Framework For Behavior Change Research Articles

Barriers and enablers to bowel cancer screening participation in remote Tasmania: A qualitative study using the theoretical domains framework.

Identify barriers and enablers for remote Tasmanians participating in bowel cancer screening through the National Bowel Cancer Screening Program. A small remote Tasmanian community. Tasmanian remote community members aged 50 years and over. A qualitative study conducted 16 semi-structured interviews. Two researchers conducted in-person and telephone interviews. Questions were directed by an interview guide developed using the Theoretical Domains Framework for behaviour change and Behaviour Change Wheel. Two researchers analysed data using directed content analysis with a flexible inductive approach. Four themes related to barriers and enablers to completing the National Bowel Cancer Screening Program screening kit in remote Tasmania. Themes included the subject of screening, physical screening kit, the process and outcome of the kit. Several barrier and enabler sub-themes overlapped or were linked, as many enablers mitigated barriers. For example, social influences, awareness level, steps in completing screening, and planning and timing to screen. Social support and discussing screening with others were key enablers, whereas lack of these were barriers. For remote communities, taking the kit to the post office was a barrier from often knowing the post officer. A bowel bus providing screening and information support services may reduce the travel burden of follow-up diagnostic tests and support low-literacy individuals to screen. Barriers and enablers exist within each stage of the screening process, from what influences an individual decision to screen, through to the outcome. To improve screening rates in rural/remote Tasmania, barriers and enablers to screening must be considered.

An approach to persons who are not willing to engage in behavioural change.

With its unique position, primary health care (PHC) can provide health promotion and prevention services, including lifestyle behavioural counselling. Unhealthy lifestyle behaviours are very prevalent among patients attending PHC, with many patients unwilling to change or in the precontemplation stage. While patients in the contemplation stage are better managed using the 5As approach of motivational interviewing counselling, those unwilling or not ready for change necessitate a different approach, such as the 5Rs of motivational interviewing (MI) counselling. The 5Rs MI approach holds promise in motivating unwilling individuals to consider embarking on the journey of behavioural change. The 5Rs approach is not a stand-alone checklist of tasks implemented in isolation but is best integrated within a theoretical behavioural change framework. Of the four health-related behavioural change theoretical frameworks that are frequently used, the transtheoretical stages of the change model are the most used. This continued professional development article provides a summary review of the literature on behavioural change theories as they apply to lifestyle health behaviour change and presents the 5Rs approach as a feasible and practical approach to manage patients who are unwilling to change or in the precontemplation stage. This offers a beacon of hope for improved patient outcomes in a PHC system saddled with high prevalence of modifiable unhealthy lifestyle behaviours.

Identifying barriers and facilitators to follow-up after endovascular aortic repair (EVAR): Qualitative study design and protocol

Endovascular aortic repair (EVAR) is now first line therapy for most patients with abdominal aortic aneurysms (AAA) as it reduces perioperative morbidity and mortality compared to open surgery. However, up to 40 % of patients do not undergo recommended follow-up, increasing risk of subsequent rupture. Risk factors for loss to follow-up have been studied retrospectively, however, qualitative studies assessing perceived barriers and facilitators to follow-up have not been performed and there are few qualitative protocols within the vascular surgery literature. This article presents a qualitative descriptive study protocol aimed at understanding and improving post-operative follow-up adherence after EVAR developed through an iterative process based on the Theoretical Domains Framework of behavior change. Steps include:•Selection of target behavior and study design•Development of study materials, sampling/recruitment strategy, and data collection•Qualitative data analysis and reporting findingsWe demonstrate the feasibility of this study by pilot testing of the semi-structured interview guides on a small group of patients, healthcare providers, and key personnel. This protocol aims to describe key stakeholder experiences within the healthcare system that will ultimately serve as the basis for future multi-institutional research piloting intervention strategies to improve EVAR follow-up.

