Barriers and facilitators to sustainable operating theatres: a systematic review using the Theoretical Domains Framework.

BACKGROUND: The health sector contributes significantly to the climate crisis. Operating theatres (OTs) in particular are a major contributor of greenhouse gas emissions and waste, and while there are several evidence-based guidelines to reduce this impact, these are often not followed. The authors systematically reviewed the literature to identify barriers and facilitators of sustainable behaviour in OTs, categorising these using the Theoretical Domains Framework (TDF). MATERIALS AND METHODS: Medline, Embase, PsychInfo, and Global Health databases were searched for articles published between January 2000 and June 2023, using the concepts: barriers and facilitators, sustainability, and surgery. Two reviewers screened abstracts from identified studies, evaluated quality, and extracted data. Identified determinants were mapped to TDF domains and further themes as required. The results were reported in line with PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) and AMSTAR (A MeaSurement Tool to Assess Systematic Reviews) guidelines. RESULTS: Twenty-one studies were selected for analysis and assessment (17 surveys and four interview studies) comprising 8286 participants, including surgeons, nurses, and anaesthetists. Eighteen themes across 10 TDF domains were identified. The most common barriers to adoption of green behaviours in OTs were in domains of: 'knowledge' ( N =18), for example knowledge of sustainable practices; 'environmental context and resources' ( N =16) for example personnel shortage and workload and inadequate recycling facilities; 'social influences' ( N =9) for example lack of leadership/organisational mandate or support; 'beliefs about consequences' ( N =9) for example concerns regarding safety. Intention was the most common facilitator, with 11 studies citing it. CONCLUSIONS: Despite intentions to adopt sustainable practices in OTs, this review identified several barriers to doing so. Interventions should focus on mitigating these, especially by improving staff's knowledge of sustainability practices and working within the environmental context and time pressures. Furthermore, institutional change programmes and policies are needed to prioritise sustainability at the hospital and trust level. Additional qualitative work should also be conducted using behavioural frameworks, to more comprehensively investigate barriers and determinants to decarbonise OTs.

An SMS and animated video intervention to increase uptake of breast cancer screening: a randomised controlled trial.

BACKGROUND: Breast cancer screening attendance in the UK has fallen, and London has the lowest uptake nationally. This study tested the impact of a behavioural science-informed reminder SMS, and animated video intervention on screening uptake. METHODS: This three-armed randomised controlled trial took place in two screening services in London (each service operated across a range of static sites such as hospitals, and mobile sites). We included participants who were registered with GP as female, aged 50-70 years, and not screened in the past 3 years. We excluded those who had opted out of screening messages or were in care. Participants were assigned into three groups via the final two digits of their NHS number (ratio 34:33:33): control group (received usual care reminder), behavSMS group (behavioural science-informed SMS reminder addressing reducing negative emotions and information on health consequences), or behavSMS+video group (behavioural SMS plus link to animation). Researchers were masked to allocation. The SMS and video were co-designed with stakeholders using the Behaviour Change Wheel. Invitation processes changed during the COVID-19 pandemic, and therefore, we did separate analyses for those receiving a timed appointment (n=9027), and an open invitation to book an appointment (n=25 020). Messages were sent 7 days and 1 day before the appointment, plus 7 days after the open invitation letter. Group differences in the primary outcome of attendance within 3 months of invitation (and secondary outcome of booking for open invites) were assessed using χ2, and logistic regression controlling for age, ethnicity, deprivation, and first invitation. This trial is registered with ClinicalTrials.gov, NCT05395871. FINDINGS: Recruitment took place between July 18, and Oct 21, 2022. For timed invitations, 3094 participants were assigned to the control group, 2952 to the behavSMS group, and 2981 to the behavSMS+video group. For open invitations groups sizes were 8654, 8095, and 8271 respectively. Median age was 59 years for participants who received a timed appointment, and 58 years for those who received an open invitation. There were no attendance differences for timed appointments (intention-to-treat analysis): 71·9% (2225/3094) in control group; 69·9% (2064/2952) in behavSMS group; 71·7% (2137/2981) in behavSMS+video group (χ2(2)=3·47, p=0·176), even when controlling for covariates. There were no attendance differences for open invitations either: 7·4% (4104/8654) in control group, 8·3% (3909/8095) in behavSMS group, 48·1% (3978/8271) in behavSMS+video (χ2(2)=1·40, p=0·497), including when controlling for covariates. However, in the per-protocol analysis (of those with valid mobile numbers), intervention groups were more likely to book an appointment: 44·7% (3238/7274) in control group, 46·3% (3121/6744) in behavSMS group, and 46·3% (3199/6910) in behavSMS+video group (χ2(2)=6·01, p=0·050). INTERPRETATION: Despite positive stakeholder feedback during co-design, the SMS or SMS+video interventions did not increase breast screening attendance compared with the usual SMS reminder. A limitation is that only 5·8% participants followed the video link. Links within SMS are unlikely to be an effective way to disseminate video content, and alternative options are being explored. FUNDING: NHS England and National Institute for Health and Care Research (NIHR).

