StopApp: Using the Behaviour Change Wheel to Develop an App to Increase Uptake and Attendance at NHS Stop Smoking Services

Health professionals' practices and perspectives of post-stroke coordinated discharge planning: a national survey

Background It is best practice for stroke services to coordinate discharge care plans with primary/community care providers to ensure continuity of care. This study aimed to describe health professionals' practices in stroke discharge planning within Australia and the factors influencing whether discharge planning is coordinated between hospital and primary/community care providers. Methods A mixed-methods survey informed by the Theoretical Domains Framework was distributed nationally to stroke health professionals regarding post-stroke discharge planning practices and factors influencing coordinated discharge planning (CDP). Data were analysed using descriptive statistics and content analysis. Results Data from 42 participants working in hospital-based services were analysed. Participants reported that post-stroke CDP did not consistently occur across care providers. Three themes relating to perceived CDP needs were identified: (1) a need to improve coordination between care providers, (2) service-specific management of the discharge process, and (3) addressing the needs of the stroke survivor and family . The main perceived barriers were the socio-political context and health professionals' beliefs about capabilities . The main perceived facilitators were health professionals' social/professional role and identity, knowledge, and intentions . The organisation domain was perceived as both a barrier and facilitator to CDP. Conclusion Australian health professionals working in hospital-based services believe that CDP promotes optimal outcomes for stroke survivors, but experience implementation challenges. Efforts made by organisations to ensure workplace culture and resources support the CDP process through policies and procedures may improve practice. Tailored implementation strategies need to be designed and tested to address identified barriers.

Conditions for successful implementation of couple-based collaborative management model of diabetes among community-dwelling older Chinese: a qualitative comparative analysis

BACKGROUND

Diabetes mellitus is a prevalent and potentially devastating chronic illness affecting many older adults. Given spousal involvement in many aspects of diabetes management, coping with their partners is increasingly seen as a potential solution to make up for limited resources. This study aimed to identify the key conditions for optimal implementation of couple-based collaborative management model (CCMM) among Chinese older couples with type 2 diabetes mellitus.

METHODS

Older couples and community healthcare practitioners were selected according to couples' joint intervention attendance rate and community's average attendance rate. This mixed methods research consisted of a qualitative phase and a quantitative phase. In the qualitative phase, in-depth interviews were conducted among 12 pairs of couples in the intervention group and 4 corresponding practitioners, in the follow-up period of the multicentered RCT from January to April 2022. Qualitative comparative analysis (QCA) in the quantitative phase to identify conditions influencing CCMM's implementation and to explore necessary and sufficient combinations of conditions (i.e., solutions) for improving patients' glycated hemoglobin (HbA1c) control (outcome).

RESULTS

Key conditions included implementation process, couple's role in diabetes management, their belief and perception of CCMM, as well as objective obstacles and subjective initiative for behavior change. Accordingly, major barriers in CCMM's implementation were patients' strong autonomy (particularly among husbands), misbelief and misperception about diabetes management as a result of low literacy, and mistrust of the practitioners. QCA further revealed that no single condition was necessary for effective HbA1c control, while three types of their combinations would be sufficient. Solution 1 and 2 both comprised the presence of spousal willingness to help, plus correct belief and perception of diabetes management, well embodying the utility of couple collaborative management in supporting patients' HbA1c control. On the other hand, solution 3 indicated that high-quality implementation even without spousal support, can promote the patient's subjective initiative to overcome objective obstacles, suggesting enhanced self-management for HbA1c control.

CONCLUSIONS

Tailored CCMM should be implemented in reference to older couple's preferences and literacy levels, to ensure intervention fidelity, and establish correct understanding of collaborative management among them.

Supporting Pain Self-Management in Patients With Cancer: App Development Based on a Theoretical and Evidence-Driven Approach

BACKGROUND

To inform the development of an intervention, it is essential to have a well-developed theoretical understanding of how an intervention causes change, as stated in the UK Medical Research Council guidelines for developing complex interventions. Theoretical foundations are often ignored in the development of mobile health apps intended to support pain self-management for patients with cancer.

OBJECTIVE

This study aims to systematically set a theory- and evidence-driven design for a pain self-management app and specify the app's active features.

METHODS

The Behavior Change Wheel (BCW) framework, a step-by-step theoretical approach to the development of interventions, was adopted to achieve the aim of this study. This started by understanding and identifying sources of behavior that could be targeted to support better pain management. Ultimately, the application of the BCW framework guided the identification of the active contents of the app, which were characterized using the Behavior Change Technique Taxonomy version 1.

RESULTS

The theoretical analysis revealed that patients may have deficits in their capability, opportunity, and motivation that prevent them from performing pain self-management. The app needs to use education, persuasion, training, and enablement intervention functions because, based on the analysis, they were found the most likely to address the specified factors. Eighteen behavior change techniques were selected to describe precisely how the intervention functions can be presented to induce the desired change regarding the intervention context. In other words, they were selected to form the active contents of the app, potentially reducing barriers and serving to support patients in the self-management of pain while using the app.

CONCLUSIONS

This study fully reports the design and development of a pain self-management app underpinned by theory and evidence and intended for patients with cancer. It provides a model example of the BCW framework application for health app development. The work presented in this study is the first systematic theory- and evidence-driven design for a pain app for patients with cancer. This systematic approach can support clarity in evaluating the intervention's underlying mechanisms and support future replication.

Facilitators and barriers of preventive behaviors against COVID-19 during Ramadan: A phenomenology of Indonesian adults

Introduction

Intercity mobility restriction, physical distancing, and mask-wearing are preventive behaviors to reduce the transmission of COVID-19. However, strong cultural and religious traditions become particular challenges in Indonesia. This study uses the Behavior Change Wheel to explore barriers and facilitators for intercity mobility restriction, physical distancing, and mask-wearing during Ramadan.

Methods

Semi-structured in-depth interviews with 50 Indonesian adults were conducted between 10 April and 4 June 2020. Having mapped codes into the Capacity, Opportunity, Motivation - Behavior (COM-B), and Theoretical Domain Framework (TDF) model, we conducted summative content analysis to analyze the most identified factors to preventive behaviors and proposed interventions to address those factors.

Results

Belief about the consequence of preventive behaviors was the most mentioned facilitator to all preventive behaviors among compliers. However, optimism as a TDF factor was commonly mentioned as a barrier to preventive behaviors among non-compliers, while environmental context and resources were the most commonly mentioned factors for intercity mobility restriction.

Conclusions

Public health intervention should be implemented considering the persuasion and involvement of religious and local leaders. Concerning job and economic context, policy related to the intercity mobility restriction should be reconsidered to prevent a counterproductive effect.

The perceptions and adoption of environmentally sustainable practices among anesthesiologists-a qualitative study

PURPOSE

Previous surveys of anesthesiologists showed that despite a strong interest in implementing environmentally sustainable anesthetic practices, less than a third do so. Qualitative understanding of the capability, opportunity, and motivational factors that influence "green" behavior will inform the design of effective interventions to promote environmentally sustainable practices in the operating room (OR).

METHODS

We conducted 23 semistructured interviews with anesthesiologists, with data saturation achieved. Applying the Behavior Change Wheel, interview questions addressed "capability," "opportunity," and "motivation" determinants of behavior.

RESULTS

Preference for sevoflurane and syringe reuse were most commonly cited as existing environmentally sustainable anesthetic practices. Several participants reported lack of knowledge and feedback as impediments to sustainable anesthetic practices. Reported physical barriers included inadequate recycling facilities and abundance of supplies. Interviewees also discussed the importance of habitual behavior in improving skill sets and reducing cognitive load required to perform environmentally sustainable practices. General awareness of environmental issues and aggregation of marginal gains were reasons for environmentally sustainable measures in the OR. Organizational practice and culture played a significant role in the propagation of sustainable anesthetic practices, with senior staff often carrying a greater influence. While the majority preferred a top-down approach to effect change, others favored the use of incentives.

CONCLUSION

This study provides insight into the factors that influence the adoption of environmentally sustainable practices in the OR. Measures to promote these practices include education and training, feedback on efforts, engagement of senior anesthetists as role models and for change management, environmental restructuring, and policy designs that balance a top-down vs bottom-up approach to influencing change.

Theory-based behavioral change interventions to improve periodontal health

Periodontal disease is a significant global health burden affecting half of the world's population. Given that plaque and inflammation control are essential to the attainment of periodontal health, recent trends in preventive dentistry have focused on the use of behavioral models to understand patient psychology and promote self-care and treatment compliance. In addition to their uses in classifying, explaining and predicting oral hygiene practices, behavioral models have been adopted in the design of oral hygiene interventions from individual to population levels. Despite the growing focus on behavioral modification in dentistry, the currently available evidence in the field of periodontology is scarce, and interventions have primarily measured changes in patient beliefs or performance in oral hygiene behaviors. Few studies have measured their impact on clinical outcomes, such as plaque levels, gingival bleeding and periodontal pocket reduction, which serve as indicators of the patient's disease status and quality of oral self-care. The present narrative review aims to summarize selected literature on the use of behavioral models to improve periodontal outcomes. A search was performed on existing behavioral models used to guide dental interventions to identify their use in interventions measuring periodontal parameters. The main models were identified and subsequently grouped by their underlying theoretical area of focus: patient beliefs (health belief model and cognitive behavioral principles); stages of readiness to change (precaution adoption process model and transtheoretical model); planning behavioral change (health action process approach model, theory of planned behavior and client self-care commitment model); and self-monitoring (self-regulation theory). Key constructs of each model and the findings of associated interventions were described. The COM-B model, a newer behavioral change system that has been increasingly used to guide interventions and policy changes, is discussed with reference to its use in oral health settings. Within the limitations of the available evidence, interventions addressing patient beliefs, motivation, intention and self-regulation could lead to improved outcomes in periodontal health. Direct comparisons between interventions could not be made due to differences in protocol design, research populations and follow-up periods. The conclusions of this review assist clinicians with implementing psychological interventions for oral hygiene promotion and highlight the need for additional studies on the clinical effects of behavioral model-based interventions.

Behavior Change Techniques in Digital Health Interventions for Midlife Women: Systematic Review

BACKGROUND

Digital health interventions are efficacious in health-promoting behaviors (eg, healthy eating and regular physical activity) that mitigate health risks and menopausal symptoms in midlife. However, integrated evidence-based knowledge about the mechanisms of change in these interventions is unclear.