Barriers and facilitators to using a clinical decision support tool for the management of osteoarthritis pain in patients undergoing hemodialysis: a qualitative study

BackgroundWhile osteoarthritis is a significant issue within the hemodialysis population and contributes to reduced quality of life, pain related to osteoarthritis is poorly managed by healthcare professionals (HCPs) in hemodialysis settings due to the absence of clinical guidance applicable to this population. The purpose of this study was to explore the perceptions of HCPs on the barriers and facilitators to using a clinical decision support tool for osteoarthritis pain management in the hemodialysis setting.MethodsA qualitative descriptive study was conducted. Purposeful and snowball sampling techniques were used to recruit hemodialysis clinicians from academic and community settings across multiple Canadian provinces. One-to-one interviews were conducted with clinicians using a semi-structured, open ended interview guide informed by the Theoretical Domains Framework, a behavior change framework. A general inductive approach was applied to identify the main themes of barriers and facilitators.ResultsA total of 11 interviews were completed with 3 nephrologists, 2 nurse practitioners and 6 pharmacists. Findings revealed 6 main barriers and facilitators related to the use of the clinical decision support tool. Alignment of the tool with practice roles emerged as a key barrier and facilitator. Other barriers included challenges related to the dialysis environment, varying levels of clinician comfort with pain medications, and limited applicability of the tool due to patient factors. An important facilitator was the intrinsic motivation among clinicians to use the tool.ConclusionsMost participants across the included hemodialysis settings expressed satisfaction with the clinical decision support tool and acknowledged its overall potential for improving osteoarthritis pain management among patients on hemodialysis. Future implementation of the tool may be limited by existing roles and practices at different institutions. Increased collaboration among hemodialysis and primary care teams may promote uptake of the tool.

Eliciting Clinician Perspectives on Asymptomatic Bacteriuria to Identify Targets for Antimicrobial Stewardship Education and Decision Support.

The aim of this study was to elicit clinicians' perspectives to help reduce antibiotic prescribing for asymptomatic bacteriuria and improve a patient-centered educational brochure for older adults with urinary tract infections or asymptomatic bacteriuria. Between October 2023 and April 2024, we conducted semi-structured qualitative interviews of clinicians who treat patients aged ≥65 years for urinary tract infections or bacteria in the urine, at infectious disease clinics, community senior living facilities, memory care clinics, and general practice. We developed an interview guide based on a behavior change framework and thematically analyzed written transcripts of audio-recorded interviews using inductive and deductive coding techniques. We identified several common themes surrounding management of asymptomatic bacteriuria from clinicians. These included an emphasis on ordering and interpreting urine tests, tension between guidelines and individual patient care for older adults, use of epidemiologic data to influence prescribing practices, pre-prepared communication talking points, and interest in educational materials for patients and clinical teams. Education about the need for symptoms to supplement urine testing, data about the impact of overuse of antibiotics, and oral and written communication strategies should be addressed to reduce antibiotic prescribing for asymptomatic bacteriuria.

Effectiveness of behaviour change interventions to reduce the risk of faecal contamination in urban irrigated vegetable value chains – applying the COM-B behavioural framework

ABSTRACT In low- and middle-income countries, inadequate sanitation results in faecal contamination of the water used by urban farmers for irrigation. Consumers of raw contaminated vegetables run the risk of developing diarrhoeal diseases and helminth infections, which are a leading cause of under-five mortality and impact the well-being and productivity of millions of adults. This review identifies the evidence base for assessing which factors determine the success and/or failure of interventions that aim to manage the risk of faecal contamination in the urban irrigated vegetable value chain. We carried out a systematic search of the literature from the perspective of the COM-B behaviour framework (Capability + Opportunity + Motivation = Behaviour). Our results reveal that most interventions address stakeholders’ opportunity or capability to adopt safe practices without adequately considering their motivation. Interventions often focus on one sector rather than on the whole value chain (sanitation, agriculture, trade, consumption). To effectively change hygiene and food safety practices in the urban irrigated vegetable value chain, stakeholders’ intrinsic motivations need to be identified. Where WHO's multi-barrier approach is the best option, we recommend building on local multistakeholder platforms and adopting a behaviour change framework to support the largely technical change from farm to fork.