Improving the quality of written communication at patient discharge: triangulation of qualitative analyses and intervention co-design.

BACKGROUND: Poor handovers between hospital and primary care threaten safe discharges, with elderly and frail patients most at risk of harm. Using Behavioural Science we explored influences and identified relevant behaviour change techniques (BCTs) to improve written handovers and safety during discharge. METHODS: We conducted two qualitative studies: (1) ethnographic observations (>80 h) collected by five researchers in five purposively sampled clinical areas of a London teaching hospital, investigating routine work and interactions of hospital staff involved in discharges; and (2) 12 semi-structured interviews with hospital staff involved in discharge exploring influences on preparations of written handovers. Written consent was sought from clinical leads for ethnographic observations and from interview participants. Ethnographic fieldnotes and interview transcripts were thematically analysed using inductive and deductive approaches, respectively. Study findings were triangulated to identify key influences, mapped onto the Theoretical Domains Framework (TDF). We identified appropriate BCTs to address observed influences within each TDF domain using the Theory and Techniques Tool. Health-care workers (n=15), patients (n=2) and carers (n=2) selected and designed an intervention to improve written handovers in two workshops. Hospital workshop participants were involved with preparing written discharge handovers. Public participants had either recently been discharged from hospital or cared for someone recently discharged, including patients from groups especially vulnerable during discharge. FINDINGS: Triangulation of study findings generated 11 key influences on preparations of written handovers within five TDF domains: knowledge (eg, lack of awareness of guidelines), skills (staff experience), social or professional role and identity (effective communication), environmental context and resources (working patterns), and social influences (lack of feedback). 14 BCTs were identified to address these influences, including behavioural rehearsal or practice, instruction on how to perform a behaviour, and social support (practical). Workshop participants selected and designed a multifaceted educational intervention to improve written handovers. INTERPRETATION: The quality of handover documentation prepared by hospital staff for primary care teams is affected by influences from multiple domains, requiring a multifaceted approach to improve handovers. Although only based on findings from one hospital, the designed intervention should be tested in clinical settings with key stakeholders, including primary care staff, to evaluate impact on quality of written handovers and patient safety. FUNDING: National Institute for Health and Care Research (NIHR) Imperial Patient Safety Translational Research Centre.

Impact of messaging informed by behavioural science on uptake of targeted lung health checks: a service evaluation.

BACKGROUND: Lung cancer is the most common cause of cancer death in the UK, and incidence is strongly associated with increasing age. Screening can improve survival by detecting cancer earlier. Targeted Lung Health Check (TLHC) programme is a lung cancer screening pilot offered to smokers or ex-smokers aged 55-74 years in certain areas of England. However, uptake remains as low as 20% in London. We did a service evaluation to assess the effect of adding messaging informed by behaviour science to invitation letters on TLHC uptake. METHODS: The intervention involved adding to the standard invitation letter a box with a two-sentence behavioural message targeted at mitigating fatalistic beliefs and low risk perception, as well as promoting clinician endorsement and the value of early detection. Allocation to receive either standard or intervention letters was done at West London GP practice level, with approximate pairing between practices. From Sept 22, 2022, to Nov 28, 2022, 9464 invitations were sent to eligible individuals (4842 standard and 4622 intervention) covering 20 GP practices. The primary outcome (uptake) was a booked appointment date within 4 months of the invitation letter being sent. TIDieR checklist was used for methodology and reporting guidelines. We used χ2 analysis to test for significant differences in uptake, and mixed-effects logistic regression to control for demographic covariates. FINDINGS: Demographic characteristics were similar in the control and intervention groups, with mean ages of 63·3 and 63·0 years, average index of multiple deprivation (IMD) deciles of 6·33 and 5·53, and percentage of female participants 42·1% (n=2038) and 43·7% (n=2022), respectively. Uptake of TLHC was significantly higher in the intervention group (25·8%, n=1192) than in the control group (20·4%, n=987; χ2(1)=38·762, p<0·0001). A logistic regression model estimated likelihood of uptake was 37·5% (95% CI 12·1-63·2) higher in the intervention group (p=0·004). Patients aged 60-64, 65-69 and 70-75 years were 23·5% (10·7-36·3, p=0·0003), 28·3% (14·5-42·0, p<0·0001), and 32·6% (18·3-47·0, p<0·0001) more likely to attend than those aged 55-59 years. The likelihood of attendance decreased on the basis of deprivation (IMD decile; b=0·060, 95% CI 0·035-0·087, p<0·0001), female gender (b=0·156, 0·057-0·254, p=0·002), and for ex-smokers compared with smokers (b=0·580, 0·467-0·693, p<0·0001). INTERPRETATION: This simple, no-cost addition of behavioural messaging to invitation letters can significantly improve screening uptake and is recommended for wider rollout. These findings are consistent with other studies. However, a limitation is that the allocation to study arm was at GP practice level and the study was not randomised. FUNDING: RM Partners, the West London Cancer Alliance.