OBJECTIVE

This systematic review aimed to evaluate studies on behavior change techniques (BCTs) and mechanisms of change in digital health interventions aimed at promoting health-enhancing behaviors in midlife women (aged 40-65 years).

METHODS

A systematic literature search of the electronic databases PubMed, Web of Science, PsycINFO, and Cochrane Central Register of Controlled Trials in the Cochrane Library was conducted. In total, 2 independent reviewers selected the studies for inclusion, extracted data, and completed BCT mapping of eligible studies. The mechanism of action and intervention functions of eligible studies were evaluated using the behavior change wheel framework. Reporting of psychological theory use within these interventions was explored using the Theory Coding Scheme. Mode of delivery, psychological theory, and BCTs were presented as descriptive statistics.

RESULTS

In total, 13 interventions (including 1315 women) reviewed used 13 (SD 4.30, range 6-21) BCTs per intervention on average. The "Shaping knowledge" and "Repetition and substitution" behavior change categories were used most frequently, with 92% (12/13) of the interventions implementing at least one of the BCTs from these 2 categories. Only 13.98% (169/1209) of the 93 available BCTs were used, with "Instructions on behaviour" most frequently used (12/13, 92%). The behavior change wheel mapping suggests that half of the intervention content aimed to increase "Capability" (49/98, 50% of the intervention strategies), "Motivation" (41/98, 42%), and "Opportunity" (8/98, 8%). "Behavioural Regulation" was the most frequently used mechanism of action (15/98, 15%), followed by increasing "Knowledge" (13/98, 13%) and "Cognitive and Interpersonal skills" (10/98, 10%). A total of 78% (7/9) of the intervention functions were used in the studies to change behavior, primarily through "Enablement" (60/169, 35.5%), whereas no study used "Restriction" or "Modelling" functions. Although 69% (9/13) of the interventions mentioned a psychological theory or model, most (10/13, 77%) stated or suggested rather than demonstrated the use of a theoretical base, and none reported explicit links between all BCTs within the intervention and the targeted theoretical constructs. Technological components were primarily based on web-based (9/13, 69%) modes of delivery, followed by phone or SMS text message (8/13, 62%) and wearables (7/13, 54%).

CONCLUSIONS

The findings of this review indicate an overall weak use of theory, low levels of treatment fidelity, insignificant outcomes, and insufficient description of several interventions to support the assessment of how specific BCTs were activated. Thus, the identified limitations in the current literature provide an opportunity to improve the design of lifestyle health-enhancing interventions for women in midlife.

TRIAL REGISTRATION

PROSPERO CRD42021259246; https://tinyurl.com/4ph74a9u.

Using the Behaviour Change Wheel to develop an oral hygiene self-care intervention for Punjabi immigrant adults: an illustrative example

BACKGROUND

This article describes the development of an oral hygiene self-care behaviour change intervention (Safeguard Your Smile [SYS]) for Punjabi immigrant adults, using the Behaviour Change Wheel (BCW) theoretical framework.

METHODS

The 3 stages and 8 steps of the BCW were followed to develop the face-to-face SYS intervention. Identification of the problem in behavioural terms was enabled by referring to the results of a qualitative focus group (FG) previously conducted by the research team. Following the BCW method, the sources of behaviour were defined in terms of capability, opportunity, and motivation. Appropriate intervention functions, policy categories, behaviour change techniques (BCTs), and modes of delivery were then identified, selected, and mapped. Concrete strategies were chosen to bring about the desired oral hygiene self-care behavioural change.

RESULTS

Two main barriers to oral hygiene self-care faced by Punjabi immigrant adults were identified from the original FG: 1) inadequate knowledge and 2) inconsistent daily routine. Oral hygiene self-care behaviour was designated as a target behaviour, detailing frequency, duration, and technique. Five intervention functions (education, training, modelling, environmental restructuring, and enablement) and 2 policy categories (communication and service provision) were identified to influence the capability, opportunity, and motivation related to oral hygiene self-care behaviour. Nine BCTs were selected to influence desired oral hygiene self-care behaviour among adults.

CONCLUSION

The development process for this SYS intervention may be employed by researchers to design a behaviour change intervention for other populations. However, additional strategies tailored to each specific context and population must be incorporated.

STOP- a training intervention to optimise treatment for smoking cessation in community pharmacies: cluster randomised controlled trial

BACKGROUND

Community pharmacies serve people with high levels of tobacco-related illness, but throughput in NHS Stop Smoking Services in pharmacies remains relatively low. We investigated the effectiveness of a complex intervention to increase service uptake and retention.

METHODS

We randomised 60 pharmacies in England and Wales to the STOP intervention or usual practice in a pragmatic, parallel-group, controlled trial over 11 months. Smokers were blind to the allocation. The intervention was theory-based consultation skills training for pharmacy staff with environmental prompts (badges, calendars and behavioural cues). The primary outcome was the number of smokers attending an initial consultation and setting a quit date.

RESULTS

The intervention made no significant difference in setting a quit date, retention or quit rate. A total of 631 adult smokers (service users) enrolled and set a quit date in intervention pharmacies compared to 641 in usual practice pharmacies, a rate ratio of 0.75 (95% CI 0.46 to 1.23) adjusted for site and number of prescriptions. A total of 432 (68%) service users were retained at 4 weeks in intervention and 500 (78%) in usual practice pharmacies (odds ratio 0.80, 0.41 to 1.55). A total of 265 (42%) service users quit smoking at 4 weeks in intervention and 276 (43%) in usual practice pharmacies (0.96, 0.65 to 1.43). The pharmacy staff were positive about the intervention with 90% (56/62) stating that it had improved their skills. Sixty-eight per cent would strongly recommend the training to others although there was no difference in self-efficacy for service delivery between arms. Seventy of 131 (53%) service users did not complete the 6-month follow-up assessment. However, 55/61 (90%) service users who completed follow-up were satisfied or very satisfied with the service. All usual practice arm service users (n = 33) and all but one in the intervention arm (n = 27) would recommend the service to smokers.

CONCLUSIONS

We found high levels of retention and acceptable quit rates in the NHS pharmacy stop smoking service. Despite pharmacy staff providing positive feedback on the STOP intervention, it made no difference to service throughput. Thus, other factors may currently limit service capacity to help smokers to quit.

TRIAL REGISTRATION

ISRCTN, ISRCTN16351033 . Retrospectively registered.

Identifying barriers and facilitators of hearing protection use in early-career musicians: a basis for designing interventions to promote uptake and sustained use

OBJECTIVE

The current study aimed to: i) determine the patterns of hearing protection device (HPD) use in early-career musicians, ii) identify barriers to and facilitators of HPD use, and iii) use the Behaviour Change Wheel (BCW) to develop an intervention to increase uptake and sustained use of HPDs.

DESIGN

A mixed-methods approach using questionnaires and semi-structured interviews.

STUDY SAMPLE

Eighty early-career musicians (age range = 18-26 years; women n = 39), across all categories of musical instrument.

RESULTS

42.5% percent of participants reported using HPDs at least once a week, 35% less than once a week, and 22.5% reported never using HPDs for music-related activities. Six barriers and four facilitators of HPD use were identified. Barriers include the impact of HPDs on listening to music and performing, and a lack of concern about noise exposure. Barriers/facilitators were mapped onto the Theoretical Domains Framework. Following the systematic process of the BCW, our proposed intervention strategies are based on 'Environmental Restructuring', such as providing prompts to increase awareness of noisy settings, and 'Persuasion/Modelling', such as providing credible role models.

CONCLUSIONS

For the first time, the present study demonstrates the use of the BCW for designing interventions in the context of hearing conservation.

Developing public transport messaging to provide crowding information during COVID-19: Application of the COM-B model and behaviour change wheel

The COVID-19 outbreak meant that using public transport was potentially unsafe for risk of catching and transmitting the virus. UK anxiety is high with lockdowns preventing a normal way of life for over a year. A lack of ability to travel freely causes numerous declines in quality of life including social isolation and poor physical and mental health. People need crowding information to choose safer travel options and subdue coronavirus. To provide effective guidance, it is essential to empirically formulate messaging to create clarity and trust which can be acted upon in confidence. Behaviour Change Techniques incorporating the Behaviour Change Wheel and COM-B model have been utilised in vast areas of public health intervention development and messaging. There is consensus that public transport information needs to be clearer and more accessible but BCTs have not been utilised in the development of public transport advice. This paper outlines the development of crowding messaging for public transport on a platform available to UK travellers. Barriers and facilitators were explored; related behaviours, intervention functions and behaviour change techniques were mapped. Specific message phrasing was developed utilising the mapped functions and advice from the literature. With the COVID-19 outbreak, having accessible and effective messaging for safely using public transport is a continuation of the work recently conducted examining the best ways to present public health information. It is important to be transparent when developing messaging and interventions accessible to the public and this work forms a basis for continued exploration and development in this area.

Addressing Emotional and Psychological Problems Associated With Hearing Loss: Perspective of Consumer and Community Representatives

PURPOSE

Hearing loss causes emotional distress and can contribute to the development of psychological difficulties, yet emotional and psychological issues are not addressed within current audiology services. The purpose of this study was to use focus groups with consumer and community representatives to explore how we might improve the provision of support for clients experiencing emotional and psychological issues in relation to their hearing loss.

PARTICIPANTS

Adults with hearing loss (n = 19) and their significant others (n = 9), as well as 10 hearing health care professionals (n = 4 hearing health care clinicians, n = 4 reception staff, and n = 2 clinical managers), participated in consumer and community engagement focus groups.

METHOD

Consumer and community representatives were tasked with (a) identifying the stakeholders involved in supporting adults experiencing emotional or psychological difficulties on account of their hearing loss, (b) describing the behaviors undertaken by each stakeholder group, and (c) selecting target behavior(s) that could optimally form the basis of an intervention program to improve the quality and frequency of support provided to people experiencing emotional and psychological problems in the audiology setting.

RESULTS

Participants identified 12 stakeholder groups involved in supporting adults with hearing loss experiencing emotional and psychological problems. The three behaviors voted by participants to be the most promising for a behavioral intervention included the clinician (a) asking about, (b) providing information on, and (c) delivering therapeutic intervention for emotional and psychological well-being within audiological service provision.

CONCLUSION

Consumer and community stakeholder representatives indicate a general desire for hearing health care clinicians to deliver support for the emotional and psychological issues that arise relating to hearing loss.

