Framework For Behavior Change Research Articles

Selecting an intervention to prevent ketoacidosis at diabetes diagnosis in children using a behavior change framework.

The rate of diabetic ketoacidosis (DKA), a preventable, life-threatening complication of diabetes, at the time of diagnosis in children remains unacceptably high worldwide. We describe our initial approach to selecting a national DKA prevention strategy, to be implemented by the Canadian Pediatric Endocrine Group DKA Prevention Working Group, informed by a framework for behavior change interventions. Existing interventions were identified from a systematic review and our own gray literature search. We then characterized interventions using the Behavior Change Wheel, a framework to inform and drive behavior change, and matched interventions to behavioral targets, audiences, and identified barriers and facilitators. Feedback from the CPEG DKA prevention working group was incorporated into the intervention plan. We identified 27 interventions. Our proposed target behaviors are: (1) prompt recognition of symptoms of diabetes in children; (2) urgent attendance to medical care with a request for an office-based test for diabetes; and (3) rapid confirmation of diagnosis and urgent consultation with pediatric diabetes experts. We initially identified four possible intervention functions including education, training, environment restructuring, and enablement. Feedback from the working group favored education intervention functions including symptom recognition messages targeting parents, caregivers, teachers, and providers and messages about how to make a rapid diagnosis and need for urgent referral targeting providers. The Behavior Change Wheel has been used successfully in selecting interventions in other clinical areas. We describe how we used this framework to provide a foundation for developing an intervention to prevent DKA at diabetes diagnosis in children.

Decarbonising existing homes in Wales: a participatory behavioural systems mapping approach.

To reduce carbon emissions, urgent change is needed to high-carbon human behaviours including home energy use. Previous policy failures point to insufficient integration of systemic and behavioural approaches which are too often seen as alternative and incompatible approaches to bring about change. A novel behavioural systems mapping approach was used to inform national policy recommendations for energy-saving retrofit of homes in Wales. Three participatory workshops were held with the independent Welsh residential decarbonisation advisory group ('the Advisory Group') to: (1) map relationships between actors, behaviours and influences on behaviour within the home retrofit system; (2) provide training in the Behaviour Change Wheel (BCW) framework and (3) use these to develop policy recommendations for interventions. Recommendations were analysed using the capability, opportunity and motivation (COM-B) model of behaviour to assess whether they addressed these factors. Two behavioural systems maps (BSMs) were produced, representing privately rented and owner-occupied housing tenures. The main causal pathways and feedback loops in each map are described. Necessary interventions to achieve national-scale retrofit included: government-led investment, campaigns and awareness-building, financial-sector funding mechanisms, enforcement of regulations and creating more streamlined and trusted supply chain services. Of 27 final policy recommendations, six addressed capability, 24 opportunity and 12 motivation. Participatory behavioural systems mapping can be used in conjunction with behaviour change frameworks to develop policy recommendations that address the behavioural determinants of complex environmental problems in a systemic way. Research is underway to refine and extend the approach through application to other sustainability challenges and methods of constructing systems maps.

Barriers and enablers to access childhood cataract services across India. A qualitative study using the Theoretical Domains Framework (TDF) of behaviour change.

Early presentation for childhood cataract surgery is an important first step in preventing related visual impairment and blindness. In the absence of neonatal eye screening programmes in developing countries, the early identification of childhood cataract remains a major challenge. The primary aim of this study was to identify potential barriers to accessing childhood cataract services from the perspective of parents and carers, as a critical step towards increasing the timely uptake of cataract surgery. In-depth interviews were conducted using a pre-designed topic guide developed for this study to seek the views of parents and carers in nine geographic locations across eight states in India regarding their perceived barriers and enablers to accessing childhood cataract services. A total of 35 in-depth interviews were conducted including 30 at the hospital premises and 5 in the participants' homes. All interviews were conducted in the local language and audio taped for further transcription and analysis. Data were organised using NVivo 11 and a thematic analysis was conducted utilising the Theoretical Domains Framework (TDF), an integrative framework of behavioural theories. The themes identified from interviews related to 11 out of 12 TDF domains. TDF domains associated with barriers included: 'Environmental context and resources', 'Beliefs about consequences' and 'Social influences'. Reported enablers were identified in three theoretical domains: 'Social influences', 'Beliefs about consequences' and 'Motivations and goals'. This comprehensive TDF approach enabled us to understand parents' perceived barriers and enablers to accessing childhood cataract services, which could be targeted in future interventions to improve timely uptake.