Patient financial incentives to improve asthma management: a systematic review.

OBJECTIVES: The objectives of this systematic review are to identify studies that assess the effectiveness of patient-directed financial incentive interventions to improve asthma management behaviours, determine overall effectiveness of financial incentives, identify design characteristics of effective interventions and assess the impact on longer-term outcomes in the context of asthma. DESIGN: Systematic review with narrative synthesis. DATA SOURCES: Electronic databases (MEDLINE, Embase, Global Health, PsycINFO, CINAHL, PubMed and Web of Science) and grey literature sources (NHS Digital, CORE, ProQuest, Clinical Trials Register and EU Clinical Trials Register) were searched in November 2021 and updated March 2023. ELIGIBLITY CRITERIA: Eligible articles assessed financial incentives to improve asthma management behaviours (attendance at appointments, medication adherence, tobacco smoke/allergen exposure, inhaler technique and asthma education) for patients with asthma or parents/guardians of children with asthma. Eligible study design included randomised controlled, controlled or quasi-randomised trials and retrospective/prospective cohort, case-controlled or pilot/feasibility studies. SYNTHESIS: A narrative synthesis was conducted; eligible studies were grouped by asthma management behaviours and financial incentive framework domains. RESULTS: We identified 4268 articles; 8 met the inclusion criteria. The studies were from the USA (n=7) and the UK (n=1). Asthma management behaviours included attendance at appointments (n=4), reduction in smoke exposure (n=1) and medication adherence (n=3). Five studies demonstrated positive behaviour change, four of which were significant (attendance at appointments (n=3) showed significant differences between intervention and control: 73% and 49% in one study, 46.3% and 28.9% in another, and 35.7% and 18.9%, respectively; medication adherence (n=1) showed significant change from 80% during intervention to 33% post intervention). These four significant studies used 'positive gain', 'certain', 'fixed' financial incentives of smaller magnitude, given for 'all' instances of behaviour. CONCLUSION: There is some evidence that patient-directed financial incentives improve asthma management behaviours. However, in view of the wide heterogeneity in study design and measured outcomes, determining overall effectiveness was challenging. PROSPERO REGISTRATION NUMBER: CRD42021266679.

Investigating the national implementation of SMS and mobile messaging in population screening (The SIPS study).

BACKGROUND: The increasing use of mobile messaging within healthcare, poses challenges for screening programmes, which involve communicating with large, diverse populations. This modified Delphi study aimed to create guidance regarding the use of mobile messaging for screening programmes, to facilitate greater, and equitable screening uptake. METHODS: Initial recommendations were derived from a literature review, expert scoping questionnaire, public consultation, and discussion with relevant national organisations. Experts from the fields of public health, screening commissioning, industry and academia voted upon the importance and feasibility of these recommendations across two consensus rounds, using a 5-point Likert scale. Items reaching consensus, defined a priori at 70%, on importance and feasibility formed 'core' recommendations. Those reaching this threshold on importance only, were labelled 'desirable'. All items were subsequently discussed at an expert meeting to confirm suitability. FINDINGS: Of the initial 101 items, 23 reached consensus regarding importance and feasibility. These 'core' items were divided across six domains: message content, timing, delivery, evaluation, security, and research considerations. 'Core' items such as explicitly specifying the sender and the role of patient involvement in development of screening message research had the highest agreement. A further 17 'desirable' items reached consensus regarding importance, but not feasibility, including the integration into GP services to enable telephone verification. INTERPRETATION: These findings forming national guidance for services, will enable programmes to overcome implementation challenges and facilitate uptake of screening invitations. By providing a list of desirable items, this study provides areas for future consideration, as technological innovation in messaging continues to grow. FUNDING: NIHR Imperial Patient Safety Translational Research Centre.