#LetsUnlitterUK: A demonstration and evaluation of the Behavior Change Wheel methodology

The Behavior Change Wheel is the most comprehensive and practically useful methodology available for developing behavior change interventions. The current article demonstrates how it can be applied to optimize pro-environmental behaviors and, in so doing, give interventionists access to a rigorous set of theories and techniques for systematically developing pro-environmental interventions. Section 1 describes the development of an intervention to increase people's intentions to post anti-littering messages on social media. Study 2 describes the development and evaluation of an intervention to increase people's actual anti-littering posts. Both evaluations are randomized controlled trials that compare the effectiveness of the developed intervention with interventions less informed by the Wheel. We found interventions completely informed by the Wheel to be more effective than interventions less (or not at all) informed by the Wheel. The discussion explores how the Behavior Change Wheel methodology can be used to design future pro-environment interventions.

Examining the Utility of Social Media in COVID-19 Vaccination: Unsupervised Learning of 672,133 Twitter Posts

BACKGROUND

Although COVID-19 vaccines have recently become available, efforts in global mass vaccination can be hampered by the widespread issue of vaccine hesitancy.

OBJECTIVE

The aim of this study was to use social media data to capture close-to-real-time public perspectives and sentiments regarding COVID-19 vaccines, with the intention to understand the key issues that have captured public attention, as well as the barriers and facilitators to successful COVID-19 vaccination.

METHODS

Twitter was searched for tweets related to "COVID-19" and "vaccine" over an 11-week period after November 18, 2020, following a press release regarding the first effective vaccine. An unsupervised machine learning approach (ie, structural topic modeling) was used to identify topics from tweets, with each topic further grouped into themes using manually conducted thematic analysis as well as guided by the theoretical framework of the COM-B (capability, opportunity, and motivation components of behavior) model. Sentiment analysis of the tweets was also performed using the rule-based machine learning model VADER (Valence Aware Dictionary and Sentiment Reasoner).

RESULTS

Tweets related to COVID-19 vaccines were posted by individuals around the world (N=672,133). Six overarching themes were identified: (1) emotional reactions related to COVID-19 vaccines (19.3%), (2) public concerns related to COVID-19 vaccines (19.6%), (3) discussions about news items related to COVID-19 vaccines (13.3%), (4) public health communications about COVID-19 vaccines (10.3%), (5) discussions about approaches to COVID-19 vaccination drives (17.1%), and (6) discussions about the distribution of COVID-19 vaccines (20.3%). Tweets with negative sentiments largely fell within the themes of emotional reactions and public concerns related to COVID-19 vaccines. Tweets related to facilitators of vaccination showed temporal variations over time, while tweets related to barriers remained largely constant throughout the study period.

CONCLUSIONS

The findings from this study may facilitate the formulation of comprehensive strategies to improve COVID-19 vaccine uptake; they highlight the key processes that require attention in the planning of COVID-19 vaccination and provide feedback on evolving barriers and facilitators in ongoing vaccination drives to allow for further policy tweaks. The findings also illustrate three key roles of social media in COVID-19 vaccination, as follows: surveillance and monitoring, a communication platform, and evaluation of government responses.

Supporting smoking cessation and preventing relapse following a stay in a smoke-free setting: a meta-analysis and investigation of effective behaviour change techniques

BACKGROUND AND AIMS

Admission to a smoke-free setting presents a unique opportunity to encourage smokers to quit. However, risk of relapse post-discharge is high, and little is known about effective strategies to support smoking cessation following discharge. We aimed to identify interventions that maintain abstinence following a smoke-free stay and determine their effectiveness, as well as the probable effectiveness of behaviour change techniques (BCTs) used in these interventions.

METHODS

Systematic review and meta-analyses of studies of adult smokers aged ≥ 18 years who were temporarily or fully abstinent from smoking to comply with institutional smoke-free policies. Institutions included prison, inpatient mental health, substance misuse or acute hospital settings. A Mantel-Haenszel random-effects meta-analysis of randomized controlled trials (RCTs) was conducted using biochemically verified abstinence (7-day point prevalence or continuous abstinence). BCTs were defined as 'promising' in terms of probable effectiveness (if BCT was present in two or more long-term effective interventions) and feasibility (if BCT was also delivered in ≥ 25% of all interventions).

RESULTS

Thirty-seven studies (intervention n = 9041, control n = 6195) were included: 23 RCTs (intervention n = 6593, control n = 5801); three non-randomized trials (intervention n = 845, control n = 394) and 11 cohort studies (n = 1603). Meta-analysis of biochemically verified abstinence at longest follow-up (4 weeks-18 months) found an overall effect in favour of intervention [risk ratio (RR) = 1.27, 95% confidence interval (CI) = 1.08-1.49, I²  = 42%]. Nine BCTs (including 'pharmacological support', 'goal-setting (behaviour)' and 'social support') were characterized as 'promising' in terms of probable effectiveness and feasibility.

CONCLUSIONS

A systematic review and meta-analyses indicate that behavioural and pharmacological support is effective in maintaining smoking abstinence following a stay in a smoke-free institution. Several behaviour change techniques may help to maintain smoking abstinence up to 18 months post-discharge.

Evaluation and Refinement of a Bank of SMS Text Messages to Promote Behavior Change Adherence Following a Diabetes Prevention Program: Survey Study

Background

SMS text messaging is a low-cost and far-reaching modality that can be used to augment existing diabetes prevention programs and improve long-term diet and exercise behavior change adherence. To date, little research has been published regarding the process of SMS text message content development. Understanding how interventions are developed is necessary to evaluate their evidence base and to guide the implementation of effective and scalable mobile health interventions in public health initiatives and in future research.

Objective

This study aims to describe the development and refinement of a bank of SMS text messages targeting diet and exercise behavior change to be implemented following a diabetes prevention program.

Methods

A bank of 124 theory-based SMS text messages was developed using the Behaviour Change Wheel and linked to active intervention components (behavior change techniques [BCTs]). The Behaviour Change Wheel is a theory-based framework that provides structure to intervention development and can guide the use of evidence-based practices in behavior change interventions. Once the messages were written, 18 individuals who either participated in a diabetes prevention program or were a diabetes prevention coach evaluated the messages on their clarity, utility, and relevance via survey using a 5-point Likert scale. Messages were refined according to participant feedback and recoded to obtain an accurate representation of BCTs in the final bank.

Results

76/124 (61.3%) messages were edited, 4/124 (3.2%) were added, and 8/124 (6.5%) were removed based on participant scores and feedback. Of the edited messages, 43/76 (57%) received minor word choice and grammar alterations while retaining their original BCT code; the remaining 43% (33/76, plus the 4 newly written messages) were recoded by a reviewer trained in BCT identification.

Conclusions

This study outlines the process used to develop and refine a bank of SMS text messages to be implemented following a diabetes prevention program. This resulted in a bank of 120 theory-based, user-informed SMS text messages that were overall deemed clear, useful, and relevant by both individuals who will be receiving and delivering them. This formative development process can be used as a blueprint in future SMS text messaging development to ensure that message content is representative of the evidence base and is also grounded in theory and evaluated by key knowledge users.

Palm oil: Understanding barriers to sustainable consumption

Palm oil is relatively inexpensive, versatile, and popular, generating great economic value for Southeast Asian countries. However, the growing demand for palm oil is leading to deforestation and biodiversity loss. The current study is the first to employ a capability-opportunity-motivation (COM-B) framework in green consumerism, to determine which capability, opportunity, and motivation factors strongly predict the intentional purchasing of sustainable palm oil products by Australian consumers (N = 781). Exploratory factor analysis revealed four main types of predictors of SPO purchasing–Pro-Green Consumption Attitudes, Demotivating Beliefs, Knowledge and Awareness, and Perceived Product Availability. Multiple regression revealed that these four factors explained 50% of the variability in SPO purchasing behaviour, out of which Knowledge and Awareness accounted for 18% of the unique variance. Perceived Product Availability and Pro-Green Consumption Attitudes were also significant predictors but accounted for only 2% and 1% of unique variance, respectively. These results provide a valuable foundation for designing behaviour change interventions to increase consumer demand for sustainable palm oil products.

Using the behavior change wheel to develop text messages to promote diet and physical activity adherence following a diabetes prevention program

Improving diet and physical activity (PA) can reduce the risk of developing type 2 diabetes (T2D); however, long-term diet and PA adherence is poor. To impact population-level T2D risk, scalable interventions facilitating behavior change adherence are needed. Text messaging interventions supplementing behavior change interventions can positively influence health behaviors including diet and PA. The Behavior Change Wheel (BCW) provides structure to intervention design and has been used extensively in health behavior change interventions. Describe the development process of a bank of text messages targeting dietary and PA adherence following a diabetes prevention program using the BCW. The BCW was used to select the target behavior, barriers and facilitators to engaging in the behavior, and associated behavior change techniques (BCTs). Messages were written to map onto BCTs and were subsequently coded for BCT fidelity. The target behaviors were adherence to diet and PA recommendations. A total of 16 barriers/facilitators and 28 BCTs were selected for inclusion in the messages. One hundred and twenty-four messages were written based on selected BCTs. Following the fidelity check a total of 43 unique BCTs were present in the final bank of messages. This study demonstrates the application of the BCW to guide the development of a bank of text messages for individuals with prediabetes. Results underscore the potential utility of having independent coders for an unbiased expert evaluation of what active components are in use. Future research is needed to demonstrate the feasibility and effectiveness of resulting bank of messages.

Proof-of-Concept Support for the Development and Implementation of a Digital Assessment for Perinatal Mental Health: Mixed Methods Study

Background

Perinatal mental health symptoms commonly remain underdiagnosed and undertreated in maternity care settings in the United Kingdom, with outbreaks of disease, like the COVID-19 pandemic, further disrupting access to adequate mental health support. Digital technologies may offer an innovative way to support the mental health needs of women and their families throughout the perinatal period, as well as assist midwives in the recognition of perinatal mental health concerns. However, little is known about the acceptability and perceived benefits and barriers to using such technologies.

Objective

The aim of this study was to conduct a mixed methods evaluation of the current state of perinatal mental health care provision in the United Kingdom, as well as users’ (women and partners) and midwives’ interest in using a digital mental health assessment throughout the perinatal period.

