Behavior Change Research Research Articles

10.Y.2. Unlocking innovation: trustworthy co-creation for tackling complex public health challenges

Abstract Background Public health interventions often have limited effects, with few achieving large-scale implementation. Moreover, these interventions frequently fail to replicate their effects in real-world settings, possibly due to an overemphasis on generating universal knowledge through theory building and testing in controlled conditions. An alternative approach involves developing interventions within specific contexts, fostering collaborative knowledge generation, and establishing equitable partnerships. Co-creation offers a transformative strategy for addressing complex public health issues by generating real-world solutions. However, utilizing co-creation in public health presents challenges, including a lack of guidance on implementation and evaluation in public health settings. This underscores the need to integrate real-world co-creation with rigorous research to establish a reliable methodology grounded in both scientific evidence and participatory principles. Workshop This Pecha Kucha-style workshop will explore the essence of an evidence-based co-creation methodology developed through rigorous research by the European-funded H2020 Marie Sklodowska-Curie Innovative Training Network, Health CASCADE, and its partners. Emphasizing the significance of fostering innovative solutions to public health challenges, the workshop will provide key considerations for designing co-creation projects. It will also examine the role of enabling technologies in optimizing hybrid intelligence for effective co-creation, highlighting their contribution to collaboration enhancement. Perspectives from co-creators will be presented to offer unique insights into their experience of the co-creation process. Additionally, the workshop will elucidate the adaptation of co-creation processes within the Danish context, exploring collaborative efforts across sectors and shedding light on cross-sectoral cooperation intricacies. A moderated panel discussion will conclude the workshop, facilitating deeper engagement with the presented topics. Delegates will gain insight into applying co-creation in health promotion and behaviour change research, navigating prevalent challenges through Health CASCADE’s systematic approach, and discovering strategies for fostering effective and inclusive co-creation. They will also acquire strategies and resources to overcome potential obstacles, fostering more effective and inclusive approaches to complex public health challenges. Key messages • Co-creation presents a powerful approach to addressing complex public health challenges by fostering collaboration, creativity, and inclusivity across diverse stakeholders and communities. • Effective and trustworthy implementation of co-creation requires an understanding of its principles and methods, enabling technologies, and strong partnerships across sectors and institutions.

Descriptive norms can "backfire" in hyper-polarized contexts.

Descriptive social norms interventions, where a behavior is promoted by learning that others engage in that behavior, are a cornerstone of behavior change research and practice. Here, we examine the effect of learning about the behavior of outgroup members in a hyper-polarized context: mask-wearing during the COVID-19 pandemic. Contrary to prior findings, we find a descriptive social norm "backfire": Across three experiments, Biden supporters increased their mask-wearing intentions after being informed that most Trump supporters never wore masks. We also provide evidence consistent with a mechanism whereby this effect was driven by changes in perceptions about how negatively ingroup members view nonmask wearing. Finally, in a fourth study, Biden supporters show the traditional descriptive norms effect (rather than a backfire) from the same treatment when in a nonpolarized context: dishonesty in a coin-flipping task. These findings help to clarify why descriptive social norm interventions promote behavior change, and underscore the importance of social norms in motivating prosocial behaviors. They also suggest an update to current best practices in the design of descriptive norm interventions: in polarized contexts, it can be beneficial to publicize antisocial behavior of outgroup members.

Behavioral exposure for interoceptive tolerance (BE-FIT): A stage II randomized clinical trial protocol