Developing the PEAK mood, mind, and marks program to support university students’ mental and cognitive health through physical exercise: a qualitative study using the Behaviour Change Wheel

BackgroundConcerns about mental and cognitive health are common among university students. Engaging in regular physical exercise has been shown to enhance both mental health and cognitive performance, yet most students are not participating in the level of exercise required to obtain these benefits. The Behaviour Change Wheel (BCW) provides a framework for developing behavioural interventions that are informed by theory, evidence, and stakeholder perspectives. The current study aimed to apply the BCW to develop the PEAK Mood, Mind, and Marks program (i.e., PEAK), a behaviour change intervention designed to increase university students’ exercise engagement for the benefit of their mental and cognitive health.MethodsPEAK was developed across three stages of the BCW: (1) understand the target behaviour, (2) identify intervention options, and (3) identify intervention content and delivery mode. Development was informed by triangulated data from a systematic literature review, co-design consultations with key stakeholders, and knowledge of relevant experts. Consultations with stakeholders involved focus groups with 25 university students and individual interviews with 10 university leaders and staff to identify barriers and facilitators to students’ exercise engagement and the adoption and implementation of PEAK by universities. Template analysis was used to code transcripts to the capability, opportunity, and motivation (COM-B) model of behaviour. The BCW was applied to identify the most appropriate intervention types and behaviour change techniques (BCTs).ResultsThirty-one barriers and facilitators were identified and mapped to seven intervention types (Education; Modelling; Persuasion; Environmental Restructuring; Incentivisation; Training; and Enablement) and 26 BCTs, which were delivered across digital channels and in-person. The final intervention consisted of multiple components targeting students’ capability (e.g., increasing knowledge about the mental and cognitive health benefits of exercise), opportunity (e.g., providing a flexible range of accessible exercise options and social support), and motivation (e.g., increasing the perceived importance of exercise) to exercise.ConclusionsUniversity students and staff describe a need and appetite for more empowering, scalable solutions to support students’ mental and cognitive health. Exercise-based approaches that are informed by behaviour change frameworks, evidence, and stakeholder perspectives, such as PEAK, have the potential to address this need. Current findings will inform a pilot of PEAK to evaluate its efficacy and implementation.

Nudging in organizations: How to avoid behavioral interventions being just a façade

The utilization of nudging—behavioral interventions aimed at influencing the actions of employees or clients—has gained traction in organizations due to its perceived universal efficacy and cost-effectiveness. However, this paper presents a critical view, arguing that the success of a nudge is significantly influenced by a specific context, challenging the notion of it being a universal solution for organizational behavior modification. This paper highlights three primary concerns: the absence of a comprehensive behavioral change framework; an overemphasis on immediate effects and ad hoc successes at the expense of changing deep-seated motivations, decision-making capabilities, or organizational processes; and a tendency among managers to rely on anecdotal beliefs rather than robust evidence. The paper offers a framework for understanding these challenges and proposes organizational policies (training of managers and continuous organizational experimentation) to implement effective nudging strategies. This framework’s validity is supported by evidence from semi-structured interviews and focus group with industry professionals.

Factors influencing central nervous system medication deprescribing and behavior change in hospitalized older adults.

Central nervous system (CNS) medications are linked to higher morbidity and mortality in older adults. Hospitalization allows for deprescribing opportunities. This qualitative study investigates clinician and patient perspectives on CNS medication deprescribing during hospitalization using a behavioral change framework, aiming to inform interventions and identify recommendations to enhance hospital deprescribing processes. This qualitative study focused on hospitalists, primary care providers, pharmacists, and patients aged ≥60 years hospitalized on a general medicine service and prescribed ≥1 CNS medications. Using semi-structured interviews and focus groups, we aimed to evaluate patient medication knowledge, prior deprescribing experiences, and decision-making preferences, as well as provider processes and tools for medication evaluation and deprescribing. Rapid qualitative analysis applying the Capability, Opportunity, Motivation, and Behavior (COM-B) framework revealed themes influencing deprescribing behavior in patients and providers. A total of 52 participants (20 patients and 32 providers) identified facilitators and barriers across deprescribing steps and generated recommended strategies to address them. Clinicians and patients highlighted the opportunity for CNS medication deprescribing during hospitalizations, facilitated by multidisciplinary teams enhancing clinicians' capability to make medication changes. Both groups also stressed the importance of intensive patient engagement, education, and monitoring during hospitalizations, acknowledging challenges in timing and extent of deprescribing, with some patients preferring decisions deferred to outpatient clinicians. Hospitalist and pharmacist recommendations centered on early pharmacist involvement for medication reconciliation, expanding pharmacy consultation and clinician education on deprescribing, whereas patients recommended enhancing shared decision-making through patient education on medication adverse effects, tapering plans, and alternatives. Hospitalists and PCPs also emphasized standardized discharge instructions and transitional care calls to improve medication review and feedback during care transitions. Clinicians and patients highlighted the potential advantages of hospital interventions for CNS medication deprescribing, emphasizing the necessity of addressing communication, education, and coordination challenges between inpatient and outpatient settings.

