Development of a behaviour change intervention to promote sanitation and latrine use in rural India.

BACKGROUND: Across developing countries poor sanitation is associated with disease often found widespread in rural populations. OBJECTIVES: This objective of this study was to conduct a formative research and feasibility evaluation of the behavioural intervention designed to improve latrine use in rural India. METHODS: Study conducted in four villages of Rajasthan, where latrine use is low and open defecation may spread disease. To identify the intervention a literature review was conducted, a survey of 497 households, and focus groups in village households (8-10 women and children). Seven focus groups with 63 women were conducted. Based on the survey results, the behaviour change intervention is developed utilising the Capability-Opportunity-Motivation-behaviour model and MINDSPACE framework. One intervention component involves psychological aspects that engage villagers through a pledge; the other component is provision of small incentives to facilitate latrine use. Feasibility and acceptability of the intervention was examined in the study population. The 30-day intervention was delivered to women in 38 randomly selected households who despite having a functional latrine did not use it. Thematic analysis, binary logistic regression analysis and feasibility evaluation of the intervention conducted. Post-intervention feedback from 22 participating households was obtained. RESULTS: The piloted intervention was feasible and so a revised design is offered. Results driving this evaluation include barriers identified, and used to improved intervention design in the current study. Village authority figures influenced behaviours across the villages and so did factors of convenience (ß = 5.28, p < 0.01), relief (ß = 5.49, p < 0.01), comfort (ß = 2.36, p < 0.01), Construction cost (ß=-1.98, p < 0.01) and safety (ß = 2.93, p < 0.01) were significant concerns associated with latrine use in the context of prevalent OD in the region. The logistic regression baseline model for the dependant variables indicated a significant increase in latrine use. Based on the feasibility study, the intervention is refined in several ways. CONCLUSIONS: Our theory-driven approach improves latrine use in Rajasthan and offers a useful tool to facilitate hygiene behaviour.

Can guidelines rein in oxygen use? A retrospective cross-sectional study using routinely collected data.

Oxygen is one of the most commonly used emergency therapies. Like other therapies, oxygen can cause harm if used inappropriately. During the COVID-19 pandemic, guidelines were released to optimize oxygen and medication use. In the current study, we examine whether oxygen and medication use during the first wave of the COVID-19 pandemic was in concordance with new guidelines. A retrospective cross-sectional study was conducted using routinely collected data from University of Birmingham NHS Foundation Trust in England. Patients were admitted between April 2020 and September 2020, were over the age of 18 years, and had a confirmed diagnosis of COVID-19. To assess adherence to the oxygen guidelines (i.e. SpO2 adherence), the percentage of times oxygen therapy was administered within, over, and under guideline specifications were calculated for patients overall, and then for patients with and without chronic obstructive pulmonary disease (COPD)/pulmonary disease separately. Next, two multinomial regression analyses were conducted to assess whether clinical processes, pre-admission diagnoses, and other demographic factors were related to oxygen use. Analysis 1 included patients not diagnosed with COPD/pulmonary disease. Analysis 2 included patients diagnosed with COPD/pulmonary disease. Results are reported as tallies, percentages, and odds ratios with 95% confidence intervals. To assess adherence to a new medication guideline, the percentage of patients administered oxygen and dexamethasone was calculated for those admitted after 25 June 2020. The overall number of patients included in our SpO2 adherence analyses was 8751 (female = 4168). Oxygen was used within guideline specifications less than half the time, i.e. 41.6% (n = 3638/8751); non-adherence involving under-administering (3.5%, n = 304/8751) was markedly lower than over-administering (55.0%, n = 4809/8751). Adherence was higher for patients without COPD (43.7%, n = 3383/7741) than with COPD (25.2%, n = 255/1010). Under-administering was low across groups (non-COPD 3.5%, n = 274/7741 and COPD 2.9%, n = 30/1010). Over-administering was markedly lower for non-COPD (52.3%, n = 4084/7741) than COPD (71.8%, n = 725/1010) patients. Diagnoses associated with over-administering varied across the groups. Regarding the dexamethasone guidelines, of the 6397 patients admitted after the 24th of June, only 12.6% (n = 805) received dexamethasone. Suboptimal use of oxygen and medication were common during the first wave of the COVID-19 pandemic. As found in previous studies, over-administering was more common than under-administering. The new guidelines issued during the COVID-19 pandemic were not by themselves sufficient to optimize oxygen use. Behavioural strategies are explored which may help policymakers optimize oxygen use.

