Enabling women to access preferred methods of contraception: a rapid review and behavioural analysis.

BACKGROUND: Many pregnancies in the UK are either unplanned or ambivalent. This review aimed to (i) explore barriers and facilitators to women choosing and accessing a preferred method of contraception in the United Kingdom, and (ii) identify opportunities for behavioural interventions based on examination of interventions that are currently available nationally. METHODS: Three databases were searched, and experts contacted to identify grey literature for studies presenting barriers and facilitators to women choosing and accessing a preferred method of contraception, conducted in the UK and published between 2009 and October 2019. Information on barriers and facilitators were coded into overarching themes, which were then coded into Mechanisms of Actions (MoAs) as listed in the Theory and Techniques Tool. National interventions were identified by consulting stakeholders and coded into the Behaviour Change Wheel. The match between barriers/facilitators and intervention content was assessed using the Behaviour Change Wheel. RESULTS: We included 32 studies and identified 46 barrier and facilitator themes. The most cited MoA was Environmental Context and Resources, which primarily related to the services women had access to and care they received. Social Influences, Beliefs about Consequences (e.g., side effects) and Knowledge were also key. The behavioural analysis highlighted four priority intervention functions (Modelling, Enablement, Education and Environmental Restructuring) that can be targeted to support women to choose and access their preferred method of contraception. Relevant policy categories and behaviour change techniques are also highlighted. CONCLUSIONS: This review highlights factors that influence women's choices and access to contraception and recommends opportunities that may be targeted for future interventions in order to support women to access preferred contraception. REGISTRATION: Protocol was registered with PROSPERO (an international database of prospectively registered systematic reviews in health and social care) in December 2019, CRD42019161156 .

Reducing expectations for antibiotics in primary care: a randomised experiment to test the response to fear-based messages about antimicrobial resistance.

BACKGROUND: To reduce inappropriate antibiotic use, public health campaigns often provide fear-based information about antimicrobial resistance (AMR). Meta-analyses have found that fear-based campaigns in other contexts are likely to be ineffective unless respondents feel confident they can carry out the recommended behaviour ('self-efficacy'). This study aimed to test the likely impact of fear-based messages, with and without empowering self-efficacy elements, on patient consultations/antibiotic requests for influenza-like illnesses, using a randomised design. METHODS: We hypothesised that fear-based messages containing empowering information about self-management without antibiotics would be more effective than fear alone, particularly in a pre-specified subgroup with low AMR awareness. Four thousand respondents from an online panel, representative of UK adults, were randomised to receive three different messages about antibiotic use and AMR, designed to induce fear about AMR to varying degrees. Two messages (one 'strong-fear', one 'mild-fear') also contained empowering information regarding influenza-like symptoms being easily self-managed without antibiotics. The main outcome measures were self-reported effect of information on likelihood of visiting a doctor and requesting antibiotics, for influenza-like illness, analysed separately according to whether or not the AMR information was 'very/somewhat new' to respondents, pre-specified based on a previous (non-randomised) survey. RESULTS: The 'fear-only' message was 'very/somewhat new' to 285/1000 (28.5%) respondents, 'mild-fear-plus-empowerment' to 336/1500 (22.4%), and 'strong-fear-plus-empowerment' to 388/1500 (25.9%) (p = 0.002). Of those for whom the respective information was 'very/somewhat new', only those given the 'strong-fear-plus-empowerment' message said they would be less likely to request antibiotics if they visited a doctor for an influenza-like illness (p < 0.0001; 182/388 (46.9%) 'much less likely'/'less likely', versus 116/336 (34.5%) with 'mild-fear-plus-empowerment' versus 85/285 (29.8%) with 'fear-alone'). Those for whom the respective information was not 'very/somewhat new' said they would be less likely to request antibiotics for influenza-like illness (p < 0.0001) across all messages (interaction p < 0.0001 versus 'very/somewhat new' subgroup). The three messages had analogous self-reported effects on likelihood of visiting a doctor and in subgroups defined by believing antibiotics would 'definitely/probably' help an influenza-like illness. Results were reproduced in an independent randomised survey (additional 4000 adults). CONCLUSIONS: Fear could be effective in public campaigns to reduce inappropriate antibiotic use, but should be combined with messages empowering patients to self-manage symptoms effectively without antibiotics.

Pre-notification and reminder SMS text messages with behaviourally informed invitation letters to improve uptake of NHS Health Checks: a factorial randomised controlled trial.

