Policy as an approach to behaviour change: encouraging visits to the outdoors during leisure and recreation to promote health and wellbeing in Scotland

The probability of an intervention being effective is likely increased if it is designed following a behavioural analysis and with the aid of evidence-based intervention frameworks. For example, the Behaviour Change Wheel (BCW) framework and its associated COM-B model of behaviour have been used successfully as a starting point for designing behaviour change interventions. However, the BCW framework can also be applied at a later stage in the design process, such as when an intervention has been designed but before it is deployed. Here we describe the application of the BCW framework and COM-B model to evaluate and refine already designed interventions. We use a multidisciplinary multi-site project (‘City4Age’) as a case study. The project aims to promote independent living of older adults through the deployment of interventions using wearable and environment-based technology. We conducted face-to-face interviews with site representatives to identify the target behaviours, perceived barriers and facilitators, intervention functions, and modes of delivery for each planned intervention. Additionally, literature reviews were conducted to identify evidence-based facilitators and barriers for each targeted behaviour. Subsequently, we 1) compared the intervention functions proposed by the project-sites with those most likely to be effective according to the BCW; and 2) assessed the congruency of the barriers and facilitators identified by the pilot-sites with those identified in the literature. For five planned interventions across two project-sites (Birmingham and Singapore), two had intervention functions unlikely to be effective according to the BCW. The two planned interventions to promote social engagement did not address barriers or facilitators evident in the literature, indicating they required refinement. Applying the BCW framework allowed to identify which interventions needed refining. It also helped in providing specific guidance in our recommendations for improvements prior to deployment.

BackgroundMedication adherence is an important but highly complex set of behaviors, which for life-threatening and infectious diseases such as HIV carry critical consequences for individual and public health. There is growing evidence that mobile phone text messaging interventions (mHealth) connecting providers with patients positively impact medication adherence, particularly two-way engagement platforms that require bidirectional communication versus one-way in which responses are not mandatory. However, mechanisms of action have not been well defined. The Behavior Change Wheel is a comprehensive framework for behavior change that includes an all-encompassing model of behavior known as Capability Opportunity Motivation-Behavior and is complemented by a taxonomy of behavior change techniques. Evaluating mHealth interventions for medication adherence using these tools could provide useful insights that may contribute to optimizing their integration into the healthcare system and successful scaling-up.ObjectiveThis study aimed to help address the current knowledge gap regarding how two-way mHealth interventions for medication adherence may work by applying the Behavior Change Wheel to characterize WelTel: an interactive digital health outreach platform with robust evidence for improving adherence to antiretroviral therapy.MethodsTo characterize how WelTel may promote medication adherence, we applied the Behavior Change Wheel to systematically (1) generate a behavioral diagnosis through mapping known antiretroviral therapy adherence barriers onto the Capability Opportunity Motivation-Behavior model of behavior, (2) specify the behavior change techniques that WelTel delivers, (3) link identified behavior change techniques to corresponding intervention functions of the Behavior Change Wheel, and (4) connect these behavior change techniques and intervention functions to respective Capability Opportunity Motivation-Behavior influences on behavior to determine potential mechanisms of action.ResultsOur evaluation of WelTel using the Behavior Change Wheel suggests that most of its impact is delivered primarily through its personalized communication component, in which 8 different behavior change techniques were identified and linked with 5 intervention functions (environmental restructuring, enablement, education, persuasion, and training). Its mechanisms of action in promoting antiretroviral therapy adherence may involve addressing all Capability Opportunity Motivation-Behavior influences on behavior (physical and psychological capability, physical and social opportunity, reflective and automatic motivation).ConclusionsSystematically unpacking the potential active ingredients of effective interventions facilitates the creation and implementation of more parsimonious, tailored, and targeted approaches. Evaluating WelTel using the Behavior Change Wheel has provided valuable insights into how and why such interactive two-way mHealth interventions may produce greater impact than one-way in addressing both nonintentional and intentional forms of nonadherence. The application of the Behavior Change Wheel for evidence synthesis across mHealth interventions targeting various conditions would contribute to strengthening the knowledge base regarding how they may work to impact medication adherence behavior.