Application and Extension of the Alcohol Recovery Narratives Conceptual Framework.

Recovery narratives are personal stories of health problems and recovery. A systematic review proposed a conceptual framework characterising alcohol misuse recovery narratives, consisting of eight principal dimensions, each with types and subtypes. The current study aims to apply and extend this preliminary conceptual framework. Semi-structured interviews were conducted to collect alcohol misuse recovery narratives from adult participants. A two-stage inductive and deductive thematic analysis approach was used to assess the relevance of the dimensions and types included in the preliminary conceptual framework and identify new components. The sample consisted of 11 participants from diverse socioeconomic backgrounds who had previously displayed varying degrees of alcohol misuse. All conceptual framework dimensions (genre, identity, recovery setting, drinking trajectories, drinking behaviours and traits, stages, spirituality and religion, and recovery experience) were present in the collected narratives. Three dimensions were extended by adding types and subtypes. Whilst the existing conceptual framework fitted the collected narratives, a new dimension describing the alcohol environment was required to fully characterise narratives. Types included in the alcohol environment dimension were policy and practice and social dynamics. The extended framework could guide the production of resources enabling clinicians to engage with narratives shared by their clients.

Using multi-criteria decision analysis to describe stakeholder preferences for new quality improvement initiatives that could optimise prescribing in England.

Background: Hospital decision-makers have limited resources to implement quality improvement projects. To decide which interventions to take forward, trade-offs must be considered that inevitably turn on stakeholder preferences. The multi-criteria decision analysis (MCDA) approach could make this decision process more transparent. Method: An MCDA was conducted to rank-order four types of interventions that could optimise medication use in England's National Healthcare System (NHS) hospitals, including Computerised Interface, Built Environment, Written Communication, and Face-to-Face Interactions. Initially, a core group of quality improvers (N = 10) was convened to determine criteria that could influence which interventions are taken forward according to the Consolidated Framework for Implementation Research. Next, to determine preference weightings, a preference survey was conducted with a diverse group of quality improvers (N = 356) according to the Potentially All Pairwise Ranking of All Possible Alternatives method. Then, rank orders of four intervention types were calculated according to models with criteria unweighted and weighted according to participant preferences using an additive function. Uncertainty was estimated by probabilistic sensitivity analysis using 1,000 Monte Carlo Simulation iterations. Results: The most important criteria influencing what interventions were preferred was whether they addressed "patient needs" (17.6%)' and their financial "cost (11.5%)". The interventions' total scores (unweighted score out of 30 | weighted out of 100%) were: Computerised Interface (25 | 83.8%), Built Environment (24 | 79.6%), Written Communication (22 | 71.6%), and Face-to-Face (22 | 67.8%). The probabilistic sensitivity analysis revealed that the Computerised Interface would be the most preferred intervention over various degrees of uncertainty. Conclusions: An MCDA was conducted to rank order intervention types that stand to increase medication optimisation across hospitals in England. The top-ranked intervention type was the Computerised Interface. This finding does not imply Computerised Interface interventions are the most effective interventions but suggests that successfully implementing lower-ranked interventions may require more conversations that acknowledge stakeholder concerns.

Implementation and Evaluation of Two Nudges in a Hospital's Electronic Prescribing System to Optimise Cost-Effective Prescribing.