A new communication approach to encourage lung cancer screening action in rural eligible populations

ObjectiveThe purpose of this study was to develop an effective communication approach to encourage lung cancer screening action within rural screening-eligible populations. MethodsAn iterative research approach using targeted engagement with the priority population was used. Findings were triangulated through multiple methods, including two surveys and concept testing interviews. The Health Belief Model and the Extended Parallel Process Model served as study frameworks. ResultsInitial findings suggest that threat levels are high in the priority population and an emphasis on barrier mitigation messaging may drive action. Health campaign posters integrating these findings were developed and tested with the priority population. The new health campaign posters were tested against examples of previously used health campaign posters. Findings suggest that the new health campaign posters were more effective in spurring lung cancer screening motivation and intention to act in the priority population compared to current health campaign poster examples. ConclusionMessaging focused on gain-framing, inoculation messaging, and barrier mitigation may be more effective in encouraging lung cancer screening action in rural eligible populations. InnovationThis project outlines a systematic process to developing effective, targeted communication approaches using behavior change and persuasive communication frameworks along with engagement from priority populations.

Theoretical models applied to understand infection prevention and control practices of healthcare workers during the COVID-19 pandemic: A systematic review

Background Effective infection prevention and control (IPC) practices among healthcare workers are crucial to prevent the spread of COVID-19 and other infections in healthcare settings. Aim To synthesise evidence on behaviour change theories, models, or frameworks applied to understand healthcare workers’ IPC practices during the COVID-19 pandemic. Methods PubMed, EBSCOhost interface, ProQuest interface, MEDLINE (Ovid), and grey literature were searched for primary studies published between December 2019 and May 2023. The Mixed Method Appraisal Tool evaluated the methodological quality of the studies. Two reviewers independently completed study selection, data extraction, and quality assessment. Results The search yielded 2110 studies, of which 19 were included. Seven behaviour change theories, models, and frameworks were identified, with the Health Belief Model and Theoretical Domains Framework being the most employed. Based on these theories, models, and frameworks, the included studies identified cognitive, environmental, and social factors influencing healthcare workers’ compliance with COVID-19 IPC practices. Discussion This review offers insights into the critical role of behavioural change theories, models, or frameworks in understanding the factors influencing healthcare workers’ compliance with IPC practices during COVID-19. It also highlights the potential of these theories in guiding the development of evidence-based interventions to improve healthcare workers’ compliance with IPC practices.

BARRIERS AND ENABLERS TO EXERCISE ADHERENCE IN PEOPLE WITH CHRONIC LOW BACK PAIN: A SYSTEMATIC REVIEW OF QUALITATIVE EVIDENCE

INTRODUCTION Exercise is a first line treatment for chronic low back pain, reducing pain and disability in the short-term. However, exercise benefits decrease over time, with a lack of long-term exercise adherence a potential reason for this. This study aimed to synthesize the perceptions and beliefs of individuals with chronic low back pain and identify their barriers and enablers to exercise adherence. METHODS We searched CENTRAL, EMBASE, CINAHL, SPORTDiscus, PubMed, PsycINFO, CINAHL, and Scopus databases from inception to 28th February 2023 for qualitative studies that explored the factors influencing exercise adherence for people with chronic low back pain. A hybrid approach combining inductive analysis using thematic synthesis and a deductive analysis, which included the Theoretical Domains Framework of behaviour change was used to analyse data. We assessed methodological quality using the Critical Appraisal Skills Programme checklist and the level of confidence of the themes found using the Confidence in the Evidence from Reviews of Qualitative Studies (GRADE-CERQual). RESULTS Twenty-three papers (n=21 studies) were included (n=478 participants). Four main themes impacted exercise adherence: 1) exercise, pain, and the body, 2) psychological factors, 3) social factors and 4) external factors. These themes contained 16 subthemes that were predominantly both barriers and enablers to exercise adherence. There was moderate to high confidence across the findings. CONCLUSION Our analysis found that individual’s experiences of barriers and enablers were most appropriately represented across a spectrum, where influencing factors could be a barrier or enabler to exercise adherence. Barriers and enablers were also found to be specific to pre-exercise, during exercise and post-exercise situations. This may lead to an improved and targeted approach to increasing exercise adherence. Further research is required to develop interventions that can use these findings for a more personalised and patient centred approach to treatment.