Introduction Prescribing cascades, which occur when a medication is used to treat the side effect of another medication, are important contributors to polypharmacy. There is an absence of studies that evaluate the implementation or impact of existing interventions to address prescribing cascades in practice. Aim To design theory-informed options for interventions to address prescribing cascades within interprofessional primary care teams. Methods The Behaviour Change Wheel (BCW) framework, and its eight steps, were applied to guide intervention development by the research team. Three target behaviours were drafted and prioritised for intervention development based on data collected as part of two qualitative studies exploring why and how cascades occur across practice settings.[1,2] A target behaviour was selected and the COM-B (capability, opportunity, motivation-behaviour) model was then applied to identify the relevant factors for interprofessional primary care teams. The BCW was used to determine the relevant intervention types and policy options for the behaviour. Next, corresponding behaviour change techniques (BCTs) were identified and intervention options drafted. Prioritisation of behaviours and intervention examples were guided by the APEASE criteria (Affordability, Practicability, Effectiveness/cost-effectiveness, Acceptability, Side-effects/safety, Equity). Results The three target behaviours involved supporting: 1) healthcare providers to ask about, investigate and manage cascades (often through deprescribing), 2) the public to ask about prescribing cascades, and 3) the public to share medication histories and experiences with healthcare providers. The team selected the healthcare provider behaviour, called A-I-D (ask, investigate, deprescribe), for intervention development. Psychological capability and physical opportunity were determined to be the most relevant COM-B components, corresponding to education, training, environmental restructuring, and enablement intervention types and the guidelines, communications and marketing, and service provision policy options within the BCW model. Ultimately, 10 intervention options comprised of BCTs were developed by the team, which are ready for further prioritisation by stakeholders. These can be grouped into three categories: provision of educational content or materials for use by clinicians, provision of consultation or training to support clinicians, and knowledge mobilisation strategies. Through the process, the team identified that development of a practice guidance tool, which assists healthcare providers to investigate and manage prescribing cascades, is needed to support further intervention development. Conclusion The BCW framework guided the design of intervention options that will support primary care clinicians practising in interprofessional teams to address prescribing cascades. A limitation of this work is that applying the BCW framework required several judgements by the team, comprised of scientists, pharmacists, and nurses but not a general practitioner physician. Many but not all have practised with primary care interprofessional teams. When identifying interventions for future consultation, it was determined that the development of a practice guidance tool (i.e., which assists with identifying, investigating, and managing prescribing cascades) underpinned all the proposed interventions for addressing prescribing cascades in practice. Further research is needed to determine what primary care clinicians will need in this practice guidance tool and how it will be used in practice, to support its development.

Background: People with substance use disorders (PLSUD) face significant stigma, impeding treatment. Psychosocial interventions could reduce stigma, but the underlying mechanisms are unclear. Aim: This review analyzed authors’ behavioral explanations supporting stigma-reduction outcomes and explored links between these mechanisms and behavior change. Methods: A search was conducted through PubMed, Google Scholar, and a cross-reference search of the published systematic reviews on PLSUD. Inclusion criteria encompassed clinical trials targeting various populations and employing diverse intervention types. Data extraction and thematic analysis were performed using the Theoretical Domain Framework (TDF) to classify emergent themes and codes. The Behavior Change Wheel (BCW) framework was applied to understand the potential behavior change mechanism. Results: Of the 670 initially identified studies, 29 met the inclusion criteria. Most were from the US. These studies represented diverse intervention types, including social contact, psychoeducation, and peer support programs. Thematic analysis revealed 17 themes. Key themes included awareness building, social contact, and emotion processing. Awareness-building efforts targeted self-awareness, public perceptions, and societal expectations, while social contact interventions focused on direct interactions and sharing lived experiences. Strategies like mindfulness and meta-cognitive approaches were identified to aid emotion processing and cognitive reappraisal. The themes were categorized into ten TDF domains. “Knowledge” was the most common captured domain. The BCW framework surmised the interrelationship within domains and between domains and capability-motivation-opportunity. Conclusion: Psychosocial interventions for stigma reduction in PLSUD operate through multifaceted mechanisms. Understanding these mechanisms is crucial for designing effective interventions and addressing the complex dynamics of stigma surrounding SUDs.

