Barriers and facilitators for healthy lifestyle and recommendations for counseling in endometrial cancer follow-up care: a qualitative study

OBJECTIVES

Lifestyle promotion during follow-up consultations may improve long-term health and quality of life in endometrial cancer patients. This study aimed to identify barriers and facilitators to improve and sustain a healthy lifestyle that can be translated to behavioral methods and strategies for lifestyle counseling.

METHODS

Endometrial cancer patients from three hospitals were recruited to participate in a semi-structured interview. The data were transcribed and coded. Thematic analysis was applied to identify themes and the behavior change wheel was used as a theoretical framework. Data saturation was confirmed after 18 interviews.

RESULTS

Barriers included knowledge gaps as well as lack of motivation and environmental opportunities to engage in health-promoting behavior. Facilitators included applying incremental lifestyle changes, social support, positive reinforcements, and the ability to overcome setbacks.

CONCLUSIONS

We propose the following intervention functions: education, persuasion, training, environmental restructuring, and enablement. Suitable behavior change techniques to deliver the intervention functions include information about the consequences of certain behavior, feedback on behavior, credible source, graded tasks, habit formation, restructuring of the environment, prompts/cues, goal setting, action planning, and social support. Including these recommendations in lifestyle counseling could aid lasting lifestyle change since it suits the needs and preferences of patients.

Effects of an Individualized mHealth-Based Intervention on Health Behavior Change and Cardiovascular Risk Among People With Metabolic Syndrome Based on the Behavior Change Wheel: Quasi-Experimental Study

BACKGROUND

Metabolic syndrome (MetS) is a common public health challenge. Health-promoting behaviors such as diet and physical activity are central to preventing and controlling MetS. However, the adoption of diet and physical activity behaviors has always been challenging. An individualized mobile health (mHealth)-based intervention using the Behavior Change Wheel is promising in promoting health behavior change and reducing atherosclerotic cardiovascular disease (ASCVD) risk. However, the effects of this intervention are not well understood among people with MetS in mainland China.

OBJECTIVE

We aimed to evaluate the effects of the individualized mHealth-based intervention using the Behavior Change Wheel on behavior change and ASCVD risk in people with MetS.

METHODS

We conducted a quasi-experimental, nonrandomized study. Individuals with MetS were recruited from the health promotion center of a tertiary hospital in Zhejiang province, China. The study involved 138 adults with MetS, comprising a control group of 69 participants and an intervention group of 69 participants. All participants received health education regarding diet and physical activity. The intervention group additionally received a 12-week individualized intervention through a WeChat mini program and a telephone follow-up in the sixth week of the intervention. Primary outcomes included diet, physical activity behaviors, and ASCVD risk. Secondary outcomes included diet self-efficacy, physical activity self-efficacy, knowledge of MetS, quality of life, and the quality and efficiency of health management services. The Mann-Whitney U test and Wilcoxon signed rank test were primarily used for data analysis. Data analysis was conducted based on the intention-to-treat principle using SPSS (version 25.0; IBM Corp).

RESULTS

Baseline characteristics did not differ between the 2 groups. Compared with the control group, participants in the intervention group showed statistically significant improvements in diet behavior, physical activity behavior, diet self-efficacy, physical activity self-efficacy, knowledge of MetS, physical health, and mental health after a 12-week intervention (P=.04, P=.001, P=.04, P=.04, P=.001, P=.04, P=.04, and P<.05). The intervention group demonstrated a statistically significant improvement in outcomes from pre- to postintervention evaluations (P<.001, P=.03, P<.001, P=.04, P<.001, P<.001, and P<.001). The intervention also led to enhanced health management services and quality.

CONCLUSIONS

The individualized mHealth-based intervention using the Behavior Change Wheel was effective in promoting diet and physical activity behaviors in patients with MetS. Nurses and other health care professionals may incorporate the intervention into their health promotion programs.