Patient Perceptions of Physical Activity After a Diagnosis of Giant Cell Arteritis: Analysis of Multinational Qualitative Data.

To explore patient perceptions of physical activity in giant cell arteritis (GCA). This was a multinational qualitative study, analyzing interview data collected from participants from the UK (n=25) and Australia (n=11) with a definitive diagnosis of GCA from imaging or biopsy. Interview transcripts were analyzed using thematic analysis to identify themes related to physical activity. This was secondary analysis of data collected to explore health-related quality of life in people with GCA. A total of 108 individual codes pertaining to physical activity were identified. These were grouped into 2 overarching themes: barriers to and facilitators of physical activity, each with 4 subthemes. Barriers were categorized into physical symptoms (including visual loss, fatigue, weakness, pain, and stiffness), perceptions of personal capability (including poor stamina, confidence, and mobility), negative perceptions of physical activity, and negative consequences. Facilitators of physical activity were categorized into external facilitators (including motivation from health care professionals and support groups), access to appropriate facilities, personal strategies (including pacing and goal-setting), and personal facilitators (including internal motivation to improve symptoms, and positive reinforcement). A range of barriers and facilitators to physical activity were identified in relation to GCA. Future work could include development of an intervention to support physical activity in patients with GCA; ideally this intervention should be underpinned by an appropriate behavioral change framework and codesigned with patients.

Overcoming Barriers to Injectable Therapies: Development of the ORBIT Intervention Within a Behavioural Change Framework.

It is estimated among individuals with type 2 diabetes (T2D) requiring injectable therapies to achieve optimal glycaemic control, one-third are reluctant to initiate therapies, with approximately 80% choosing to discontinue or interrupt injectable regimens soon after commencement. Initiation of injectables is a complex issue, with effectiveness of such treatments undermined by non-adherence or poor engagement. Poor engagement and adherence are attributed to psychological aspects such as individuals' negative perceptions of injectables, depression, anxiety, feelings of shame, distress and perceived lack of control over their condition. The aim of this study was to describe the development of a structured diabetes intervention to address psychological barriers to injectable treatments among a cohort of those with T2D; conducted within a behavioural change framework. An evidence base was developed to inform on key psychological barriers to injectable therapies. A systematic review highlighted the need for theory-based, structured diabetes education focussed on associated psychological constructs to inform effective, patient-centric provisions to improve injectable initiation and persistence. Findings from the focus groups with individuals who had recently commenced injectable therapies, identified patient-centric barriers to initiation and persistence with injectables. Findings from the systematic review and focus groups were translated via Behavioural Change Wheel (BCW) framework to develop an intervention for people with T2D transitioning to injectable therapies: Overcoming and Removing Barriers to Injectable Treatment in T2D (ORBIT). This article describes how psychological barriers informed the intervention with these mapped onto relevant components, intervention functions and selected behaviour change techniques, and finally aligned with behaviour change techniques. This article outlines the systematic approach to intervention development within the BCW framework; guiding readers through the practical application of each stage. The use of the BCW framework has ensured the development of the intervention is theory driven, with the research able to be evaluated and validated through replication due to the clarity around processes and tasks completed at each stage.

Understanding Farmers' Behavior and Their Decision-Making Process in the Context of Cattle Diseases: A Review of Theories and Approaches.

