By olga.perski, on 16 April 2020
Written by Dr David Crane
What is happening now is a mass, shared, life-changing psychological event. Potentially. The long-term effects of any event are of course impossible to predict for individuals. But on a global level, the substantial changes so-far wrought by this pandemic suggests COVID-19 could have a lasting effect on the behaviour of a large number of people.
In the space of three months, a threat has gone in public consciousness from theoretical to powerful enough to force billions of people to make fundamental changes to their daily lives. Behaviours unthinkable a short time ago, such as staying at home for weeks on end, are now so commonly accepted as to make being outside feel uncomfortable. Behaviours still largely unconscious, such as touching one’s face, somehow need to be changed because there is a non-trivial chance that something so simple and commonplace could now lead to our, or somebody else’s, demise.
Everything we are doing to develop a vaccine and change our behaviour will hopefully mean that when compared to previous pandemics the number of deaths will be low. And it is probably true that our ancestors had to live with more uncertainty on a regular basis than we are experiencing now. So why might this event be so significant psychologically? Because it could result in a paradigm shift in our awareness of the fragility of life and the benefits of collaboration. One experienced by a great many people over a large swathe of the world at more or less the same time.
The chance that we or our loved ones might die in the near future has, for most of us, gone from effectively zero to something noticeably greater in a short space of time. The risk remains mercifully small but cannot be dismissed entirely, even by the young, healthy, rich and/or powerful. Those who downplay the risk will still probably be more careful about keeping their distance and washing their hands, even when not demanded by new social norms. And if the only reason this is done is for fear of infecting others, that still represents a substantial change in threat perception since Christmas.
By the time this is pandemic is over, it is likely that almost all of us will know people who have died and others who have suffered, even if we escape suffering ourselves. Awareness of death’s proximity will be increased by the availability of its news. TV, newspapers and radio will tell us about people we have heard of who have died, or tragedies that people we can relate to have suffered. Social media will be full of heart-wrenching stories from people we know who have lost people they loved; the most moving of which will be shared more widely themselves, so enlarging the circle of grief far beyond usual bounds.
A subject many people prefer not to think about will be pushed into consciousness for a considerable period of time. Reactions will fall along a spectrum of course, from totally unaffected to completely petrified. Though many people unaffected by a change in their proximity to death are likely to be affected by one or other of the loss of their job (now or possibly soon), wider concerns about the economy, fears for what society is about to go through, worries for other people, or just that deeply unsettling feeling that many of the things that used to be relied upon are now less secure.
Something microscopic has seemingly come out of nowhere to upend our world with astonishing speed. Finding this a destabilising experience seems a perfectly appropriate response. This is a profound change.
But profound changes do not have wholly negative outcomes. Human beings have the inherent capacity – and tendency – to make life-altering events turn to our advantage. In normal times we carry on doing what we’ve always done until it’s abundantly obvious it no longer works. It can take years of disconfirming experiences before we accept that things which used to relieve pain or bring pleasure now have the opposite effect. And those are the big, noticeable, things. Much of our now ineffective behaviour is too small to be seen.
In exceptional times change is thrust upon us. Routines are forcibly broken, usual behaviour prevented. We can’t do what we’ve always done because it is impossible, impractical or obviously ineffective. Which makes it easier to see what’s as it should be and what needs adjustment. Behaviour that might otherwise be automatic and habitual (like drinking alcohol when stressed), is brought into awareness, from where decisions about whether to continue are more easily made. Opportunities to gain clarity on our priorities happen rarely in our lifetime, it is hard to think when previously they have happened to so many people at the same time.
A force multiplier of COVID-19 is that along with opportunity to change, it also provides a significant amount of motivation too. Because the virus only makes obvious that which has always, and will always, be true: life is fragile and the future is uncertain. It’s easy to procrastinate when we think we’ve got plenty of time. We tend to be more proactive when we realise that’s not so. This principle is something we understand intellectually and have probably experienced mildly. The difference now is how salient it could become.
In addition to opportunity and motivation, the third element for behaviour change to take place, capability, could also be increased by the pandemic. Or rather, by its survival. Simply getting through this will boost many people’s self-efficacy and sense of resilience and resourcefulness; with people who experienced more doubts likely to see greater increases than people who experienced few. Capability is also increased by motivation to change, which could increase substantially, and skills teaching, which is abundant.
Thoughts of everyone doing whatever they want may inspire fears of a hedonistic, anarchic, free-for-all. But if that were true, we would expect to see people being at least equally selfish when they felt most threatened. If our evolutionary tendency was towards self-interest, surely that would be more obvious when our survival was at risk.