BACKGROUND: The NHS Health Check (NHS HC) is a cardiovascular risk assessment to prevent cardiovascular disease. Public Health England (PHE) wants to increase uptake. METHODS: We explored the impact of behaviourally informed invitation letters and pre-notification and reminder SMS on uptake of NHS HCs. Patients at 28 General Practices in the London Borough of Southwark who were eligible to receive an NHS HC between 1st November 2013 and 31st December 2014 were included. A double-blind randomised controlled trial with a mixed 2 (pre-notification SMS - yes or no) × 4 (letter - national template control, open-ended, time-limited, social norm) × 2 (reminder SMS - yes or no) factorial design was used. The open-ended letter used simplification, behavioural instruction and a personalised planning prompt for patients to record the date and time of their NHS HC. The time-limited letter was similar but stated the NHS HC was due in a named forthcoming month. The social norms letter was similar to the open-ended letter but included a descriptive social norms message and testimonials from local residents and no planning prompt. The outcome measure was attendance at an NHS HC. RESULTS: Data for 12, 244 invites were analysed. Uptake increased in almost all letter and SMS combinations compared to the control letter without SMS (Uptake 18%), with increases of up to 12 percentage points for the time-limited letter with pre-notification and reminder (Uptake 30%; Adjusted Odds Ratio AOR 1.86; 95% CI 1.45-2.83; p < 0.00); 10 percentage points for the open-ended letter with reminder (Uptake 27%; AOR 1.68; 95% CI 1.31-2.17; p < 0.00) and a 9 percentage point increase using the time-limited letter with reminder (Uptake 27%; AOR 1.61; 95% CI 1.25-2.10; p < 0.00). The reminder SMS increased uptake for all intervention letters. The pre-notification did not add to this effect. CONCLUSIONS: This large randomised controlled trial adds support to the evidence that small, low cost behaviourally informed changes to letter-based invitations can increase uptake of NHS HCs. It also provides novel evidence on the effect of SMS reminders and pre-notification on NHS HC attendance. TRIAL REGISTRATION: Retrospectively Registered (24/01/2014) ISRCTN36027094 .

Provision of social norm feedback to high prescribers of antibiotics in general practice: a pragmatic national randomised controlled trial.

BACKGROUND: Unnecessary antibiotic prescribing contributes to antimicrobial resistance. In this trial, we aimed to reduce unnecessary prescriptions of antibiotics by general practitioners (GPs) in England. METHODS: In this randomised, 2 × 2 factorial trial, publicly available databases were used to identify GP practices whose prescribing rate for antibiotics was in the top 20% for their National Health Service (NHS) Local Area Team. Eligible practices were randomly assigned (1:1) into two groups by computer-generated allocation sequence, stratified by NHS Local Area Team. Participants, but not investigators, were blinded to group assignment. On Sept 29, 2014, every GP in the feedback intervention group was sent a letter from England's Chief Medical Officer and a leaflet on antibiotics for use with patients. The letter stated that the practice was prescribing antibiotics at a higher rate than 80% of practices in its NHS Local Area Team. GPs in the control group received no communication. The sample was re-randomised into two groups, and in December, 2014, GP practices were either sent patient-focused information that promoted reduced use of antibiotics or received no communication. The primary outcome measure was the rate of antibiotic items dispensed per 1000 weighted population, controlling for past prescribing. Analysis was by intention to treat. This trial is registered with the ISRCTN registry, number ISRCTN32349954, and has been completed. FINDINGS: Between Sept 8 and Sept 26, 2014, we recruited and assigned 1581 GP practices to feedback intervention (n=791) or control (n=790) groups. Letters were sent to 3227 GPs in the intervention group. Between October, 2014, and March, 2015, the rate of antibiotic items dispensed per 1000 population was 126.98 (95% CI 125.68-128.27) in the feedback intervention group and 131.25 (130.33-132.16) in the control group, a difference of 4.27 (3.3%; incidence rate ratio [IRR] 0.967 [95% CI 0.957-0.977]; p<0.0001), representing an estimated 73,406 fewer antibiotic items dispensed. In December, 2014, GP practices were re-assigned to patient-focused intervention (n=777) or control (n=804) groups. The patient-focused intervention did not significantly affect the primary outcome measure between December, 2014, and March, 2015 (antibiotic items dispensed per 1000 population: 135.00 [95% CI 133.77-136.22] in the patient-focused intervention group and 133.98 [133.06-134.90] in the control group; IRR for difference between groups 1.01, 95% CI 1.00-1.02; p=0.105). INTERPRETATION: Social norm feedback from a high-profile messenger can substantially reduce antibiotic prescribing at low cost and at national scale; this outcome makes it a worthwhile addition to antimicrobial stewardship programmes. FUNDING: Public Health England.