Barriers to medication adherence in sickle cell disease: A comprehensive theory-based evaluation using the COM-B model

BACKGROUND

Sickle cell disease (SCD) affects more than 100,000 Americans, with complications such as pain episodes and acute chest syndrome. Despite the efficacy of hydroxyurea in reducing these complications, adherence remains low. Study objectives were to examine barriers to hydroxyurea adherence, and to evaluate the relationship between barriers and their impact on adherence.

METHODS

In this cross-sectional study, patients with SCD and their caregivers were enrolled if they were taking hydroxyurea. Study measures included demographics, self-report of adherence using visual analog scale (VAS), and the Disease Management and Barriers Interview (DMI)-SCD. The DMI-SCD was mapped to the Capability, Opportunity, Motivation, and Behavior (COM-B) model.

RESULTS

Forty-eight caregivers (females 83%, median age 38 [34-43]) and 19 patients (male 53%, median age 15 [13.5-18]) participated. Using VAS, many patients (63%) reported low hydroxyurea adherence, while most caregivers (75%) reported high adherence. Caregivers endorsed barriers across multiple COM-B components, with physical opportunity (e.g., cost) and reflective motivation (e.g., SCD perceptions) being the most identified categories (48% and 42%), respectively. Patients' most identified barriers included psychological capability (e.g., forgetfulness) and reflective motivation (84% and 68%), respectively. Patients' and caregivers' VAS scores negatively correlated with the number of barriers (rs  = -.53, p = .01; rs  = -.28, p = .05) and COM-B categories (rs  = -.51, p = .02; rs  = -.35, p = .01), respectively, suggesting lower adherence with more endorsed barriers.

CONCLUSIONS

Fewer barriers to hydroxyurea adherence were associated with higher adherence. Understanding barriers to adherence is essential to develop tailored interventions aimed at improving adherence.

Participant Preferences for the Development of a Digitally Delivered Gardening Intervention to Improve Diet, Physical Activity, and Cardiovascular Health: Cross-sectional Study

BACKGROUND

Low dietary intake of fruits and vegetables and physical inactivity are 2 modifiable risk factors for cardiovascular disease. Fruit and vegetable gardening can provide access to fresh produce, and many gardening activities are considered moderate physical activity. This makes gardening interventions a potential strategy for cardiovascular disease risk reduction. Previously developed gardening interventions have relied on in-person delivery models, which limit scalability and reach.

OBJECTIVE

The purpose of this study was to ascertain participant insight on intervention components and topics of interest to inform a digitally delivered, gardening-focused, multiple health behavior change intervention.

METHODS

A web-based survey was delivered via Amazon Mechanical Turk (MTurk), including quantitative and open-ended questions. Eligible participants were aged ≥20 years, could read and write in English, were US residents, and had at least a 98% MTurk task approval rating. A multilevel screening process was used to identify and exclude respondents with response inattention, poor language fluency, or suspected automated web robots (bots). Participants were asked about their interest in gardening programming, their preferences for intervention delivery modalities (1-hour expert lectures, a series of brief <5-minute videos, or in-person meetings), and what information is needed to teach new gardeners. Comparisons were made between never gardeners (NG) and ever gardeners (EG) in order to examine differences in perceptions based on prior experience. Quantitative data were summarized, and differences between groups were tested using chi-square tests. Qualitative data were coded and organized into intervention functions based on the Behavior Change Wheel.

RESULTS

A total of 465 participants were included (n=212, 45.6% NG and n=253, 54.4% EG). There was a high level of program interest overall (n=355, 76.3%), though interest was higher in EG (142/212, 67% NG; 213/253, 84.2% EG; P<.001). The majority of participants (n=282, 60.7%) preferred a series of brief <5-minute videos (136/212, 64.2% NG; 146/253, 57.7% EG; P=.16) over 1-hour lectures (29/212, 13.7% NG; 50/253, 19.8% EG; P=.08) or in-person delivery modes (47/212, 22.2% NG; 57/253, 22.5% EG; P=.93). Intervention functions identified were education and training (performing fundamental gardening and cooking activities), environmental restructuring (eg, social support), enablement (provision of tools or seeds), persuasion (offering encouragement and highlighting the benefits of gardening), and modeling (using content experts and participant testimonials). Content areas identified included the full lifecycle of gardening activities, from the fundamentals of preparing a garden site, planting and maintenance to harvesting and cooking.

