVE

This study aims to define the BCTs within digital self-management interventions or minimally guided self-help interventions for adults with eating disorders that have been evaluated within randomized controlled trials. It also assessed which of the digital interventions were grounded in theory and the range of modes of delivery included.

METHODS

A literature search identified randomized controlled trials of digital intervention for the treatment of adults with eating disorders with minimal therapist support. Each digital intervention was coded for BCTs using the established BCT Taxonomy v1; for the application of theory using an adapted version of the theory coding scheme (TCS); and for modes of delivery using the Mode of Delivery Ontology. A meta-analysis evaluated the evidence that any individual BCT moderated effect size or that other potential factors such as the application of theory or number of modes of delivery had an effect on eating disorder outcomes.

RESULTS

Digital interventions included an average of 14 (SD 2.6; range 9-18) BCTs. Self-monitoring of behavior was included in all effective interventions, with Problem-solving, Information about antecedents, Feedback on behavior, Self-monitoring of outcomes of behavior, and Action planning identified in >75% (13/17) of effective interventions. Social support and Information about health consequences were more evident in effective interventions at follow-up compared with postintervention measurement. The mean number of modes of delivery was 4 (SD 1.6; range 2-7) out of 12 possible modes, with most interventions (15/17, 88%) being web based. Digital interventions that had a higher score on the TCS had a greater effect size than those with a lower TCS score (subgroup differences: χ21=9.7; P=.002; I²=89.7%) within the meta-analysis. No other subgroup analyses had statistically significant results.

CONCLUSIONS

There was a high level of consistency in terms of the most common BCTs within effective interventions; however, there was no evidence that any specific BCT contributed to intervention efficacy. The interventions that were more strongly informed by theory demonstrated greater improvements in eating disorder outcomes compared to waitlist or treatment-as-usual controls. These results can be used to inform the development of future digital eating disorder interventions.

TRIAL REGISTRATION

PROSPERO CRD42023410060; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=410060.

A Living Lab approach to understanding dairy farmers' technology and data needs to improve herd health: Focus groups from 6 European countries

For successful development and adoption of technology on dairy farms, farmers need to be included in the innovation process. However, the design of agricultural technologies usually takes a top-down approach with little involvement of end-users at the early stages. Living Labs offer a methodology that involve end-users throughout the development process and emphasize the importance of understanding users' needs. Currently, exploration of dairy farmers' technology needs has been limited to specific types of technology (e.g., smartphone apps) and adult cattle. The aim of this study was to use a Living Lab approach to identify dairy farmers' data and technology needs to improve herd health and inform innovation development. We conducted 18 focus groups with a total of 80 dairy farmers from Belgium, Ireland, the Netherlands, Norway, Sweden, and the United Kingdom. Data were analyzed using Template Analysis, and 6 themes were generated representing the fundamental needs of autonomy, comfort, competence, community and relatedness, purpose, and security. Farmers favored technologies that provided them with convenience, facilitated their knowledge and understanding of problems on farm, and allowed them to be self-reliant. Issues with data sharing and accessibility and usability of software were barriers to technology use. Furthermore, farmers were facing problems around recruitment and management of labor and needed ways to reduce stress. Controlling aspects of the barn environment, such as air quality, hygiene, and stocking density, were particular concerns in relation to youngstock management. Overall, the findings suggest that developers of farm technologies may want to include farmers in the design process to ensure a positive user experience and improve accessibility. The needs identified in this study can be used as a framework when designing farm technologies to strengthen need satisfaction and reduce any potential harm toward needs.

Prehabilitation: The underutilised weapon for chronic pain management

Objective

Prehabilitation encompasses preparatory clinical intervention(s) delivered during the period between diagnosis and treatment commencement. Despite widespread successful usage preoperatively, psychological prehabilitation is neglected in outpatient chronic pain management. Although pain management waitlists are associated with treatment attrition and psychological and physical decline, this time window is underutilised in preventing escalation. Waitlists present an under-explored opportunity to 'prehabilitate' patients waiting for treatment. This topical review aimed to: (1) examine the effectiveness of psychological prehabilitation for pain services; (2) evaluate the psychological and physical decline associated with waiting for pain management; (3) highlight key psychological prehabilitative targets for increasing treatment engagement; (4) promote pain management psychological prehabilitation within personalised pain medicine, building recommendations for future interventions.

Methods

Studies regarding the impact of waitlists and prehabilitation for chronic pain were reviewed.