A process evaluation of the UK-wide Antibiotic Guardian campaign: developing engagement on antimicrobial resistance.

Background: Public Health England developed and led a new UK-wide pledge campaign aiming to improve behaviours around the prudent use and prescription of antibiotics. This paper presents a process evaluation for the first season of the campaign to determine the impact of the campaign and inform future campaigns. Methods: Data were collected from AntibioticGuardian.com and Google analytics between August 2014 and January 2015. The primary outcome was the decision to pledge and was assessed according to target audience, location, source and route of referral to the website. Results: There were 47 158 unique visits to the website and 12 509 visitors made a pledge (26.5%) to become Antibiotic Guardians (AGs); 69% were healthcare professionals. Social media directed the most traffic to the website (24% of the public that signed up cited social media as how they discovered the campaign), other acquisition routes such as self-directed, email or website referral, were more effective at encouraging visitors to pledge. Conclusions: The campaign completed its goal of 10 000 AGs in the first year. Further work is required to improve engagement with target audiences and determine whether this campaign has an impact on antibiotic consumption and prescribing behaviour among the public and healthcare professionals.

The effectiveness of an enhanced invitation letter on uptake of National Health Service Health Checks in primary care: a pragmatic quasi-randomised controlled trial.

BACKGROUND: The National Health Service Health Check (NHS HC) is a population level public health programme. It is a primary prevention initiative offering cardiovascular risk assessment and management for adults aged 40-74 years (every five years). It was designed to reduce the incidence of major vascular disease events by preventing or delaying the onset of diabetes, heart and kidney disease, stroke and vascular dementia . Effectiveness of the programme has been modelled on a national uptake of 75% however in 2012/13 uptake, nationally, was 49%. Ensuring a high percentage of those offered an NHS HC actually receive one is key to optimising the clinical and cost effectiveness of the programme. METHODS: A pragmatic quasi-randomised controlled trial was conducted in four general practitioner practices in Medway, England with randomisation of 3511 patients. The aim was to compare attendance at the NHS HC using the standard national invitation template letter (control) compared to an enhanced invitation letter using insights from behavioural science (intervention). The intervention letter includes i) simplification - reducing letter content for less effortful processing ii) behavioural instruction - action focused language iii) personal salience - appointment due rather than invited and iv) addressing implementation intentions with a tear off slip to record the date, time and location of the appointment. Logistic Regression explored the association between control and intervention group and attendance at a health check. RESULTS: 29.3% of patients who received the control letter and 33.5% of those who received the intervention letter attended their NHS HC (adjusted odds ratio 1.26, 95% confidence interval 1.09-1.47, p < 0.01). This was an absolute difference in uptake of 4.2 percentage points for those receiving the intervention letter. CONCLUSIONS: An invitation letter applying behavioural insights was more effective than the existing national template letter at encouraging attendance at an NHS HC. Making small, no cost behaviourally informed changes to letter invitations can improve uptake of the NHS HC. Further research is required to replicate the effect with more robust methodology and powered for sub-group analysis including socio-economic status. TRIAL REGISTRATION: Current Controlled Trials ISRCTN66757664 , date of registration 28/3/2014.

Experiences of work and sickness absence in employees with depression: an interpretative phenomenological analysis.

PURPOSE: The experience of employment with depression is explored to develop understanding of the mediators that may influence the management of depression-related sickness absence and improve theoretical understanding. METHOD: Data were collected from seven semi-structured interviews and Interpretative Phenomenological Analysis used to explore the data. RESULTS: Three interrelated themes were drawn from the participants' accounts: (1) the interaction between depression and work; (2) illness beliefs; and (3) organisational context and depression. The analysis revealed that participants appeared to hold five key perceptions about their depression and work: low control in the workplace; lack of line manager support; diminishing ability to work; the need to address depressive symptoms; and perceptions of depression. Their strength resulted in individuals reaching sickness absence thresholds. The themes and participants' accounts of their work and sickness absence and return to work behaviour are discussed in relation to relevant theory and evidence to understand how these perceptions and beliefs mediate behaviour. CONCLUSION: Individuals' health (illness representations) and work beliefs (outcome expectancies and self-efficacy for work tasks and management of health at work) appear to influence individuals' sickness absence decisions and experiences and these are mediated by individuals' experiences of organisational policies, line manager support and the messages and actions of GPs.

Using text and charts to provide social norm feedback to general practices with high overall and high broad-spectrum antibiotic prescribing: a series of national randomised controlled trials.