CONCLUSIONS

In a sample of potential web-based learners, participants were interested in a digitally delivered gardening program. They preferred brief videos for content delivery and suggested content topics that encompassed how to garden from planting to harvesting and cooking. The next step in this line of work is to identify target behavior change techniques and pilot test the intervention to assess participant acceptability and preliminary efficacy.

Feasibility and Acceptability of an Internet of Things-Enabled Sedentary Behavior Intervention: Mixed Methods Study

BACKGROUND

Encouraging office workers to break up prolonged sedentary behavior (SB) at work with regular microbreaks can be beneficial yet challenging. The Internet of Things (IoT) offers great promise for delivering more subtle and hence acceptable behavior change interventions in the workplace. We previously developed an IoT-enabled SB intervention, called WorkMyWay, by applying a combination of theory-informed and human-centered design approaches. According to the Medical Research Council's framework for developing and evaluating complex interventions such as WorkMyWay, process evaluation in the feasibility phase can help establish the viability of novel modes of delivery and identify facilitators and barriers to successful delivery.

OBJECTIVE

This study aims to evaluate the feasibility and acceptability of the WorkMyWay intervention and its technological delivery system.

METHODS

A mixed methods approach was adopted. A sample of 15 office workers were recruited to use WorkMyWay during work hours for 6 weeks. Questionnaires were administered before and after the intervention period to assess self-report occupational sitting and physical activity (OSPA) and psychosocial variables theoretically aligned with prolonged occupational SB (eg, intention, perceived behavioral control, prospective memory and retrospective memory of breaks, and automaticity of regular break behaviors). Behavioral and interactional data were obtained through the system database to determine adherence, quality of delivery, compliance, and objective OSPA. Semistructured interviews were conducted at the end of the study, and a thematic analysis was performed on interview transcripts.

RESULTS

All 15 participants completed the study (attrition=0%) and on average used the system for 25 tracking days (out of a possible 30 days; adherence=83%). Although no significant change was observed in either objective or self-report OSPA, postintervention improvements were significant in the automaticity of regular break behaviors (t₁₄=2.606; P=.02), retrospective memory of breaks (t₁₄=7.926; P<.001), and prospective memory of breaks (t₁₄=-2.661; P=.02). The qualitative analysis identified 6 themes, which lent support to the high acceptability of WorkMyWay, though delivery was compromised by issues concerning Bluetooth connectivity and factors related to user behaviors. Fixing technical issues, tailoring to individual differences, soliciting organizational supports, and harnessing interpersonal influences could facilitate delivery and enhance acceptance.

CONCLUSIONS

It is acceptable and feasible to deliver an SB intervention with an IoT system that involves a wearable activity tracking device, an app, and a digitally augmented everyday object (eg, cup). More industrial design and technological development work on WorkMyWay is warranted to improve delivery. Future research should seek to establish the broad acceptability of similar IoT-enabled interventions while expanding the range of digitally augmented objects as the modes of delivery to meet diverse needs.

Development of an Ecological Momentary Assessment-Triggered Text Message Library for Peripheral Artery Disease

This study developed an ecological momentary assessment (EMA)-triggered text message library based on the behavior change wheel framework to encourage exercise engagement in patients with peripheral artery disease (PAD). This study was conducted in three steps. In Step 1, semi-structured interviews were conducted with 15 patients with PAD. Their accounts of their exercise experiences revealed six barriers and three facilitators through thematic analysis. In Step 2, based on the findings from the prior step, the EMA survey was developed; its items included barriers to exercise, PAD-related leg symptoms, and general conditions. In Step 3, intervention functions to overcome exercise barriers were mapped, and 120 text messages were generated. Responses to the exercise barriers in the EMA survey triggered the automatic text messages. Additional studies are needed to examine the end-user acceptability of the text message library and the effectiveness of EMA-triggered text message interventions.