Factors influencing the participation of pregnant and lactating women in clinical trials: A mixed-methods systematic review.

Poor representation of pregnant and lactating women and people in clinical trials has marginalised their health concerns and denied the maternal-fetal/infant dyad benefits of innovation in therapeutic research and development. This mixed-methods systematic review synthesised factors affecting the participation of pregnant and lactating women in clinical trials, across all levels of the research ecosystem. We searched 8 databases from inception to 14 February 2024 to identify qualitative, quantitative, and mixed-methods studies that described factors affecting participation of pregnant and lactating women in vaccine and therapeutic clinical trials in any setting. We used thematic synthesis to analyse the qualitative literature and assessed confidence in each qualitative review finding using the GRADE-CERQual approach. We compared quantitative data against the thematic synthesis findings to assess areas of convergence or divergence. We mapped review findings to the Theoretical Domains Framework (TDF) and Capability, Opportunity, and Motivation Model of Behaviour (COM-B) to inform future development of behaviour change strategies. We included 60 papers from 27 countries. We grouped 24 review findings under 5 overarching themes: (a) interplay between perceived risks and benefits of participation in women's decision-making; (b) engagement between women and the medical and research ecosystems; (c) gender norms and decision-making autonomy; (d) factors affecting clinical trial recruitment; and (e) upstream factors in the research ecosystem. Women's willingness to participate in trials was affected by: perceived risk of the health condition weighed against an intervention's risks and benefits, therapeutic optimism, intervention acceptability, expectations of receiving higher quality care in a trial, altruistic motivations, intimate relationship dynamics, and power and trust in medicine and research. Health workers supported women's participation in trials when they perceived clinical equipoise, had hope for novel therapeutic applications, and were convinced an intervention was safe. For research staff, developing reciprocal relationships with health workers, having access to resources for trial implementation, ensuring the trial was visible to potential participants and health workers, implementing a woman-centred approach when communicating with potential participants, and emotional orientations towards the trial were factors perceived to affect recruitment. For study investigators and ethics committees, the complexities and subjectivities in risk assessments and trial design, and limited funding of such trials contributed to their reluctance in leading and approving such trials. All included studies focused on factors affecting participation of cisgender pregnant women in clinical trials; future research should consider other pregnancy-capable populations, including transgender and nonbinary people. This systematic review highlights diverse factors across multiple levels and stakeholders affecting the participation of pregnant and lactating women in clinical trials. By linking identified factors to frameworks of behaviour change, we have developed theoretically informed strategies that can help optimise pregnant and lactating women's engagement, participation, and trust in such trials.

A behaviour change intervention to reduce sedentary behaviour in chronic obstructive pulmonary disease: a qualitative study