Methods

Women, partners, and midwives were recruited to participate in the study, which entailed completing an online survey. Quantitative data were explored using descriptive statistics. Open-ended response data were first investigated using thematic analysis. Resultant themes were then mapped onto the components of the Capability, Opportunity, and Motivation Behavior model and summarized using descriptive statistics.

Results

A total of 829 women, 103 partners, and 90 midwives participated in the study. The provision of adequate perinatal mental health care support was limited, with experiences varying significantly across respondents. There was a strong interest in using a digital mental health assessment to screen, diagnose, and triage perinatal mental health concerns, particularly among women and midwives. The majority of respondents (n=781, 76.42%) expressed that they would feel comfortable or very comfortable using or recommending a digital mental health assessment. The majority of women and partners showed a preference for in-person consultations (n=417, 44.74%), followed by a blended care approach (ie, both in-person and online consultations) (n=362, 38.84%), with fewer participants preferring online-only consultations (n=120, 12.88%). Identified benefits and barriers mainly related to physical opportunity (eg, accessibility), psychological capability (eg, cognitive skills), and automatic motivation (eg, emotions).

Conclusions

This study provides proof-of-concept support for the development and implementation of a digital mental health assessment to inform clinical decision making in the assessment of perinatal mental health concerns in the United Kingdom.

Understanding Behavioral Intentions Toward COVID-19 Vaccines: Theory-Based Content Analysis of Tweets

BACKGROUND

Acceptance rates of COVID-19 vaccines have still not reached the required threshold to achieve herd immunity. Understanding why some people are willing to be vaccinated and others are not is a critical step to develop efficient implementation strategies to promote COVID-19 vaccines.

OBJECTIVE

We conducted a theory-based content analysis based on the capability, opportunity, motivation-behavior (COM-B) model to characterize the factors influencing behavioral intentions toward COVID-19 vaccines mentioned on the Twitter platform.

METHODS

We collected tweets posted in English from November 1-22, 2020, using a combination of relevant keywords and hashtags. After excluding retweets, we randomly selected 5000 tweets for manual coding and content analysis. We performed a content analysis informed by the adapted COM-B model.

RESULTS

Of the 5000 COVID-19 vaccine-related tweets that were coded, 4796 (95.9%) were posted by unique users. A total of 97 tweets carried positive behavioral intent, while 182 tweets contained negative behavioral intent. Of these, 28 tweets were mapped to capability factors, 155 tweets were related to motivation, 23 tweets were related to opportunities, and 74 tweets did not contain any useful information about the reasons for their behavioral intentions (κ=0.73). Some tweets mentioned two or more constructs at the same time. Tweets that were mapped to capability (P<.001), motivation (P<.001), and opportunity (P=.03) factors were more likely to indicate negative behavioral intentions.

CONCLUSIONS

Most behavioral intentions regarding COVID-19 vaccines were related to the motivation construct. The themes identified in this study could be used to inform theory-based and evidence-based interventions to improve acceptance of COVID-19 vaccines.

Understanding willingness to access and experiences of NHS Stop Smoking Services: a qualitative systematic review with meta-aggregation synthesis

OBJECTIVES

NHS Stop Smoking Services (NHS-SSS) have been available in the United Kingdom (UK) since 2000. The service has proven to be effective, however uptake remains below aspirations. Understanding people's willingness and reasons for accessing and engaging with NHS-SSS is, therefore, important. The aim of this systematic review is to summarise the findings from qualitative research to understand people's views, perceptions and willingness to access NHS-SSS.

STUDY DESIGN

Qualitative systematic review with meta-aggregation synthesis.

METHODS

Four electronic databases were searched for published qualitative studies, from Jan 2000 to Jan 2020. Following the screening, data extraction and quality assessment, data synthesis was conducted using meta-aggregation based on a patient-centred theoretical framework. We explored five 'demand-side' dimensions of service accessibility: the ability to perceive, seek, reach, pay and engage. Confidence in the synthesised findings relating to dependability and credibility was established using CONQual.

RESULTS

Seventeen studies were included in the review. Twelve categories emerged, contributing to five synthesised statements, all with a CONQual rating of moderate confidence. Access and willingness to use NHS-SSS were found to be related to an individual's readiness to perceive that smoking is a problem for which a solution should be sought, their ability to seek a perceived effective treatment, to conveniently reach NHS-SSS, their perceptions around associated costs and tailoring care to improve engagement with individuals.

CONCLUSIONS

By using a theoretical framework incorporating healthcare access, this study provides policymakers valuable insights into people's willingness to access these services. Willingness to access NHS-SSS is multifaceted, nuanced and complex. Strategies to promote NHS-SSS uptake should include making services more attractive, relevant and responsive to individual perceptions around smoking and health. Given the higher prevalence of smoking in less affluent socioeconomic groups and in some ethnic minority groups, the importance of having a comprehensive and inclusive tobacco control policy, one that is linguistically and culturally sensitive, cannot be overstated.

A digital behaviour change intervention to increase booking and attendance at Stop Smoking Services: the MyWay feasibility RCT

Background

Smoking remains a leading cause of illness and preventable death. NHS Stop Smoking Services increase quitting, but, as access is in decline, cost-effective interventions are needed that promote these services. StopApp™ (Coventry University, Coventry, UK) is designed to increase booking and attendance at Stop Smoking Services.

Design

A two-arm feasibility randomised controlled trial of StopApp (intervention) compared with standard promotion and referral to Stop Smoking Services (control) was conducted to assess recruitment, attrition and health equity of the design, alongside health economic and qualitative process evaluations.

Setting

Smokers recruited via general practitioners, community settings and social media.

Participants

Smokers aged ≥ 16 years were recruited in one local authority. Participants had to live or work within the local authority area, and there was a recruitment target of 120 participants.

Interventions

StopApp to increase booking and attendance at Stop Smoking Services.

Main outcome measures

Participants completed baseline measures and follow-up at 2 months post randomisation entirely online. Objective data on the use of Stop Smoking Services were collected from participating Stop Smoking Services, and age groups, sex, ethnicity and socioeconomic status in baseline recruits and follow-up completers/non-completers were assessed for equity.

Results

Eligible participants (n = 123) were recruited over 116 days, with good representation of lower socioeconomic status groups; black, Asian and minority ethnic groups; and all age groups. Demographic profiles of follow-up completers and non-completers were broadly similar. The attrition rate was 51.2%, with loss to follow-up lowest in the social media setting (n = 24/61; 39.3%) and highest in the general practitioner setting (n = 21/26; 80.8%). Most measures had < 5% missing data. Social media represented the most effective and cost-efficient recruitment method. In a future, definitive, multisite trial with recruitment driven by social media, our data suggest that recruiting ≥ 1500 smokers over 12 months is feasible. Service data showed that five bookings for the Stop Smoking Services were scheduled using StopApp, of which two did not attend. Challenges with data access were identified. A further five participants in the intervention arm self-reported booking and accessing Stop Smoking Services outside StopApp compared with two control arm participants. Event rate calculations for the intervention were 8% (Stop Smoking Services data), 17% (including self-reports) and 3.5% from control arm self-reports. A conservative effect size of 6% is estimated for a definitive full trial. A sample size of 840 participants would be required to detect an effect for the primary outcome measure of booking a Stop Smoking Services appointment in a full randomised controlled trial. The process evaluation found that participants were satisfied with the research team contact, study methods and provision of e-vouchers. Staff interviews revealed positive and negative experiences of the trial and suggestions for improvements, including encouraging smokers to take part.

Conclusion

This feasibility randomised controlled trial found that, with recruitment driven wholly or mainly by social media, it is possible to recruit and retain sufficient smokers to assess the effectiveness and cost-effectiveness of StopApp. The study methods and measures were found to be acceptable and equitable, but accessing Stop Smoking Services data about booking, attendance and quit dates was a challenge. A full trial may be feasible if service data are accessible. This will require careful planning with data controllers and a targeted social media campaign for recruitment. Changes to some study measures are needed to avoid missing data, including implementation of a more intensive follow-up data collection process.

Future work

We plan a full, definitive randomised controlled trial if the concerns around data access can be resolved, with adaptations to the recruitment and retention strategy.

Limitations

Our trial had high attrition and problems with collecting Stop Smoking Services data, which resulted in a reliance on self-reporting.

Trial registration

Research Registry: 3995. The trial was registered on 18 April 2018.

Funding

This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 9, No. 5. See the NIHR Journals Library website for further project information.

Improving young children's handwashing behaviour and understanding of germs: The impact of A Germ's Journey educational resources in schools and public spaces

CONTEXT

Effective handwashing can prevent the spread of germs, including Covid-19. However, young children can lack a fundamental understanding of germ transfer. A Germ's Journey educational resources were designed to support young children in learning about germs and handwashing. These resources include a book, website, song, online games and glo-gel activities that are informed by a behaviour change model.

RESEARCH GAP

Prior research has not evaluated the impacts of these resources on behavioural outcomes.

PURPOSE OF THE STUDY

Two intervention studies evaluated the impacts of these resources on both knowledge and behavioural outcomes.

METHOD

In Study 1, children (n = 225) were recruited from four schools and randomly assigned by classrooms to participate in a multicomponent intervention (vs. control). In Study 2, children (n = 104) were recruited from a museum and randomly assigned to participate in a song intervention (vs. control). Trained observers recorded participants' engagement in six handwashing behaviours and their understanding of germs. These behavioural and knowledge outcomes were analysed using regression and related analyses.

RESULTS

In Study 1, significant improvements were observed between baseline and follow up in the intervention group for both behavioural scores (Est = 0.48, SE = 0.14, t = 3.30, p = 0.001) and knowledge scores (Est = 2.14, SE = 0.52, z = 4.11, p < 0.001), whereas these improvements were not observed in the control group (ts < 1). In Study 2, the intervention group had significantly higher behavioural scores compared to the control group (Est. = -0.71, SE = 0.34, t = -2.07, p = 0.04).

CONCLUSION

This research demonstrates that specifically designed hand hygiene educational resources can improve handwashing practice and understanding in young children, and could lead to the reduction of the transmission of disease within this group.

Barriers and opportunities for cleanliness of shared sanitation facilities in low-income settlements in Kenya

Background

The sharing of sanitation facilities is a common practice in low-income areas in sub-Saharan Africa. However, shared sanitation is currently categorized as a limited sanitation service, and may therefore not count towards meeting the global goals. These shared facilities are often the only option available for most residents in low-income settlements, and improving their cleanliness and overall management is key to reducing open defecation and risk of disease. This study sought to investigate barriers and opportunities for improved cleanliness of shared sanitation facilities in low-income settlements of Kisumu city, Kenya.