Results

Findings demonstrated that the psychological constructs of patient expectations, health locus of control, self-efficacy and pain catastrophizing dynamically influence attrition, treatment engagement and outcomes while waiting. These constructs are amenable to change, emphasising their potential utility within a targeted waitlist intervention.

Conclusions

Prehabilitating chronic pain patients towards treatment engagement could circumvent cycles of failed treatment seeking, preventing psychological and physical decline, and reducing healthcare utilisation. Utilising the waitlist to identify psychosocial risk factors (external health locus of control, low self-efficacy and high pain catastrophizing) would identify who requires additional support to prevent increased risk of treatment failure, enhancing personalised care before prescribed treatment is accessed. This review cements the urgent need for pain services to engage proactively with prehabilitation innovation.

Enhancing making every contact count (MECC) training and delivery for the third and social economy (TSE) sector: a strategic behavioural analysis

OBJECTIVE

To enhance Making Every Contact Count (MECC, an opportunistic approach to health promotion), training in the Third and Social Economy (TSE, all groups and organisations primarily working towards social justice, outside of the government or household) by examining the degree to which the behavioural content of MECC training tackled significant factors influencing MECC delivery.

METHODS AND MEASURES

A strategic behavioural analysis design. Semi-structured interviews with service providers (n = 15) and users (n = 5) were coded for barriers and facilitators of MECC delivery using the Theoretical Domains Framework (TDF). Existing MECC training was coded for behaviour change techniques (BCTs) and intervention functions (IFs). The degree to which BCTs and IFs addressed the key TDF domains of influences on MECC delivery in the TSE were examined using prespecified tools.

RESULTS

Seven key TDF domains of influences in MECC delivery were identified. Overall, only 9/31 linked BCTs were utilised within MECC training, with percentage utilisation of relevant BCTs for each domain ranging from 0% to 66.7%. Training adequately addressed 2/7 key domains.

CONCLUSION

The TSE and healthcare share many common key TDF domains, although there are differences in how each are relevant. Limitations and recommendations for MECC training are discussed.

Improving retrospective intervention descriptions: Lessons learned from research on type 2 diabetes programmes in the United Kingdom and the Republic of Ireland

In recent years, multiple countries worldwide have implemented behavioural interventions within national healthcare systems. Describing the content of these interventions is critical to improve their implementation, replication, and effectiveness, as well as to advance behavioural science. Tools, such as the Behaviour Change Technique Taxonomy, can enhance the quality of intervention description and reporting. As interventions are frequently developed without the use of such tools, retrospective coding of existing interventions to accurately characterise their content is becoming more common. However, the use of these tools for retrospective coding poses various challenges, the discussion of which has been neglected to date. This commentary discusses the challenges encountered when retrospectively describing the content of five nationally implemented programmes for type 2 diabetes in the United Kingdom and the Republic of Ireland and suggests recommendations to tackle these challenges. We present important methodological, practical, and ethical considerations for researchers to reflect on, relevant to the retrospective description of existing interventions. Specifically, we discuss (i) the importance of positive relationships and collaboration with intervention stakeholders, (ii) the practical and ethical considerations when analysing the content of implemented interventions, (iii) the independence of research teams and the potential for misclassification of intervention content, and (iv) the challenges associated with the analysis of intervention content using behavioural science tools. There is a growing demand for more robust approaches to address the methodological, practical, and ethical challenges associated with such studies. The present commentary describes key issues to be considered by research teams, as well as concrete recommendations to improve the retrospective characterisation of intervention content.

How can interventions more directly address drivers of unprofessional behaviour between healthcare staff?

Unprofessional behaviours (UBs) between healthcare staff are widespread and have negative impacts on patient safety, staff well-being and organisational efficiency. However, knowledge of how to address UBs is lacking. Our recent realist review analysed 148 sources including 42 reports of interventions drawing on different behaviour change strategies and found that interventions insufficiently explain their rationale for using particular strategies. We also explored the drivers of UBs and how these may interact. In our analysis, we elucidated both common mechanisms underlying both how drivers increase UB and how strategies address UB, enabling the mapping of strategies against drivers they address. For example, social norm-setting strategies work by fostering a more professional social norm, which can help tackle the driver 'reduced social cohesion'. Our novel programme theory, presented here, provides an increased understanding of what strategies might be effective to adddress specific drivers of UB. This can inform logic model design for those seeking to develop interventions addressing UB in healthcare settings.