ObjectivesTo document the experiences of people with chronic obstructive pulmonary disease (COPD) who underwent a behaviour change intervention to reduce sedentary behaviour (SB) in a clinical trial. Design and participantsQualitative study using semi-structured interviews to explore perspectives of the behaviour change intervention and specific intervention components in people with stable COPD on the waitlist for pulmonary rehabilitation. SettingThree outpatient pulmonary rehabilitation programmes in Sydney, Australia. InterventionsThe six-week behaviour change intervention with once weekly contact with a physiotherapist aimed to reduce SB by replacing it with light-intensity physical activity (PA) and by breaking up prolonged SB. Main outcome measuresOf 30 participants who completed the behaviour change intervention, interviews were conducted with 13 participants and analysed using the ‘capability, opportunity, motivation, behaviour (COM-B)’ framework of behaviour change. ResultsIntervention components regarded as most helpful by participants were verbal education on health consequences on SB, goal setting, and self-monitoring of, and feedback on, step count using activity trackers. There was a clear preference during goal setting to increase PA rather than to reduce SB. Physical limitations and enjoyment of SB were the most reported barriers to reducing SB. ConclusionsGoal setting, verbal education, and self-monitoring of, and feedback on step count, were viewed positively by people with COPD and may show promise for reducing SB and increasing PA based on individual preference. Contribution of the paper•When given the choice, most people with stable COPD undergoing a behaviour change intervention preferred to increase their physical activity levels rather than reduce sedentary behaviour, which challenges previous assumptions that reducing sedentary behaviour is more feasible for people with COPD than increasing physical activity.•The behaviour change intervention improved the confidence and motivation of people with stable COPD to reduce their sedentary behaviour but did not alter their physical limitations or enjoyment of sedentary behaviour, which were perceived as barriers to change.•Goal setting, verbal education, and self-monitoring of, and feedback on, step count using activity trackers were identified as the most helpful strategies for changing sedentary behaviour and physical activity in people with stable COPD.

Behavior Change Approaches in Digital Technology-Based Physical Rehabilitation Interventions Following Stroke: Scoping Review.

Digital health technologies (DHTs) are increasingly used in physical stroke rehabilitation to support individuals in successfully engaging with the frequent, intensive, and lengthy activities required to optimize recovery. Despite this, little is known about behavior change within these interventions. This scoping review aimed to identify if and how behavior change approaches (ie, theories, models, frameworks, and techniques to influence behavior) are incorporated within physical stroke rehabilitation interventions that include a DHT. Databases (Embase, MEDLINE, PsycINFO, CINAHL, Cochrane Library, and AMED) were searched using keywords relating to behavior change, DHT, physical rehabilitation, and stroke. The results were independently screened by 2 reviewers. Sources were included if they reported a completed primary research study in which a behavior change approach could be identified within a physical stroke rehabilitation intervention that included a DHT. Data, including the study design, DHT used, and behavior change approaches, were charted. Specific behavior change techniques were coded to the behavior change technique taxonomy version 1 (BCTTv1). From a total of 1973 identified sources, 103 (5%) studies were included for data charting. The most common reason for exclusion at full-text screening was the absence of an explicit approach to behavior change (165/245, 67%). Almost half (45/103, 44%) of the included studies were described as pilot or feasibility studies. Virtual reality was the most frequently identified DHT type (58/103, 56%), and almost two-thirds (65/103, 63%) of studies focused on upper limb rehabilitation. Only a limited number of studies (18/103, 17%) included a theory, model, or framework for behavior change. The most frequently used BCTTv1 clusters were feedback and monitoring (88/103, 85%), reward and threat (56/103, 54%), goals and planning (33/103, 32%), and shaping knowledge (33/103, 32%). Relationships between feedback and monitoring and reward and threat were identified using a relationship map, with prominent use of both of these clusters in interventions that included virtual reality. Despite an assumption that DHTs can promote engagement in rehabilitation, this scoping review demonstrates that very few studies of physical stroke rehabilitation that include a DHT overtly used any form of behavior change approach. From those studies that did consider behavior change, most did not report a robust underpinning theory. Future development and research need to explicitly articulate how including DHTs within an intervention may support the behavior change required for optimal engagement in physical rehabilitation following stroke, as well as establish their effectiveness. This understanding is likely to support the realization of the transformative potential of DHTs in stroke rehabilitation.

Using the Transtheoretical Model of Behavior Change to Explore Forest Landowner Perspectives on Water Quality

Family forest owners (FFOs) are critical stakeholders in ensuring many conservation outcomes, including improved water quality. In the highly forested Lake Champlain basin of Vermont, FFOs likely play a particularly important role in addressing water quality impairment. This study focused on FFOs’ thinking and decision-making around management practices on their land. Based on a dataset of 28 interviews collected using a semi-structured interview approach, the interviews were qualitatively coded and analyzed using the Transtheoretical Model of behavior change (TTM) framework. Our findings suggest that interviewed landowners were concerned about basin water quality but generally not aware of the connection between watershed health and actions taken on their particular forest parcel. We further describe how three TTM Processes of Change (helping relationships, consciousness raising, and environmental re-evaluation) may influence landowners’ decisions to manage their forests with water quality in mind. Our results suggest pathways for the design and targeting of behavioral change interventions based on the TTM that should inform landowner outreach as well as further research.