Methods

Thirty-nine in-depth interviews and 11 focus group discussions were held with residents – mainly tenants and landlords – of a low-income settlement in Kisumu. Analysis followed a thematic approach to define the problem, specify the target behaviour and identify the changes needed.

Results

Sanitation facilities were mainly pit latrines, typically shared among landlords and tenants. Participants singled out behavioural (poor use of the shared toilets) and social (lack of cooperation in cleaning) challenges that led to unclean shared toilets. Available opportunities for improvement included instituting clear cleaning plans, improving communication among users, and enhanced problem-solving mechanisms between landlords and tenants. These approaches could form the basis for designing intervention strategies for improving the cleanliness of shared sanitation facilities.

Conclusion

The results highlight the need to focus on social aspects for improvement of cleanliness in shared sanitation facilities in low-income settlements. Through a social approach, shared sanitation facilities can be managed appropriately to provide the millions of low-income residents in Kenya an opportunity to access sanitation. This study provides further evidence on approaches for improved management of shared sanitation facilities in line with the World Health Organization’s (WHO) Joint Monitoring Program’s (JMP) recommendation for high quality shared facilities.

Experts' Views on Behaviour Change Techniques for Smoking Cessation in Pregnancy: A Qualitative Study

Smoking during pregnancy is a global health problem which has devastating health implications. Behavioural support is an important part of smoking cessation support for pregnant women. Research has identified barriers and facilitators (B&Fs) and effective behaviour change techniques (BCTs) to aid women's quit attempts. However, the extent to which and how these BCTs are used in practice is unclear. The research aimed to establish experts' views on how behavioural support can be optimised and techniques operationalised in clinical practice, by identifying ways to address known B&Fs for smoking cessation in pregnancy. A focus group discussion took place with six experts, which highlighted how BCTs can be used in practice to support women in their quit attempts. A thematic analysis was conducted to elicit overarching themes. Five themes were found: involving the family, empowering women, using incentives to boost motivation, using practical techniques to help women with their quit attempts and managing expectations about nicotine replacement therapy. Empowering women to make their own decisions and encouraging small positive changes in smoking habits, using visual aids (e.g., growth charts) to inform women of the harms of smoking to the baby and treating families holistically were deemed important.

The perceived impact of Covid-19 on periodontal practice in the United Kingdom: A questionnaire study

INTRODUCTION

COVID-19 has impacted dentistry in unprecedented ways.

OBJECTIVE

The following research aimed to investigate the impact of the COVID-19 pandemic on periodontal practice in the United Kingdom using the COM-B (Capability Opportunity Motivation-Behaviour) model as the basis for a questionnaire.

BASIC RESEARCH DESIGN

An online survey link was sent to all members of the British Society of Periodontology and Implant Dentistry. A total of 358 responses were received and analysed.

RESULTS

The great majority of participants thought that the pandemic had an impact on their profession, while only 4.7 % had no concerns. The main worries related to financial concerns and ability to provide appropriate levels of care. More than 80 % of respondents agreed that their establishment was compliant with infection control procedures. Some participants felt benefits mainly in terms of more time for CPD activities. It was felt that some of the changes needed will need to be sustained long-term.

CONCLUSIONS

Respondents were generally worried. However, they perceived they had the physical and psychological ability to effect changes to their practice, higher than the physical and social opportunities that they were afforded. Although the COVID-19 pandemic is causing profound changes and worries for the profession of Periodontology, clinicians are clear about their capability to control the situation and feel they have the motivation to make the required changes.

CLINICAL SIGNIFICANCE

COVID-19 has presented clinicians with novel challenges. Investigating the professional response to change and expected impact is of interest in the current climate as we navigate the 'new normal'. Assessing the results could be useful in informing support strategies moving forward.

Developing strategies to improve fidelity of delivery of, and engagement with, a complex intervention to improve independence in dementia: a mixed methods study

BACKGROUND

It is important to evaluate fidelity of delivery and engagement during feasibility trials. However, there is little guidance on how to systematically develop strategies to improve implementation if problems arise. We aimed to: 1) Assess fidelity of delivery and engagement, 2) Identify factors influencing fidelity of delivery and engagement, and 3) Develop strategies to improve fidelity of delivery of, and engagement with, a complex intervention to improve independence in dementia, within a feasibility trial.

METHODS

A mixed methods evaluation of an intervention that aimed to improve independence in dementia. To assess fidelity of delivery and engagement, observation and self-report methods were used: 60% of audio-recorded intervention sessions were transcribed and reliably rated for fidelity. Providers (n = 12) and people with dementia/supporters (n = 34) were asked to complete checklists after each session. Descriptive statistics were used to analyse the data. To identify factors influencing fidelity and engagement, one-to-one semi-structured interviews were conducted with providers (n = 8), people with dementia (n = 7) and supporters (n = 7). Thematic analysis and content analysis were used to analyse data. To develop strategies, we followed four steps proposed by the authors of the Behaviour Change Wheel (1. Understanding the behaviour, 2. Identifying intervention functions, 3. Specifying intervention content, 4. Identifying mode of delivery).

RESULTS

Researcher ratings indicated moderate fidelity and provider/participant ratings indicated high fidelity of delivery. Knowledge, providers' attributes, ease of adaptation of the intervention in relation to participants' needs and logistical considerations influenced fidelity. We developed four strategies to improve fidelity of delivery of PRIDE: 1) showing a video, 2) giving an instruction sheet, 3) giving time to practice and 4) providing continued support. Participants reported high levels of engagement. Participants' attributes, capability and opportunity influenced engagement. We developed four strategies to improve engagement with PRIDE: 1) a session summary document, 2) clear instructions, 3) time to practice activity and 4) providing regular compulsory telephone support.

CONCLUSION

Fidelity of delivery and engagement are complex behaviours. This manuscript provides an example of how the Behaviour Change Wheel can be used during a feasibility trial to systematically develop strategies to improve implementation of complex interventions.

Behavior Change Techniques Included in Reports of Social Media Interventions for Promoting Health Behaviors in Adults: Content Analysis Within a Systematic Review

BACKGROUND

Social media are an increasingly commonly used platform for delivering health promotion interventions. Although recent research has focused on the effectiveness of social media interventions for health promotion, very little is known about the optimal content within such interventions, and the active ingredients to promote health behavior change using social media are not clear. Identifying which behavior change techniques (BCTs) are reported may help to clarify the content of interventions using a generalizable terminology that may facilitate future intervention development.

OBJECTIVE

This study aimed to identify which BCTs are reported in social media interventions for promoting health behavior change in adults.

METHODS

We included 71 studies conducted with adult participants (aged ≥18 years) and for which social media intervention was considered interactive in a Cochrane review of the effectiveness of such interventions. We developed a coding manual informed by the Behavior Change Technique Taxonomy version 1 (BCTTv1) to identify BCTs in the included studies. We identified BCTs in all study arms (including control) and described BCTs in the group and self-directed components of studies. We characterized the dose of delivery for each BCT by low and high intensity. We used descriptive analyses to characterize the reported BCTs.

RESULTS

Our data consisted of 71 studies published from 2001 to 2017, mainly conducted in high-income countries (n=65). Most studies (n=31) used tailored, interactive websites to deliver the intervention; Facebook was the most used mainstream platform. In developing our coding manual, we adapted some BCTTv1 instructions to better capture unique nuances of how BCTs were operationalized in social media with respect to likes, retweets, smiles, congratulations, and badges. Social support (unspecified), instruction on how to perform the behavior, and credible source were most frequently identified BCTs in intervention arms of studies and group-delivery settings, whereas instruction on how to perform the behavior was most commonly applied in self-directed components of studies, control arms, and individual participant settings. Instruction on how to perform the behavior was also the most frequently reported BCT in both intervention and control arms simultaneously. Instruction on how to perform the behavior, social support (unspecified), self-monitoring of behavior, information about health consequences, and credible source were identified in the top 5 BCTs delivered with the highest intensity.

CONCLUSIONS

This study within a review provides a detailed description of the BCTs and their dose to promote behavior change in web-based, interactive social media interventions. Clarifying active ingredients in social media interventions and the intensity of their delivery may help to develop future interventions that can more clearly build upon the existing evidence.

Influences on the Uptake of and Engagement With Health and Well-Being Smartphone Apps: Systematic Review

BACKGROUND

The public health impact of health and well-being digital interventions is dependent upon sufficient real-world uptake and engagement. Uptake is currently largely dependent on popularity indicators (eg, ranking and user ratings on app stores), which may not correspond with effectiveness, and rapid disengagement is common. Therefore, there is an urgent need to identify factors that influence uptake and engagement with health and well-being apps to inform new approaches that promote the effective use of such tools.

OBJECTIVE

This review aimed to understand what is known about influences on the uptake of and engagement with health and well-being smartphone apps among adults.

METHODS

We conducted a systematic review of quantitative, qualitative, and mixed methods studies. Studies conducted on adults were included if they focused on health and well-being smartphone apps reporting on uptake and engagement behavior. Studies identified through a systematic search in Medical Literature Analysis and Retrieval System Online, or MEDLARS Online (MEDLINE), EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsychINFO, Scopus, Cochrane library databases, DataBase systems and Logic Programming (DBLP), and Association for Computing Machinery (ACM) Digital library were screened, with a proportion screened independently by 2 authors. Data synthesis and interpretation were undertaken using a deductive iterative process. External validity checking was undertaken by an independent researcher. A narrative synthesis of the findings was structured around the components of the capability, opportunity, motivation, behavior change model and the theoretical domains framework (TDF).

RESULTS

Of the 7640 identified studies, 41 were included in the review. Factors related to uptake (U), engagement (E), or both (B) were identified. Under capability, the main factors identified were app literacy skills (B), app awareness (U), available user guidance (B), health information (E), statistical information on progress (E), well-designed reminders (E), features to reduce cognitive load (E), and self-monitoring features (E). Availability at low cost (U), positive tone, and personalization (E) were identified as physical opportunity factors, whereas recommendations for health and well-being apps (U), embedded health professional support (E), and social networking (E) possibilities were social opportunity factors. Finally, the motivation factors included positive feedback (E), available rewards (E), goal setting (E), and the perceived utility of the app (E).

