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Research on changing behaviour within/beyond the health care setting
Lucy Yardley, Sascha Miller, Ben Ainsworth Centre for Applications of Health Psychology
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Key behaviours contributing to antibiotic stewardship
• preventing infections occurring and spreading
• reducing inappropriate antimicrobial demand and use
(by targeting health professional and/or public behaviour)
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Reducing inappropriate antimicrobial demand/use EU-funded project led by Paul Little, primary
care: ‘GRACE/INTRO’
• web-based GP education (plus patient booklet) to reduce antibiotic prescribing/resistance across Europe
• intervention created in English by CAHP team, translated/modified for Spain, Poland, Belgium, Netherlands
• trialled in 246 practices, successfully reduced prescribing ca. 20% (Lancet, 2014)
• about to be disseminated via CLAHRC
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Using the LifeGuide software to develop the intervention
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Reducing inappropriate antimicrobial demand/use ‘Internet Dr’
(with Paul Little, Mike Moore, Judy Joseph, Steph Hughes)
Web-based self-care advice for respiratory symptoms to reduce GP consultations (hence antibiotic use)
Successfully trialled in students and primary care
Included in CLAHRC rollout of INTRO
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Preventing infections occurring and spreading Behaviour to reduce transmission of pandemic flu
DoH-funded inter-institution collaboration, led by PHE (Influence)
Developed/evaluated (using mixed methods) messages to promote vaccination uptake, antiviral use
Behaviour to reduce transmission of respiratory infection in the home
Handwashing intervention: PRIMIT
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PRIMIT WEBSITE: INCREASING HAND-WASHING TO
LOWER TRANSMISSION OF INFECTIONS
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RANDOMISED CONTROLLED TRIAL
• Aim to lowering number of illnesses & severity at home
• 20,066 participants over 3 winters
• Households of 2 or more
• Measures at baseline, 1, 2 & 3 months
• Colds, flu & gastrointestinal viruses
• Sample cross-checked with GP notes & nasal swabs
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WEBSITE LAYOUT
• 4 sessions across 3.5 weeks
• Tunnelled section then menu
• Tailored content: demograph, daily
handwashing level, feedback
• 4 types of content: motivational,
information, planning, tailored
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SESSION 1, TUNNELLED PAGES, MOTIVATION
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MOTIVATION
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PLANNING
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PLANNING, TAILORED
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PLANNING, TAILORED
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PLANNING
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FURTHER SESSIONS, TUNNELLED PAGES
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RCT FINDINGS
• Handwashing 10+ times a day at final measure:
• 53.1% of intervention group
• 36.6% of control group
• Fewer consultations in intervention group
• Fewer gastrointestinal infections in intervention group
• No effects of gender, age, deprivation on outcomes
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How did the PRIMIT website
change hand hygiene behaviour? Analysis of behaviour change in study
of 19000 people
Ben Ainsworth, Mary Steele, Beth Stuart, Judith Joseph, Paul Little & Lucy Yardley
@benainsworth
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Relationship of TPB constructs to hand-washing
Construct Change across time
M (SD) Association with
change in behaviour
Intention +0.94 (1.2) r(6050) = .46
Attitude +0.47 (.97) r(6049) = .30
Perceived Behavioural Control +0.59 (1.6) r(5959) = .17
Perceived Risk +0.12 (1.36) r(5938) = .11
Subjective Norms +0.73 (1.61) r(5957) = .26
• Used pre-post questionnaires to determine associations
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What mediated behaviour change?
Usage Analysis
3 ways to investigate:
– Website session usage (did any session / pattern of sessions lead to hand-washing increase?)
– Content (did any particular content lead to hand-washing increase?)
– Population demographics (Did individual differences lead to different use of the website?)
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Website usage (Sessions 1 - 4)
Session visited Number (/8993) %
1 8843 98.3
2 6636 73.8
3 5411 60.2
4 4850 54.0
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Website usage (sessions 1 to 4– in relation to behaviour)
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
4.5
5.0
One Two Three Four
Baseline Follow-up
• Similar outcomes observed regardless of whether users logged in 1-4 times (overall effect size hp
2 = .003). • Supports notion that ‘impact’ is in first session. • No difference between groups for intention change across 16-weeks
(F = 2.2, p = .09)
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What mediated behaviour change?
Usage Analysis
3 ways to investigate:
– Website session usage (did any session / pattern of sessions lead to hand-washing increase?)
– Content (did any particular content lead to hand-washing increase?)
– Population demographics (Did individual differences lead to different use of the website?)
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What mediated change in handwashing? _ PRIMIT Intervention Design
Tailored content
Information pages
Motivational pages
If-then planning
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Website usage (Session 1 subdivision)
Lifeguide visualisation tool used to determine common usage pathway patterns.
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Website usage (TPB Codings) – in relation to Session 1 outcome
0.00
0.05
0.10
0.15
0.20
0.25
0.30
0.35
0.40
0.45
0.50
Enhance motivation If-then planning Tailored feedback Information Provision
No Yes
• Note: confound of ‘order effect’ (i.e. users progress through website in specific order)
Content Effect size (dcorr)
Enhance motivation
0.36
If-then planning
0.35
Tailored Feedback
0.33
Information Provision
0.11
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What mediated behaviour change?
Usage Analysis
3 ways to investigate:
– Website session usage (did any session / pattern of sessions lead to hand-washing increase?)
– Content (did any particular content lead to hand-washing increase?)
– Population demographics (Did individual differences lead to different use of the website?)
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Dose effect – did session 1 have a different effect in women vs. men, or in +40 vs -40
• No gender differences for number of sessions used. • Younger users more likely to use 1 or 2 sessions, but not to continue until end.
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Conclusions & Implications
• Importance of if-then planning for habitual behaviour
• Sustained engagement with website unnecessary
• Value of detailed usage analysis
- more in-depth analysis can look at specific variables for specific interventions
• Interventions with less linear structure will allow better testing of specific components
- not always possible.
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Thank you for listening!
@benainsworth