Feasibility and acceptability of a personalised script-elicitation method for improving evening sleep hygiene habits.

Background: Attempts to improve evening sleep hygiene have overlooked that sleep preparation behaviours are often undertaken automatically with little awareness; that is, habitually. This mixed-methods study assessed aspects of the feasibility and acceptability of a novel behavioural intervention procedure ('script elicitation'), which encourages reflection on and reorganisation of the content and sequencing of habitual evening pre-sleep routines. Methods: The study was advertised via social media, and circular lists at a UK university. Twenty-four UK-based adults, reporting <6 h/night sleep, were recruited. At baseline, they completed sleep hygiene and quality measures, then participated in an online, one-to-one script elicitation interview. This involved the interviewer working with the participant to generate a fine-grained description of the content, organisation and variability of their typical pre-sleep routine, and plan a more sleep-conducive alternative routine to follow over the next week. One week later, participants completed sleep quality and hygiene measures, and a semi-structured interview about the intervention. Feasibility was assessed using quantitative data on response rates and attrition, and acceptability via sleep hygiene and quality scores, and qualitative data on intervention experiences. Results: All criteria were met. The target response rate was exceeded, none of the 24 participants dropped out, and sleep hygiene and quality scores either improved or remained stable. In interviews, all participants reported finding script elicitation useful. Script elicitation raised participants' awareness of habitual sleep hygiene routines, which gave many a newfound sense of autonomy over changing their sleep hygiene habits. While the habitual nature of existing routines obstructed change for some participants, most reported successfully changing aspects of their routine, and achieving behaviour, sleep and wellbeing improvements. Discussion: Script elicitation is a promising and acceptable method for tackling poor evening sleep hygiene habits. A more rigorous trial is warranted.

Evaluating the impact of a novel behavioural science informed animation upon breast cancer screening uptake: protocol for a randomised controlled trial.

BACKGROUND: Breast cancer screening is estimated to save 1300 lives annually in the United Kingdom. Despite this, uptake of invitations has fallen over the past decade. Behavioural science-informed interventions addressing the determinants of attendance behaviour have shown variable effectiveness. This may be due to the narrow repertoire of techniques trialled, and the difficulties of implementation at a population-scale. The aim of this study is to evaluate the impact on breast screening uptake of a novel behavioural video intervention which can contain more complex combinations of behavioural change techniques. METHODS: A 3-armed randomised controlled trial will be undertaken in London comparing the impact of (1) the usual care SMS reminder, to (2) a behavioural plain text SMS reminder and (3) a novel video sent as a link within the behavioural plain text SMS reminder. A total of 8391 participants (2797 per group) will be allocated to one of the three trial arms using a computer randomisation process, based upon individuals' healthcare identification numbers. The novel video has been co-designed with a diverse range of women to overcome the barriers faced by underserved communities and the wider population. The behavioural SMS content has also been co-designed through the same process as the video. Messages will be sent through the current reminder system used by the London screening programmes, with reminders 7 days and 2 days prior to a timed appointment. The primary outcome is attendance at breast cancer screening within 3 months of the initial invitation. Secondary outcomes will include evaluating the impact of each message amongst socio-demographic groups and according to the appointment type e.g. first invitation or recall. DISCUSSION: In addition to general declining trends in attendance, there is also concern of increasing healthcare inequalities with breast cancer screening in London. The current novel intervention, designed with underserved groups and the general population, incorporates several behavioural techniques to overcome the barriers to attendance. Understanding its potential impact in a real-world setting therefore may provide significant information on how to address reducing attendance and healthcare disparities. TRIAL REGISTRATION: This study was registered on ClinicalTrials.gov ( NCT05395871 ) on the 27th May 2022.

A population survey on beliefs around cervical cancer screening: determining the barriers and facilitators associated with attendance.