Understanding farmers' behavior regarding disease control is essential to successfully implement behavior change interventions that improve uptake of best practices. A literature review was conducted to identify theoretical underpinnings, analytical methodologies, and key behavioral determinants that have been described to understand farmers' behavior in disease control and prevention on cattle farms. Overall, 166 peer-reviewed manuscripts from studies conducted in 27 countries were identified. In the past decade, there were increasing reports on farmers' motivators and barriers, but no indication of application of appropriate social science methods. Furthermore, the majority (58%) of reviewed studies lacked a theoretical framework in their study design. However, when a theoretical underpinning was applied, the Theory of Planned Behavior was most commonly used (14% of total). The complexity of factors impacting farmers' behavior was illustrated when mapping all described key constructs of the reviewed papers in behavior change frameworks, such as the socioecological framework and the Capability, Opportunity and Motivation Behavior (COM-B) model. Constructs related to personal influences and relationships between farmers and veterinarians were overrepresented, whereas constructs related to other interpersonal and contextual environments were not extensively studied. There was a general lack of use of validated scales to measure constructs and empirically validated theoretical frameworks to understand and predict farmers' behavior. Furthermore, studies mainly focused on measurements of intention of stakeholder behavior rather than actual behavior, although the former is a poor predictor of the latter. Finally, there is still a lack of robust evidence of behavior change interventions or techniques that result in a successful change in farmers' behavior. We concluded that for a sustainable behavior change, studies should include wider constructs at individual, interpersonal, and contextual levels. Furthermore, the use of empirically validated constructs and theoretical frameworks is encouraged. By using coherent frameworks, researchers could link constructs to design interventions, and thereby take the first step toward theory-driven, evidence-based interventions to influence farmers' behavior for disease control.

Behavior Change Interventions for Health Promotion in Physical Therapist Research and Practice: An Integrative Approach.

There is an increasing focus on health promotion in physical therapist research and practice. A clinical model (Health-Focused Physical Therapy Model) was developed for identifying major steps in the delivery of health promotion focusing on adoption of healthy lifestyle behaviors. One of the primary steps within this model is the design and delivery of behavior change interventions. Such interventions involve coordinated sets of activities that target change in a specific pattern of unhealthy behavior (eg, physical inactivity, smoking). This Perspective contends that the science and practice of behavior change interventions can be significantly advanced in the field of physical therapy (implementation science) through the integration of behavior change frameworks and techniques within the context of an experimental medicine approach for health behavior change. This perspective presents the integration of the Theoretical Domains Framework, the Behavior Change Wheel, including the Capability Opportunity Motivation-Behavior core system, and the Behavior Change Technique Taxonomy as a comprehensive approach for designing and delivering behavior change interventions in physical therapy. An experimental medicine approach is described, outlining a 4-step process in the design, delivery, and evaluation of behavior change interventions that can be applied to health promotion in physical therapist research and practice. The proposed integrative approach can advance public health and health promotion through healthy lifestyle behavior change in the field of physical therapy.

Determinants of COVID-19 Vaccine Acceptance among the Adult Population of Bangladesh Using the Health Belief Model and the Theory of Planned Behavior Model.

Vaccination is undoubtedly one of the most effective strategies to halt the COVID-19 pandemic. The current study aimed to investigate the acceptance of COVID-19 vaccination and its associated factors using two health behavior change frameworks: the Health Belief Model (HBM) and the Theory of Planned Behavior (TPB). A total of 639 Bangladeshi adults (mean age: 24 years) participated in a cross-sectional online study between July and August 2021. The questionnaire covered questions regarding vaccine intentions, sociodemographic features, health status, perceived trust in/satisfaction with health authorities, reasons for vaccine hesitancy, and factors related to the health behavior change frameworks. Hierarchical logistic regression was employed to determine associations between these predictors and vaccine acceptance. The intention to get a COVID-19 vaccination was expressed among 85% of the participants. In fully adjusted models, students and respondents with more normal body weights reported higher intentions to get vaccinated. Respondents were also more likely to seek vaccination if they reported greater levels of perceived susceptibility, benefits, and cues to action, as well as lower levels of barriers and self-efficacy. Fear of future vaccine side effects was the most common reason for COVID-19 vaccine hesitancy and was expressed by 94% of the vaccine-hesitant respondents. These factors should be considered by health authorities in Bangladesh and perhaps other countries when addressing the plateauing COVID-19 vaccination rates in many populations.