Precision feedback: A conceptual model

Introduction

When performance data are provided as feedback to healthcare professionals, they may use it to significantly improve care quality. However, the question of how to provide effective feedback remains unanswered, as decades of evidence have produced a consistent pattern of effects-with wide variation. From a coaching perspective, feedback is often based on a learner's objectives and goals. Furthermore, when coaches provide feedback, it is ideally informed by their understanding of the learner's needs and motivation. We anticipate that a "coaching"-informed approach to feedback may improve its effectiveness in two ways. First, by aligning feedback with healthcare professionals' chosen goals and objectives, and second, by enabling large-scale feedback systems to use new types of data to learn what kind of performance information is motivating in general. Our objective is to propose a conceptual model of precision feedback to support these anticipated enhancements to feedback interventions.

Methods

We iteratively represented models of feedback's influence from theories of motivation and behavior change, visualization, and human-computer interaction. Through cycles of discussion and reflection, application to clinical examples, and software development, we implemented and refined the models in a software application to generate precision feedback messages from performance data for anesthesia providers.

Results

We propose that precision feedback is feedback that is prioritized according to its motivational potential for a specific recipient. We identified three factors that influence motivational potential: (1) the motivating information in a recipient's performance data, (2) the surprisingness of the motivating information, and (3) a recipient's preferences for motivating information and its visual display.

Conclusions

We propose a model of precision feedback that is aligned with leading theories of feedback interventions to support learning about the success of feedback interventions. We plan to evaluate this model in a randomized controlled trial of a precision feedback system that enhances feedback emails to anesthesia providers.

A systematic review of experimentally tested implementation strategies across health and human service settings: evidence from 2010-2022

BACKGROUND

Studies of implementation strategies range in rigor, design, and evaluated outcomes, presenting interpretation challenges for practitioners and researchers. This systematic review aimed to describe the body of research evidence testing implementation strategies across diverse settings and domains, using the Expert Recommendations for Implementing Change (ERIC) taxonomy to classify strategies and the Reach Effectiveness Adoption Implementation and Maintenance (RE-AIM) framework to classify outcomes.

METHODS

We conducted a systematic review of studies examining implementation strategies from 2010-2022 and registered with PROSPERO (CRD42021235592). We searched databases using terms "implementation strategy", "intervention", "bundle", "support", and their variants. We also solicited study recommendations from implementation science experts and mined existing systematic reviews. We included studies that quantitatively assessed the impact of at least one implementation strategy to improve health or health care using an outcome that could be mapped to the five evaluation dimensions of RE-AIM. Only studies meeting prespecified methodologic standards were included. We described the characteristics of studies and frequency of implementation strategy use across study arms. We also examined common strategy pairings and cooccurrence with significant outcomes.

FINDINGS

Our search resulted in 16,605 studies; 129 met inclusion criteria. Studies tested an average of 6.73 strategies (0-20 range). The most assessed outcomes were Effectiveness (n=82; 64%) and Implementation (n=73; 56%). The implementation strategies most frequently occurring in the experimental arm were Distribute Educational Materials (n=99), Conduct Educational Meetings (n=96), Audit and Provide Feedback (n=76), and External Facilitation (n=59). These strategies were often used in combination. Nineteen implementation strategies were frequently tested and associated with significantly improved outcomes. However, many strategies were not tested sufficiently to draw conclusions.

CONCLUSION

This review of 129 methodologically rigorous studies built upon prior implementation science data syntheses to identify implementation strategies that had been experimentally tested and summarized their impact on outcomes across diverse outcomes and clinical settings. We present recommendations for improving future similar efforts.

Translating the behaviour change technique taxonomy version 1 into Spanish: Methodology and validation

Background

Precise and unequivocal specification of intervention content is key to facilitating the accumulation and implementation of knowledge. The Behaviour Change Technique Taxonomy v1 (BCTTv1) is the most widely used classification of behaviour change techniques (BCTs), providing a shared, standardized vocabulary to identify the active ingredients of behavioural interventions. However, the BCTTv1 is only available in English and this hampers its broad use and adoption. The aim of the present article is to report the process of translation of the BCTTv1 into Spanish.

Methods

A bilingual team led the translation of the BCTTv1, involving seven iterative steps: (i) establish a Committee, (ii) forward translation from English to Spanish, (iii) back translation from Spanish to English, (iv) comparison of original BCTTv1 and back translation, (v) opportunistic comparison against an independent BCTTv1 translation, (vi) empirical testing, and (vii) final Committee review.