But selfish behaviour does not appear to be prevalent. The opposite, in fact. Millions of people are risking their lives so we can live ours. Hundreds of thousands of support groups have spontaneously formed so people can look after each other. Acts of generosity and thoughtfulness abound, amongst friends and strangers alike. This represents, I suggest, large-scale evidence of enlightened self-interest: the understanding that our interests are best served by helping others. Because there is nothing like feeling vulnerable to make us realise how much we need other people. And perhaps nothing has made more people feel more vulnerable than this.
By talking about positive outcomes I do not mean to belittle the great suffering that will occur. Many people will be left in dire circumstances as a result of this crisis, some may never fully recover from losing people they love, others might find the threat too overwhelming to deal with, let alone make the most of. We cannot forget that a great many people will need help through and after this.
We also should not expect positive change to be guaranteed. Bad actors will seek to use this for their benefit. Our motivation to change will fluctuate and we should anticipate resistance internally and from others. Changing behaviour takes time and requires persistence. It does not come easy on an individual level, let alone a societal one.
Reasons for optimism come from three places. First, we are not talking about people having an intellectual appreciation of why change is important, these are visceral experiences, which are usually more salient. Second, even if only a tiny percentage are driven to change, that still represents a very large number in absolute terms. Third, the visceral experience large numbers of people are having is unlikely to be for more separateness. We might hope.
The world before COVID-19 seemed headed towards greater inequality and protectionism. What we are presented with now is a lesson in cooperation. To get through this crisis we need strangers to risk their safety to take care of our health, keep us supplied and perform the other services we now know are essential. Almost everyone has agreed to make sacrifices to prevent the transmission of disease, even those who feel the risk to themselves be small. Perhaps most importantly, the opportunity to help others allows a great many more of us to experience the primal boost to self-worth that comes from feeling of value.
We sometimes forget that we are a group species whose success lies more in our ability to cooperate than compete. Competition doesn’t work in a crisis, challenges like these can only be overcome by working together. The experience of this even being possible, how good it feels and how effective it can be, is perhaps what is needed for us to address the even bigger challenges the world will soon face.
Dr David Crane is founder of the popular smoking cessation app, Smoke Free. His interest in behaviour change started in primary school and hasn’t really stopped since.
By olga.perski, on 18 February 2020
The UCL TechSharing Seminar Series aims to foster knowledge exchange between academics, clinicians, policy makers and industry professionals working at the intersection of healthcare and digital technologies. The first seminar in the 2020 iteration of the series (supported by the UCL Institute of Healthcare Engineering) took place on January 16th and was hosted in collaboration with the London School of Hygiene and Tropical Medicine (LSHTM). The seminar focused on healthcare delivery (e.g. point of care diagnostics, clinical decision-making, remote data collection) via smartphone apps and related technologies in low resource settings. Four speakers provided fascinating insights into the opportunities and challenges of conducting digital health research in a global context. A number of important lessons were highlighted across the presentations, summarised below.
The next seminar in the series will focus on ethics in multidisciplinary digital health collaborations (date TBD).
In his keynote presentation, Dr Andrew Bastawrous talked about his journey to setting up PeekVision – an organisation which uses smartphone technology and related software to support eye testing and care in remote locations. While cost-effective solutions are available (e.g. glasses, cataract surgery), accessibility issues mean that millions of people in need of eye care are not catered for. Dr Bastawrous drew on his personal and clinical experiences to demonstrate how a technology like PeekVision can help meet such healthcare needs. He talked about how the ideas behind the project evolved, starting from early, logistically cumbersome population-based research (e.g. screening programmes) which required the transport of costly NHS diagnostic equipment to remote and poorly connected areas in sub-Saharan Africa, to projects involving teacher-led and smartphone-enabled eye tests. Peek Vision’s story highlights the importance of adapting to the local context, engaging a wide range of community members (e.g. parents, headmasters, teachers) and seizing unexpected opportunities – in communities where access to running water, high quality roads, or electricity is limited, the majority of people might still have access to mobile phones.
Lessons learnt: (1) without diligent and transparent data collection and analysis at each stage of the project, it would not have had the same impact, as the data collected allowed the project team to identify areas for improvement; (2) simple solutions are often preferable to complex ones, such as using a piece of string (as opposed to sophisticated algorithms) to measure the right distance for conducting smartphone-enabled eye tests.