Effect of Dietary Intervention Designed with Behavior Change Wheel on Compliance with Dietary Control in Women with Gestational Diabetes Mellitus: Study Protocol for a Randomized Controlled Trial

BACKGROUND AND PURPOSE

Previous studies have shown that women with GDM can benefit from following dietary recommendations, which are based on food exchange serving (FES) and glycemic load (GL), but compliance with dietary recommendations in women with GDM is not ideal. Therefore, the aim of this paper is to design a dietary intervention program based on behavior change wheel (BCW) to affect GDM women's compliance with FES based on GL, and to compare the effects of this dietary intervention program versus general dietary management on compliance with dietary recommendations, improving maternal glucose metabolism, and reducing adverse pregnancy outcomes in women with GDM.

METHODS

This paper is a methodological description of a two-arm randomized controlled trial. In this study, eligible women with GDM will be recruited and divided into the control group (n = 30) and the intervention group (n = 30). Women with GDM will respectively receive general dietary management (control group) and dietary intervention designed with BCW (intervention group) until after delivery. Information about pregnant women will be collected through questionnaires or prenatal and delivery records.

CONCLUSION

This randomized controlled trial is designed specifically for women with GDM to achieve effective blood glucose control by strengthening GDM women's compliance with dietary recommendations. If this dietary intervention designed with BCW proves to be effective, then BCW may deserve to be applied to more areas of self-management in women with GDM.

The Development of the Psychological Determinants of Exercise Questionnaire for Japanese Older Adults: A Questionnaire Based Upon the Theoretical Domains Framework

Japan has become a super-aged society. To overcome the negative implications of this, practitioners are increasingly using exercise-based interventions to reduce the requirement for long-term care among Japanese older adults. However, no comprehensive means of assessing the wide range of exercise behavioral determinants exists for this population. Thus, the principle aim of this study was to develop a questionnaire based upon the theoretical domains framework-a framework that has synthesized a wide range of behavior change theories. Completed responses were received from 1,000 Japanese older adults who resided in the Kansai area of Japan. Findings were suggestive of good reliability and validity for seven unique psychological determinants of exercise. This study was the first to provide a measurement tool related to a distinct range of psychological determinants of exercise among Japanese older adults.

Pragmatic approaches for addressing alcohol in general practice: Development of a tailored implementation intervention

Introduction

Alcohol consumption is a leading global risk factor for ill-health and premature death. Alcohol screening and brief interventions (SBI) delivered in primary care is effective at reducing alcohol consumption, but routine implementation remains problematic. Screening all patients for excessive drinking (universal screening) is resource-intensive and may be at odds with general practitioners' (GPs') perceived professional role. This study aimed to develop a tailored, theory-based training intervention to strengthen GPs' ability to address alcohol and to manage alcohol-related health problems through a pragmatic approach based on clinical relevance.

Methods

A qualitative study design involving focus group interviews and a structured questionnaire for free text replies with GPs in Norway. Behavioral analysis assessed factors influencing delivery of SBI according to the 'capability, opportunity, motivation and behavior' (COM-B) model to inform intervention development using the Behavior Change Wheel. Qualitative data were analyzed using framework analysis and an iterative approach was adopted to develop the training.

Results

A purposive sample of GPs attended the focus groups (n = 25) and completed the questionnaire (n = 55). Four areas required additional support including: understanding the link between alcohol use and health problems; opening up the conversation on alcohol use; addressing alcohol and dealing with obstacles; and following-up and maintaining change. Findings informed the development of a four-session interactive training intervention and a digital intervention for providing support for patients between consultations to address the identified needs.

Conclusion

This work highlights the value of pragmatic, relevance-based clinical strategies, as opposed to universal screening approaches to addressing alcohol in primary care. A pragmatic approach is more in line with GPs existing sclinical skill set and holds the potential to improve widespread uptake and implementation of SBI in routine primary care.