BackgroundStroke survivors are highly sedentary; thus, breaking up long uninterrupted bouts of sedentary behaviour could have substantial health benefit. However, there are no intervention strategies specifically aimed at reducing sedentary behaviour tailored for stroke survivors. The purpose of this study was to use co-production approaches to develop an intervention to reduce sedentary behaviour after stroke.MethodsA series of five co-production workshops with stroke survivors, their caregivers, stroke service staff, exercise professionals, and researchers were conducted in parallel in two-stroke services (England and Scotland). Workshop format was informed by the behaviour change wheel (BCW) framework for developing interventions and incorporated systematic review and empirical evidence. Taking an iterative approach, data from activities and audio recordings were analysed following each workshop and findings used to inform subsequent workshops, to inform both the activities of the next workshop and ongoing intervention development.FindingsCo-production workshop participants (n = 43) included 17 staff, 14 stroke survivors, six caregivers and six researchers. The target behaviour for stroke survivors is to increase standing and moving, and the target behaviour for caregivers and staff is to support and encourage stroke survivors to increase standing and moving. The developed intervention is primarily based on co-produced solutions to barriers to achieving the target behaviour. The developed intervention includes 34 behaviour change techniques. The intervention is to be delivered through stroke services, commencing in the inpatient setting and following through discharge into the community. Participants reported that taking part in intervention development was a positive experience.ConclusionsTo our knowledge, this is the first study that has combined the use of co-production and the BCW to develop an intervention for use in stroke care. In-depth reporting of how a co-production approach was combined with the BCW framework, including the design of bespoke materials for workshop activities, should prove useful to other researchers and practitioners involved in intervention development in stroke.

Mothers and teenage daughters walking to health: using the behaviour change wheel to develop an intervention to improve adolescent girls' physical activity

Young people's engagement with online counselling remains an endemic obstacle faced by mental health services. This study utilises the Behaviour Change Wheel (BCW) framework to systematically explore the barriers and facilitators of young people's behavioural engagement with online webchat counselling. The current study defines behavioural engagement as any observable or active contribution by the young person in the webchat sessions, such as written verbalisation and self‐expression. Semi‐structured interviews with counsellors (n = 8) and open‐ended questionnaire data from 43 young people (aged 18–25 years) were gathered and then coded. Nine core themes were identified including communication difficulties, the safety of the webchat environment, absence of face‐to‐face communication, ambiguity in messages or pauses, reaching goals, optimism about outcomes, pre‐existing anxieties, mood or well‐being and wanting/not wanting to attend. Using the BCW framework, these themes were mapped to broad intervention functions and behaviour change techniques (BCTs) to provide suggestions to optimise young people's engagement with online counselling. These include the application of persuasive design features, the use of social strategies, increased counsellor training and greater personalisation of the online therapeutic approach. Future research can determine the effectiveness of these proposed strategies and BCTs to enrich the emerging engagement strategy field and the wider digital and mental health behaviour change literature.

ABSTRACTThere are few process evaluations of school-based alcohol education programmes, especially examining teacher’s role in implementation. Using a Behaviour Change Wheel (BCW) framework, this qualitative study identifies the barriers and enablers to teacher delivery of the Talk About Alcohol (TAA) programme in UK secondary schools and provides strategies for improvement in this context. Ten teachers were interviewed about influences on their delivery of the TAA programme. Interview transcripts were analysed thematically using the Theoretical Domains Framework (TDF) and then Behaviour Change Techniques (BCTs) were identified for optimisation. Key enablers included increased knowledge from training and resources, increased confidence and effective resource design. Barriers included social pressure on students and further training on complex issues related to alcohol use such as consent. Delivery was influenced by a range of positive enablers which can inform other school-based alcohol interventions. Strategies for optimisation include follow-up training sessions, notifications of new updates to the programme resources, training highlighting past successes for teachers and further action planning for students. This evaluation highlights how the BCW approach can be used to improve teacher implementation in educational research.

