Development of a theory-based interactive digital intervention to improve condom use in men in sexual health clinics: an application of qualitative methods using the behaviour change wheel

Abstract

BackgroundEffective interventions for sexually transmitted infections (STIs) are more likely to have made extensive use of behaviour change theory and techniques and to have involved users in intervention design than those that are not effective; however, how to include theory in the design of behaviour change interventions is not clear. Recently, a framework for intervention has been developed that is a synthesis of the theoretical ideas depicted in 19 other frameworks (the behaviour change wheel [BCW]). The BCW defines behaviour change as requiring capability, opportunity, and motivation. These factors form the hub of the BCW around which are positioned the nine intervention functions aimed at addressing deficits in one or more of these factors. We are developing a digital intervention to increase condom use in men in sexual health clinics, drawing on published work on barriers to condom use, behaviour change theory, and the views of men attending clinics to design the content and interactive features of the intervention. We present our experience of use of the BCW to incorporate these three sources of information into the design of a behaviour change intervention. MethodsInformation from three sources was combined: a review of the published work on barriers and facilitators to condom use; workshops with clinical and academic experts in sexual health; and semi-structured interviews with men attending sexual health clinics. This information was combined with use of the BCW framework to identify what theoretical domains needed to be targeted to change behaviour (eg, condom use skills, beliefs about consequences of behaviour) and how these should be targeted (eg, interactive features and behaviour change techniques). FindingsFindings from the review of publications and interviews with men affected the intervention content. Reduced pleasure was the most prominent barrier to condom use. Other barriers included absence of accurate knowledge about risk (eg, believing that one can make judgments about risk), and difficulty using condoms in “the heat of the moment”. The intervention was therefore designed to target these factors. Furthermore, published work suggests that many people make errors when using condoms, and so an activity training people in condom use was included. Men who were interviewed wanted information about STI symptoms and consequences, and so this was also included. Combining information from different sources is essential in designing a complex intervention; however, managing such a wealth of data can prove challenging. BCW helped to provide structure for this process, by sorting the findings into the categories set out by it. It was helpful in perceiving how each intervention target maps onto a theoretical domain and to guide decisions about how to prompt behaviour change. For example, inaccurate beliefs about ability to judge the risk of STIs is a psychological capability that we targeted by developing an interactive activity that depicts scenarios for asymptomatic chlamydia acquisition within a sexual network. This activity draws on the behaviour change techniques, including giving information about health consequences, comparative imagining of future outcomes, and vicarious consequences. InterpretationThe BCW provides a good starting point for intervention development and is a good framework for integration of information. The BCW integrates theoretical principles from multiple models of health behaviour, providing a systematic way of considering several influences on behaviour and planning the ways that an intervention may seek to change behaviour. Getting consensus between experts about which dimensions were most important was sometimes difficult. To overcome this limitation, we used data from the review of published work and the interviews to make informed decisions within the research team. FundingThis research was part of a wider project, which was funded by a NIHR Health Technology Assessment grant.