Results

Changes as a result of the translation process included relabelling BCTs, amending definitions, and fixing conceptual and grammatical inconsistencies, yielding the final version. Very satisfactory inter-coder reliability in BCT identification was observed as part of the empirical testing (i.e., prevalence and bias-adjusted kappa scores > 0.8).

Conclusions

This work provides the Spanish-speaking population with a rigorous and validated BCTTv1 translation which can be used in both research and practice to provide a greater level of intervention detail for evidence synthesis, comparison, and replication of behaviour change interventions. The translation process described here may prove helpful to guide future translation efforts in behavioural science and beyond.

Efficacy of interventions and techniques on adherence to physiotherapy in adults: an overview of systematic reviews and panoramic meta-analysis

BACKGROUND

Adherence to physiotherapeutic treatment and recommendations is crucial to achieving planned goals and desired health outcomes. This overview of systematic reviews synthesises the wide range of additional interventions and behaviour change techniques used in physiotherapy, exercise therapy and physical therapy to promote adherence and summarises the evidence of their efficacy.

METHODS

Seven databases (PEDro, PubMed, Cochrane Library, Web of Science, Scopus, PsycINFO and CINAHL) were systematically searched with terms related to physiotherapy, motivation, behaviour change, adherence and efficacy (last searched on January 31, 2023). Only systematic reviews of randomised control trials with adults were included. The screening process and quality assessment with AMSTAR-2 were conducted independently by the two authors. The extracted data was synthesised narratively. In addition, four meta-analyses were pooled in a panoramic meta-analysis.

RESULTS

Of 187 reviews identified in the search, 19 were included, comprising 205 unique trials. Four meta-analyses on the effects of booster sessions, behaviour change techniques, goal setting and motivational interventions showed a significantly small overall effect (SMD 0.24, 95% CI 0.13, 0.34) and no statistical heterogeneity (I2 = 0%) in the panoramic meta-analysis. Narrative synthesis revealed substantial clinical and methodological diversity. In total, the certainty of evidence is low regarding the efficacy of the investigated interventions and techniques on adherence, due to various methodological flaws. Most of the RCTs that were included in the reviews analysed cognitive and behavioural interventions in patients with musculoskeletal diseases, indicating moderate evidence for the efficacy of some techniques, particularly, booster sessions, supervision and graded exercise. The reviews provided less evidence for the efficacy of educational and psychosocial interventions and partly inconsistent findings. Most of the available evidence refers to short to medium-term efficacy. The combination of a higher number of behaviour change techniques was more efficacious.

CONCLUSIONS

The overview of reviews synthesised various potentially efficacious techniques that may be combined for a holistic and patient-centred approach and may support tailoring complex interventions to the patient's needs and dispositions. It also identifies various research gaps and calls for a more holistic approach to define and measure adherence in physiotherapy.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42021267355.

Perceptions of Preventable Cancer Burden Among US-Based Firefighters: A Mixed Methods Cross-Sectional Study

OBJECTIVE

Characterize experiences with cancer and perceptions of the preventable cancer burden attributable to diet among firefighters.

DESIGN

A cross-sectional survey was distributed to assess cancer history and perceptions of cancer.

SETTING

US.

PARTICIPANTS

US-based firefighters.

MAIN OUTCOME MEASURE(S)

History of cancer, perceptions of cancer, and perceptions of diet as a means to prevent cancer.

ANALYSIS

Descriptive statistics and use of the Behaviour Change Technique Taxonomy v1 (BCTTv1) to evaluate qualitative responses.

RESULTS

A total of 471 firefighters participated. Nearly half (48.4%) voiced they strongly agreed that they were at risk for cancer, whereas 44.6% agreed that changing diet could decrease cancer risk. The most common BCTTv1 codes focused on types of education, including "Instruction on how to perform the behavior" (45.1%, n = 189), followed by those centered on behavior execution (eg, "Action planning" [24.8%, n = 104]). Qualitatively, many were concerned about misinformation.

CONCLUSIONS AND IMPLICATIONS

Firefighters acknowledge the role of diet in cancer risk and have a desire for knowledge and behavioral support (eg, goal setting) that includes an emphasis on evidence and tackling misinformation. This information should serve as the basis of future interventions that target diet.