The second talk was delivered by Dr Cathy Holloway who shared the story behind the UCL Global Disability Innovation Hub. The Hub brings together international organisations, including the World Health Organisation, and local partners in India and Africa, to support a range of initiatives focused on improving the lives of people living with disabilities. For example, the Hub is involved in the building and testing of innovative assistive technologies such as prosthetics in low resource settings. Dr Holloway shared insights into both practical and ethical challenges facing researchers working in the field of assistive technologies. First, many countries have other health priorities, such as poorly controlled malaria or HIV, and struggle to fund core healthcare services, such as teaching and nursing. In this context, initiatives that immediately save lives are more likely to be adopted and supported by governments and charitable organisations. Second, assistive technologies can sometimes increase disability and dependence. For example, providing people with smartphones may require that the majority of features/functionalities are first removed to reduce costs, or create dependence on carers or other intermediaries who are tasked with accessing and handling sensitive data on the devices (e.g. bank accounts).
Lessons learnt: (1) securing sustainable funding for global disability research and related activities remains challenging; (2) project partners often possess useful domain expertise, but may have less experience working within multidisciplinary collaborations with technology developers and researchers; (3) securing ethical approval for research conducted across different countries can take much longer than anticipated; (4) the success of global health projects relies on trust and regular communication with stakeholders and partners – it is therefore key to budget for site visits to strengthen links between project partners and better understand the context where the work is taking place.
Dr Michelle Heys from the UCL Institute of Child Health presented on NeoTree, a not-for-profit and open source smartphone app to support clinical decision-making in neonatal care. In the absence of specialist paediatricians in many low resource settings, target end-users include nurses and healthcare assistants who oversee the day-to-day care of the newborns. NeoTree was developed in line with the Medical Research Council’s framework for the development and evaluation of complex interventions and is grounded in co-design and participatory research with relevant stakeholders, including nurses and doctors. NeoTree also aims to improve the ways in which data are collected and managed in neonatal units. The NeoTree platform is currently used for the admission and discharge of babies across hospitals in Malawi and Zimbabwe and offers diagnostic support for nursing staff. Dr Heys discussed the potential for the platform to deliver training and behaviour change interventions for healthcare workers in the near future.
Lessons learnt: (1) technology can be an important part of the solution, but capacity building and education of healthcare workers remain necessary to improve health outcomes; (2) building and implementing algorithms to support clinical decision making in the real world remains a challenge – there are still grey areas that are difficult for algorithms to replace, which are normally addressed by humans drawing on their accumulated experience and clinical judgement.
The final talk was delivered by Dr Chrissy Roberts (LSHTM) and focused on technology platforms that enable high quality data collection ‘for the masses’, i.e. for anyone without specialist IT skills. Dr Roberts has set up and is now curating the Open Data Research Kits. His work has spanned the establishment of secure servers at LSHTM which support data collection and management for global partners, through to establishing a tablet-rental scheme for data capture, training for field workers, and curating online learning resources. Currently, the Open Data Research Kits are used by researchers globally, including the recent Ebola outbreak in the Democratic Republic of the Congo. Dr Robert’s work is grounded in the need for a system that can be used to reliably and securely collect high quality data in global contexts, particularly in resource-poor and challenging environments (including extreme weather conditions!). Dr Roberts outlined how the Open Data Research Kits help to meet core requirements that he and other global health researchers have for a data capturing system: being able to work both off- and online; encryption, zero cost, remote/automated monitoring, instant data sharing, media assisted surveys (to capture images, barcodes, audio and video), third party app integration and sustainability.
Lessons learnt: (1) with the right tools (many are open access and affordable), anyone can collect high quality data in low resource settings; (2) community-based technologies and software can be more sustainable and up-to-date than commercial software thanks to the existence of a wide network of users and contributors; (3) demystification through training can help to increase uptake of new technologies among those who remain skeptical (e.g. teaching MSc students and field workers how to use new software can help promote such technologies to senior team members).
Dr Aleksandra Herbec is a mixed-methods researcher specialising in tobacco control, behavioural science and digital health. She is based at the UCL Centre for Behaviour Change where she investigates ways to improve antibiotic stewardship and infection prevention and control and leads evaluations of smartphone-based aids for medication adherence and smoking cessation.
Dr Nikki Newhouse is an interdisciplinary qualitative researcher whose primary research interest is in human-computer interaction, in particular the development and evaluation of complex digital interventions to support physical and psychological wellbeing across the lifespan. She is based at the Nuffield Department of Primary Care Health Sciences at the University of Oxford.
Dr Olga Perski is an interdisciplinary researcher working at the intersection of behavioural science and technology. She is a Research Associate in the UCL Tobacco and Alcohol Research Group, where her work is focused on the development and evaluation of digital interventions for smoking cessation and alcohol reduction.
How to design a health app for users who are not motivated to change? Insights from the Precious app
By olga.perski, on 4 February 2020
The Precious app was designed to support healthy living: a physically active lifestyle, balanced nutrition and stress management. In a study published in JMIR mHealth and uHealth, we describe how we designed the Precious physical activity app features for users whose needs are not met by traditional activity tracker apps.