BackgroundExercise anxiety is a novel mechanism related to non-adherence to exercise and lifestyle physical activity. We developed a cognitive-behavioral treatment, Behavioral Exposure For Interoceptive Tolerance (BE-FIT), which is a manualized, values-based exposure intervention developed to target exercise anxiety that is delivered as a supplement to outpatient cardiac rehabilitation (CR). MethodWe describe a Stage II randomized controlled trial (RCT) that is designed to test BE-FIT, compared to a Health Education Control (HEC) intervention on exercise and physical activity outcomes at end-of-treatment (EOT) and follow-ups (Weeks 12, 18, and 24), and evaluate mechanisms of change (i.e., reductions in exercise anxiety). Adults (N = 146) who are ≥40 years of age, cleared for outpatient exercise-based CR, low active and have elevated exercise anxiety will be recruited. The primary study hypothesis is that BE-FIT compared to HEC will result in higher levels of overall exercise and lifestyle physical activity at EOT and follow-ups. The second hypothesis is that BE-FIT vs HEC will produce greater reductions in exercise anxiety at EOT and Week 12. The third hypothesis is that reductions in exercise anxiety at EOT and Weeks 12 will mediate the effect of BE-FIT on activity outcomes at Weeks 18 and 24. DiscussionWe expect the results of this study will produce knowledge regarding BE-FIT's efficacy and mechanisms of action. Our goal is to better understand “how and why” the intervention is (or is not) effective and for whom, and increase collective knowledge and reproducibility of behavior change research.

Understanding Health Beliefs and Health Behaviors in Older Adults at Risk for Alzheimer's Disease.

There are significant public health benefits to delaying the onset of Alzheimer's disease (AD) in individuals at risk. However, adherence to brain healthy behaviors is low. The Health Belief Model proposes that specific beliefs are mediators of behavior change. To characterize health belief measures from the Science of Behavior Change Research Network (SBCRN) in an older adult population and associations between health beliefs, AD risk, and current health behaviors. A total of 172 individuals from the Rhode Island AD Prevention Registry participated. SBCRN health belief measures included assessments of future time perspective, self-efficacy, deferment of gratification, and consideration of future consequences. Outcome measures included individual AD risk index score, dementia risk awareness, and lifestyle behaviors including physical, cognitive, and social activity. Participants who were older had higher scores for AD risk, lower future time perspective, and lower generalized self-efficacy (all at p < 0.001). Higher generalized self-efficacy was related to increased physical activity (p < 0.010). Higher future time perspective (p < 0.001) and generalized self-efficacy (p = 0.48) were associated with lower AD risk score. Subjective cognitive decline (SCD) was associated with lower self-efficacy, ability to delay gratification, and a less expansive future time perspective. Greater self-efficacy and perceived future time remaining were associated with lower AD risk and greater engagement in physical activity. SCD was associated with health beliefs that may negatively affect engagement in positive brain health behaviors. Assessment of and psychoeducation about these intrapersonal health belief constructs may be important targets for behavioral interventions to reduce AD risk.

Sociological interventions for the diphtheria outbreak in Nigeria: addressing misconceptions, cultural biases, and promoting vaccination

Diphtheria is a fatal bacterial infection primarily affecting the respiratory system, characterized by a thick membrane formation in the throat, caused by Corynebacterium diphtheriae. This manuscript elucidates sociological interventions, aimed at protecting the population of Nigeria from diphtheria, a preventable yet persisting health threat. It delves into diverse strategies that could be employed to combat misconceptions, navigate deeply ingrained cultural biases, and instill the significance of vaccination within the context of diphtheria outbreak and prevention. The research question was: "What are the sociological interventions, used to address misconceptions, cultural biases, and promote vaccination in the context of diphtheria prevention in Nigeria?" In response to this inquiry, a comprehensive review methodology was employed to systematically gather, evaluate, and synthesize relevant literature outputs. The literature search, conducted across diverse academic databases and repositories, yields a rich collection of studies, reports, and case studies. The lens of Symbolic Interactionism was applied. The sociological interventions, considered in this context, engage directly with communities, healthcare providers, and local leaders. It addresses the vital need to combat misconceptions, cultural biases, and vaccine hesitancy, fostering a deeper understanding of the dynamic interplay between sociological factors and healthcare interventions. Sociological interventions for diphtheria protection in Nigeria require culturally sensitive approaches, community engagement, health education, addressing vaccine hesitancy, offering accessible vaccination services, tackling socioeconomic barriers, targeted messaging, behavioral change communication, data collection, and research collaborations to understand and address sociocultural factors influencing vaccine uptake and prevention. The findings and implications offer valuable insights for policymakers, healthcare providers, and researchers, and lay the groundwork for more effective strategies to protect the population from this preventable disease