BACKGROUND: Sending a social norms feedback letter to general practitioners who are high prescribers of antibiotics has been shown to reduce antibiotic prescribing. The 2017-9 Quality Premium for primary care in England sets a target for broad-spectrum prescribing, which should be at or below 10% of total antibiotic prescribing. We tested a social norm feedback letter that targeted broad-spectrum prescribing and the addition of a chart to a text-only letter that targeted overall prescribing. METHODS: We conducted three 2-armed randomised controlled trials, on different groups of practices: Trial A compared a broad-spectrum message and chart to the standard-practice overall prescribing letter (practices whose percentage of broad-spectrum prescribing was above 10% and who had relatively high overall prescribing). Trial C compared a broad-spectrum message and a chart to a no-letter control (practices whose percentage of broad-spectrum prescribing was above 10% and who had relatively moderate overall prescribing). Trial B compared an overall-prescribing message with a chart to the standard practice overall letter (practices whose percentage of broad-spectrum prescribing was below 10% but who had relatively high overall prescribing). Letters were posted to general practitioners, timed to be received on 1 November 2018. The primary outcomes were practices' percentage of broad-spectrum prescribing (trials A and C) and overall antibiotic prescribing (trial B) each month from November 2018 to April 2019 (all weighted by the number and characteristics of patients registered in the practice). RESULTS: We randomly assigned 1909 practices; 58 closed or merged during the trial, leaving 1851 practices: 385 in trial A, 674 in trial C, and 792 in trial B. AR(1) models showed that there were no statistically significant differences in our primary outcome measures: trial A ß = - .199, p = .13; trial C ß = .006, p = .95; trial B ß = - .0021, p = .81. In all three trials, there were statistically significant time trends, showing that overall antibiotic prescribing and total broad-spectrum prescribing were decreasing. CONCLUSION: Our broad-spectrum feedback letters had no effect on broad-spectrum prescribing; adding a bar chart to a text-only letter had no effect on overall antibiotic prescribing. Broad-spectrum and overall prescribing were both decreasing over time. TRIAL REGISTRATION: ClinicalTrials.gov NCT03862794. March 5, 2019.

A Systematic Review of Nudge Interventions to Optimize Medication Prescribing.

Background: The benefits of medication optimization are largely uncontroversial but difficult to achieve. Behavior change interventions aiming to optimize prescriber medication-related decisions, which do not forbid any option and that do not significantly change financial incentives, offer a promising way forward. These interventions are often referred to as nudges. Objective: The current systematic literature review characterizes published studies describing nudge interventions to optimize medication prescribing by the behavioral determinants they intend to influence and the techniques they apply. Methods: Four databases were searched (MEDLINE, Embase, PsychINFO, and CINAHL) to identify studies with nudge-type interventions aiming to optimize prescribing decisions. To describe the behavioral determinants that interventionists aimed to influence, data were extracted according to the Theoretical Domains Framework (TDF). To describe intervention techniques applied, data were extracted according to the Behavior Change Techniques (BCT) Taxonomy version 1 and MINDSPACE. Next, the recommended TDF-BCT mappings were used to appraise whether each intervention applied a sufficient array of techniques to influence all identified behavioral determinants. Results: The current review located 15 studies comprised of 20 interventions. Of the 20 interventions, 16 interventions (80%) were effective. The behavior change techniques most often applied involved prompts (n = 13). The MINDSPACE contextual influencer most often applied involved defaults (n = 10). According to the recommended TDF-BCT mappings, only two interventions applied a sufficient array of behavior change techniques to address the behavioral determinants the interventionists aimed to influence. Conclusion: The fact that so many interventions successfully changed prescriber behavior encourages the development of future behavior change interventions to optimize prescribing without mandates or financial incentives. The current review encourages interventionists to understand the behavioral determinants they are trying to affect, before the selection and application of techniques to change prescribing behaviors. Systematic Review Registration: [https://www.crd.york.ac.uk/prospero/], identifier [CRD42020168006].

Interventions to change purchasing behaviour in supermarkets: a systematic review and intervention content analysis.