A Smartphone-Based Self-Management Intervention for Individuals with Bipolar Disorder (LiveWell): Qualitative Study on User Experiences of the Behavior Change Process.

BackgroundBipolar disorder is a severe mental illness characterized by recurrent episodes of depressed, elevated, and mixed mood states. The addition of psychotherapy to pharmacological management can decrease symptoms, lower relapse rates, and improve quality of life; however, access to psychotherapy is limited. Mental health technologies such as smartphone apps are being studied as a means to increase access to and enhance the effectiveness of adjunctive psychotherapies for bipolar disorder. Individuals with bipolar disorder find this intervention format acceptable, but our understanding of how people utilize and integrate these tools into their behavior change and maintenance processes remains limited.ObjectiveThe objective of this study was to explore how individuals with bipolar disorder perceive and utilize a smartphone intervention for health behavior change and maintenance.MethodsIndividuals with bipolar disorder were recruited via flyers placed at university-affiliated and private outpatient mental health practices to participate in a pilot study of LiveWell, a smartphone-based self-management intervention. At the end of the study, all participants completed in-depth qualitative exit interviews. The behavior change framework developed to organize the intervention design was used to deductively code behavioral targets and determinants involved in target engagement. Inductive coding was used to identify themes not captured by this framework.ResultsIn terms of behavioral targets, participants emphasized the importance of managing mood episode–related signs and symptoms. They also discussed the importance of maintaining regular routines, sleep duration, and medication adherence. Participants emphasized that receiving support from a coach as well as seeking and receiving assistance from family, friends, and providers were important for managing behavioral targets and staying well. In terms of determinants, participants stressed the important role of monitoring for their behavior change and maintenance efforts. Monitoring facilitated self-awareness and reflection, which was considered valuable for staying well. Some participants also felt that the intervention facilitated learning information necessary for managing bipolar disorder but others felt that the information provided was too basic.ConclusionsIn addition to addressing acceptability, satisfaction, and engagement, a person-based design of mental health technologies can be used to understand how people experience the impact of these technologies on their behavior change and maintenance efforts. This understanding may then be used to guide ongoing intervention development. The participants’ perceptions aligned with the intervention’s primary behavioral targets and use of a monitoring tool as a core intervention feature. Participant feedback further indicates that developing additional content and tools to address building and engaging social support may be an important avenue for improving LiveWell. A comprehensive behavior change framework to understand participant perceptions of their behavior change and maintenance efforts may help facilitate ongoing intervention development.

Using the Medical Research Council framework and public involvement in the development of a communication partner training intervention for people with primary progressive aphasia (PPA): Better Conversations with PPA