Developments and Challenges in Behaviour-Change Research

Developments and Challenges in Behaviour-Change Research

Partnerships to protect nature: a Community of Practice approach to human behaviour change research and practice

Partnerships to protect nature: a Community of Practice approach to human behaviour change research and practice

Beyond mediators: A critical review and methodological path forward for studying mechanisms in alcohol use treatment research.

Understanding how treatments for alcohol use disorder (AUD) facilitate behavior change has long been recognized as an important area of research for advancing clinical care. However, despite decades of research, the specific mechanisms of change for most AUD treatments remain largely unknown because most prior work in the field has focused only on statistical mediation. Statistical mediation is a necessary but not sufficient condition to establish evidence for a mechanism of change. Mediators are intermediate variables that account statistically for the relationship between independent and dependent variables, whereas mechanisms provide more detailed explanations of how an intervention leads to a desired outcome. Thus, mediators and mechanisms are not equivalent. To advance mechanisms of behavior change research, in this critical review we provide an overview of methodological shortfalls of existing AUD treatment mechanism research and introduce an etiologically informed precision medicine approach that facilitates the testing of mechanisms of behavior change rather than treatment mediators. We propose a framework for studying mechanisms in alcohol treatment research that promises to facilitate our understanding of behavior change and precision medicine (i.e., for whom a given mechanism of behavior change operates and under what conditions). The framework presented in this review has several overarching goals, one of which is to provide a methodological roadmap for testing AUD recovery mechanisms. We provide two examples of our framework, one pharmacological and one behavioral, to facilitate future efforts to implement this methodological approach to mechanism research. The framework proposed in this critical review facilitates the alignment of AUD treatment mechanism research with current theories of etiologic mechanisms, precision medicine efforts, and cross-disciplinary approaches to testing mechanisms. Although no framework can address all the challenges related to mechanisms research, our goal is to help facilitate a shift toward more rigorous and falsifiable behavior change research.

“I saw a fox in Melbourne CBD”: Urban travel behaviour changes during COVID-19 and beyond

An unexpected outcome of the COVID-19 pandemic were the dramatic travel behaviour changes experienced in cities worldwide, which, could result in more sustainable transport systems. Consequently, there is a need for longer-term post-pandemic travel behaviour change research. This study aimed to investigate city-level travel behaviour changes during and post-pandemic. To our knowledge, this is the first qualitative study exploring the permanency of COVID-19 travel behaviour changes. This study involved a literature review of 41 studies and in-depth interviews with 19 transport stakeholders in metropolitan Melbourne, Australia. Melbourne is a valuable study area, given that it was the most locked-down city globally. Overall, the results of this study suggest that post-pandemic travel behaviour will be different to pre-pandemic, with working from home (WFH) an integral influence on travel behaviour. In addition, several overarching travel behaviour changes were identified: WFH significantly increased during the pandemic and is anticipated to continue post-pandemic. Both public transport and private motor vehicle (PMV) trips decreased during lockdowns; while PMV rebounded quickly, public transport remained low, and a long recovery is expected. Active transport (cycling and walking) increased during the pandemic and appear likely to endure. Finally, while shared travel modes have received less attention, modal variance is expected in the future. This study has made several key contributions. It consolidated our understanding of the wide range of urban travel behaviour changes experienced during and anticipated post-COVID-19. Secondly, it synthesised current knowledge of recent post-COVID-19 travel behaviour change research. Thirdly, this study demonstrated that complementary qualitative studies strengthen transport research by unearthing new insight into the reasons underpinning travel behaviours, which could be vital for developing solutions. Furthermore, this study identified critical future research topics. Given that most countries are learning to live with the virus, it is an opportune time to investigate whether these intended travel behaviours have endured.