This systematic review and intervention content analysis used behavioural science frameworks to characterise content and function of interventions targeting supermarket shoppers' purchasing behaviour, and explore if coherence between content and function was linked to intervention effectiveness. Study eligibility: in-store interventions (physical supermarkets) with control conditions, targeting objectively measured food and/or non-alcoholic drink purchases, published in English (no date restrictions). Eleven electronic databases were searched; reference lists of systematic reviews were hand-searched. Methodological quality was assessed using the GATE checklist. A content analysis was performed to characterise intervention content and function, and theoretical coherence between these, using the Behaviour Change Wheel, Behaviour Change Techniques Taxonomy, and Typology of Interventions in Proximal Physical Micro-Environments (TIPPME). Forty-six articles (49 interventions) met inclusion criteria; 26 articles (32 interventions) were included in the content analysis. Twenty behaviour change techniques (BCTs), and four TIPPME intervention types were identified; three BCTs ('Prompts/cues', 'Material incentive', and 'Material reward') were more common in effective interventions. Nineteen interventions solely employed theoretically appropriate BCTs. Theoretical coherence between BCTs and intervention functions was more common in effective interventions. Effective interventions included price promotions and/or in-store merchandising. Future research should explore the effect of specific BCTs using factorial study designs. PROSPERO Registration: CRD42017071065.

Retrospective coding of health care professional cancer screening behaviours and of real-world interventions designed to support them: Identifying recommendations to optimize intervention design.

OBJECTIVES: Screening can detect cancer earlier. Uptake of breast, cervical, and bowel cancer screening in England is below 75%. This study identifies the barriers and facilitators underpinning HCP screening behaviours which can support screening uptake, and reviews the design of real-world interventions targeting these, assessing for congruence between the two. The aim was to provide recommendations to improve the design of interventions. DESIGN AND METHODS: Barriers/facilitators were identified by a literature review and qualitatively coded using the theoretical domains framework (TDF). Interventions were identified by stakeholders and coded using the behaviour change wheel and the taxonomy of behaviour change techniques. Congruence was assessed through comparing the intervention designs with behavioural science experts' recommendations which link the TDF domains to intervention design. Recommendations targeted missed opportunities. RESULTS: Barriers/facilitators were extracted from 60 papers and most frequently coded to the TDF domains: environmental context and resources, knowledge and beliefs about consequences. Thirty-one interventions were identified, most frequently education, training or enablement functions, delivered via communication/marketing or service provision, and using BCTs designed to shape knowledge or highlight the consequences of or antecedents to screening. Intervention design was largely congruent with recommendations. However, there was less use of persuasion and modelling intervention functions and a reliance on BCTs such as providing instruction when other BCTs could be considered. CONCLUSIONS: Recommendations include to consider a broader range of intervention functions and BCTs, particularly for training interventions which should make use of recommended BCTs such as 'graded tasks'.

Optimizing Making Every Contact Count (MECC) interventions: A strategic behavioral analysis.

OBJECTIVE: This Strategic Behavioral Analysis aimed to: identify barriers and facilitators to health care professionals' implementation of Making Every Contact Count (MECC); code behavioral components of nationally delivered interventions to improve MECC implementation; assess the extent to which these components are theoretically congruent with identified theoretical domains representing barriers and facilitators. Comparing national interventions that aim to support implementation of behavior change related activity to the barriers and facilitators for the target behavior enables identification of opportunities being missed in practice; thereby, facilitating intervention optimization. METHOD: A mixed-method study involving: a systematic review to identify barriers and facilitators to implementing MECC classified using the COM-B model and Theoretical Domains Framework (TDF); a content analysis of national interventions to improve MECC implementation in England using the Behavior Change Wheel (BCW) and Behavior Change Techniques Taxonomy (BCTTv1); linking intervention content to barriers identified in the systematic review. RESULTS: Across 27 studies, the most frequently reported barriers related to eight TDF domains: Environmental Context and Resources, Beliefs About Capabilities, Knowledge, Beliefs About Consequences, Intentions, Skills, Social Professional Role and Identity, and Emotions. National interventions aimed at supporting MECC implementation included on average 5.1 BCW intervention functions (Education, Modeling, Persuasion, and Training were used in all interventions) and 8.7 BCTs. Only 21% of BCTs potentially relevant to key domains were used across interventions. The majority of BCTs linked to seven of the eight most important domains were not used in any existing interventions. CONCLUSIONS: Intervention developers should seize missed opportunities by incorporating more theoretically relevant BCTs to target barriers to implementing MECC. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

A randomised experiment of health, cost and social norm message frames to encourage acceptance of swaps in a simulation online supermarket.