BackgroundPrimary progressive aphasia is a language-led dementia resulting in a gradual dissolution of language. Primary progressive aphasia has a significant psychosocial impact on both the person and their families. Speech and language therapy is one of the only available management options, and communication partner training interventions offer a practical approach to identify strategies to support conversation. The aim of this study was to define and refine a manual and an online training resource for speech and language therapists to deliver communication partner training to people with primary progressive aphasia and their communication partners called Better Conversations with primary progressive aphasia.MethodsThe Better Conversations with primary progressive aphasia manual and training program were developed using the Medical Research Council framework for developing complex interventions. The six-stage development process included 1. Exploratory review of existing literature including principles of applied Conversation Analysis, behaviour change theory and frameworks for chronic disease self-management, 2. Consultation and co-production over 12 meetings with the project steering group comprising representatives from key stakeholder groups, 3. Development of an initial draft, 4. Survey feedback followed by a consensus meeting using the Nominal Group Techniques with a group of speech and language therapists, 5. Two focus groups to gather opinions from people with PPA and their families were recorded, transcribed and Thematic Analysis used to examine the data, 6. Refinement.ResultsCo-production of the Better Conversations with primary progressive aphasia resulted in seven online training modules, and a manual describing four communication partner training intervention sessions with accompanying handouts. Eight important components of communication partner training were identified in the aggregation process of the Nominal Group Technique undertaken with 36 speech and language therapists, including use of video feedback to focus on strengths as well as areas of conversation breakdown. Analysis of the focus groups held with six people with primary progressive aphasia and seven family members identified three themes 1) Timing of intervention, 2) Speech and language therapists’ understanding of types of dementia, and 3) Knowing what helps. These data informed refinements to the manual including additional practice activities and useful strategies for the future.ConclusionsUsing the Medical Research Council framework to develop an intervention that is underpinned by a theoretical rationale of how communication partner training causes change allows for the key intervention components to be strengthened. Co-production of the manual and training materials ensures the intervention will meet the needs of people with primary progressive aphasia and their communication partners. Gathering further data from speech and language therapists and people living with primary progressive aphasia and their families to refine the manual and the training materials enhances the feasibility of delivering this in preparation for a phase II NHS-based randomised controlled pilot-feasibility study, currently underway.

Towards a reinforcement-sensitive multiple risk behavior change model

• Health behaviors are function of psychophysiological processes and social learning. • A behavioral taxonomy grounded in trait psychophysiology and context is proposed. • ROC analyses explain predictive accuracies of personality-behavior relationships. • Behaviors differentially conditionable by punishment- or reward-oriented messages. • A reinforcement-sensitive multiple-risk behavior change framework is advisable. The personality-behavior relationship, predictive accuracies of personality measures, and their links with behavior change require a systematic examination. Drawing on the Hippocrates-Galen-Avicennic tradition and the works of Pavlov, Skinner, Mowrer, Eysenck and Gray, this article proposes a three-dimensional behavioral typology and outlines a schema for multiple risk behavior change. It is argued that behaviors, as explained by psychophysiological processes, reinforcement-sensitive behavioral systems and social learning, shall be differentially conditionable by appropriate punishment- or reward-oriented messages. A cross-sectional survey was designed to explore the hypothesized role of psychobiological personality dimensions in smoking, alcohol-use and substance-use behaviors. Two standard personality inventories and a behavioral questionnaire were administered to a sample of college students. Descriptive, correlational, and Receiver Operating Characteristic analyses were performed. Extraversion and Psychoticism showed positive correlation with Reward-sensitivity but inversely correlated with Neuroticism and Punishment-sensitivity. High Extraversion and high Psychoticism scorers, thereby Indulgent and Delinquent Behaviors, were more likely to show appetitive associations. Psychobiological personality measures that reliably classified target groups with an area under the curve greater than 0.70 included Extraversion for heavy smoking, drinking and regular drinking, Psychoticism for heavy smoking, regular drinking, substance-use and heavy substance-use, and Reward-sensitivity for heavy smoking, substance-use and heavy substance-use. The findings have validated part of the posited behavior change model, as tested. Psychobiological personality measures indicated reasonable discriminative abilities and potential use in evaluating problem behaviors in individuals and groups, notwithstanding the value of mixed assessments and data integration. The next step is to investigate a wider mix of behaviors and test effectiveness of reinforcement-oriented message interventions in multiple risk behavior change which will have implications for health communication and social marketing.