Most available physical activity apps provide factual information on performance with numbers and graphs, and they can be a great resource for those who are already active and who want to monitor their progress. Millions of users regularly log their running and cycling routes using smartphone sensors or wearables that connect with apps such as Strava. However, not everyone enjoys physical activity, and not everyone finds numerical data meaningful. For some, constantly failing to reach the goals set by exercise apps (such as 10,000 steps a day) can be a major stressor. Although good health is the goal for many, sometimes people only feel motivated to take care of themselves after facing a serious health concern.
Physical activity is good for our physical and mental wellbeing and those with the lowest levels of activity would benefit most from adopting some exercise in their life. Building on psychological research on motivation and self-regulation, we came up with two ways of catering to users with low motivation for activity in the Precious app: reflective and spontaneous support.
Reflective support through Motivational Interviewing
Most of us know about the health benefits of a physically active lifestyle. Thus, there is little need to remind people what they should do. Somewhat surprisingly, psychological research shows that a much more effective strategy is to help people think what they want to do .
In the Precious app, we used Motivational Interviewing techniques  to support people who struggle to fit physical activity into their daily lives. One of the key techniques is to ask questions that help the users reflect on how healthy behaviours could help them reach goals that are meaningful for them. When users start to express their desire to change or the reasons to become active, they are eliciting change talk. This is a central concept in Motivational Interviewing: helping people to put into words how behavioural changes can help them live a life that corresponds to their values.
In the Precious app, users are first guided to think about what really matters to them. This does not need to be health related: the basic psychological needs for human motivation are connectedness to others, experiencing competence in their actions, and having the freedom to pursue personally meaningful goals.  This thinking is based on Self-Determination Theory which has repeatedly shown that individuals engage in behaviours when these are in line with their values and identity .
Once the users have reflected on their life values, they are encouraged to think about if physical activity could help them achieve those things. Among the test users of the Precious app, physical activity was typically perceived as helpful, as physical exercise can, for instance, increase energy levels and help to manage stress. Whether people prioritise their family, their health or their career, improved physical and mental well-being is an asset.
The next step is to help users think about practical ways in which physical activity can take them closer to their life goals. For instance, if a user has indicated that feeling connected to others is most important to them, they can choose activities that can be done together with family or friends. The aim of the Motivational Interviewing tools is not simply to engage users with the app, but to engage them in the behaviour change process: to actively consider reasons for change and to take practical steps toward change (see Figure 1).
Figure 1. Screenshots from the Precious app.
Spontaneous support through gamification
Behaviour change does not necessarily require active reflection but can tap into the motivational effect of intrinsic pleasure. Gamification is the use of game elements for making a task more engaging and entertaining. For instance, the Conquer the city feature in the Precious app was designed to increase walking by making users conquer and defend areas in the area they live in by walking around buildings or blocks. Game elements can change users’ focus from feeling like they are ‘just walking’ to the task at hand and make people spontaneously active without even realising. Similar ideas have gained success in games like Ingress, Pokemon Go or Zombies, run!, where augmented reality elements lure players to walk further or run faster. An activity that is not necessarily fascinating in itself can become more enjoyable with augmented reality elements. People who do not find physical activity pleasurable may enjoy gamified visualisations, goals and challenges that they only achieve while being active.
The ‘Mountain climber’ tool provides a visual interpretation of activity and goal achievement
Following these principles, the evidence-based self-regulatory behaviour change techniques  in the Precious app were built into a Mountain climber tool (see Figure 2). It depicts daily activity as a mountain and shows a little flag on top of the mountain on days when users achieved their personal step goal. This self-regulation tool was designed so that people could monitor their daily steps even without looking at numbers. They can see if their mountain panorama is growing over time and learn what type of activities lead to the highest mountains.
Figure 2. The ‘Mountain climber’ tool.
To help users estimate more accurately how much activity they have done every day, the planning tool in the Precious app indicates how many steps each activity corresponds to. Users can fill in the minutes they spent swimming, lifting weights, etc., and the app will display how many steps these activities correspond to using MET values. All activities contribute to the daily step count and are visualised as one mountain, providing an easy day-to-day comparison.
The Precious app tries to convey that people do not need to become athletes in order to be physically active. Vacuuming the house or helping a friend to move can be the dose of daily physical activity – a realisation that can be a relief for someone with a busy schedule! The main thing is to make physical activity more enjoyable, or to at least see how it can help achieve things that matter most.
- The Precious app helped users elicit change talk in the interview situation. Will the effect carry on in a natural environment, over time?
- Health apps can be tailored to meet the needs of people with low technology literacy and little motivation for behaviour change, but how do we reach these potential users?