CONCLUSIONS

Across a wide range of populations and behaviors, 26 factors relating to capability, opportunity, and motivation appear to influence the uptake of and engagement with health and well-being smartphone apps. Our recommendations may help app developers, health app portal developers, and policy makers in the optimization of health and well-being apps.

Iterative four-phase development of a theory-based digital behaviour change intervention to reduce occupational sedentary behaviour

Introduction

As high amounts of occupational sitting have been associated with negative health consequences, designing workplace interventions to reduce sedentary behaviour (SB) is of public health interest. Digital technology may serve as a cost-effective and scalable platform to deliver such an intervention. This study describes the iterative development of a theory-based, digital behaviour change intervention to reduce occupational SB.

Methods

The behaviour change wheel and The Behaviour Change Technique Taxonomy were used to guide the intervention design process and form a basis for selecting the intervention components. The development process consisted of four phases: phase 1 – preliminary research, phase 2 – consensus workshops, phase 3 – white boarding and phase 4 – usability testing.

Results

The process led to the development and refinement of a smartphone application – Worktivity. The core component was self-monitoring and feedback of SB at work, complemented by additional features focusing on goal setting, prompts and reminders to break up prolonged periods of sitting, and educational facts and tips. Key features of the app included simple data entry and personalisation based on each individual’s self-reported sitting time. Results from the ‘think-aloud’ interviews (n=5) suggest Worktivity was well accepted and that users were positive about its features.

Conclusion

This study led to the development of Worktivity, a theory-based and user-informed mobile app intervention to reduce occupational SB. It is the first app of its kind developed with the primary aim of reducing occupational SB using digital self-monitoring. This paper provides a template to guide others in the development and evaluation of technology-supported behaviour change interventions.

Understanding decisions to use e-cigarettes or behavioural support to quit tobacco: a qualitative study of current and ex-smokers and stop smoking service staff

AIM

To examine factors influencing current and ex-smokers' decisions to use e-cigarettes or behavioural support, including potential impacts of any differences in perspectives between smokers and their local stop smoking services (SSSs).

DESIGN

Semi-structured qualitative interviews followed by framework analysis, with the 'capability', 'opportunity', 'motivation' and 'behaviour' (COM-B) model of behaviour change used to frame findings.

SETTING

SSSs and surrounding local areas in England.

PARTICIPANTS

Interviewees (n = 46) were current or recent smokers (n = 29) and SSS staff or stakeholders (n = 17).

MEASUREMENTS

Interview topic guides explored influences on smokers' choice of quit method and characteristics of support offered by local SSSs.

FINDINGS

Current and ex-smokers showed a range of views on potential risks from long-term vaping, which appeared to be particularly relevant for the capability dimension of COM-B. These different attitudes to vaping appeared to be linked to variations in people's perceived capability to assess evidence around e-cigarettes' safety. Motivations for using or avoiding e-cigarettes and SSSs often appeared to overlap: attitudes to both e-cigarettes and nicotine replacement therapy from SSSs often reflected personal experiences and views on whether switching from smoking to these alternatives represented successful quitting or simply ongoing nicotine addiction. For smokers, opportunities to use e-cigarettes or SSSs appeared to be largely determined by perceived time requirements. Furthermore, interviews with SSS professionals suggested that opportunities to access SSSs for ex-smokers who were now regular vapers may be being influenced by different e-cigarette policies adopted in individual areas.

CONCLUSIONS

In England, smokers' decisions to use e-cigarettes and local stop smoking services appear to be determined by varied influences across the COM-B framework. Both smokers and stop smoking service professionals display diverse views about potential risks from e-cigarettes, which has relevance for the provision of behavioural support as well as the uptake of vaping.

International ResearchKit App for Women with Menstrual Pain: Development, Access, and Engagement

BACKGROUND

Primary dysmenorrhea is a common condition in women of reproductive age. A previous app-based study undertaken by our group demonstrated that a smartphone app supporting self-acupressure introduced by a health care professional can reduce menstrual pain.

OBJECTIVE

This study aims to evaluate whether a specific smartphone app is effective in reducing menstrual pain in 18- to 34-year-old women with primary dysmenorrhea in a self-care setting. One group of women has access to the full-featured study app and will be compared with 2 control groups who have access to fewer app features. Here, we report the trial design, app development, user access, and engagement.

METHODS

On the basis of the practical implications of the previous app-based study, we revised and reengineered the study app and included the ResearchKit (Apple Inc) framework. Behavior change techniques (BCTs) were implemented in the app and validated by expert ratings. User access was estimated by assessing recruitment progress over time. User evolution and baseline survey respondent rate were assessed to evaluate user engagement.

RESULTS

The development of the study app for a 3-armed randomized controlled trial required a multidisciplinary team. The app is accessible for the target population free of charge via the Apple App Store. In Germany, within 9 months, the app was downloaded 1458 times and 328 study participants were recruited using it without external advertising. A total of 98.27% (5157/5248) of the app-based baseline questions were answered. The correct classification of BCTs used in the app required psychological expertise.

CONCLUSIONS

Conducting an innovative app study requires multidisciplinary effort. Easy access and engagement with such an app can be achieved by recruitment via the App Store. Future research is needed to investigate the determinants of user engagement, optimal BCT application, and potential clinical and self-care scenarios for app use.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03432611; https://clinicaltrials.gov/ct2/show/NCT03432611 (Archived by WebCite at http://www.webcitation.org/75LLAcnCQ).

Social Influence in the Uptake and Use of Electronic Cigarettes: A Systematic Review

CONTEXT

E-cigarettes were introduced to support smoking cessation, but their popularity has increased among nonsmokers, challenging current perspectives on their safety and effectiveness as a public health intervention. The objective of this systematic review was to identify and synthesize current evidence on the influence of social factors on e-cigarette intentions and use.

EVIDENCE ACQUISITION

MEDLINE, CINAHL, PsycINFO, and Embase were searched for studies of the effects of social factors on e-cigarette intention or use in February 2019. Studies were included if they used experimental, longitudinal, qualitative, or mixed methods designs. Advertising, social interactions, and social norms were considered as social factors; social media was considered a conduit for other social factors. Two reviewers screened all studies; bias risk was evaluated for all RCTs using the Cochrane risk of bias tool.

EVIDENCE SYNTHESIS

This review included 43 studies: 9 experimental, 11 longitudinal, 22 qualitative, and 1 mixed method. All experimental studies examined advertising and consistently showed that exposure increased intentions to use e-cigarettes. Evidence of the influence of social interactions and social norms came from longitudinal and qualitative studies, suggesting that these factors could increase e-cigarette use. Most participants were nonsmokers (81%; 22,233 of 27,303). Studies rarely considered differences in the effects of social factors on smokers and nonsmokers.

CONCLUSIONS

Given the increased popularity among nonsmokers and the potential for advertising to increase e-cigarette use, closer public health monitoring of e-cigarette uptake by nonsmokers is warranted. Future primary research should be designed to measure how social factors affect smokers and nonsmokers differently.

Development of an intervention tool for precision oral self-care: Personalized and evidence-based practice for patients with periodontal disease

Background

Oral self-care plays an important role in maintaining oral health and preventing the occurrence of oral diseases. The association between good oral care and good oral hygiene is well known. However, the adherence to a proper daily oral hygiene regimen generally remains poor, so the prevalence of oral diseases remains high. Periodontal disease is the most common oral disease in the population. To enhance the adherence to good oral hygiene behaviors for patients with periodontal disease, we developed a personalized and evidence-based mobile application as an intervention tool for the purpose of initiating and improving good oral self-care.

Objective

The objective of this study was to demonstrate the systematic development process and content of the oral self-care mobile application, OSCA.

Methods

The systematic development process of OSCA consists of three phases: behavioral diagnosis, intervention design, and assessment of OSCA. Firstly, behavioral problem of oral self-care was identified by the experts in periodontics care. Secondly, the intervention functions and the mode of delivery were designed based on the capability-opportunity-motivation behavioral model, which is the underpinning model behind the behavior change wheel framework. Thirdly, the developed app was evaluated by the experts through a heuristics evaluation checklist by adopting Morville’s Honeycomb model, and the final version of OSCA was assessed by the patients with periodontal disease using the System Usability Scale (SUS).

Results

The problems of target behavior were identified and incorporated into the design of intervention functions. For the beta version of the OSCA, experts proposed four main suggestions to improve the usefulness. Experts evaluated the beta and final versions of the app using a heuristics evaluation checklist, providing mean scores of 4.38 and 4.62, respectively. For usability testing, 87 participants completed both the specified tasks and the SUS questionnaire, providing an SUS median score of 77.5 (IQR = 12.5) and an overall mean completion time of 12.22 minutes for the specified tasks. The mean scores of the intervention functions for capability establishment, motivation enhancement, and opportunity creation were 6.13, 5.88, and 6.06, respectively.

Conclusions

The study presents a rigorous design process of developing an evidence-based and personalized mobile application for oral self-care. The results of the expert evaluation confirmed the validated design and the participants were satisfied with the designed app.

A Short Message Service Intervention to Support Adherence to Home-Based Strengthening Exercise for People With Knee Osteoarthritis: Intervention Design Applying the Behavior Change Wheel

Background

Knee osteoarthritis is a chronic condition with no known cure. Treatment focuses on symptom management, with exercise recommended as a core component by all clinical practice guidelines. However, long-term adherence to exercise is poor among many people with knee osteoarthritis, which limits its capacity to provide sustained symptom relief. To improve exercise outcomes, scalable interventions that facilitate exercise adherence are needed. SMS (short message service) interventions show promise in health behavior change. The Behavior Change Wheel (BCW) is a widely used framework that provides a structured approach to designing behavior change interventions and has been used extensively in health behavior change intervention design.

Objective

The study aimed to describe the development of, and rationale for, an SMS program to support exercise adherence in people with knee osteoarthritis using the BCW framework.

Methods

The intervention was developed in two phases. Phase 1 involved using the BCW to select the target behavior and associated barriers, facilitators, and behavior change techniques (BCTs). Phase 2 involved design of the program functionality and message library. Messages arranged into a 24-week schedule were provided to an external company to be developed into an automated SMS program.