Descriptive contents analysis of ParticiPAte CP: a participation-focused intervention to promote physical activity participation in children with cerebral palsy

Purpose ParticiPAte CP is a participation-focused therapy intervention that is effective to increase perceived performance of physical activity (PA) participation goals in children with cerebral palsy (CP). We aimed to characterise the contents of ParticiPAte CP using validated behaviour change frameworks. Materials and methods Data came from physiotherapist treatment notes and were used to specify: (1) physiotherapist-perceived barriers to behaviour change (using the International Classification of Functioning, Disability and Health Framework [ICF] and Theoretical Domains Framework), intervention content (Behaviour Change Technique Taxonomy v1), intervention functions (Behaviour Change Wheel) and mechanisms of action (Capability, Opportunity, Motivation – Behaviour model). Results Physiotherapist-perceived barriers to participation were identified in all ICF and Theoretical Domains Framework domains. ParticiPAte CP consisted of 32 behaviour change techniques, delivered via six intervention functions of the Behaviour Change Wheel, especially enablement. All six possible mechanisms of action were identified according to the Capability, Opportunity, Motivation – Behaviour model. These were targeted most frequently through Theoretical Domains Framework domains social influences, environmental context and resources, intentions, skills, knowledge, and beliefs about capabilities. Conclusions The content of a PA intervention for children with CP can be specified according to behaviour change frameworks. ParticiPAte CP was complex, with multiple targets, constituent behaviour change techniques and mechanisms of action. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12615001064594. Implications for rehabilitation Providing social support to families through practical actions such as motivating conversation, providing information, linking families to community services and participating in activities with children to support their self-efficacy may be a defining feature of effective participation-focused therapies. If children with cerebral palsy (CP) and their families nominate goals for increased frequency of attendance or improved involvement in physical activities (PAs), therapists must identify all important barriers to participation, including behavioural barriers that may be thought of less often (e.g. emotions, beliefs, optimism etc.). Promoting PA participation in children with CP may require a complex or multi-faceted therapy intervention that supports not only physical capability, but also enhances the social and physical opportunity for participation to take place and promotes the psychological capability and motivation for PA of children and families. Therapists or researchers may consider using the Behaviour Change Wheel to prospectively design their own health behaviour intervention for children with CP.

Exploring the Effect of Rational Factors and Trust in Health Behavior Change

AbstractThis study examines how rational factors and trust modify health behaviors and various stages of trust mediate the rational factors in behavior changing through four stages of it. By integrating factors of Theory of Planned Behavior (TPB) and various stages of trust, a health behavior change framework was proposed. Quantitative data on TPB, trust and behavior change were collected from Chinese youths through online survey. Structural Equation Model (SEM) was applied to analyze the data from 448 valid questionnaires to verify it. The findings show: Both TPB and trust constructs have significant impacts on modifying health behavior change; Trust mediates the effect of perceived behavioral control on health behavior change, while the stages of site content evaluation and longer‐term engagement of trust act as partial mediators; Relationships existed between TPB factors and trust stages. This study advances the understanding of health behavior change with regards to rational factors and trust stages and provides implications for stakeholders.

Nudging toward vaccination: a systematic review

BackgroundVaccine hesitancy (VH) and the global decline of vaccine coverage are a major global health threat, and novel approaches for increasing vaccine confidence and uptake are urgently needed. ‘Nudging’, defined...

117A digital resource for enhancing parental health literacy during the transition to parenthood

Abstract Background While the transition to parenthood is critical for mother-child health, traditional antenatal education has been questioned. Digital resources provide opportunities for reducing social disparities and enhancing health literacy, particularly important in a medicalized and decentralized birth environment with high caesarean and low breastfeed rates. Methods Within a Participatory Action Research (PAR) framework, formative qualitative and quantitative methods were employed to assess the cross-national transferability of Baby Buddy (UK), and deliver a locally relevant resource to inform, enhance user-provider communications and support shared decision-making. Results Using consensus-building and priority-setting techniques, we engaged with the local health professional community and parents-to-be to assess available resources, identify gaps and priorities in an eDelphi survey (N = 275 mums, 193 professionals) and gain an in-depth understanding on information-seeking behaviours and participation in decision-making in a series of focus groups with antenatal educators (N = 20) and new mums/ mums-to-be (N = 62). New material was co-created with participants and an intervention for embedding the tool in clinical practice was proposed within the COM-B behavioural change framework. Conclusions The project is a “proof of concept” for exchange of innovation and a “complimentary” model of maternal healthcare delivery. Beyond a learning experience for the participants, the use of PAR provided ground for building transdisciplinary alliances. Key messages Other than enhancing health literacy, digital resources can support the educational role of health professionals PAR provides a framework to engage with the community, building a sense of common purpose