Baby Buddy App for Breastfeeding and Behavior Change: Retrospective Study of the App Using the Behavior Change Wheel

Background

Breastfeeding plays a major role in the health of mothers and babies and has the potential to positively shape an individual’s life both in the short and long term. In the United Kingdom (UK), although 81% of women initiate breastfeeding, only 1% of women breastfeed exclusively to 6 months as recommended by the World Health Organization. In the UK, women who are socially disadvantaged and younger are less likely to breastfeed at 6 to 8 weeks postpartum. One strategy that aims to improve these statistics is the Baby Buddy app, which has been designed and implemented by the UK charity Best Beginnings to be a universal intervention to help reduce health inequalities, including those in breastfeeding.

Objective

This study aimed to retrospectively examine the development of Baby Buddy by applying the Behavior Change Wheel (BCW) framework to understand how it might increase breastfeeding self-efficacy, knowledge, and confidence.

Methods

Retrospective application of the BCW was completed after the app was developed and embedded into maternity services. A three-stage process evaluation used triangulation methods and formalized tools to gain an understanding of the potential mechanisms and behaviors used in apps that are needed to improve breastfeeding rates in the UK. First, we generated a behavioral analysis by mapping breastfeeding barriers and enablers onto the Capability, Opportunity, and Motivation-Behavior (COM-B) system using documents provided by Best Beginnings. Second, we identified the intervention functions and policy categories used. Third, we linked these with the behavior change techniques identified in the app breastfeeding content using the Behavior Change Techniques Taxonomy (BCTTv1).

Results

Baby Buddy is a well-designed platform that could be used to change breastfeeding behaviors. Findings from stage one showed that Best Beginnings had defined breastfeeding as a key behavior requiring support and demonstrated a thorough understanding of the context in which breastfeeding occurs, the barriers and enablers of breastfeeding, and the target actions needed to support breastfeeding. In stage two, Best Beginnings had used intervention and policy functions to address the barriers and enablers of breastfeeding. In stage three, Baby Buddy had been assessed for acceptability, practicability, effectiveness, affordability, safety, and equity. Several behavior change techniques that could assist women with decision making around breastfeeding (eg, information about health consequences and credible sources) and possibly affect attitudes and self-efficacy were identified. Of the 39 videos in the app, 19 (49%) addressed physical capabilities related to breastfeeding and demonstrated positive breastfeeding behaviors.

Conclusions

Applying a theoretical framework retrospectively to a mobile app is possible and results in useful information to understand potential health benefits and to inform future development. Future research should assess which components and behavioral techniques in the app are most effective in changing behavior and supporting breastfeeding.

Content and Mechanism of Action of National Antimicrobial Stewardship Interventions on Management of Respiratory Tract Infections in Primary and Community Care

A major modifiable factor contributing to antimicrobial resistance (AMR) is inappropriate use and overuse of antimicrobials, such as antibiotics. This study aimed to describe the content and mechanism of action of antimicrobial stewardship (AMS) interventions to improve appropriate antibiotic use for respiratory tract infections (RTI) in primary and community care. This study also aimed to describe who these interventions were aimed at and the specific behaviors targeted for change. Evidence-based guidelines, peer-review publications, and infection experts were consulted to identify behaviors relevant to AMS for RTI in primary care and interventions to target these behaviors. Behavior change tools were used to describe the content of interventions. Theoretical frameworks were used to describe mechanisms of action. A total of 32 behaviors targeting six different groups were identified (patients; prescribers; community pharmacists; providers; commissioners; providers and commissioners). Thirty-nine interventions targeting the behaviors were identified (patients = 15, prescribers = 22, community pharmacy staff = 8, providers = 18, and commissioners = 18). Interventions targeted a mean of 5.8 behaviors (range 1–27). Influences on behavior most frequently targeted by interventions were psychological capability (knowledge and skills); reflective motivation (beliefs about consequences, intentions, social/professional role and identity); and physical opportunity (environmental context and resources). Interventions were most commonly characterized as achieving change by training, enabling, or educating and were delivered mainly through guidelines, service provision, and communications & marketing. Interventions included a mean of four Behavior Change Techniques (BCTs) (range 1–14). We identified little intervention content targeting automatic motivation and social opportunity influences on behavior. The majority of interventions focussed on education and training, which target knowledge and skills though the provision of instructions on how to perform a behavior and information about health consequences. Interventions could be refined with the inclusion of relevant BCTs, such as goal-setting and action planning (identified in only a few interventions), to translate instruction on how to perform a behavior into action. This study provides a platform to refine content and plan evaluation of antimicrobial stewardship interventions.