BACKGROUND: Cervical screening saves approximately 5000 lives annually in England. However, screening rates have been falling continuously, and coverage in London is particularly low (64.7%). While demographic predictors of uptake have been well researched, there has been less thorough investigation of the individual barriers and facilitators which predict cervical screening attendance. Understanding modifiable factors influencing attendance can guide the design of effective interventions to increase cervical screening uptake. The aim of this study was to understand the demographic, and individual factors associated with self-reported attendance at cervical screening in London. METHODS: The study used an online survey of 500 women in London (June-July 2017). The survey included self-reported measures of past attendance, demographic variables (including age, household income, ethnicity), past experience variables, and individual variables (list of potential barriers and facilitators developed based on the Theoretical Domains Framework and existing literature, which included: environmental context and resources, perceived risk, anticipated pain/embarrassment). Participants were categorised into regular attenders and non-regular attenders. Backwards stepwise logistic regression investigated the barriers and facilitators predicting past attendance. Demographic variables with significant differences between regular and non-regular attenders were added to the final regression model. RESULTS: Of women who had previously been invited (n = 461, age range: 25-65), 34.5% (n = 159) were classified as non-regular attenders, and 65.5% (n = 302) as regular attenders. The individual barriers and facilitators predicting attendance were: cervical screening priority, memory, environmental context and resources, and intention. The only demographic variables related to regular attendance were relationship status (married/civil partnership having higher rates than single) and higher household income. Relationship status was not significant when adjusting for barriers and facilitators. Those who have ever been sexually active or who have had an STI in the past were significantly more likely to be regular attenders. CONCLUSIONS: The study shows the importance of individual barriers and facilitators in predicting self-reported cervical screening attendance. Household income was the only significant demographic variable when combined with the individual variables. Interventions targeting priority, memory, and practical barriers affecting environmental context may be expected to be effective an increasing attendance.

Which domains of the theoretical domains framework should be targeted in interventions to increase adherence to antihypertensives? A systematic review.

Nonadherence to antihypertensives is prevalent and is associated with poorer health outcomes. This study aimed to identify psychological factors associated with adherence in patients taking antihypertensives as these are potentially modifiable, and can, therefore, inform the development of effective interventions to increase adherence. PubMed, EMBASE and PsychINFO were searched to identify studies that tested for significant associations between psychological domains and adherence to antihypertensives. The domains reported were categorized according to the Theoretical Domains Framework. The quality of included studies was evaluated using the National Institute for Clinical Excellence critical appraisal of questionnaire checklist. Thirty-one studies were included. Concerns about medicines (a subdomain of 'beliefs about consequences') and 'beliefs about capabilities' consistently showed association with adherence in over five studies. Healthcare professionals should actively ask patients if they have any concerns about their antihypertensives and their belief in their ability to control their blood pressure through taking antihypertensives.

Investigating the Implementation of SMS and Mobile Messaging in Population Screening (the SIPS Study): Protocol for a Delphi Study.

BACKGROUND: The use of mobile messaging, including SMS, and web-based messaging in health care has grown significantly. Using messaging to facilitate patient communication has been advocated in several circumstances, including population screening. These programs, however, pose unique challenges to mobile communication, as messaging is often sent from a central hub to a diverse population with differing needs. Despite this, there is a paucity of robust frameworks to guide implementation. OBJECTIVE: The aim of this protocol is to describe the methods that will be used to develop a guide for the principles of use of mobile messaging for population screening programs in England. METHODS: This modified Delphi study will be conducted in two parts: evidence synthesis and consensus generation. The former will include a review of literature published from January 1, 2000, to October 1, 2021. This will elicit key themes to inform an online scoping questionnaire posed to a group of experts from academia, clinical medicine, industry, and public health. Thematic analysis of free-text responses by two independent authors will elicit items to be used during consensus generation. Patient and Public Involvement and Engagement groups will be convened to ensure that a comprehensive item list is generated that represents the public's perspective. Each item will then be anonymously voted on by experts as to its importance and feasibility of implementation in screening during three rounds of a Delphi process. Consensus will be defined a priori at 70%, with items considered important and feasible being eligible for inclusion in the final recommendation. A list of desirable items (ie, important but not currently feasible) will be developed to guide future work. RESULTS: The Institutional Review Board at Imperial College London has granted ethical approval for this study (reference 20IC6088). Results are expected to involve a list of recommendations to screening services, with findings being made available to screening services through Public Health England. This study will, thus, provide a formal guideline for the use of mobile messaging in screening services and will provide future directions in this field. CONCLUSIONS: The use of mobile messaging has grown significantly across health care services, especially given the COVID-19 pandemic, but its implementation in screening programs remains challenging. This modified Delphi approach with leading experts will provide invaluable insights into facilitating the incorporation of messaging into these programs and will create awareness of future developments in this area. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/32660.