Formative research to design an implementation strategy for a postpartum hemorrhage initial response treatment bundle (E-MOTIVE): study protocol

BackgroundPostpartum hemorrhage (PPH) is the leading cause of maternal death worldwide. When PPH occurs, early identification of bleeding and prompt management using evidence-based guidelines, can avert most PPH-related severe morbidities and deaths. However, adherence to the World Health Organization recommended practices remains a critical challenge. A potential solution to inefficient and inconsistent implementation of evidence-based practices is the application of a ‘clinical care bundle’ for PPH management. A clinical care bundle is a set of discrete, evidence-based interventions, administered concurrently, or in rapid succession, to every eligible person, along with teamwork, communication, and cooperation. Once triggered, all bundle components must be delivered. The E-MOTIVE project aims to improve the detection and first response management of PPH through the implementation of the “E-MOTIVE” bundle, which consists of (1) Early PPH detection using a calibrated drape, (2) uterine Massage, (3) Oxytocic drugs, (4) Tranexamic acid, (5) Intra Venous fluids, and (6) genital tract Examination and escalation when necessary. The objective of this paper is to describe the protocol for the formative phase of the E-MOTIVE project, which aims to design an implementation strategy to support the uptake of this bundle into practice.MethodsWe will use behavior change and implementation science frameworks [e.g. capability, opportunity, motivation and behavior (COM-B) and theoretical domains framework (TDF)] to guide data collection and analysis, in Kenya, Nigeria, South Africa, Sri Lanka, and Tanzania. There are four methodological components: qualitative interviews; surveys; systematic reviews; and design workshops. We will triangulate findings across data sources, participant groups, and countries to explore factors influencing current PPH detection and management, and potentially influencing E-MOTIVE bundle implementation. We will use these findings to develop potential strategies to improve implementation, which will be discussed and agreed with key stakeholders from each country in intervention design workshops.DiscussionThis formative protocol outlines our strategy for the systematic development of the E-MOTIVE implementation strategy. This focus on implementation considers what it would take to support roll-out and implementation of the E-MOTIVE bundle. Our approach therefore aims to maximize internal validity in the trial alongside future scalability, and implementation of the E-MOTIVE bundle in routine practice, if proven to be effective.Trial registration: ClinicalTrials.gov: NCT04341662

Barriers to implementing asthma self-management in Malaysian primary care: qualitative study exploring the perspectives of healthcare professionals

Asthma self-management is a crucial component of asthma management. We sought to explore healthcare professionals’ (HCPs’) perceptions on barriers to asthma self-management implementation in primary care. We recruited 26 HCPs from six public primary care clinics in a semi-urban district of Malaysia in 2019. The analysis was done inductively. HCPs described barriers that resonated with the “COM-B” behaviour change framework. Capability-related issues stemmed from a need for specific self-management skills training. Opportunity-related barriers included the need to balance competing tasks and limited, poorly tailored resources. Motivation-related barriers included lack of awareness about self-management benefits, which was not prioritised in consultations with perceived lack of receptiveness from patients. These were compounded by contextual barriers of the healthcare organisation and multilingual society. The approach to implementation of asthma self-management needs to be comprehensive, addressing systemic, professional, and patient barriers and tailored to the local language, health literacy, and societal context.