Designing a Personalized Digital Patient Support Program for Patients Treated With Growth Hormone: Key Design Considerations

BACKGROUND

Recombinant human growth hormone treatment can optimize growth potential; however, optimal outcomes are not always achieved for several reasons, including poor adherence. The overall objective of this project was to design a patient support program to maximize the chances of treatment success for people being treated with somatropin injection. An approach known as the behavior change wheel was used to enhance the development of the patient support program. The behavior change wheel provided a comprehensive framework to support the design of interventions.

OBJECTIVE

The aim of this paper was to describe how the steps of the behavior change wheel were applied to the development of a patient support program for individuals with growth hormone deficiency undergoing treatment with somatropin.

METHODS

We followed a series of steps that align to tenets of the behavior change wheel, namely, a narrative literature review to identify which behaviors needed to change and the potential drivers of and barriers to the behaviors, the selection of an intervention strategy and discrete behavior change techniques, and, finally, intervention specification.

RESULTS

A recent systematic review identified a range of potentially modifiable factors found to have an influence on patient adherence to growth hormone treatment. Insights from the systematic review were used to guide the development of a patient support program. The final design of the patient support program consisted of four elements: (1) a personalization questionnaire to tailor support for each individual, (2) tailored reminder and support SMS text messages, (3) nurse-led phone calls, and (4) Easypod connect, an automated electronic autoinjector drug-delivery device with a transmitter and connection platform for Saizen (somatropin) that allows automatic recording, storage, and transmission of drug-usage data, thus providing insight into suboptimal adherence.

CONCLUSIONS

The patient support program that was designed is currently being piloted with patients to assess engagement with the program and determine its impact on patient outcomes. Results from the pilot will be used to further refine the program to ensure it meets user needs.

Instant Gratification as a Method to Promote Physician Practice Guideline Adherence: A Systematic Review

Inadequate adherence to best practice guidelines may have a negative impact on the processes of critical care and patient outcomes. Instant gratification has been used to modify human behavior in industries such as gaming, lottery, and social media. We hypothesize that, if properly and purposefully utilized, IG can become a successful tool for encouraging best practice guideline adherence among critical care providers. Four major databases were searched with a medial librarian. Covidence application was used to identify studies pertaining to the instant gratification being used to improve provider adherence with best practice guidelines. A total of 712 studies were identified, and, through duplicates removal, title and abstract screening, and full-text screening, a total of 13 studies were included in the final review. The exclusion criteria used included the following: no provider gratification, wrong focus/intervention, wrong study design, patient-focused intervention, not generalizable, and no conclusion. There is a knowledge gap regarding instant gratification utilization to influence practice guideline adherence among providers. The intervention functions of the Behavior Change Wheel (BCW) were evident, especially 'persuasion' and 'incentivization', which are most pertinent to our field. The restorative process that promotes positive reinforcement can be a potential solution for alleviating inadequacies in guideline adherence. Examining interventions based on functions of the BCW has shown that an instant gratification process may have the potential in altering critical care providers' behavior and improving guideline adherence. This review is the first step towards creating smart algorithms to instantly alert providers for their actions compliant with best practices. Developing, testing, and validating the algorithms will be the next several steps.

Applying the COM-B model to patient-reported barriers to medication adherence in pediatric acute lymphoblastic leukemia

BACKGROUND

Adherence to oral chemotherapy, including 6-mercaptopurine (6-MP), is suboptimal in pediatric acute lymphoblastic leukemia (ALL), which is associated with increased risk of relapse. Study objectives were to examine self-reported adherence to 6-MP and related barriers to adherence, mapped to the capability, opportunity, motivation, and behavior (COM-B) model for behavior change.