Systematic Review of RCTs Assessing the Effectiveness of mHealth Interventions to Improve Statin Medication Adherence: Using the Behaviour-Change Technique Taxonomy to Identify the Techniques That Improve Adherence.

Statin non-adherence is a common problem in the management of cardiovascular disease (CVD), increasing patient morbidity and mortality. Mobile health (mHealth) interventions may be a scalable way to improve medication adherence. The objectives of this review were to assess the literature testing mHealth interventions for statin adherence and to identify the Behaviour-Change Techniques (BCTs) employed by effective and ineffective interventions. A systematic search was conducted of randomised controlled trials (RCTs) measuring the effectiveness of mHealth interventions to improve statin adherence against standard of care in those who had been prescribed statins for the primary or secondary prevention of CVD, published in English (1 January 2000-17 July 2020). For included studies, relevant data were extracted, the BCTs used in the trial arms were coded, and a quality assessment made using the Risk of Bias 2 (RoB2) questionnaire. The search identified 17 relevant studies. Twelve studies demonstrated a significant improvement in adherence in the mHealth intervention trial arm, and five reported no impact on adherence. Automated phone messages were the mHealth delivery method most frequently used in effective interventions. Studies including more BCTs were more effective. The BCTs most frequently associated with effective interventions were "Goal setting (behaviour)", "Instruction on how to perform a behaviour", and "Credible source". Other effective techniques were "Information about health consequences", "Feedback on behaviour", and "Social support (unspecified)". This review found moderate, positive evidence of the effect of mHealth interventions on statin adherence. There are four primary recommendations for practitioners using mHealth interventions to improve statin adherence: use multifaceted interventions using multiple BCTs, consider automated messages as a digital delivery method from a credible source, provide instructions on taking statins, and set adherence goals with patients. Further research should assess the optimal frequency of intervention delivery and investigate the generalisability of these interventions across settings and demographics.

A systematic review of interventions to improve breast cancer screening health behaviours.

Whilst breast cancer screening has been implemented in many countries, uptake is often suboptimal. Consequently, several interventions targeting non-attendance behaviour have been developed. This systematic review aims to appraise the successes of interventions, identifying and comparing the specific techniques they use to modify health behaviours. A literature search (PROSPERO CRD42020212090) between January 2005 and December 2020 using PubMed, Medline, PsycInfo, EMBASE and Google Scholar was conducted. Studies which investigated patient-facing interventions to increase attendance at breast cancer screening appointments were included. Details regarding the intervention delivery, theoretical background, and contents were extracted, as was quantitative data on the impact on attendance rates, compared to control measures. Interventions were also coded using the Behavioural Change Techniques (BCT) Taxonomy. In total fifty-four studies, detailing eighty interventions, met the inclusion criteria. Only 50% of interventions reported a significant impact on screening attendance. Thirty-two different BCTs were used, with 'prompts/cues' the most commonly incorporated (77.5%), however techniques from the group 'covert learning' had the greatest pooled effect size 0.12 (95% CI 0.05-0.19, P < 0·01, I2 = 91.5%). 'Problem solving' was used in the highest proportion of interventions that significantly increased screening attendance (69.0%). 70% of the interventions were developed using behavioural theories. These results show interventions aimed at increasing screening uptake are often unsuccessful. Commonly used approaches which focus upon explaining the consequences of not attending mammograms were often ineffective. Problem solving, however, has shown promise. These techniques should be investigated further, as should emerging technologies which can enable interventions to be feasibly translated at a population-level.

Behavioral economics informed message content in text message reminders to improve cervical screening participation: Two pragmatic randomized controlled trials.