Nurmi J, Knittle K, Ginchev T, Khattak F, Helf C, Zwickl P, Castellano-Tejedor C, Lusilla-Palacios P, Costa-Requena J, Ravaja N, Haukkala A. (2020). Engaging Users in the Behavior Change Process With Digitalized Motivational Interviewing and Gamification: Development and Feasibility Testing of the Precious App. JMIR mHealth and uHealth. DOI: 10.2196/12884 URL: https://mhealth.jmir.org/2020/1/e12884/
Johanna Nurmi is finalising her PhD in Social Psychology at the University of Helsinki and working as a visiting researcher at the Behavioural Science Group, University of Cambridge. She studies how motivational techniques and related cognitions affect individuals’ daily physical activity. Johanna’s research has been supported by the University of Helsinki; the Yrjö Jahnsson foundation; and the KAUTE foundation.
The Precious project was funded by the European Union’s Seventh Framework Programme for research, technological development and demonstration under grant agreement number 611366, and built in multidisciplinary collaborations with partners across Europe.
Find Johanna here:
The promise of public health app portals (versus commercial app stores) in promoting the adoption of digital behaviour change aids
By olga.perski, on 11 December 2019
By Dr Olga Perski & Dorothy Szinay
To estimate the likely public health impact of digital behaviour change aids, we need to consider both their effectiveness and how far they are adopted within the target population. Although digital aids for smoking cessation, alcohol reduction, physical activity and dietary improvement have small, positive effects on behaviour (in comparison with no or minimal support), they have the potential to reach a much larger number of people than conventional, face-to-face treatment. For example, digital aids are easy to access for those who live too remotely to access available face-to-face support or who feel anxious about the prospect of talking to a healthcare professional about their health. Previous studies have described the characteristics of users (e.g. smokers, drinkers) who sign up to take part in controlled trials of digital aids or who self-select to download a particular app for smoking cessation or alcohol reduction. However, we currently know little about the reach of digital aids in the general population, which makes it difficult to judge whether they are in fact delivering on their promise of wide reach.
Observed adoption rates in the general population of smokers and drinkers in England
In a recent study published in Drug and Alcohol Dependence, we assessed adoption rates and characteristics of those adopting digital aids for smoking cessation and alcohol reduction in a nationally representative sample in England. A total of 3,655 smokers and 2,998 high-risk drinkers (defined as a score of >4 on the Alcohol Use Disorders Identification Test-Consumption; AUDIT-C) who had made a past-year quit/reduction attempt were surveyed as part of the Smoking and Alcohol Toolkit Studies between 2015 and 2018. They were asked if they had used a digital aid (e.g. website, smartphone app) in a recent quit/reduction attempt. In weighted analyses (used to match the sample to the proportions of the English population on age, social grade, etc.), we found that 2.7% of smokers and 3.6% of high-risk drinkers had used a digital aid in a recent quit/reduction attempt. Hence, our findings suggest that digital aids for smoking cessation and alcohol reduction are not yet reaching a large proportion of the target population in England. Another key finding was that none of the smoking or sociodemographic variables assessed were significantly associated with the uptake of digital aids in smokers. In high-risk drinkers, however, those who were highly motivated to reduce their drinking and had a higher AUDIT score had greater odds of adoption. This means that we may specifically need to focus promotion efforts on those with lower motivation to change going forwards.
Why are adoption rates so low?
These low adoption rates could be due to the lack of public or healthcare professional awareness of, or confidence in using/recommending the use of, digital aids. It should, however, be noted that public-facing campaigns in England (e.g. Stoptober, Dry January, One You) have promoted the use of smartphone apps for smoking cessation and alcohol reduction for several years. As the Smoking and Alcohol Toolkit Studies don’t currently include measures of awareness of available aids, we weren’t able to assess if the low adoption rates are indeed attributable to low awareness. Recently, regulatory frameworks for digital aids have been developed in the UK, with related resources (e.g. the NHS Apps Library) specifically designed to help healthcare professionals and patients navigate the host of available apps. It’s hence possible that increased awareness of and confidence to use/recommend evidence-based apps via curated, public health app portals among healthcare professionals and patients may help to speed up the adoption process.
The potential for public health app portals
As part of her PhD project, funded by Public Health England, Dorothy is in the process of developing and evaluating a web-based intervention, delivered via a public health app portal, to increase the adoption of health and wellbeing apps in England. Her ongoing qualitative research aims to explore potential users’ views on available public health app portals (e.g. One You Apps), with a view to identifying areas for improvement. Early findings suggest that the majority of participants weren’t aware of existing portals, although a few had heard of some of the apps listed through social media. All participants recognised the benefit of the portals and expressed their trust in and respect towards the National Health Service/Public Health England. However, the manner in which the apps are currently presented on the portals did not meet users’ expectations and led them to continue their searches in commercial app stores. Participants thought that the apps are not as clearly presented on current health portals (as compared with commercial app stores), and a few users did not manage to find an app for their key behaviour of interest. It should be noted that, at the time of the interviews, no smoking cessation app was listed on the NHS Apps Library, and only one was listed on the One You Apps portal. The next step is to use these findings to inform the development of an intervention to promote the adoption of health and wellbeing apps, delivered by a real or sham public health app portal.