Offering lower-energy food swaps to customers of online supermarkets could help to decrease energy (kcal) purchased and consumed. However, acceptance rates of such food swaps tend to be low. This study aimed to see whether framing lower-energy food swaps in terms of cost savings or social norms could improve likelihood of acceptance relative to framing swaps in terms of health benefits. Participants (n = 900) were asked to shop from a 12-item shopping list in a simulation online supermarket. When a target high-energy food was identified in the shopping basket at check-out, one or two lower-energy foods would be suggested as an alternative (a "swap"). Participants were randomised to only see messages emphasising health benefits (fewer calories), cost benefits (lower price) or social norms (others preferred this product). Data were analysed for 713 participants after exclusions. Participants were offered a mean of 3.17 swaps (SD = 1.50), and 12.91% of swaps were accepted (health = 14.31%, cost = 11.49%, social norms = 13.18%). Swap acceptance was not influenced by the specific swap frame used (all p > .170). Age was significantly and positively associated with swap acceptance (b = 0.02, SE = 0.00, p < .001), but was also associated with smaller decreases in energy change (b = 0.46, SE = .19, p = .014). Overall, offering swaps reduced both energy (kcal) per product (b = -9.69, SE = 4.07, p = .017) and energy (kcal) per shopping basket (t712 = 11.09, p < .001) from pre- to post-intervention. Offering lower-energy food swaps could be a successful strategy for reducing energy purchased by customers of online supermarkets. Future research should explore alternative solutions for increasing acceptance rates of such swaps.

Prescriber Commitment Posters to Increase Prudent Antibiotic Prescribing in English General Practice: A Cluster Randomized Controlled Trial.

Unnecessary antibiotic prescribing contributes to Antimicrobial Resistance posing a major public health risk. Estimates suggest as many as half of antibiotics prescribed for respiratory infections may be unnecessary. We conducted a three-armed unblinded cluster randomized controlled trial (ISRCTN trial registry 83322985). Interventions were a commitment poster (CP) advocating safe antibiotic prescribing or a CP plus an antimicrobial stewardship message (AM) on telephone appointment booking lines, tested against a usual care control group. The primary outcome measure was antibiotic item dispensing rates per 1000 population adjusted for practice demographics. The outcome measures for post-hoc analysis were dispensing rates of antibiotics usually prescribed for upper respiratory tract infections and broad spectrum antibiotics. In total, 196 practice units were randomized to usual care (n = 60), CP (n = 66), and CP&AM (n = 70). There was no effect on the overall dispensing rates for either interventions compared to usual care (CP 5.673, 95%CI -9.768 to 21.113, p = 0.458; CP&AM, -12.575, 95%CI -30.726 to 5.576, p = 0.167). Secondary analysis, which included pooling the data into one model, showed a significant effect of the AM (-18.444, 95%CI -32.596 to -4.292, p = 0.012). Fewer penicillins and macrolides were prescribed in the CP&AM intervention compared to usual care (-12.996, 95% CI -34.585 to -4.913, p = 0.018). Commitment posters did not reduce antibiotic prescribing. An automated patient antimicrobial stewardship message showed effects and requires further testing.

Reducing catheter-associated urinary tract infections: a systematic review of barriers and facilitators and strategic behavioural analysis of interventions.

BACKGROUND: Reducing the need for antibiotics is crucial in addressing the global threat of antimicrobial resistance. Catheter-associated urinary tract infection (CAUTI) is one of the most frequent device-related infections that may be amenable to prevention. Interventions implemented nationally in England target behaviours related to catheter insertion, maintenance and removal, but the extent to which they target barriers to and facilitators of these behaviours is unclear. This strategic behavioural analysis applied behavioural science frameworks to (i) identify barriers to and facilitators of behaviours that lead to CAUTI (CAUTI-related behaviours) in primary, community and secondary care and nursing homes; (ii) describe the content of nationally adopted interventions; and (iii) assess the extent to which intervention content is theoretically congruent with barriers and facilitators. METHODS: A mixed-methods, three-phased study: (1) systematic review of 25 studies to identify (i) behaviours relevant to CAUTI and (ii) barriers to and facilitators of CAUTI-related behaviours, classified using the COM-B model and Theoretical Domains Framework (TDF); (2) content analysis of nationally adopted CAUTI interventions in England identified through stakeholder consultation, classified using the Behaviour Change Wheel (BCW) and Behaviour Change Techniques Taxonomy (BCTTv1); and (3) findings from 1 and 2 were linked using matrices linking COM-B and TDF to BCW/BCTTv1 in order to signpost to intervention design and refinement. RESULTS: The most frequently reported barriers to and facilitators of CAUTI-related behaviours related to 'environmental context and resources'; 'knowledge'; 'beliefs about consequences'; 'social influences'; 'memory, attention and decision processes'; and 'social professional role and identity.' Eleven interventions aiming to reduce CAUTI were identifed. Interventions were primarily guidelines and included on average 2.3 intervention functions (1-5) and six BCTs (2-11), most frequently 'education', 'training' and 'enablement.' The most frequently used BCT was 'information about health consequences' which was used in almost all interventions. Social professional role and identity and environmental context and resources were targeted least frequently with potentially relevant BCTs. CONCLUSIONS: Interventions incorporated half the potentially relevant content to target identifed barriers to and facilitators of CAUTI-related behaviours. There were missed opportunities for intervention as most focus on shaping knowledge rather than addressing motivational, social and environmental influences. This study suggests that targeting motivational, social and environmental influences may lead to more effective intervention design and refinement.