31 Understanding Health Beliefs and Health Behaviors in Older Adults at Risk for Alzheimer’s Disease

Objective:Given the aging population, there are significant public health benefits to delaying the onset of Alzheimer’s disease (AD) in individuals at risk. However, adherence to health behaviors (e.g., diet, exercise, sleep hygiene) is low in the general population. The Health Belief Model proposes that beliefs such as perceived threat of disease, perceived benefits and barriers to behavior change, and cues to action are mediators of behavior change. The aim of this study was to gain additional information on current health behaviors and beliefs for individuals at risk for developing AD. This information can then be used to inform behavioral interventions and individualized strategies to improve health behaviors that may reduce AD risk or delay symptom onset.Participants and Methods:Surveys were sent to the Rhode Island AD Prevention Registry, which is enriched for at-risk, cognitively normal adults (i.e., majority with a family history and/or an APOE e4 allele). A total of 177 individuals participated in this study. Participants were 68% female; 93% Caucasian and non-Hispanic; mean age of 69.2; 74% with family history of dementia; 40% with subjective memory decline. The survey included measures from the Science of Behavior Change (SoBC) Research Network to measure specific health belief factors, including individual AD risk, perceived future time remaining in one’s life, generalized self-efficacy, deferment of gratification, consideration of future consequences as well as dementia risk awareness and a total risk score for dementia calculated from a combination demographic, health and lifestyle behaviors.Results:Participants who were older had higher scores for dementia risk (r=0.78), lower future time perspective (r=-0.33), and lower generalized self-efficacy (r=-0.31) (all at p&lt;0.001). Higher education correlated with higher consideration of future consequences (r=-.31, p&lt;0.001) and lower overall dementia risk score (r=-0.23, p=0.006). Of all scales examined, only generalized self-efficacy had a significant linear relationship to both frequency (r2=0.06) and duration (r2=0.08) of weekly physical activity (p&lt;0.001). Total dementia risk score also had significant linear relationships (r2=0.19) with future time perspective (p&lt;0.001) and generalized self-efficacy (p=0.48).Conclusions:Overall, individuals who rated themselves higher in self-efficacy were more likely to exercise more frequently and for a longer duration. Individuals who had lower overall risk for dementia due to both demographic and behavioral factors were more likely to endorse higher self-efficacy and more perceived time remaining in their lives. Increasing self-efficacy and targeting perceived future time limitations may be key areas to increase motivation and participation in behavioral strategies to reduce AD risk. Developing individual profiles based on these scales may further allow for individually tailored intervention opportunities.

Are motivational and self-regulation factors associated with 12 months’ weight regain prevention in the NoHoW study? An analysis of European adults

PurposePreventing weight regain can only be achieved by sustained changes in energy balance-related behaviors that are associated with weight, such as diet and physical activity. Changes in motivation and self-regulatory skills can support long-term behavioral changes in the context of weight loss maintenance. We propose that experiencing a supportive climate care is associated with enhanced satisfaction of basic psychological needs, intrinsic goals, and autonomous motivation. These factors are expected to be associate with the utilization of self-regulation skills, leading to more sustained behavior changes and ultimately preventing weight regain. This hypothesis was tested in this ancillary analysis of the NoHoW trial, where the study arms were pooled and followed for 12 months.MethodsThe NoHoW was a three-center, large-scale weight regain prevention full factorial trial. In this longitudinal study, data were collected in adults who lost > 5% weight in the past year (N = 870, complete data only, 68.7% female, 44.10 ± 11.86 years, 84.47 ± 17.03 kg) during their participation in a 12-month digital behavior change intervention. Weight and validated measures of motivational- and self-regulatory skills-related variables were collected at baseline, six- and 12 months. Change variables were used in Mplus’ path analytical models informed by NoHoW’s logic model.ResultsThe bivariate correlations confirmed key mediators’ potential effect on weight outcomes in the expected causal direction. The primary analysis showed that a quarter of the variance (r2 = 23.5%) of weight regain prevention was achieved via the mechanisms of action predicted in the logic model. Specifically, our results show that supportive climate care is associated with needs satisfaction and intrinsic goal content leading to better weight regain prevention via improvements in self-regulatory skills and exercise-controlled motivation. The secondary analysis showed that more mechanisms of action are significant in participants who regained or maintained their weight.ConclusionsThese results contribute to a better understanding of the mechanisms of action leading to behavior change in weight regain prevention. The most successful participants used only a few intrinsic motivation-related mechanisms of action, suggesting that habits may have been learned. While developing a digital behavior change intervention, researchers and practitioners should consider creating supportive climate care to improve needs satisfaction and intrinsic goal contents.Trial registrationISRCTN, ISRCTN88405328, registered 12/22/2016.