- What is the role of national health organisations (e.g. the National Health Service, Public Health England) in promoting evidence-based digital behaviour change aids?
- What is the best strategy for redirecting people interested in digital behaviour change aids from commercial app stores to public health app portals?
Dr Olga Perski is a Research Associate in the UCL Tobacco and Alcohol Research Group. Her research focuses on the development and evaluation of digital aids for smoking cessation and alcohol reduction.
Dorothy Szinay is a PhD candidate at the University of East Anglia. Her research focuses on the development and evaluation of web-based interventions to increase the uptake of and engagement with health and wellbeing smartphone apps.
By Emma Norris, on 9 October 2019
By Emma Norris, Gjalt-Jorn Y. Peters, Neža Javornik, Marta M. Marques, Keegan Knittle, Alexandra Dima
The European Health Psychology Society (EHPS) had its 2019 conference from 4-7th September in Dubrovnik, Croatia. The packed programme featured a wide range of research across health psychology, including digital interventions, theoretical and methodological advances, chronic illness, preventive health and much more.
This extended blog summarises a symposium in showcasing novel techniques and tools for intervention specification entitled ‘Understanding intervention effectiveness: analysing potential for change, improving intervention reporting, and using machine-readable decision justification’. The symposium aimed to address an urgent question in health psychology: How can we design more effective interventions? The 5 presentations presented practical tools to support researchers in our united mission to increase our understanding of intervention effectiveness and better support population health. We present a summary of each presentation, followed by some concluding thoughts and questions from the symposium’s discussant Dr Alexandra Dima.
You can find the slides for the symposium here: https://osf.io/hvkaz/
Potential for change (PΔ): New metrics for tailoring and predicting response to behaviour change interventions – Keegan Knittle, University of Helsinki
A novel integrative construct, potential for change (PΔ), accounts for ceiling/floor effects to predict an individual’s likelihood of response to an intervention. Using baseline data from a randomised controlled trial testing the ‘Let’s Move It’ physical activity promotion intervention, the team calculated determinant-level PΔ scores for 12 named theoretical determinants in the intervention. They then calculated ‘PΔ-global’, the mean of the 12 PΔ-determinant scores, weighted by each determinant’s association with MVPA at baseline. In this way, PΔ could also be seen as a measure of the extent to which a theory underlying an intervention matches with an individual intervention recipient. Among intervention recipients, PΔ-global followed a normal distribution and was significantly related to increases in accelerometer-measured MVPA (r=.269; p<.001) and self-reported days per week with at least 30 minutes of MVPA (r=.175; p=.001): the intervention’s primary outcomes. Hence using data from the Let’s Move It study, PΔ-global accounted for floor/ceiling effects and predicted response to a theory-based behaviour change intervention. Possible future uses of PΔ include applying it to time-series data of individual determinants as a means to tailor intervention delivery.
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Reporting the characteristics of treatment-as-usual in health behavioural trials – Neža Javornik, University of Aberdeen
Treatment-as-usual (TAU), a common comparator in health behavioural trials, allows us to establish how effective an intervention is against an existing standard treatment, provided in a certain setting. Such treatment, typically delivered in person, can vary in different characteristics (e.g. who provided the treatment, how, how long it lasted for, what it contained) and influence behaviour and health outcomes between control group participants, and thus trial effect sizes, differently (e.g. de Bruin et al., 2009, 2010). For the interpretation and comparison of trials it is important that readers and systematic reviewers have a clear understanding what TAU in a particular trial consisted of. This requires some standard format for TAU reporting that the present study attempted to identify.
A narrative review was first conducted to identify the potentially important TAU characteristics, which were mapped onto existing reporting frameworks (Intervention Mapping, TIDieR and BCT Taxonomy v1). The identified characteristics were used to inform a modified Delphi expert consensus study, which aimed to identify the necessary and recommended TAU characteristics, and how detailed their reporting should be. Five stakeholder groups (N = 25) participated in anonymous online voting and discussion. The critical TAU characteristics to report at a general level of detail were primary health behaviours, active content, tailoring of active content, duration characteristics (frequency, number and length of sessions), the profession of the provider, and any major deviations from the intended TAU characteristics. Setting characteristics (location, setting, mode, rural/urban characteristics) were thought to be critical to report at the level of every clinic. This allows for understanding how TAU should be reported when describing health behavioural trials. In turn, that can lead to better understanding, interpretation and comparison of trials with a TAU comparator.