Since 2012, the World Health Organization has recommended household contact investigation as an evidence-based intervention to find and treat individuals with active tuberculosis (TB), the most common infectious cause of death worldwide after COVID-19. Unfortunately, uptake of this recommendation has been suboptimal in low- and middle-income countries, where the majority of affected individuals reside, and little is known about how to effectively deliver this service. Therefore, we undertook a systematic process to design a novel, theory-informed implementation strategy to promote uptake of contact investigation in Uganda, using the COM-B (Capability-Opportunity-Motivation-Behavior) model and the Behavior Change Wheel (BCW) framework. We systematically engaged national, clinic-, and community-based stakeholders and collectively re-examined the results of our own formative, parallel mixed-methods studies. We identified three core behaviors within contact investigation that we wished to change, and multiple antecedents (i.e., barriers and facilitators) of those behaviors. The BCW framework helped identify multiple intervention functions targeted to these antecedents, as well as several policies that could potentially enhance the effectiveness of those interventions. Finally, we identified multiple behavior change techniques and policies that we incorporated into a multi-component implementation strategy, which we compared to usual care in a household cluster-randomized trial. We introduced some components in both arms, including those designed to facilitate initial uptake of contact investigation, with improvement relative to historical controls. Other components that we introduced to facilitate completion of TB evaluation—home-based TB-HIV evaluation and follow-up text messaging—returned negative results due to implementation failures. In summary, the Behavior Change Wheel framework provided a feasible and transparent approach to designing a theory-informed implementation strategy. Future studies should explore the use of experimental methods such as micro-randomized trials to identify the most active components of implementation strategies, as well as more creative and entrepreneurial methods such as human-centered design to better adapt the forms and fit of implementation strategies to end users.

Background Healthcare waste is growing annually at a rate of 2–3% globally with negative implications for environmental and population health. Improving recycling of non-contaminated healthcare waste can reduce carbon emissions and landfill use with consequent financial and health co-benefits. This paper reports the development of a co-designed behavioural change recycling intervention in a small, rural hospital in Queensland, Australia. The aim was to reduce the amount of potentially recyclable or reusable non-contaminated waste currently ending up in landfill. Methods This study utilised co-design to develop a behavioural change intervention informed by an evidence-based, theoretical framework – the integrated Behaviour Change Wheel (BCW) and Theoretical Domains Framework (TDF). This study was undertaken in a 20-bed rural Queensland Health hospital and included hospital staff in the co-design of a recycling intervention. The waste streams chosen were commingled recycling stream and waste accepted by the Containers-for-Change recycling scheme. Two co-design workshops were held onsite at the hospital on 2nd June (n = 8) and 3rd August 2023 (n = 6) followed by a visit to the hospital on 31st August 2023 to implement the recycling intervention. Final data collection was undertaken at the end of November 2023. Results The co-designed intervention comprised placing commingled bins (grey with yellow lids) and CFC bins (grey with white lids) at points of recyclable waste generation with signage and ‘train-the-trainer’ education sessions with the green champions. Over the 3-month post-intervention data collection period there was a reduction of 1.25t for the general waste stream, 0.1042t of recyclable waste was recycled through the newly introduced CFC scheme, and an increase of 0.07t of commingled recyclable waste after the intervention. In summary, across a three-month period, this co-designed recycling intervention reduced CO2e by 2t. This equates to a reduction of 13,652 km of car travel in an Australian sedan or light SUV. Importantly, it also diverted approximately 3,000 plastic bottles and 866 aluminium cans from landfill. Conclusions Despite the small number of participants in the two co-design workshops, combining co-design with an evidence-based theoretical framework (BCW + TDF) produced a robust, fit-for-purpose, recycling intervention that led to behaviour change (recycling).