Expanding Nature's storytelling: extended reality and debiasing strategies for an eco-agency.

Communication in sustainability and environmental sciences is primed to be substantially changed with extended reality technology, as the emergent Metaverse gives momentum to building an urgent pro-environmental mindset. Our work focuses on immersive econarratives, supported by virtual and augmented realities, and their potential to favor an improved relationship with the environment. Considering social aggregation dynamics and cognitive bias, this article intends to (1) make the case for a new environmental narrative; (2) position extended reality as privileged settings to sustain this narrative; and (3) suggest that this storytelling should be informed by Nature's empirical evidence, i.e., ecosystem data. We see this as a chance to think this Metaverse with an embedded environmental consciousness, informed by behavior-change research.

A Digital Counselor-Delivered Intervention for Substance Use Among People With HIV: Development and Usability Study.

Substance use disorders are prevalent and undertreated among people with HIV. Computer-delivered interventions (CDIs) show promise in expanding reach, delivering evidence-based care, and offering anonymity. Use in HIV clinic settings may overcome access barriers. Incorporating digital counselors may increase CDI engagement, and thereby improve health outcomes. We aim to develop and pilot a digital counselor-delivered brief intervention for people with HIV who use drugs, called "C-Raven," which is theory grounded and uses evidence-based practices for behavior change. Intervention mapping was used to develop the CDI including a review of the behavior change research in substance use, HIV, and digital counselors. We conducted in-depth interviews applying the situated-information, motivation, and behavior skills model and culturally adapting the content for local use with people with HIV. With a user interaction designer, we created various digital counselors and CDI interfaces. Finally, a mixed methods approach using in-depth interviews and quantitative assessments was used to assess the usability, acceptability, and cultural relevance of the intervention content and the digital counselor. Participants found CDI easy to use, useful, relevant, and motivating. A consistent suggestion was to provide more information about the negative impacts of drug use and the interaction of drug use with HIV. Participants also reported that they learned new information about drug use and its health effects. The CDI was delivered by a "Raven," digital counselor, programmed to interact in a motivational interviewing style. The Raven was perceived to be nonjudgmental, understanding, and emotionally responsive. The appearance and images in the intervention were perceived as relevant and acceptable. Participants noted that they could be more truthful with a digital counselor, however, it was not unanimously endorsed as a replacement for a human counselor. The C-Raven Satisfaction Scale showed that all participants rated their satisfaction at either a 4 (n=2) or a 5 (n=8) on a 5-point Likert scale and all endorsed using the C-Raven program again. CDIs show promise in extending access to care and improving health outcomes but their development necessarily requires integration from multiple disciplines including behavioral medicine and computer science. We developed a cross-platform compatible CDI led by a digital counselor that interacts in a motivational interviewing style and (1) uses evidence-based behavioral change methods, (2) is culturally adapted to people with HIV who use drugs, (3) has an engaging and interactive user interface, and (4) presents personalized content based on participants' ongoing responses to a series of menu-driven conversations. To advance the continued development of this and other CDIs, we recommend expanded testing, standardized measures to evaluate user experience, integration with clinician-delivered substance use treatment, and if effective, implementation into HIV clinical care.