The objective of the reported research was to assess the impact of text message (SMS) reminders and their content on cervical screening rates. Women invited for cervical screening in Northwest London from February-October 2015 were eligible. 3133 women aged 24-29 (Study 1) were randomized (1, 1) to 'no SMS' (control), or a primary care physician (PCP) endorsed SMS (SMS-PCP). 11,405 women aged 30-64 (Study 2), were randomized (1, 1:1:1:1:1:1) to either: no SMS, an SMS without manipulation (SMS), the SMS-PCP, an SMS with a total or proportionate social norm (SMS-SNT or SMS-SNP), or an SMS with a gain-framed or loss-framed message (SMS-GF and SMS-LF). The primary outcome was participation at 18 weeks. In Study 1 participation was significantly higher in the SMS-PCP arm (31.4%) compared to control (26.4%, aOR, 1.29, 95%CI: 1.09-1·51; p = 0.002). In Study 2 participation was highest in the SMS-PCP (38.4%) and SMS (38.1%) arms compared to control (34.4%), (aOR: 1.19, 95%CI: 1.03-1.38; p = 0.02 and aOR: 1.18, 95%CI: 1.02-1.37; p = 0.03, respectively). The results demonstrate that behavioral SMSs improve cervical screening participation. The message content plays an important role in the impact of SMS. The results from this trial have already been used to designing effective policy for cervical cancer screening. The NHS Cervical Screening Programme started running a London-wide screening SMS campaign which was based on the cervical screening trial described here. According to figures published by Public Health England, after six months attendance increased by 4.8%, which is the equivalent of 13,400 more women being screened at 18 weeks.

A Habit-Based Randomised Controlled Trial to Reduce Sugar-Sweetened Beverage Consumption: the Impact of the Substituted Beverage on Behaviour and Habit Strength.

BACKGROUND: Excess sugar consumption has been linked to numerous negative health outcomes, such as obesity and type II diabetes. Reducing sugar-sweetened beverage (SSB) consumption may reduce sugar intake and thus improve health. The aim of the study was to test the impact of the potentially different rewarding nature of water or diet drinks as replacements for SSB, using a habit and implementation intention-based intervention. METHOD: An online randomised, two-arm parallel design was used. One hundred and fifty-eight participants (mainly from the UK and USA) who regularly consumed SSBs (Mage = 31.5, 51% female) were advised to create implementation intentions to substitute their SSB with either water or a diet drink. Measures of SSB consumption, habit strength and hedonic liking were taken at baseline and at 2 months. Water or diet drink consumption was only measured at 2 months. RESULTS: There was a large and significant reduction in SSB consumption and self-reported SSB habits for both the water and diet drink groups, but no difference between groups. There were no differences in hedonic liking for the alternative drink, alternative drink consumption and alternative drink habit between the two groups. Reduction in SSB hedonic liking was associated with reduced SSB consumption and habit. CONCLUSION: This study demonstrates that an implementation intention-based intervention achieved substantial reductions in SSB consumption and habits. It also indicates that hedonic liking for SSBs and alternative drinks are associated with changes in consumption behaviour. Substituting SSBs with water or diet drinks was equally as effective in reducing SSB consumption.

Threats to safe transitions from hospital to home: a consensus study in North West London primary care.

BACKGROUND: Transitions between healthcare settings are vulnerable points for patients. AIM: To identify key threats to safe patient transitions from hospital to primary care settings. DESIGN AND SETTING: Three-round web-based Delphi consensus process among clinical and non-clinical staff from 39 primary care practices in North West London, England. METHOD: Round 1 was a free-text idea-generating round. Rounds 2 and 3 were consensus-obtaining rating rounds. Practices were encouraged to complete the questionnaires at team meetings. Aggregate ratings of perceived level of importance for each threat were calculated (1-3: 'not important', 4-6: 'somewhat important', 7-9: 'very important'). Percentage of votes cast for each patient or medication group were recorded; consensus was defined as ≥75%. RESULTS: A total of 39 practices completed round 1, 36/39 (92%) completed round 2, and 30/36 (83%) completed round 3. Round 1 identified nine threats encompassing problems involving communication, service organisation, medication provision, and patients who were most at risk. 'Poor quality of handover instructions from secondary to primary care teams' achieved the highest rating (mean rating at round 3 = 8.43) and a 100% consensus that it was a 'very important' threat. Older individuals (97%) and patients with complex medical problems taking >5 medications (80%) were voted the most vulnerable. Anticoagulants (77%) were considered to pose the greatest risk to patients. CONCLUSION: This study identified specific threats to safe patient transitions from hospital to primary care, providing policymakers and healthcare providers with targets for quality improvement strategies. Further work would need to identify factors underpinning these threats so that interventions can be tailored to the relevant behavioural and environmental contexts in which these threats arise.

Exploratory study of the impact of perceived reward on habit formation.