The impact of school-based cooking classes on vegetable intake, cooking skills and food literacy of children aged 4-12 years: A systematic review of the evidence 2001-2021

BACKGROUND

Many children consume a poor quality diet with only a third of children aged 6-9 years eating vegetables daily. A high quality diet is important for good health in childhood; however, the prevalence of children living with obesity has doubled from 10% to 23% during primary school in the UK. Cooking lessons have the potential to improve diet quality and reduce obesity prevalence in childhood, both of which are associated with improved cardiometabolic outcomes in adulthood. The aim of this systematic review is to investigate the impact of school-based cooking classes on cooking skills, food literacy and vegetable intake of children aged 4-12 years.

METHODS

We conducted a systematic review of OVID Medline, OVID Embase, EBSCO CINHAL and EBSCO ERIC for comparative studies that evaluated outcomes of children receiving cooking classes compared to a control group. Interventions included contained food preparation or a cooking activities and took place on school premises. Risk of bias was assessed using ROB2 and Robins-I. Outcomes were pooled in a meta-analysis using a random-effects model using standardised mean differences or reviewed using narrative synthesis. Certainty of evidence was assessed using GRADE.

RESULTS

We included 21 studies, (6 randomised). Meta-analysis showed a small positive effect on cooking self-efficacy of 0.39 units (95% CI 0.05 to 0.54), and a small positive effect on vegetable intake of 0.25 units (95% CI 0.05 to 0.45). Programmes with more than 6 h of cooking showed the greatest effects.

CONCLUSIONS

Children's cooking programmes result in small improvements in cooking efficacy and vegetable intake, particularly those with more than 6 h of classes. It is recommended that future interventions use consistent measurement for children's food literacy and cooking confidence.

A data extraction template for the behaviour change intervention ontology

Background

The Behaviour Change Intervention Ontology (BCIO) aims to improve the clarity, completeness and consistency of reporting within intervention descriptions and evidence synthesis. However, a recommended method for transparently annotating intervention evaluation reports using the BCIO does not currently exist. This study aimed to develop a data extraction template for annotating using the BCIO.

Methods

The BCIO data extraction template was developed in four stages: i) scoping review of papers citing component ontologies within the BCIO, ii) development of a draft template, iii) piloting and revising the template, and iv) dissemination and maintenance of the template.

Results

A prototype data extraction template using Microsoft Excel was developed based on BCIO annotations from 14 papers. The 'BCIO data extraction template v1' was produced following piloting and revision, incorporating a facility for user feedback.

Discussion

This data extraction template provides a single, accessible resource to extract all necessary characteristics of behaviour change intervention scenarios. It can be used to annotate the presence of BCIO entities for evidence synthesis, including systematic reviews. In the future, we will update this template based on feedback from the community, additions of newly published ontologies within the BCIO, and revisions to existing ontologies.

From risk communication about asymptomatic atherosclerosis to cognitive and emotional reactions and lifestyle modification

BACKGROUND

Non-adherence in the general population to preventive guidelines on cardiovascular disease calls for an interdisciplinary approach acknowledging psychological factors of relevance for risk communication and lifestyle modification. Evidence is building up regarding the advantage of sharing arterial imaging evidence of subclinical atherosclerosis with asymptomatic individuals, but there is limited understanding of how this relates to mechanisms of importance for behavioural change. Longitudinal studies on associations between patients' reactions and lifestyle modification are missing. The population-based randomized controlled trial VIPVIZA investigates the impact of pictorial information about subclinical atherosclerosis, added to traditional risk factor-based communication. The intervention includes a personalized, colour-coded and age-related risk communication strategy and a motivational conversation, and has been shown to reduce cardiovascular disease risk.

METHODS

In the present study we assessed cognitive and emotional reactions to the intervention, and how these reactions are associated to lifestyle modification. The participants' evaluation of the risk communication was assessed in the intervention group (n = 1749). Lifestyle modification was assessed with a lifestyle index based on physical activity, diet, smoking and alcohol consumption at baseline and after 3 years. Associations between cognitive and emotional response and lifestyle modification were tested with analyses of covariance in a subset of participants (n = 714-857).

RESULTS

The intervention increased understanding of personal CVD risk, the possibility to influence the risk, and how to influence the risk. Severity of atherosclerosis was associated with emotional reactions, but emotions of strong negative valence were uncommon. Cognitive response and emotional arousal evoked by the intervention were positively associated with lifestyle modification, whereas negative emotions in isolation were not. High level of cognitive response in combination with high level of emotional arousal was found to be most beneficial for lifestyle modification.