PROCEDURE

Forty-nine parents (median, 39 years old; 76% females) and 15 patients (median, 17 years old, 20% females) completed the study survey.

RESULTS

Suboptimal adherence was reported in 43% of parents and 73% of patients. Most parents and patients (80% and 90%, respectively) reported ≥1 adherence barrier. Parents reported difficulty helping their child meet others with ALL (43%), contacting community organizations (39%), and meeting other parents (37%). Patients reported difficulty finding out what their medications are (40%), finding out what 6-MP does (47%), and meeting other patients (40%). Using the COM-B, we found that parents and patients endorsed barriers in multiple components, especially physical (55%, 67%) and social opportunity (56%, 47%), highlighting that barriers to adherence may be multifaceted.

CONCLUSIONS

Our results suggest that parents and patients with ALL face various prevalent barriers to medication adherence and provide insight into the development of behavioral interventions focused on promoting adherence, which is essential to prevent relapse and optimize health outcomes in ALL.

A Facilitated Web-Based Self-Management Tool for People With Type 1 Diabetes Using an Insulin Pump: Intervention Development Using the Behavior Change Wheel and Theoretical Domains Framework

BACKGROUND

Type 1 diabetes (T1D) requires intensive self-management (SM). An insulin pump is designed to better support personal T1D management, but at the same time, it exacerbates the complexity and requirements of SM. Research shows that people with diabetes are likely to benefit from navigating and connecting to local means of social support and resources through web-based interventions that offer flexible, innovative, and accessible SM. However, questions remain as to which behavior change mechanisms within such resources benefit patients most and how to foster engagement with and endorsement of SM interventions.

OBJECTIVE

The aim of this study was to evaluate the perspectives and experiences of people with T1D using an insulin pump and specialist health care professionals (HCPs) and determine what behavior change characteristics and strategies are required to inform the optimization of an existing web-based social network (SN) intervention to support SM.

METHODS

Focus groups with insulin pump users (n=19) and specialist HCPs (n=20) in 6 National Health Service (NHS) trusts across the south of England examined the barriers and enablers to incorporating and self-managing an insulin pump. An analysis was undertaken using the Behavior Change Wheel and Theoretical Domains Framework, followed by a taxonomy of behavior change techniques (BCTs) to identify the contents of and strategies for the implementation of a complex health intervention.

RESULTS

A total of 4 themes represent the SM perspectives and experiences of stakeholders: (1) a desire for access to tailored and appropriate resources and information-the support and information required for successful SM are situational and contextual, and these vary according to time and life circumstances, and therefore, these need to be tailored and appropriate; (2) specific social support preferences-taking away isolation as well as providing shared learnings and practical tips, but limitations included the fear of judgment from others and self-pity from peers; (3) the environmental context, that is, capacity and knowledge of pump clinic HCPs-HCPs acknowledge the patient's need for holistic support but lack confidence in providing it; and (4) professional responsibility and associated risks and dangers, whereas HCPs are fearful of the consequences of promoting non-NHSSM support, and they question whether SM support fits into their role. BCTs were identified to address these issues.

CONCLUSIONS

The use of behavioral theory and a validated implementation framework provided a comprehensive approach for systematically identifying barriers and enablers of self-managing T1D with an insulin pump. A web-based SN intervention appears to offer additional forms of SM support while complementing NHS services. However, for intervention implementation, HCPs' apprehensions about responsibility when signposting to non-NHS SM support would need to be addressed, and opportunistic features would need to be added, through which pump users could actively engage with other people living with T1D.