Adherence and eating experiences differ between participants following a flexitarian or vegetarian diet in a 10-week randomised dietary intervention trial

Flexitarian, vegetarian and vegan diets are increasingly popular, particularly amongst young adults. This is the first randomised dietary intervention to investigate the health, wellbeing, and behavioural implications of consuming a basal vegetarian diet that additionally includes low-to-moderate amounts of red meat compared to one containing plant-based meat alternatives (PBMAs) in young adults (NCT04869163)(1). The objective for the current analysis is to measure adherence to the intervention, nutrition behaviours, and participants’ experience with their allocated dietary group. Eighty healthy young adults participated in this 10-week dietary intervention as household pairs. Household pairs were randomised to receive approximately three serves of beef and lamb meat (average of 390 g total cooked weight per person per week, flexitarian group) or PBMAs (350–400 g, vegetarian group) on top of a basal vegetarian diet. Participants were supported to adopt healthy eating behaviours, and this intervention was developed and implemented using a behaviour change framework(2). Diet adherence (eating allocated meat or PBMA, abstaining from animal-based foods not provided by researchers) was monitored daily, with total scores calculated at the end of the 10-week intervention period. Eating experiences were measured by the Positive Eating Scale and a purpose-designed exit survey, and a food frequency questionnaire measured dietary intake. Analyses used mixed effects modelling taking household clustering into account. The average total adherence score was 91.5 (SD = 9.0) out of a possible 100, with participants in the flexitarian group scoring higher (96.1, SD = 4.6, compared to 86.7, SD = 10.0; p < 0.001). Those receiving meat were generally more satisfied with this allocation compared to those receiving the PBMAs, even though a leading motivation for participants joining the study was an opportunity to try plant-based eating (35% expressed that that interest). Participants in both intervention groups had increased vegetable intake (p < 0.001), and reported more positive eating experiences (p = 0.020) and satisfaction with eating (p = 0.021) at the end of the 10-week intervention relative to baseline values. Behavioural methods to encourage engagement with the trial were successful, as participants demonstrated excellent adherence to the intervention. The flexitarian and vegetarian diets elicited different responses in adherence and eating experience. This holds relevance for the inclusion of red meat and PBMAs in healthy, sustainable dietary patterns beyond this study alone.

Mapping the potential of meal kits to influence parental food literacy: an application of behaviour change frameworks

Cooking at home and eating together provide opportunities to improve family nutrition and promote healthy dietary habits. Commercial meal kit subscription services (MKSSs) (e.g. HelloFresh™, Marley Spoon™, EveryPlate™) may support parents to overcome obstacles to family meal provisioning and facilitate food literacy development. A gap exists in our understanding of how and why meal kits may elicit behaviour change, and opportunities to increase their behaviour change capability. This study aimed to examine the theoretical potential of Australian MKSSs to promote parental food literacy using the Behaviour Change Wheel (BCW)(1) and associated Theoretical Domains Framework (TDF)(1) and Behaviour Change Technique Taxonomy v1 (BCTTv1)(2). A one-week subscription was purchased for all Australian-based MKSSs (n = 9) and key meal kit components (subscription and meal planning features, meal kit delivery and website content) were coded using the retrospective application of these behaviour change frameworks. Parental food literacy-related behaviours were informed by a Food Literacy framework(3). Identified BCTs were mapped to the TDF using the Theory and Techniques Tool to identify theoretical mechanisms of action. The key meal kit components identified mapped to eight of the nine BCW intervention functions. These components primarily served the functions of enablement and environmental restructuring to support cooking at home. Thirty-five of the 93 possible BCTs were identified across the nine MKSSs reviewed, ranging from 19 to 29 BCTs per company, and linked to 13 of the 14 TDF domains. The most frequently identified mechanisms of action (TDF) targeted changes in motivation (n = 27) and capability (n = 19) to influence parental food literacy. Australian-based MKSSs incorporate a wide range of BCTs that target mechanisms of action associated with food literacy-related behaviours. These findings provide a strong theoretical evidence-base for the potential of commercial MKSSs to enhance parental food literacy. However, the extent to which these services may influence behaviour change or impact family food intakes is currently unknown. Therefore further research is required to evaluate the healthfulness and effectiveness of MKSSs.

