Implementing Germ Defence digital behaviour change intervention via all primary care practices in England to reduce respiratory infections during the COVID-19 pandemic: an efficient cluster randomised controlled trial using the OpenSAFELY platform. (preprint)

Background:  Germ Defence (www.germdefence.org) is an evidence-based interactive website that promotes behaviour change for infection control within households. To maximise the potential of Germ Defence to effectively reduce the spread of COVID-19 the intervention needed to be implemented at scale rapidly. Methods: With the approval of NHS England, we implemented an efficient two-arm (1:1 ratio) cluster randomised controlled trial (RCT) to examine the effectiveness of randomising implementation of Germ Defence via GP practices across England, UK, compared with usual care. GP practices randomised to the intervention arm (n=3292) were emailed and asked to disseminate the Germ Defence intervention to all adult patients via mobile phone text, email or social media. GP practices randomised to the usual care arm (n=3287) maintained standard management for the 4-month trial period after and then asked to share Germ Defence with their adult patients.  The primary outcome was the rate of GP presentations for respiratory tract infections (RTI) per patient. Secondary outcomes comprised rates of acute RTIs, confirmed COVID-19 diagnoses, suspected COVID-19 diagnoses, COVID-19 symptoms, gastrointestinal infection diagnoses, antibiotic usage, hospital admissions.  The impact of the intervention on outcome rates was assessed using negative binomial regression modelling within the OpenSAFELY platform. The uptake of intervention by GP practice, and by patients were measured via website analytics. Results: Germ Defence was used 310,731 times. The average satisfaction score after using the website was 7.52 (0-10 not at all to very satisfied, N = 9933). There was no evidence of a difference in the rate of RTIs between intervention and control practices (rate ratio (RR) 1.01, 95%CI 0.96, 1.06, p=0.70). This was similar to all other eight health outcomes. Patient engagement within intervention arm practices ranged from 0- 48% of a practice list. Practices with high levels of intervention uptake (>11%) had a lower proportion of minority ethnic groups. Conclusions:  We demonstrated that rapid large-scale implementation of a digital behavioural intervention can be evaluated with a novel efficient prospective RCT methodology analysing routinely collected patient data entirely within a trusted research environment. Trial registration: This trial was registered in the ISRCTN registry (14602359) on 12 August 2020.

Infection control in the home: A qualitative study exploring perceptions and experiences of adhering to protective behaviours in the home during the COVID-19 pandemic (preprint)

We sought to explore people’s perceptions of adhering to infection control behaviours in the home during the COVID-19 pandemic in order to increase our understanding of adherence, and to inform the adaptation of an online behavioural intervention called Germ Defence. Thirteen participants completed thinkaloud interviews. Data were analysed using thematic analysis. The interviews were triangulated with open-ended survey data from 124 participants.Thematic analysis generated 7 themes; perceived risk, belief in the efficacy of protective behaviours, acceptability of the behaviours, having capacity to perform the behaviours, habit forming reduces effort involved in the behaviours, having the confidence to perform the behaviours, and social norms affecting motivation to engage in the behaviours. Behaviours such as isolating and social distancing at home were identified as less acceptable than cleaning and handwashing, influenced by the need for connection and intimacy with other household members. This was especially true in the absence of symptoms and when levels of perceived risk were low. People felt more empowered when they understood that even small changes, such as spending some time apart, were worthwhile in order to reduce exposure and lessen viral load.The current study provided valuable insight into the acceptability and feasibility of the protective behaviours, and how behavioural guidelines could be presented to the public during a pandemic. The findings were used to directly inform the optimisation of the Germ Defence intervention.

Current infection control behaviour patterns in the UK, and how they can be improved by 'Germ Defence', an online behavioural intervention to reduce the spread of COVID-19 in the home. (preprint)

Background: Germ Defence (https://germdefence.org/) is a freely available website providing behavioural advice for infection control within households, using behaviour change techniques. This observational study reports current infection control behaviours in the home in UK and international users of the website, and examine how they might be improved to reduce the spread of COVID-19. Method: 28,285 users sought advice from four website pathways (to protect themselves generally, to protect others if the user was showing symptoms, to protect themselves if household members were showing symptoms, and to protect a household member who is at high risk) and completed outcome measures of current infection control behaviours within the home (self-isolation, social distancing, putting shopping/packages aside, wearing face-covering, cleaning and disinfecting, handwashing), and intentions to change these behaviours. Results: Current user behaviours mean scores varied across all infection control measures but were between 'sometimes' and 'quite often', except handwashing ('very often'). Behaviours were similar regardless of the website pathway used. After using Germ Defence, users recorded intentions to improve infection control behaviour across all website pathways and for all behaviours. Conclusions: Self-reported infection control behaviours other than handwashing are lower than is optimal for infection prevention, although reported handwashing is much higher. The advice using behaviour change techniques in Germ Defence led to intentions to improve these behaviours. This has been shown previously to reduce the incidence, severity and transmission of infections. These findings suggest that promoting Germ Defence within national and local public health guidance could reduce COVID-19 transmission.