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Acyclic Behaviour Change Diagrams: human- and machine readable reporting of what interventions target and how – Gjalt-Jorn Ygram Peters, Open University of the Netherlands
To progress behaviour change science, research syntheses are crucial. However, they are also costly, and unfortunately, often yield relatively weak conclusions because of poor reporting. Specifically, in the context of behaviour change, the structural and causal assumptions underlying behaviour change interventions are often poorly documented, and no convenient yet comprehensive format exists for reporting such assumptions.
In this talk, Acyclic Behaviour Change Diagrams (ABCDs) were introduced. ABCDs consist of two parts. First, there is a convention that allows specifying the assumptions most central to the dynamics of behaviour change in a uniform, machine-readable manner. Second, there is a freely available tool to convert such an ABCD specification into a human-readable visualisation (the diagram), included in the open source R package ‘behaviorchange’.
ABCD specifications are tables with seven columns, where each row represents one hypothesized causal chain. Each chain consists of a behaviour change principle (BCP), for example a BCT, that leverages one or more evolutionary learning processes; the corresponding conditions for effectiveness; the practical application implementing the BCP; the sub-determinant that is targeted, such as a belief; the higher-level determinant that belief is a part of; the sub-behaviour that is predicted by that determinant; and the ultimate target behaviour. The ABCD is illustrated using an evidence-based intervention to promote hearing protection.
ABCDs conveniently make important assumptions underlying behaviour change interventions clear to editors and reviewers, but also help to retain an overview during intervention development or analysis. Simultaneously, because ABCD specifications are machine-readable, they maximize research synthesis efficiency.
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Development of an ontology characterising the ‘source’ delivering behaviour change interventions – Emma Norris, University College London
Understanding who delivers interventions, or the ‘source’ of interventions, is an important consideration in understanding an intervention’s effectiveness. However this source is often poorly reported. In order to accumulate evidence across studies, it is important to use a comprehensive and consistent method for reporting intervention characteristics, including the intervention source. As part of the Human Behaviour-Change Project, this study used a structured method to develop an ontology specifying source characteristics, forming part of the Behaviour Change Intervention Ontology.
The current version of the Source Ontology has 196 entities covering Source’s occupational role, socio-demographics, expertise, relationship with individuals targeted by the intervention, and whether the source was paid to deliver the intervention. The Source Ontology captures key characteristics of those delivering behaviour change interventions. This is useful for replication, implementation and evidence synthesis and provides a framework for describing source when writing and reviewing evaluation reports.
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Enhancing research synthesis by documenting intervention development decisions: Examples from two behaviour change frameworks – Marta M. Marques, Trinity College Dublin & Gjalt-Jorn Y. Peters, Open University of the Netherlands
To support the development of behaviour change interventions, there is a considerable amount of guidance (e.g. Intervention Mapping) on how to select behaviours, identify behavioural determinants, and select methods/techniques. When it comes to decisions about which modes of delivery are best for certain methods, and how they should be designed, there is little guidance.
While researchers make these decisions during the development of interventions, these decisions are not well documented, and as such, opportunities to learn from the justifications of those decisions are lost. An easily usable, systematic, efficient and machine-readable approach to reporting decisions and justifications of such decisions would improve this situation and enable accumulation of knowledge that at present remains largely implicit.
We introduced ‘justifier’, an R package that allows reading and organizing fragments of text that encode such decisions and justifications. By adhering to a few simple guidelines, the meeting minutes and documentation of the intervention development process become machine-readable, enabling aggregation of the decisions and their evidence base over one or multiple intervention development processes. Tools such as heat-maps can be used to visualise these patterns, quickly making salient where decisions were based on higher and lower quality evidence.
We presented examples of key decisions to justify during intervention development, using common steps in the Intervention Mapping Protocol and the Behaviour Change Wheel. Using the proposed ‘justifier’ format document the decisions and their justifications in these key domains provides greater insight in the intervention development process.
Link to talk: https://osf.io/zmb3g/
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Discussion: Why and when would research teams use these tools? – Alexandra Dima, Health Services and Performance Research, University Claude Bernard Lyon 1, France
Participating in a symposium that introduces 5 new tools for intervention development and reporting (or reading a blog about such symposium) may generate mixed feelings of enthusiasm and anxiety. On one hand, as it has been previously stated at the EHPS conference, it is an exciting time to be a researcher. We have the possibility to do better work and communicate better about it, so that our individual contributions can add to the common edifice of evidence. On the other hand, ‘5 new tools’ also means ‘5 new ideas’ to get one’s head around, convince others of their importance for the project, and link to specific actions or habits to integrate in the workflow. Most likely, on top of 100 more ideas one needs to master during a usual research project – assuming there is time and funding to adopt them all and work towards best practices in research, and the resulting high-quality evidence. Getting to grips with these new tools requires effort, and we should not underestimate the cost involved. On the contrary, we need to plan for it. Yet, I would argue that these 5 tools, if used adequately and at the right moment in the research process, have the potential to save costs. They do this by making it easier to ask some good but uncomfortable questions which are unavoidable in any intervention development and reporting process.