Providing healthcare workers with cost information about the medications they prescribe can influence their decisions. The current study aimed to analyse the impact of two nudges that presented cost information to prescribers through a hospital's electronic prescribing system. The nudges were co-created by the research team: four behavioural scientists and the lead hospital pharmacist. The nudges were rolled out sequentially. The first nudge provided simple cost information (percentage cost-difference between two brands of mesalazine: Asacol® and Octasa®). The second nudge provided information about the potential annual cost savings if the cheaper medication were selected across the National Health Service. Neither nudge influenced prescribing. Prescribing of Asacol® and Octasa® at baseline and during the implementation of the first nudge did not differ (at p ≥ 0.05), nor was there a difference between the first nudge and second (at p ≥ 0.05). Although these nudges were not effective, notable administrative barriers were overcome, which may inform future research. For example, although for legal reasons the cost of medicine cannot be displayed, we were able to present aggregated cost information to the prescribers. Future research could reveal more behavioural factors that facilitate medication optimisation.

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].

Characteristics of alcohol recovery narratives: Systematic review and narrative synthesis.

BACKGROUND AND AIMS: Narratives of recovery from alcohol misuse have been analysed in a range of research studies. This paper aims to produce a conceptual framework describing the characteristics of alcohol misuse recovery narratives that are in the research literature, to inform the development of research, policy, and practice. METHODS: Systematic review was conducted following PRISMA guidelines. Electronic searches of databases (Ovid MEDLINE, EMBASE, CINHAL, PsychInfo, AMED and SCOPUS), grey literature, and citation searches for included studies were conducted. Alcohol recovery narratives were defined as "first-person lived experience accounts, which includes elements of adversity, struggle, strength, success, and survival related to alcohol misuse, and refer to events or actions over a period of time". Frameworks were synthesised using a three-stage process. Sub-group analyses were conducted on studies presenting analyses of narratives with specific genders, ages, sexualities, ethnicities, and dual diagnosis. The review was prospectively registered (PROSPERO CRD42021235176). RESULTS: 32 studies were included (29 qualitative, 3 mixed-methods, 1055 participants, age range 17-82years, 52.6% male, 46.4% female). Most were conducted in the United States (n = 15) and Europe (n = 11). No included studies analysed recovery narratives from lower income countries. Treatment settings included Alcoholic Anonymous (n = 12 studies), other formal treatment, and 'natural recovery'. Eight principle narrative dimensions were identified (genre, identity, recovery setting, drinking trajectory, drinking behaviours, stages, spirituality and religion, and recovery experience) each with types and subtypes. All dimensions were present in most subgroups. Shame was a prominent theme for female narrators, lack of sense of belonging and spirituality were prominent for LGBTQ+ narrators, and alienation and inequality were prominent for indigenous narrators. CONCLUSIONS: Review provides characteristics of alcohol recovery narratives, with implications for both research and healthcare practice. It demonstrated knowledge gaps in relation to alcohol recovery narratives of people living in lower income countries, or those who recovered outside of mainstream services. PROTOCOL REGISTRATION: Prospero registration number: CRD42020164185.

How Do High-Performance Work Systems Affect Individual Outcomes: A Multilevel Perspective.

Research on high-performance work systems (HPWS) has suggested that a potential disconnection may exist between organizational-level HPWS and employee experienced HPWS. However, few studies have identified factors that are implied within such a relationship. Using a sample of 397 employees, 84 line managers, and 21 HR executives in China, we examined whether line managers' goal congruence can reduce the difference between organizational-level HPWS and employee experienced HPWS. Furthermore, this study also theorized and tested organization-based self-esteem (OBSE) as a mediator in the associations between employee experienced HPWS and job performance and job satisfaction. Using multilevel analyses, we found that line managers' goal congruence strengthened the relationship between organizational-level HPWS and employee experienced HPWS, such that the relationship was significant and positive when line managers' goal congruence was high, but a non-significant relationship when line managers' goal congruence was low. Moreover, employee experienced HPWS indirectly affected job performance and job satisfaction through the mechanism of OBSE beyond social exchange perspective.