Surgery school\u2014who, what, when, and how: results of a national survey of multidisciplinary teams delivering group preoperative education

BackgroundGroup education is increasing in popularity as a means of preparing patients for surgery. In recent years, these ‘surgery schools’ have evolved from primarily informing patients of what to expect before and after surgery, to providing support and encouragement for patients to ‘prehabilitate’ prior to surgery, through improving physical fitness, nutrition and emotional wellbeing.MethodA survey aimed at clinicians delivering surgery schools was employed to capture a national overview of activity to establish research and practice priorities in this area. The survey was circulated online via the Enhanced Recovery after Surgery UK Society and the Centre for Perioperative Care mailing lists as well as social media.ResultsThere were 80 responses describing 28 active and 4 planned surgery schools across the UK and Ireland. Schools were designed and delivered by multidisciplinary teams, contained broadly similar content and were well attended. Most were funded by the National Health Service. The majority included aspects of prehabilitation most commonly the importance of physical fitness. Seventy five percent of teams collected patient outcome data, but less than half collected data to establish the clinical effectiveness of the school. Few describe explicit inclusion of evidence-based behavior change techniques, but collaboration and partnerships with community teams, gyms and local charities were considered important in supporting patients to make changes in health behaviors prior to surgery.ConclusionIt is recommended that teams work with patients when designing surgery schools and use evidence-based behavior change frameworks and techniques to inform their content. There is a need for high-quality research studies to determine the clinical effectiveness of this type of education intervention.

Exploring the Perceived Barriers and Benefits of Physical Activity Among Wounded, Injured, and/or Sick Military Veterans

Wounded, injured, and/or sick (WIS) military veterans face significant physical and psychosocial challenges following discharge from service. Physical activity can have many positive effects on the holistic wellbeing of such individuals. However, little knowledge exists regarding the perceived barriers and benefits of physical activity within this population, creating challenges surrounding physical activity promotion. Therefore, this study was designed to identify key barriers and benefits among this population, so that informed approaches to encourage participation in physical activity can be developed. A questionnaire related to the perceived barriers and benefits of physical activity was completed by 105 WIS British military veterans. Participants were predominantly male, physically active, served in the British Army, and described their injury as frequently impacting their daily living. Factor analysis revealed that poor mental health, negative beliefs about physical activity, and low beliefs about physical capability were prominent barriers represented in the data. However, only veterans’ beliefs about their physical capability were related to physical activity levels and differed between active and insufficiently active participants. Beliefs identified as benefits of physical activity that correlated with physical activity levels were improved mental and physical health, a sense of purpose, and increased physical fitness. Subsequently, barriers and benefits were categorized using the Behaviour Change Wheel, a behavior change framework, that indicated intervention functions of education, incentivization, and persuasion might be effective methods of increasing physical activity behavior among WIS veterans. Ultimately, this will lead to greater engagement with physical activity and improved health and wellbeing within this population.

Children's Experiences of Their Journey to School: Integrating Behaviour Change Frameworks to Inform the Role of the Built Environment in Active School Travel Promotion.

Childhood obesity is a public health problem with multiple effects on children’s life. Promoting Active School Travel (AST) could provide an inclusive opportunity for physical activity and shape healthy behaviours. Data for this cross-sectional study were drawn from questionnaires carried out in five primary schools located in Newcastle upon Tyne, UK, in neighbourhoods chosen for their variability in IMD (index of multiple deprivation) and spatial structure of street networks (measured through space syntax measure of integration). A randomly selected and heterogenic sample of 145 pupils (aged 9–10) completed an open-ended questionnaire to state what they like and dislike about their journey to school. Thematic analysis identified four typologies (environmental context, emotions, social influences and trip factors) based on the Theoretical Domains Framework (TDF) and specific themes and sub-themes underlying children’s affective experiences of their journeys to school. This study is the first known to authors to attempt to adapt the Capability, Opportunity and Motivation Behaviour (COM-B) model into AST and children’s experiences and associated behavioural domains with design aspects. Such an insight into children’s attitudes could inform urban planners and designers about how to apply more effective behaviour change interventions, targeting an AST increase among children.