Motiva.DM2 project. A pilot behavioral intervention on diet and exercise for individuals with type 2 diabetes mellitus

Regular physical activity has a range of benefits for children's health, academic achievement, and behavioral development, yet they face barriers to participation. The aim of the study was to systematically develop an intervention for improving Chinese children's physical activity participation, using the Behavior Change Wheel (BCW) and Theoretical Domains Framework (TDF). The BCW and TDF were used to (i) understand the behavior (through literature review), (ii) identify intervention options (through the TDF-intervention function mapping table), (iii) select content and implementation options [through behavior change technique (BCT) taxonomy and literature review], and (iv) finalize the intervention content (through expert consultation, patient and public involvement and engagement, and piloting). A systematic iterative process was followed to design the intervention by following the steps recommended by the BCW. This systematic process identified 10 relevant TDF domains to encourage engagement in physical activity among Chinese children: knowledge, memory, attention and decision processes, social influences, environmental context and resources, beliefs about capabilities, beliefs about consequences, social/professional role and identity, emotions, and physical skills. It resulted in the selection of seven intervention functions (education, persuasion, environmental restricting, modeling, enablement, training, and incentivization) and 21 BCTs in the program, delivered over a period of 16 weeks. The BCW and TDF allowed an in-depth consideration of the physical activity behavior among Chinese children and provided a systematic framework for developing the intervention. A feasibility study is now being undertaken to determine its acceptability and utility.

Background：Physical activity is inadequate in older adults with AF and frailty. Being physically active improves health outcomes and reduces the healthcare burden. Theory-based behaviour change interventions are necessary to enhance physical activity. The aim of this study was to develop an intervention guided by the Behaviour Change Wheel theory to improve physical activity in older patients with AF and frailty. Objective：Our aim was to develop a behaviour change intervention for older patients with AF and frailty to increase their physical activity, improve physical health and reduce the national healthcare burden. Methods：Our study used a framework based on the Behaviour Change Wheel theory to develop a behaviour change intervention through eight steps. Using semi-structured interviews, we identified the determinants of physical activity in older patients with AF and frailty using the COM-B and TDF. Appropriate intervention functions and various policies addressing the determinants of physical functioning in elderly patients with AF and frailty were then selected based on APEASE criteria. Finally, appropriate behaviour change techniques were screened after the APEASE criteria to help achieve translation of the intervention function into intervention content. Results：Our study identified 12 factors that promote and 12 factors that hinder physical activity. We selected seven intervention functions and 15 behavior change techniques based on these factors. These 7 intervention functions and 15 behavior change techniques are eligible for APEASE criteria. We then determined to use an app as a delivery model. Finally, behavioral change interventions were provided for elderly patients with AF combined with frailty to increase the physical activity level and compliance. Conclusions：The Behavior Change Wheel provides a systematic approach to designing behavior change interventions, which can enhance physical activity and delay frailty in elderly patients with AF and frailty and reduce healthcare burden. Findings suggest that potential interventions should focus on enhancing disease knowledge, teaching physical activity skills, providing social support, and using appropriate behavior change techniques in older adults with AF and frailty. Our next step will be to conduct a feasibility study to assess the acceptability and effectiveness of intervention programs.

Effectiveness of a Teach-Back Education Program on Perioperative Pain in Patients With Lung Cancer: An Intervention Study Using Behavior Change Wheel

Objective:This study used the Behaviour Change Wheel (BCW) and Theoretical Domains Framework (TDF) to identify parental factors that are associated with increasing their child’s fruit and vegetable consumption. The information gathered enabled a behavioural diagnosis and the identification of intervention functions to increase fruit and vegetable consumption in children.Design:A qualitative design using open-ended online survey methodology was utilised.Setting:United Kingdom.Participants:Twenty-eight parents of primary school-aged children (4–11 years) aged 29–51 years participated.Results:Thematic and summative analysis identified skills in preparation and cooking, awareness of and desire to increase fruit and vegetable intake, knowledge of the recommendations and better health for their child as the main facilitators. The main barriers were time and financial constraints, their child’s food preferences and refusal to eat fruit and vegetables, negative role modelling from parents and grandparents and beliefs that fruit and vegetable intake will increase with age. For behaviour change to occur, ‘knowledge’, ‘social influences’, ‘environmental context and resources’, ‘beliefs about consequences’ and ‘beliefs about capabilities’ need to be altered.Conclusions:Novel findings suggest that future intervention development should focus on parental beliefs and skills around how to increase fruit and vegetable consumption as their child ages and expanding parental knowledge on the benefits of fruit and vegetable consumption such as mental and future health. The use of the TDF and BCW identified appropriate intervention functions that will guide future behaviour change techniques, modes of delivery and policy categories that best target increasing children’s fruit and vegetable consumption.