Results

The target behavior was identified as participation in self-directed home-based strengthening exercise 3 times a week for 24 weeks. A total of 13 barriers and 9 facilitators of the behavior and 20 BCTs were selected to use in the intervention. In addition, 198 SMS text messages were developed and organized into a 24-week automated program that functions by prompting users to self-report the number of home exercise sessions completed each week. Users who reported ≥3 exercise sessions/week (adherent) received positive reinforcement messages. Users who reported &lt;3 exercise sessions/week (nonadherent) were asked to select a barrier (from a list of standardized response options) that best explains why they found performing the exercises challenging in the previous week. This automatically triggers an SMS containing a BCT suggestion relevant to overcoming the selected barrier. Users also received BCT messages to facilitate exercise adherence, irrespective of self-reported adherence.

Conclusions

This study demonstrates application of the BCW to guide development of an automated SMS intervention to support exercise adherence in knee osteoarthritis. Future research is needed to assess whether the intervention improves adherence to the prescribed home-based strengthening exercise.

Perceived Barriers and Facilitators to Breaking Up Sitting Time among Desk-Based Office Workers: A Qualitative Investigation Using the TDF and COM-B

High amounts of sedentary behaviour, such as sitting, can lead to adverse health consequences. Interventions to break up prolonged sitting in the workplace have used active workstations, although few studies have used behaviour change theory. This study aimed to combine the Theoretical Domains Framework (TDF) and the Capability, Opportunity, and Motivation to Behaviour system (COM-B) to investigate perceived barriers and facilitators to breaking up sitting in desk-based office workers. Semi-structured interviews with 25 desk-based employees investigated barriers and facilitators to breaking up sitting in the workplace. Seven core inductive themes were identified: ‘Knowledge-deficit sitting behaviour’, ‘Willingness to change’, ‘Tied to the desk’, ‘Organisational support and interpersonal influences’, ‘Competing motivations’, ‘Emotional influences’, and ‘Inadequate cognitive resources for action’. These themes were then deductively mapped to 11 of the 14 TDF domains and five of the six COM-B constructs. Participants believed that high amounts of sitting had adverse consequences but lacked knowledge regarding recommendations and were at times unmotivated to change. Physical and social opportunities were identified as key influences, including organisational support and height-adjustable desks. Future research should identify intervention functions, policy categories and behaviour change techniques to inform tailored interventions to change sitting behaviour of office workers.

Mobile Applications for the Treatment of Tobacco Use and Dependence

PURPOSE OF REVIEW

Smoking remains a leading preventable cause of premature death in the world; thus, developing effective and scalable smoking cessation interventions is crucial. This review uses the Obesity-Related Behavioral Intervention Trials (ORBIT) model for early phase development of behavioral interventions to conceptually organize the state of research of mobile applications (apps) for smoking cessation, briefly highlight their technical and theory-based components, and describe available data on efficacy and effectiveness.

RECENT FINDINGS

Our review suggests that there is a need for more programmatic efforts in the development of mobile applications for smoking cessation, though it is promising that more studies are reporting early phase research such as user-centered design. We identified and described the app features used to implement smoking cessation interventions, and found that the majority of the apps studied used a limited number of mechanisms of intervention delivery, though more effort is needed to link specific app features with clinical outcomes. Similar to earlier reviews, we found that few apps have yet been tested in large well-controlled clinical trials, although progress is being made in reporting transparency with protocol papers and clinical trial registration.

SUMMARY

ORBIT is an effective model to summarize and guide research on smartphone apps for smoking cessation. Continued improvements in early phase research and app design should accelerate the progress of research in mobile apps for smoking cessation.

Accessing National Health Service Stop Smoking Services in the UK: a COM-B analysis of barriers and facilitators perceived by smokers, ex-smokers and stop smoking advisors

OBJECTIVE

Smokers who access free National Health Service (NHS) Stop Smoking Services (SSS) in the UK are four times more likely to stop smoking, yet uptake of the services has been in decline in recent years. Evidence was collated to explore the beliefs of smokers, ex-smokers and Stop Smoking Advisors (SSAs) about SSS and the barriers and facilitators to access.

STUDY DESIGN

Mixed-methods design including i) a search of the literature; ii) a cross-sectional online questionnaire completed by 38 smokers and ex-smokers; and iii) semistructured interviews with 5 SSAs.

METHODS

PubMed, Web of Science, Scopus, Prospero and the NIHR Portfolio were searched in October 2017 to identify relevant studies. Smokers and ex-smokers were recruited to the online questionnaire via Public Health websites and social media in Warwickshire. SSAs identified via Public Health Warwickshire were invited to take part in an interview conducted over the telephone. Findings were collated and analysed using the COM-B ('Capability', 'Opportunity', 'Motivation' and 'Behaviour') model framework.

RESULTS

A range of practical and psychological or belief-based barriers and facilitators to accessing SSS were identified within all the components of the COM-B model, aside from physical capability, for example; 'Psychological capability', such as lack of understanding about what the service offers; 'Reflective motivation', such as lack of confidence in service efficacy; and 'Social opportunity', such as recommendations from healthcare professionals to attend. Suggestions and consideration on how future tobacco control intervention and public health messages can address these components are reported.

CONCLUSIONS

Public health interventions and campaigns may benefit from focussing on addressing the well-known perceived barriers and facilitators smokers experience, in particular focussing on the components of the COM-B that have been identified as being important to increase the uptake of SSS.

What do cost-effective health behaviour-change interventions contain? A comparison of six domains

OBJECTIVES

To help implement behaviour change interventions (BCIs) in practice it is important to be able to characterize their key components. This study compared broad features of cost-effective BCIs that addressed smoking, diet, physical activity, alcohol and sexual health. It also assessed the association of these with the magnitude of the cost-effectiveness estimates.

METHODS

A content analysis of 79 interventions based on 338 intervention descriptions was conducted, using the Behaviour Change Wheel (BCW) to classify intervention content in terms of intervention functions, and the BCT taxonomy to identify and categorise component Behaviour Change Techniques (BCT). Regression analysis identified the association of these with upper (pessimistic) and lower (optimistic) cost-effectiveness estimates.

RESULTS

The most and least common functions and BCT clusters were education (82.3%) and shaping knowledge (79.7%), and coercion (3.8%) and covert learning (2.5%). Smoking interventions contained the largest ([Formula: see text] = 12) number of BCTs and were most cost-effective. Several other factors were associated with worse (coercionfunction βupper = 36551.24; shaping knowledgeBCT βlower = 2427.78; comparison of outcomesBCT βupper = 9067.32; repetition and substitutionBCT βupper = 7172.47) and better (modellingfunction βlower = -2905.3; environmental restructuringfunction βupper = -8646.28; reward and threatBCT βupper = -5577.59) cost-effectiveness (p<0.05).

DISCUSSION

Cost-effective BCIs rely heavily on education with smoking interventions exhibiting the most comprehensive range of BCTs. Providing an example to aspire to, restructuring the environment and rewarding positive behaviour may be associated with greater cost-effectiveness.

Tailored digital behaviour change intervention with e-referral system to increase attendance at NHS stop smoking services (the MyWay project): study protocol for a randomised controlled feasibility trial

INTRODUCTION

In the UK, smokers who use stop smoking services (SSSs) are four times more likely to stop smoking than smokers who do not. Attendance has declined, warranting the development of interventions to address this. StopApp is a novel, brief online behaviour change intervention designed to address common barriers to SSS attendance. It links to widely commissioned service management software that enables instant appointment booking at a user's location and time of choice.

METHODS AND ANALYSIS

A two-arm parallel group, individual participant feasibility randomised controlled trial of StopApp (intervention) compared with the standard promotion of and referral to SSSs (control). The study includes a nested qualitative process evaluation to assess the acceptability of the research processes, with a subsample of participants. Smokers aged over 16 years will be recruited via three routes: General Practice (GP), community settings and online. After consenting and the collection of baseline data, participants will be randomised to control or intervention groups. Participants in the intervention group receive a link to StopApp and those in the control group receive standard web-based information about the SSSs. All participants are told they can book a SSS appointment but are under no obligation to do so. Online follow-up 2 months post randomisation includes data on SSS use and carbon monoxide verified 4-week quit rates. The study aims to recruit 162 smokers.

ETHICS AND DISSEMINATION

Ethics approval has been granted by the West Midlands-Edgbaston NHS Research Ethics Committee. The findings will be reported in conferences and peer-reviewed publications; and will be used to design the parameters necessary for a definitive trial to ascertain the effectiveness of StopApp at increasing booking and attendance at SSSs compared with existing methods for encouraging uptake.

General practitioners' views on managing knee osteoarthritis: a thematic analysis of factors influencing clinical practice guideline implementation in primary care

Background

Osteoarthritis (OA) is diagnosed and managed primarily by general practitioners (GPs). OA guidelines recommend using clinical criteria, without x-ray, for diagnosis, and advising strengthening exercise, aerobic activity and, if appropriate, weight loss as first-line treatments. These recommendations are often not implemented by GPs. To facilitate GP uptake of guidelines, greater understanding of GP practice behaviour is required. This qualitative study identified key factors influencing implementation of these recommendations in the primary-care setting.

Methods

Semi-structured interviews with eleven GPs were conducted, transcribed verbatim, coded by two independent researchers and analysed with an interpretive thematic approach using the COM-B model (Capability/Opportunity/Motivation-Behaviour) as a framework.

Results

Eleven themes were identified. Psychological capability themes: knowledge gaps, confidence to effectively manage OA, and skills to facilitate lifestyle change. Physical opportunity themes: system-related factors including time limitations, and patient resources. Social opportunity theme: influences from patients. Reflective motivation themes: GP's perceived role, and assumptions about people with knee OA. Automatic motivation themes: optimism, habit, and unease discussing weight. The findings demonstrated diverse and interacting influences on GPs' practice.

Conclusion

The identified themes provide insight into potential interventions to improve OA management in primary-care settings. Key suggestions include: improvements to OA clinical guidelines; targeting GP education to focus on identified knowledge gaps, confidence, and communication skills; development and implementation of new models of service delivery; and utilising positive social influences to facilitate best-practice behaviours. Complex, multimodal interventions that address multiple factors (both barriers and facilitators) are likely to be necessary.

Facilitators and barriers to smoking cessation among minority men using the behavioral-ecological model and Behavior Change Wheel: A concept mapping study

Background and aim

Universal smoking cessation strategies are not always successful for minorities, among whom smoking is highly prevalent despite high intention to quit. This study identifies facilitators for smoking cessation, as perceived by minority male smokers, that can inform a culturally appropriate national plan for smoking prevention and cessation.