The NIH Science of Behavior Change Program: Looking Toward the Future

The National Institutes of Health established the Science of Behavior Change (SOBC) program to promote basic research on the initiation, personalization, and maintenance of health behavior change. The SOBC Resource and Coordinating Center now leads and supports activities to maximize the creativity, productivity, scientific rigor, and dissemination of the experimental medicine approach and experimental design resources. Here, we highlight those resources, including the Checklist for Investigating Mechanisms in Behavior-change Research (CLIMBR) guidelines introduced in this special section. We describe the ways in which SOBC can be applied across a range of domains and contexts, and end by considering ways to extend SOBC’s perspective and reach, so as to best promote behavior change linked with health, quality of life, and well-being.

Improving the Rigor of Mechanistic Behavioral Science: The Introduction of the Checklist for Investigating Mechanisms in Behavior-Change Research (CLIMBR)

Diverse fields rely on the development of effective interventions to change human behaviors, such as following prescribed medical regimens, engaging in recommended levels of physical activity, getting vaccinations that promote individual and public health, and getting a healthy amount of sleep. Despite recent advancements in behavioral intervention development and behavior-change science, systematic progress is stalled by the lack of a systematic approach to identifying and targeting mechanisms of action that underlie successful behavior change. Further progress in behavioral intervention science requires that mechanisms be universally prespecified, measurable, and malleable. We developed the CheckList for Investigating Mechanisms in Behavior-change Research (CLIMBR) to guide basic and applied researchers in the planning and reporting of manipulations and interventions relevant to understanding the underlying active ingredients that do—or do not—drive successful change in behavioral outcomes. We report the rationale for creating CLIMBR and detail the processes of its development and refinement based on feedback from behavior-change experts and NIH officials. The final version of CLIMBR is included in full.

The Status of Household Electricity Use Behaviour Research in South Africa between 2000 and 2022

Unsustainable use of electricity has severe implications on the environment and human well-being. With an estimated consumption of about 20% of total global electricity demand, the household sector is a key player in efforts for crafting interventions for reducing electricity consumption. Despite increasing calls for behavioural solutions to electricity conservation at the household level, more attention has been paid to technical than behavioural interventions. Yet a deeper understanding of electricity use behaviour is needed to design interventions and engender integration of behavioural interventions into demand-side management and decision making. Although South Africa is energy insecure and a major greenhouse gas emitter, less attention has been paid to household electricity use using behavioural lenses. Using a scoping review approach, this study inductively reviewed publications to examine the state of research on household electricity use in South Africa, focussing on (1) research trends and contexts, (2) conceptual focus, (3) proposed interventions for reducing electricity consumption and (4) future research needs. Very few publications considered reported and actual electricity use behaviour. Most publications (65%) paid attention to technical dimensions for reducing household electricity consumption such as economic nudges and technical retrofits, rather than behavioural strategies. Of the publications that focussed on behaviour, very few explicitly examined reported electricity use behaviour. Most publications did not consider the role of partnerships in designing interventions for reducing electricity consumption but rather employed individualistic perspectives. Overall, the results suggest that calls for behaviour change research have not been fully heeded. More studies on electricity use behaviour in different contexts, including across an income heterogeneity gradient, and the role of context dependent collective settings in drafting interventions, are required to better inform pathways to sustainable electricity use.