Content and Mechanism of Action of National Antimicrobial Stewardship Interventions on Management of Respiratory Tract Infections in Primary and Community Care.

A major modifiable factor contributing to antimicrobial resistance (AMR) is inappropriate use and overuse of antimicrobials, such as antibiotics. This study aimed to describe the content and mechanism of action of antimicrobial stewardship (AMS) interventions to improve appropriate antibiotic use for respiratory tract infections (RTI) in primary and community care. This study also aimed to describe who these interventions were aimed at and the specific behaviors targeted for change. Evidence-based guidelines, peer-review publications, and infection experts were consulted to identify behaviors relevant to AMS for RTI in primary care and interventions to target these behaviors. Behavior change tools were used to describe the content of interventions. Theoretical frameworks were used to describe mechanisms of action. A total of 32 behaviors targeting six different groups were identified (patients; prescribers; community pharmacists; providers; commissioners; providers and commissioners). Thirty-nine interventions targeting the behaviors were identified (patients = 15, prescribers = 22, community pharmacy staff = 8, providers = 18, and commissioners = 18). Interventions targeted a mean of 5.8 behaviors (range 1-27). Influences on behavior most frequently targeted by interventions were psychological capability (knowledge and skills); reflective motivation (beliefs about consequences, intentions, social/professional role and identity); and physical opportunity (environmental context and resources). Interventions were most commonly characterized as achieving change by training, enabling, or educating and were delivered mainly through guidelines, service provision, and communications & marketing. Interventions included a mean of four Behavior Change Techniques (BCTs) (range 1-14). We identified little intervention content targeting automatic motivation and social opportunity influences on behavior. The majority of interventions focussed on education and training, which target knowledge and skills though the provision of instructions on how to perform a behavior and information about health consequences. Interventions could be refined with the inclusion of relevant BCTs, such as goal-setting and action planning (identified in only a few interventions), to translate instruction on how to perform a behavior into action. This study provides a platform to refine content and plan evaluation of antimicrobial stewardship interventions.

Improving Management of Respiratory Tract Infections in Community Pharmacies and Promoting Antimicrobial Stewardship: A Cluster Randomised Control Trial with a Self-Report Behavioural Questionnaire and Process Evaluation.

In England, 81% of all antibiotic prescriptions originate in primary care/community settings, of which up to 20% are thought to be inappropriate. Community pharmacies are often the first point of community contact for patients with suspected infections; providing an opportunity for community pharmacy teams to promote antimicrobial stewardship (AMS). The objective of the study was to improve the management of infections and antimicrobial stewardship in community pharmacies. The study methodology included a non-blinded cluster randomised control trial with pharmacy staff in 272 community pharmacies in England. The intervention arm received an AMS webinar and a patient facing respiratory tract infection (RTI) leaflet (TARGET TYI-RTI) for use in everyday practice for four weeks. The control arm received a webinar on how to participate in the study. The primary outcome was self-reported referrals to general practitioners (GPs). The secondary outcomes were; provision of self-care advice/ written information to patients, referrals to pharmacists, sign-posting to non-prescription medicines and common barriers and facilitators to advice-giving in community pharmacies. Ethics approval was granted by the Public Health England Research Ethics and Governance Group. 66.91% (182 of 272) of pharmacies provided 3649 patient consultation data reports across both arms. Use of the leaflet was associated with a lower likelihood of referrals to GPs for certain RTIs (p < 0.05) and a more frequent provision of self-care advice than the control (p = 0.06). Opportunities to deliver self-care advice were limited due to lack of time. Pharmacy staff had good motivation and capability for managing self-limiting infections but the opportunity to do so was a perceived barrier. Use of the TARGET leaflet facilitated pharmacy staff to give more self-care advice and decreased referrals to GPs.

Optimising antimicrobial stewardship interventions in English primary care: a behavioural analysis of qualitative and intervention studies.