Implementing eHealth-based behaviour change support within a nutrition intervention trial improves adherence to study-related behaviours in healthy young adults

Nutrition intervention trials play a key role in informing clinical and dietary guidelines. Within these trials, we need participants to change their behaviours; however, researchers seldom systematically consider how to support participants with these changes, contributing to poor adherence. Here we evaluate how using a behaviour change framework to develop support within a dietary intervention impacts young adults’ adherence to required trial behaviours. In the Protein Diet Satisfaction (PREDITION) trial, 80 young adults were randomised to a flexitarian or vegetarian diet for 10-weeks to investigate the psychological and cardiometabolic effects of moderate lean red meat consumption as part of a balanced diet(1). To understand these outcomes, it was key that participants within the trial (i) ate a healthy, basal vegetarian diet (excluding meat, poultry, and fish not provided by research team) and (ii) reported their dietary intake daily on a smartphone application (required to evaluate intervention compliance). To enhance adherence to these behaviours the Nine Principles framework was used to develop behaviour change support (BCS)(2). Key components of the BCS included access to a dietitian-led Facebook group, text reminders, and food delivery. Effectiveness was measured using the following analyses of the 78 participants who completed the study: pre-post change in targeted dietary habits over time using a subscore of the Healthy Diet Habits Index, adherence score to reporting over 10-weeks, Facebook group engagement, and impact evaluation. Analysis included linear imputation modelling, t-tests, and chi-square analysis. The total Healthy Diet Habits Index subscore out of 16 significantly increased from baseline to week 10 (10.6 ± 2.6 to 11.2 ± 2.6, p = 0.011), demonstrating maintenance of a healthy diet. Overall adherence to reporting was high across the 10 weeks, with the total population mean reporting score 90.4 ± 14.6 out of a possible 100. This strengthens study validity, allowing us to confidently report if participants complied with study requirements of consuming the intervention protein (red meat or plant-based meat alternatives) on top of a basal vegetarian diet. Although relatively low active Facebook engagement was observed (on average <1 ‘react’ per post), most participants agreed the text messages and Facebook groups supported them to adhere to recording (63%) and eating healthily (60%), respectively. This is the first study to provide an example of how a framework can be used to systematically develop, implement, and assess BCS within a nutrition trial. This appears to be a promising way to enhance adherence to study-related behaviours, including the burdensome task of reporting dietary intake. We believe this has great potential to improve research validity and decrease resource waste, not only for the PREDITION trial but in future dietary intervention trials.

Developing an intervention to support dietary change for shift workers living with type 2 diabetes: A stakeholder consultation.

Shift workers, compared to day workers, are more likely to be diagnosed with type 2 diabetes (T2D). Currently, there is no tailored programme of dietary support available to either shift workers living with T2D or employers. An intervention development consultation workshop was convened in June 2023 with the aim of evaluating potential interventions to identify those with a potential to take forward for further development. Findings from prior formative research into factors influencing dietary behaviour in shift workers with T2D were mapped to potential interventions addressing the barriers and enablers to healthy eating reported by shift workers with T2D. The findings of the Shift-Diabetes Study were presented in the context of the COM-B (Capability, Opportunity, Motivation, Behaviour) theoretical framework of behaviour change. Three interventions in turn were presented to attendees: (1) Educational resources and structured education, (2) Increasing availability and accessibility of food on a night shift and (3) Biofeedback and tailored advice. Seven workshop attendees were invited to express their thoughts, using the APEASE criteria (Affordability, Practicability, Effectiveness, Acceptability, Side-effects/Safety, Equity) to guide the discussion. The workshop was conducted online and recorded, and transcripts were thematically coded to the APEASE framework. The workshop highlighted the importance of multilevel interventions to support dietary behaviour change in this occupational group. Priority actions identified include (i) understanding barriers to 24/7 food availability, (ii) including shift workers in clinical diabetes studies and (iii) research to understand the effectiveness of continuous glucose monitoring in shift workers with T2D.