Attractor landscapes: a unifying conceptual model for understanding behaviour change across scales of observation

ABSTRACT Models and theories in behaviour change science are not in short supply, but they almost exclusively pertain to a particular facet of behaviour, such as automaticity or reasoned action, or to a single scale of observation such as individuals or communities. We present a highly generalisable conceptual model which is widely used in complex systems research from biology to physics, in an accessible form to behavioural scientists. The proposed model of attractor landscapes can be used to understand human behaviour change on different levels, from individuals to dyads, groups and societies. We use the model as a tool to present neglected ideas in contemporary behaviour change science, such as hysteresis and nonlinearity. The model of attractor landscapes can deepen understanding of well-known features of behaviour change (research), including short-livedness of intervention effects, problematicity of focusing on behavioural initiation while neglecting behavioural maintenance, continuum and stage models of behaviour change understood within a single accommodating framework, and the concept of resilience. We also demonstrate potential methods of analysis and outline avenues for future research.

Strengthening the research-practice loop in applied animal behavior: Introduction to the special issue.

Though operant learning has been applied to socially significant animal behavior for many years, connections between these practical applications and the basic science that supports them have weakened over time. There is a need for replications and extensions of technologies derived from basic research to applied animal settings, and for practical questions to be taken back to the lab where they can be modeled and studied under controlled conditions before incorporating the results in applied behavior-change research and practice. This special issue highlights ways that behavior analysis can contribute to and support the development of evidence-based applications with animals. Articles in this issue provide context for the relationship between basic research and practice in animal behavior, apply basic principles to animal behavior practice, and investigate practical problems using basic research techniques. Each of these is important for a robust interchange between basic science and practice. Here we comment on the contributions of each article to the literature and identify directions for future research.

Learning From the Past: The Role of Social and Behavior Change Programming in Public Health Emergencies.

<h3>Key Messages</h3> The prevalence of emerging infectious diseases (EIDs) is rising at an unprecedented rate, and influencing human behavior is often the first line of defense to slow disease transmissions. We synthesize the contributions that social and behavior change research and programming has made in 6 recent EIDs that reached epidemic proportions: HIV, severe acute respiratory syndrome, Middle East respiratory syndrome, Zika virus, Ebola virus disease, and coronavirus disease. Analysis of successful and unsuccessful responses to EID outbreaks suggests 5 primary lessons learned that can be used by SBC experts in future EID responses: engage communities, build trust through transparent risk communication, segment audiences for tailored interventions, prioritize behaviors, and cultivate political will and commitment. Incorporating SBC experts into EID responses can reduce mortality and improve efficiency in such precarious and time-sensitive settings.

Development and design of the first structured clinic-based program in lower resource settings to transition emerging adults with type 1 diabetes from pediatric to adult care.

Type 1 diabetes (T1D) is increasing in young people worldwide and more children in resource limited settings are living into adulthood. There is a need for rigorous testing and reporting of evidence-based and stakeholder-informed strategies that transition individuals with T1D from pediatric to adult care. We present the development of and design of the first structured transition program in Delhi, India, to inform similar efforts in India and resource limited settings. The intervention development team included clinicians and researchers with expertise in T1D and the implementation context. To select intervention outcomes, establish intervention targets, and design session modules, we drew upon formative research conducted at prospective intervention implementation sites, consensus guidelines, and previous care transition and behavior change research conducted in developed settings. We used the Template for Intervention Description and Replication and GUIDance for the rEporting of intervention Development checklists to report the intervention and development process. The 15-month program ("PATHWAY") includes five quarterly ~30 minute sessions delivered predominantly by diabetes educators at pediatric and adult clinics, which coincide with routine care visits. Primary program components include educational and behavioral sessions that address psychosocial drivers of clinic attendance and self-management, diabetes educators as transition coordinators and counselors, and a one-year "overlap period" of alternating visits between pediatric and adult providers. We followed a systematic and transparent process to develop PATHWAY, which facilitated rich description of intervention context, guiding principles, targets, and components. Dependence on previously published program examples to design PATHWAY may have introduced challenges for program feasibility and effectiveness, underscoring the importance of input gathering from prospective intervention actors at multiple points in the development process. This detailed report in combination with future evaluations of PATHWAY support efforts to increase rigorous development and testing of strategies to improve outcomes among emerging adults with T1D.