OBJECTIVE: While various interventions have helped reduce antibiotic prescribing, further gains can be made. This study aimed to identify ways to optimise antimicrobial stewardship (AMS) interventions by assessing the extent to which important influences on antibiotic prescribing are addressed (or not) by behavioural content of AMS interventions. SETTINGS: English primary care. INTERVENTIONS: AMS interventions targeting healthcare professionals' antibiotic prescribing for respiratory tract infections. METHODS: We conducted two rapid reviews. The first included qualitative studies with healthcare professionals on self-reported influences on antibiotic prescribing. The influences were inductively coded and categorised using the Theoretical Domains Framework (TDF). Prespecified criteria were used to identify key TDF domains. The second review included studies of AMS interventions. Data on effectiveness were extracted. Components of effective interventions were extracted and coded using the TDF, Behaviour Change Wheel and Behaviour Change Techniques (BCTs) taxonomy. Using prespecified matrices, we assessed the extent to which BCTs and intervention functions addressed the key TDF domains of influences on prescribing. RESULTS: We identified 13 qualitative studies, 41 types of influences on antibiotic prescribing and 6 key TDF domains of influences: 'beliefs about consequences', 'social influences', 'skills', 'environmental context and resources', 'intentions' and 'emotions'. We identified 17 research-tested AMS interventions; nine of them effective and four nationally implemented. Interventions addressed all six key TDF domains of influences. Four of these six key TDF domains were addressed by 50%-67% BCTs that were theoretically congruent with these domains, whereas TDF domain 'skills' was addressed by 24% of congruent BCTs and 'emotions' by none. CONCLUSIONS: Further improvement of antibiotic prescribing could be facilitated by: (1) national implementation of effective research-tested AMS interventions (eg, electronic decision support tools, training in interactive use of leaflets, point-of-care testing); (2) targeting important, less-addressed TDF domains (eg, 'skills', 'emotions'); (3) using relevant, under-used BCTs to target key TDF domains (eg, 'forming/reversing habits', 'reducing negative emotions', 'social support'). These could be incorporated into existing, or developed as new, AMS interventions.

Optimising Interventions for Catheter-Associated Urinary Tract Infections (CAUTI) in Primary, Secondary and Care Home Settings.

Catheter-associated urinary tract infections (CAUTI) are common yet preventable. Healthcare professional behaviours, such as reducing unnecessary catheter use, are key for preventing CAUTI. Previous research has focused on identifying gaps in the national response to CAUTI in multiple settings in England. This study aimed to identify how national interventions could be optimised. We conducted a multi-method study comprising: a rapid review of research on interventions to reduce CAUTI; a behavioural analysis of effective research interventions compared to national interventions; and a stakeholder focus group and survey to identify the most promising options for optimising interventions. We identified 37 effective research interventions, mostly conducted in United States secondary care. A behavioural analysis of these interventions identified 39 intervention components as possible ways to optimise national interventions. Seven intervention components were prioritised by stakeholders. These included: checklists for discharge/admission to wards; information for patients and relatives about the pros/cons of catheters; setting and profession specific guidelines; standardised nationwide computer-based documentation; promotion of alternatives to catheter use; CAUTI champions; and bladder scanners. By combining research evidence, behavioural analysis and stakeholder feedback, we identified how national interventions to reduce CAUTI could be improved. The seven prioritised components should be considered for future implementation.

A randomised trial of the effect of appearance versus health-framed messages on engagement with an online brief screening and alcohol reduction intervention.

Objectives: To compare the impact of appearance versus health-framed messages on engagement in a brief web-based risk screening and alcohol reduction intervention. Design: Randomised trial delivered via Drinkaware's website. Visitors were exposed to appearance (n = 51,588) or health-framed messages (n = 52,639) directing them towards an AUDIT-C risk screening questionnaire. Users completing this questionnaire were given feedback on their risk level and extended frame-congruent information. Outcomes: The primary outcome is completion of the AUDIT-C questionnaire. The secondary outcome is whether the participant accessed any of four further resources. Results: The appearance-framed message led to a small but significant increase in the number of users completing the AUDIT-C compared to the health-framed message (n = 3,537, 6.86% versus n = 3,355, 6.37%, p < 0.01). Conversely, following subsequent risk feedback, users exposed to extended health-framed information were more likely to access further resources (n = 1,146, 2.17% versus n = 942, 1.83%, p < 0.01). Conclusions: Physical appearance-framed messages increased the likelihood of engagement with an online alcohol screening and brief intervention tool, whereas health-framed messages increased the likelihood of accessing further resources. This highlights the potential for the use of multi-level approaches in alcohol reduction interventions.