CONCLUSIONS

The results demonstrate the potential of communicating asymptomatic atherosclerosis with a pictorial, colour-coded and age-related strategy, also including a motivational conversation. Furthermore, the results show the importance of CVD risk communication evoking engagement, and that an interaction between cognitive and emotional reactions might be central for sustained lifestyle modification. Our results also indicate that, in an asymptomatic population, atherosclerosis screening may strengthen disease prevention and health promotion.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01849575. Registration date 08/05/2013.

Building on Existing Classifications of Behavior Change Techniques to Classify Planned Coping Strategies: Physical Activity Diary Study

BACKGROUND

When trying to be more physically active, preparing for possible barriers by considering potential coping strategies increases the likelihood of plan enactment. Digital interventions can support this process by providing personalized recommendations for coping strategies, but this requires that possible coping strategies are identified and classified. Existing classification systems of behavior change, such as the compendium of self-enactable techniques, may be reused to classify coping strategies in the context of physical activity (PA) coping planning.

OBJECTIVE

This study investigated whether coping strategies created by a student population to overcome barriers to be physically active can be mapped onto the compendium of self-enactable techniques and which adaptations or additions to the frameworks are needed.

METHODS

In total, 359 Flemish university students created action and coping plans for PA for 8 consecutive days in 2020, resulting in 5252 coping plans. A codebook was developed iteratively using the compendium of self-enactable techniques as a starting point to code coping strategies. Additional codes were added to the codebook iteratively. Interrater reliability was calculated, and descriptive statistics were provided for the coping strategies.

RESULTS

Interrater reliability was moderate (Cohen κ=0.72) for the coded coping strategies. Existing self-enactable techniques covered 64.6% (3393/5252) of the coded coping strategies, and added coping strategies covered 28.52% (n=1498). The remaining coping strategies could not be coded as entries were too vague or contained no coping strategy. The added classes covered multiple ways of adapting the original action plan, managing one's time, ensuring the availability of required material, and doing the activity with someone else. When exploring the data further, we found that almost half (n=2371, 45.1%) of the coping strategies coded focused on contextual factors.

CONCLUSIONS

The study's objective was to categorize PA coping strategies. The compendium of self-enactable techniques addressed almost two-thirds (3393/5252, 64.6%) of these strategies, serving as valuable starting points for classification. In total, 9 additional strategies were integrated into the self-enactable techniques, which are largely absent in other existing classification systems. These new techniques can be seen as further refinements of "problem-solving" or "coping planning." Due to data constraints stemming from the COVID-19 pandemic and the study's focus on a healthy Flemish student population, it is anticipated that more coping strategies would apply under normal conditions, in the general population, and among clinical groups. Future research should expand to diverse populations and establish connections between coping strategies and PA barriers, with ontologies recommended for this purpose. This study is a first step in classifying the content of coping strategies for PA. We believe this is an important and necessary step toward digital health interventions that incorporate personalized suggestions for PA coping plans.

Experiences of social support by participants with morbid obesity who participate in a rehabilitation program for health-behavior change: a qualitative study

BACKGROUND

Obesity is a global public health concern with significant implications for individuals' physical health and overall well-being. Health-behavior change programs are crucial for addressing obesity and its associated health risks. Social support plays a central role in facilitating successful outcomes in these programs, yet limited qualitative research exists on the experiences of individuals with morbid obesity participating in such interventions. Thus, this study explores how participants with morbid obesity experienced social support in a group-based rehabilitation program for health-behavior change.

METHODS

Fourteen participants in a group-based rehabilitation health-behavior change program in Norway were interviewed using semi-structured interviews. Data were analyzed with thematic analysis.

RESULTS

The thematic analysis revealed three primary sources of social support: support from other participants in the group, social support from family and friends, and support from the interdisciplinary team. The participants emphasized the significance of ongoing social support throughout their health-behavior change program. Participants appreciated fostering a sense of community and regular interaction with other members of the program to ensure ongoing social support.

CONCLUSIONS

Participants outlined the importance of maintaining a sense of community in the group and appreciated platforms for facilitating ongoing interactions and support among group participants. Future studies should focus on long-term interventions, tailored approaches for individuals with diverse needs involving family and friends, and the impact of enhanced peer support. By understanding the role of social support in health-behavior change programs, interventions can be optimized to better support individuals with morbid obesity.