Methods

We conducted in 2013 a three-stage study among Arab minority male current and former smokers (ages 18–64) in Israel, among whom smoking is very high: first, a Concept Mapping (CM) study with 102 and 202 participants in the brainstorming, and sorting and rating phases respectively. Second, we assigned clusters identified in the CM study to contingency levels using the Behavioral Ecological Model (BEM). Third, we classified clusters into intervention functions and policies using the Behavior Change Wheel (BCW).

Findings

The CM study revealed 58 barriers and facilitators for smoking prevention and cessation that were sorted into 11 clusters by the participants. These clusters were analogous to four BEM level contingency of smoking (social, institutional, community and individual). We classified it into two main policy categories, based on the BCW: 1- restructuring the socio-political environment of smoking through affirmative government's policies towards Arab minority in Israel, and 2-developing a culturally appropriate plan for smoking cessation in Arab local authorities including: raising awareness about tobacco hazards; enforcing anti-smoking laws; strengthening community institutional action; providing smoking cessation services; considering raising prices for tobacco products, addressing psychological sources of smoking in Arab men.

Conclusions

Our study revealed barriers, facilitators and contingencies of smoking prevention and cessation with two main policy action items among the Arab minority in Israel: changing the socio-political environment of smoking, and developing a culturally appropriate smoking prevention and cessation national plan. Our study framework can inform policies and culturally appropriate interventions for smoking prevention and cessation in other minorities.

Supporting nurses to adopt healthy eating behaviours

Nurses have a central role in health education and promotion, particularly with regard to supporting individuals to optimise their nutritional intake and engage in healthy eating behaviours. However, high rates of obesity, unhealthy eating behaviours and low levels of physical activity have been found among nurses. Nursing is a challenging profession, and a high workload, a lack of resources and shift work may affect nurses' ability to adopt healthy lifestyles. Supporting nurses to improve aspects of their eating behaviours, such as the nutritional value, timing and frequency of meals, can have a positive effect on their health which, in turn, may enhance their ability to care for patients. Although there is much literature available on the benefits of healthy eating, there is a lack of practical guidance for nurses on how to enhance their nutritional intake. This article uses a case study to examine the occupational and personal factors that may affect nurses' ability to engage in healthy eating behaviours, and identifies how healthcare organisations and individual nurses can use a behavioural change approach to optimise nutritional intake.

Lost in Translation: Transforming Behaviour Change Techniques into Engaging Digital Content and Design for the StopApp

Frameworks to support the application of behaviour change theory to the choice of behaviour change techniques (BCTs) in designing digital behaviour change interventions (DBCIs) are becoming well established, and have been employed by the authors in the development of StopApp. However, guidance on the next stage—effective operationalisation (translation) of these BCTs to a digital context, including the precise delivery and design of “behavioural intervention technology” (BIT) elements, is still in its infancy. This is despite growing recognition of the need to optimise engagement and usability, alongside a theoretical basis, for intervention effectiveness. The aim of this study was to explore methods to translate BCTs into digital content in an accurate and systematic manner. We describe the process of using co-creation (user-led) rather than expert-driven methods in the development of user-facing features and design in StopApp, including the iterative “bottom-up” and “top-down processes” necessary for accurate BCT translation. We found a small disparity between the intended and actual BCT content, reflecting the difficulties of translating BCTs into digital intervention content and the need for better guidance and methodical approaches to enhance this under-researched process. The involvement of our Patient and Public Involvement (PPI) group throughout these processes is described.

Breaking Free from Smoking: A Novel Digital Smoking Cessation Intervention for Offenders in UK Prisons

Introduction: The level of smoking cessation support across UK prisons is variable, with most offering pharmacological support, such as nicotine replacement therapy. However, with a complete smoking ban in prisons in England now imminent, additional standardised behavioural support is necessary to help offenders go smoke-free.

Aims: This study used the Behaviour Change Wheel to aim to develop the content of an online smoking cessation intervention for offenders, with consideration of their capability, motivation and opportunity for behaviour change.

Methods: This was an intervention development study. The Behaviour Change Wheel was used to map cognitive, behavioural, physiological and social targets for the intervention, onto appropriate intervention techniques for inclusion in the smoking cessation programme for offenders.

Results: Psychological capability, social opportunity and reflective and automatic motivation were identified through deductive thematic analysis as areas of change required to achieve smoking cessation. A total of 27 behavioural change techniques were chosen for this smoking cessation intervention and were mapped onto the Lifestyle Balance Model which provided the theoretical basis on which the components of the programme are conceptualised. This included strategies around increasing motivation to quit, anticipating smoking triggers, modifying smoking-related thoughts, regulating emotions, managing cravings, replacing smoking and rewarding nicotine abstinence and adopting a healthier lifestyle.

Conclusions: Through the utilisation of the Behaviour Change Wheel, the development process of this digital smoking cessation intervention was achieved. Further research is planned to evaluate the clinical effectiveness of this intervention and to explore how the programme is implemented in practice within prison settings.

Improving Behavioral Support for Smoking Cessation in Pregnancy: What Are the Barriers to Stopping and Which Behavior Change Techniques Can Influence These? Application of Theoretical Domains Framework

Behavioral support interventions are used to help pregnant smokers stop; however, of those tested, few are proven effective. Systematic research developing effective pregnancy-specific behavior change techniques (BCTs) is ongoing. This paper reports contributory work identifying potentially-effective BCTs relative to known important barriers and facilitators (B&Fs) to smoking cessation in pregnancy; to detect priority areas for BCTs development. A Nominal Group Technique with cessation experts (n = 12) elicited an expert consensus on B&Fs most influencing women's smoking cessation and those most modifiable through behavioral support. Effective cessation interventions in randomized trials from a recent Cochrane review were coded into component BCTs using existing taxonomies. B&Fs were categorized using Theoretical Domains Framework (TDF) domains. Matrices, mapping BCT taxonomies against TDF domains, were consulted to investigate the extent to which BCTs in existing interventions target key B&Fs. Experts ranked "smoking a social norm" and "quitting not a priority" as most important barriers and "desire to protect baby" an important facilitator to quitting. From 14 trials, 23 potentially-effective BCTs were identified (e.g., information about consequences). Most B&Fs fell into "Social Influences", "Knowledge", "Emotions" and "Intentions" TDF domains; few potentially-effective BCTs mapped onto every TDF domain. B&Fs identified by experts as important to cessation, are not sufficiently targeted by BCT's currently within interventions for smoking cessation in pregnancy.

Development of a Behavior Change Intervention to Improve Sexual Health Service Use Among University Undergraduate Students: Mixed Methods Study Protocol

BACKGROUND

University students are at risk for acquiring sexually transmitted infections and suffering other negative health outcomes. Sexual health services offer preventive and treatment interventions that aim to reduce these infections and associated health consequences. However, university students often delay or avoid seeking sexual health services. An in-depth understanding of the factors that influence student use of sexual health services is needed to underpin effective sexual health interventions.

OBJECTIVE

In this study, we aim to design a behavior change intervention to address university undergraduate students' use of sexual health services at two universities in Nova Scotia, Canada.

METHODS

This mixed methods study consists of three phases that follow a systematic approach to intervention design outlined in the Behaviour Change Wheel. In Phase 1, we examine patterns of sexual health service use among university students in Nova Scotia, Canada, using an existing dataset. In Phase 2, we identify the perceived barriers and enablers to students' use of sexual health services. This will include focus groups with university undergraduate students, health care providers, and university administrators using a semistructured guide, informed by the Capability, Opportunity, Motivation-Behaviour Model and Theoretical Domains Framework. In Phase 3, we identify behavior change techniques and intervention components to develop a theory-based intervention to improve students' use of sexual health services.

RESULTS

This study will be completed in March 2018. Results from each phase and the finalized intervention design will be reported in 2018.

CONCLUSIONS

Previous intervention research to improve university students' use of sexual health services lacks a theoretical assessment of barriers. This study will employ a mixed methods research design to examine university students' use of sexual health service and apply behavior change theory to design a theory- and evidence-based sexual health service intervention. Our approach will provide a comprehensive foundation to co-design a theory-based intervention with service users, health care providers, and administrators to improve sexual health service use among university students and ultimately improve their overall health and well-being.

Designing an implementation intervention with the Behaviour Change Wheel for health provider smoking cessation care for Australian Indigenous pregnant women

BACKGROUND

Indigenous smoking rates are up to 80% among pregnant women: prevalence among pregnant Australian Indigenous women was 45% in 2014, contributing significantly to the health gap for Indigenous Australians. We aimed to develop an implementation intervention to improve smoking cessation care (SCC) for pregnant Indigenous smokers, an outcome to be achieved by training health providers at Aboriginal Medical Services (AMS) in a culturally competent approach, developed collaboratively with AMS.

METHOD

The Behaviour Change Wheel (BCW), incorporating the COM-B model (capability, opportunity and motivation for behavioural interventions), provided a framework for the development of the Indigenous Counselling and Nicotine (ICAN) QUIT in Pregnancy implementation intervention at provider and patient levels. We identified evidence-practice gaps through (i) systematic literature reviews, (ii) a national survey of clinicians and (iii) a qualitative study of smoking and quitting with Aboriginal mothers. We followed the three stages recommended in Michie et al.'s "Behaviour Change Wheel" guide.

RESULTS

Targets identified for health provider behaviour change included the following: capability (psychological capability, knowledge and skills) by training clinicians in pharmacotherapy to assist women to quit; motivation (optimism) by presenting evidence of effectiveness, and positive testimonials from patients and clinicians; and opportunity (environmental context and resources) by promoting a whole-of-service approach and structuring consultations using a flipchart and prompts. Education and training were selected as the main intervention functions. For health providers, the delivery mode was webinar, to accommodate time and location constraints, bringing the training to the services; for patients, face-to-face consultations were supported by a booklet embedded with videos to improve patients' capability, opportunity and motivation.

CONCLUSIONS

The ICAN QUIT in Pregnancy was an intervention to train health providers at Aboriginal Medical Services in how to implement culturally competent evidence-based practice including counselling and nicotine replacement therapy for pregnant patients who smoke. The BCW aided in scientifically and systematically informing this targeted implementation intervention based on the identified gaps in SCC by health providers. Multiple factors impact at systemic, provider, community and individual levels. This process was therefore important for defining the design and intervention components, prior to a conducting a pilot feasibility trial, then leading on to a full clinical trial.