Using the theoretical domains framework to explore reasons for missed opportunities for vaccination among children in Kano, Nigeria: a qualitative study in the pre-implementation phase of a collaborative quality improvement project

Background: Missed opportunities for vaccination (MOV) have been identified as an important contributor to low childhood immunization coverage. In this study, we explore the reasons for MOV from the perspective of caregivers of children aged 0-23 months attending primary health care (PHC) facilities in Nassarawa Local Government Area (LGA) of Kano State, Nigeria. This was to inform the implementation of a quality improvement program to reduce MOV. Methodology: An exploratory qualitative research was conducted using focus group discussions (FGD) with caregivers of children aged 0-23 months that visited PHC facilities. The study was conducted in three purposively selected PHC facilities in Nassarawa, Kano. The caregivers were purposively selected from the three PHC facilities and were homogenous in terms of their place of residence. Each FGD was conducted face-to-face in a private room within the health facility. During the discussion, participants maintained a circular sitting arrangement. The FGD were audio-recorded, transcribed verbatim, and analyzed using template analysis approach through the lens of the theoretical domains framework (TDF) and the capability, opportunity, motivation - behavior (COM-B) model. The researchers that conducted this study are epidemiologists and implementation scientists with experience in immunization programs. They are multilingual, and some are fluent in both English and Hausa language. Although four of them are medical doctors, however, they do not have any affiliations or provide health services in any of the PHC facilities where this study was conducted. Result: Five FGD with 30 caregivers was conducted. The caregivers were aged between 19 and 32 years and lived within the LGA. Based on their lived experiences, several factors that are responsible for MOV were identified and categorized into three constructs based on the COM-B model. Capability encompassed caregiver's inadequate knowledge of the vaccines that children need. The opportunity included contextual factors such as non-screening of home-based records, health worker's refusal to offer immunization services, and husband's refusal due to socio-cultural beliefs. Finally, motivation included fear of the side effects of vaccination. Conclusion: This study identified a useful framework that aided deeper insights into caregiver-related factors responsible for MOV in Nassarawa, Kano. Some of the findings from this study can be used to inform change ideas in a quality improvement program and should be explored.

Development of a Complex Intervention to Improve Adherence to Antidiabetic Medication in Older People Using an Anthropomorphic Virtual Assistant Software

Introduction: Improving adherence to antidiabetic medication is crucial, resulting in improved health outcomes, cost reduction, and minimization of waste. A lack of underlying theory in existing interventions may explain the limited success in sustaining behavior change. This paper describes the development of a theory and evidence-based complex intervention to improve adherence to oral antidiabetics in older people via a software prototype with an anthropomorphic virtual assistant.

Methods: The Behavior Change Wheel (BCW) was used to develop a theoretical understanding of the change process, corresponding to the first phase of the Medical Research Council Framework for developing and evaluating complex interventions. At the BCW core is a model of human behavior (COM-B), which posits that human behavior (B) results from the interaction between capabilities (C), opportunities (O), and motivation (M). Literature-derived medication adherence determinants were mapped onto COM-B components. Then, intervention functions (IFs) were selected employing the APEASE criteria. Finally, standardized behavior change techniques (BCTs) were chosen based on their suitability and their effectiveness on medication adherence trials. The prototype was developed for android devices; its core was implemented in Unity3D, using a female 3D virtual assistant, named Vitória.

Results: Two COM-B components were identified as main targets for behavior change—psychological capability and reflective motivation; these were linked with four IFs—education, persuasion, enablement, and environmental restructuring. Eleven BCTs were, in turn, linked with the IFs. An example of a BCT is “problem solving”; it requires users to pinpoint factors influencing non-adherence and subsequently offers strategies to achieve the desired behavior. BCTs were operationalized into the dialogues with Vitória and into supplementary software features. Vitória communicates with users verbally and non-verbally, expressing emotions. Input options consist of buttons or recording values, such as medication taken.

Conclusion: The present approach enabled us to derive the most appropriate BCTs for our intervention. The use of an explicit bundle of BCTs, often overlooked in interventions promoting medication adherence, is expected to maximize effectiveness and facilitates replication. The first prototype is being refined with users and health professionals’ contributions. Future work includes subjecting the prototype to usability tests and a feasibility trial.