Saldanha I, Smith V, Toomey E, Williamson P. Using behavioural science to enhance use of core outcome sets in trials: protocol

Background

Core outcome sets (COS) represent agreed-upon sets of outcomes, which are the minimum that should be measured and reported in all trials in specific health areas. Use of COS can reduce outcome heterogeneity, selective outcome reporting, and research waste, and can facilitate evidence syntheses. Despite benefits of using COS, current use of COS in trials is low. COS use can be understood as a behaviour, in that it is something trialists do, or not do, adequately. The aim of this study is to identify strategies, informed by behaviour change theory, to increase COS use in trials.

Methods

The project will be conducted in two stages, informed by the behaviour change wheel (BCW). The BCW is a theoretically based framework that can be used to classify, identify, and develop behaviour change strategies. In Stage 1, barriers and enablers to COS use will be extracted from published studies that examined trialist's use of COS. Barriers and facilitators will be mapped to the components of COM-B model (capability, opportunity, and motivation), which forms part of the BCW framework. Stage 2 will build on Stage 1 findings to identify and select intervention functions and behaviour change techniques to enhance COS use in trials.

Discussion

The findings of this study will provide an understanding of the behavioural factors that influence COS use in trials and what strategies might be used to target these factors to increase COS use in trials.

Saldanha I, Smith V, Toomey E, Williamson P. Using behavioural science to enhance use of core outcome sets in trials: protocol

BACKGROUND

Core outcome sets (COS) represent agreed-upon sets of outcomes, which are the minimum that should be measured and reported in all trials in specific health areas. Use of COS can reduce outcome heterogeneity, selective outcome reporting, and research waste, and can facilitate evidence syntheses. Despite benefits of using COS, current use of COS in trials is low. COS use can be understood as a behaviour, in that it is something trialists do, or not do, adequately. The aim of this study is to identify strategies, informed by behaviour change theory, to increase COS use in trials.

METHODS

The project will be conducted in two stages, informed by the behaviour change wheel (BCW). The BCW is a theoretically based framework that can be used to classify, identify, and develop behaviour change strategies. In Stage 1, barriers and enablers to COS use will be extracted from published studies that examined trialist's use of COS. Barriers and facilitators will be mapped to the components of COM-B model (capability, opportunity, and motivation), which forms part of the BCW framework. Stage 2 will build on Stage 1 findings to identify and select intervention functions and behaviour change techniques to enhance COS use in trials.

DISCUSSION

The findings of this study will provide an understanding of the behavioural factors that influence COS use in trials and what strategies might be used to target these factors to increase COS use in trials.

Specifying how intervention content is communicated: Development of a Style of Delivery Ontology

Background: Investigating and enhancing the effectiveness of behaviour change interventions requires detailed and consistent specification of all aspects of interventions. We need to understand not only their content, that is the specific techniques, but also the source, mode, schedule, and style in which this content is delivered. Delivery style refers to the manner by which content is communicated to intervention participants. This paper reports the development of an ontology for specifying the style of delivery of interventions that depend on communication. This forms part of the Behaviour Change Intervention Ontology, which aims to cover all aspects of behaviour change intervention scenarios. Methods: The Style of Delivery Ontology was developed following methods for ontology development used in the Human Behaviour-Change Project, with seven key steps: 1) defining the scope of the ontology, 2) identifying key entities and developing their preliminary definitions by reviewing 100 behaviour change intervention evaluation reports and existing classification systems, 3) refining the ontology by piloting the ontology through annotations of 100 reports, 4) stakeholder review by eight behavioural science and public health experts, 5) inter-rater reliability testing through annotating 100 reports using the ontology, 6) specifying ontological relationships between entities, and 7) disseminating and maintaining the ontology. Results: The resulting ontology is a five-level hierarchical structure comprising 145 unique entities relevant to style of delivery. Key areas include communication processes, communication styles, and attributes of objects used in communication processes. Inter-rater reliability for annotating intervention evaluation reports was α=0.77 (good) for those familiar with the ontology and α=0.62 (acceptable) for those unfamiliar with it. Conclusions: The Style of Delivery Ontology can be used for both annotating and describing behaviour change interventions in a consistent and coherent manner, thereby improving evidence comparison, synthesis, replication, and implementation of effective interventions.