BACKGROUND: Habits (learned automatic responses to contextual cues) are considered important in sustaining health behaviour change. While habit formation is promoted by repeating behaviour in a stable context, little is known about what other variables may contribute, and whether there are variables which may accelerate the habit formation process. The aim of this study was to explore variables relating to the perceived reward value of behaviour - pleasure, perceived utility, perceived benefits, and intrinsic motivation. The paper tests whether reward has an impact on habit formation which is mediated by behavioural repetition, and whether reward moderates the relationship between repetition and habit formation. METHODS: Habit formation for flossing and vitamin C tablet adherence was investigated in the general public following an intervention, using a longitudinal, single-group design. Of a total sample of 118 participants, 80 received an online vitamin C intervention at baseline, and all 118 received a face-to-face flossing intervention four weeks later. Behaviour, habit, intention, context stability (whether the behaviour was conducted in the same place and point in routine every time), and reward variables were self-reported every four weeks, for sixteen weeks. Structured equation modelling was used to model reward-related variables as predictors of intention, repetition, and habit, and as moderators of the repetition-habit relationship. RESULTS: Habit strength and behaviour increased for both target behaviours. Intrinsic motivation and pleasure moderated the relationship between behavioural repetition and habit. Neither perceived utility nor perceived benefits predicted behaviour nor interacted with repetition. Limited support was obtained for the mediation hypothesis. Strong intentions unexpectedly weakened the repetition-habit relationship. Context stability mediated and for vitamin C, also moderated the repetition-habit relationship. CONCLUSIONS: Pleasure and intrinsic motivation can aid habit formation through promoting greater increase in habit strength per behaviour repetition. Perceived reward can therefore reinforce habits, beyond the impact of reward upon repetition. Habit-formation interventions may be most successful where target behaviours are pleasurable or intrinsically valued.

Financial disincentives? A three-armed randomised controlled trial of the effect of financial Incentives in Diabetic Eye Assessment by Screening (IDEAS) trial.

OBJECTIVE: Conflicting evidence exists regarding the impact of financial incentives on encouraging attendance at medical screening appointments. The primary aim was to determine whether financial incentives increase attendance at diabetic eye screening in persistent non-attenders. METHODS AND ANALYSIS: A three-armed randomised controlled trial was conducted in London in 2015. 1051 participants aged over 16 years, who had not attended eye screening appointments for 2 years or more, were randomised (1.4:1:1 randomisation ratio) to receive the usual invitation letter (control), an offer of £10 cash for attending screening (fixed incentive) or a 1 in 100 chance of winning £1000 (lottery incentive) if they attend. The primary outcome was the proportion of invitees attending screening, and a comparative analysis was performed to assess group differences. Pairwise comparisons of attendance rates were performed, using a conservative Bonferroni correction for independent comparisons. RESULTS: 34/435 (7.8%) of control, 17/312 (5.5%) of fixed incentive and 10/304 (3.3%) of lottery incentive groups attended. Participants who received any incentive were significantly less likely to attend their appointment compared with controls (risk ratio (RR)=0.56; 95% CI 0.34 to 0.92). Those in the probabilistic incentive group (RR=0.42; 95% CI 0.18 to 0.98), but not the fixed incentive group (RR=1.66; 95% CI 0.65 to 4.21), were significantly less likely to attend than those in the control group. CONCLUSION: Financial incentives, particularly lottery-based incentives, attract fewer patients to diabetic eye screening than standard invites in this population. Financial incentives should not be used to promote screening unless tested in context, as they may negatively affect attendance rates.

The development and validation of a Real Time Location System to reliably monitor everyday activities in natural contexts.

INTRODUCTION: The accurate measurement of behaviour is vitally important to many disciplines and practitioners of various kinds. While different methods have been used (such as observation, diaries, questionnaire), none are able to accurately monitor behaviour over the long term in the natural context of people's own lives. The aim of this work was therefore to develop and test a reliable system for unobtrusively monitoring various behaviours of multiple individuals within the same household over a period of several months. METHODS: A commercial Real Time Location System was adapted to meet these requirements and subsequently validated in three households by monitoring various bathroom behaviours. RESULTS: The results indicate that the system is robust, can monitor behaviours over the long-term in different households and can reliably distinguish between individuals. Precision rates were high and consistent. Recall rates were less consistent across households and behaviours, although recall rates improved considerably with practice at set-up of the system. The achieved precision and recall rates were comparable to the rates observed in more controlled environments using more valid methods of ground truthing. CONCLUSION: These initial findings indicate that the system is a valuable, flexible and robust system for monitoring behaviour in its natural environment that would allow new research questions to be addressed.