First, asking the question ‘Is there any potential for change in the target behaviour and its determinants?’ is among those key uncomfortable questions at the beginning of an intervention study. In principle one would need at least an estimation of mean and standard deviation for a sample size calculation to move on. The PΔ scores ask this question also at the individual level and thus confront us with a key conceptual puzzle: if you know that participants vary in their potential to be influenced by the intervention, should you control for it to estimate the ‘real’ effect of the intervention? PΔ scores propose a way to quantify this variation – if baseline data indicate large variations, then tailoring needs to be considered.
Second, variation is not only present in the target group, but also in the services available to them at baseline, raising another uncomfortable question: “what is already there in terms of behaviour change activities, or ‘treatment-as-usual’?”. The TAU characteristics checklist is also best considered at the beginning of intervention development. If you are planning a multi-centric study, it is even more important to ask these questions early since this is in a way a PΔ for the participating centers. Considering this checklist brings with it numerous options to consider about the intervention itself. Would it be better to add an extra service or modify the work of existing providers? Would it be beneficial or even possible to improve standardization, granularity, and reporting in current practice? Finding a balance between benefit and feasibility starts with TAU characterization.
A third uncomfortable question is: ‘who is going to do it?’ The Source Ontology gives us the common dictionary (for humans and machines alike) to report this clearly, but it’s initial value is in my opinion also as a decision tool. Once you know what 196 types of sources are available you just can’t avoid this question. No, it is not obvious that the pharmacist, or the schoolteacher, will do it. In a time of evolution towards integrated care, this question will quickly take us to the revelation that most behaviour change processes are supported by several types of people and organization, and the effect of TAU or interventions is the result of all these.
Fourth, once you are well into intervention development and start getting answers to these initial questions, another, maybe even more uncomfortable question pops up: ‘what is the logic of what we are trying to do?’. At this moment you are safer from forgetting to ask basic questions, but the dangers of lack of coherence and making choices you will regret later on is still high. ABCD props you to do the right thing: have a visual check of consistency first for yourself and then to discuss with the research team and stakeholders and make sure everyone has a chance to input at this stage and pick up any awkward or missing links. ABCD will come in handy also when reporting and for systematic reviews, if research teams will use it consistently for similar studies. But there will be little to report if ABCD, and the intervention development process it supports, are not used routinely in the development phase.
And finally, an uncomfortable and apparently innocent question with profound consequences throughout the process is: ‘what decisions should we document and how?’ The other 4 tools point to various choices which, if not taken consciously, may impact unexpectedly on intervention effectiveness and evidence quality. Justifier proposes a way to make these choices and record the decisions in a way that can be accessed automatically and tested in systematic reviews. Imagining a world in which such tools become routine practice, in time and with adequate coordination between research teams we will be able to compare these choices in terms of intervention and evidence-related outcomes. But the more tangible benefit for the individual researcher is building good habits for writing meeting minutes that can be used for feedback on the development process.
Link to Discussion talk: https://osf.io/up4t9/
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If you are setting up an intervention project currently, this would be a good moment to ask yourself whether you could test these tools in your project, and where. The symposium presenters have all been there and are happy to advise. For the EHPS community, and other groups interested in health behaviour change, it is time to ask ourselves how to coordinate support for research teams worldwide to have easier access and training for implementing methodological innovations in their work and, most importantly, to test their effectiveness in real research practice.
You can find the slides for the symposium here: https://osf.io/hvkaz/
Alexandra Dima (@a__dima) is a Senior Research Fellow in Health Sciences at Université Claude Bernard Lyon.
Neža Javornik (@NJavornik) is a PhD student in the Health Psychology Group at the University of Aberdeen.
Marta M. Marques (@marta_m_marques) is a Marie Skłodowska-Curie Fellow at Trinity College Dublin, and Honorary Research Fellow at the Centre for Behaviour Change, University College London
Gjalt-Jorn Y. Peters (@matherion) is an Assistant Professor in Methodology, Statistics and Health Psychology at the Open University of the Netherlands.
Keegan Knittle (@keeganknittle) is a University Researcher at the University of Helsinki focusing on understanding people’s motivations for behaviour.