Experiences of online group support for engaging and supporting participants in the National Health Service Digital Diabetes Prevention Programme: A qualitative interview study.

OBJECTIVES: The National Health Service Digital Diabetes Prevention Programme is a nine-month behavioural intervention for adults in England at risk of type 2 diabetes. This qualitative study aimed to explore how service users engaged with the group support available within the programme. METHODS: The majority of participants (n = 33), all service users, were interviewed twice via telephone, at 2-4 months into the programme, and at the end of the programme at 8-10 months. Semi-structured interviews covered participants' experiences of online group support functions and how such groups served as a route of support to aid participants' behavioural changes. Data were analysed using manifest thematic analysis. RESULTS: The majority of participants valued the format of closed group chats, which provided an interactive platform to offer and receive support during their behaviour change journey. However, engagement with group chats reduced over time, and some participants did not find them useful when there was a lack of common interests within the group. Health coaches helped to promote engagement and build rapport among participants within the group chats. Participants reported mixed experiences of discussion forums. CONCLUSIONS: Programme developers should consider how to optimise online group support to help service users make behavioural changes, in terms of format, participant composition and use of health coach moderators. Further research is required to better understand who might benefit most from 'group chat' or 'discussion forum' support. Health coach moderation of online support groups is likely to facilitate engagement.

Design and Early Use of the Nationally Implemented Healthier You National Health Service Digital Diabetes Prevention Programme: Mixed Methods Study.

BACKGROUND: The Healthier You National Health Service Digital Diabetes Prevention Programme (NHS-digital-DPP) is a 9-month digital behavior change intervention delivered by 4 independent providers that is implemented nationally across England. No studies have explored the design features included by service providers of digital diabetes prevention programs to promote engagement, and little is known about how participants of nationally implemented digital diabetes prevention programs such as this one make use of them. OBJECTIVE: This study aimed to understand engagement with the NHS-digital-DPP. The specific objectives were to describe how engagement with the NHS-digital-DPP is promoted via design features and strategies and describe participants' early engagement with the NHS-digital-DPP apps. METHODS: Mixed methods were used. The qualitative study was a secondary analysis of documents detailing the NHS-digital-DPP intervention design and interviews with program developers (n=6). Data were deductively coded according to an established framework of engagement with digital health interventions. For the quantitative study, anonymous use data collected over 9 months for each provider representing participants' first 30 days of use of the apps were obtained for participants enrolled in the NHS-digital-DPP. Use data fields were categorized into 4 intervention features (Track, Learn, Coach Interactions, and Peer Support). The amount of engagement with the intervention features was calculated for the entire cohort, and the differences between providers were explored statistically. RESULTS: Data were available for 12,857 participants who enrolled in the NHS-digital-DPP during the data collection phase. Overall, 94.37% (12,133/12,857) of those enrolled engaged with the apps in the first 30 days. The median (IQR) number of days of use was 11 (2-25). Track features were engaged with the most (number of tracking events: median 46, IQR 3-22), and Peer Support features were the least engaged with, a median value of 0 (IQR 0-0). Differences in engagement with features were observed across providers. Qualitative findings offer explanations for the variations, including suggesting the importance of health coaches, reminders, and regular content updates to facilitate early engagement. CONCLUSIONS: Almost all participants in the NHS-digital-DPP started using the apps. Differences across providers identified by the mixed methods analysis provide the opportunity to identify features that are important for engagement with digital health interventions and could inform the design of other digital behavior change interventions.

Engagement with a nationally-implemented digital behaviour change intervention: Usage patterns over the 9-month duration of the National Health Service Digital Diabetes Prevention Programme.

Background: Digital behaviour change interventions may offer a scalable way to promote weight loss by increasing physical activity and improving diet. However, user engagement is necessary for such benefits to be achieved. There is a dearth of research that assesses engagement with nationally implemented digital programmes offered in routine practice. The National Health Service Digital Diabetes Prevention Programme (NHS-DDPP) is a nine-month digital behaviour change intervention delivered by independent providers for adults in England who are at high risk of developing type 2 diabetes. This study reports engagement with the NHS-DDPP for users enrolled onto the programme over the nine-month duration. Methods: Anonymous usage data was obtained for a cohort of service users (n = 1826) enrolled on the NHS-DDPP with three independent providers, between December 2020 and June 2021. Usage data were obtained for time spent in app, and frequency of use of NHS-DDPP intervention features in the apps including self-monitoring, goal setting, receiving educational content (via articles) and social support (via health coaches and group forums), to allow patterns of usage of these key features to be quantified across the nine-month intervention. Median usage was calculated within nine 30-day engagement periods to allow a longitudinal analysis of the dose of usage for each feature. Results: App usage declined from a median of 32 min (IQR 191) in month one to 0 min (IQR 14) in month nine. Users self-monitored their behaviours (e.g., physical activity and diet) a median of 117 times (IQR 451) in the apps over the nine-month programme. The open group discussion forums were utilised less regularly (accessed a median of 0 times at all time-points). There was higher engagement with some intervention features (e.g., goal setting) when support from a health coach was linked to those features. Conclusions: App usage decreased over the nine-month programme, although the rate at which the decrease occurred varied substantially between individuals and providers. Health coach support may promote engagement with specific intervention features. Future research should assess whether engagement with particular features of digital diabetes prevention programmes is associated with outcomes such as reduced bodyweight and HbA1c levels.

Reflections of patient and public involvement from a commissioned research project evaluating a nationally implemented NHS programme focused on diabetes prevention.

Patient and Public Involvement and Engagement (PPIE) in research is recognised by the National Institute for Health and Care Research as crucial for high quality research with practical benefit for patients and carers. Patient and public contributors can provide both personal knowledge and lived experiences which complement the perspectives of the academic research team. Nevertheless, effective PPIE must be tailored to the nature of the research, such as the size and scope of the research, whether it is researcher-led or independently commissioned, and whether the research aims to design an intervention or evaluate it. For example, commissioned research evaluations have potential limits on how PPIE can feed into the design of the research and the intervention. Such constraints may require re-orientation of PPIE input to other functions, such as supporting wider engagement and dissemination. In this commentary, we use the 'Guidance for Reporting Involvement of Patients and the Public' (GRIPP2) short form to share our own experiences of facilitating PPIE for a large, commissioned research project evaluating the National Health Service Diabetes Prevention Programme; a behavioural intervention for adults in England who are at high risk of developing type 2 diabetes. The programme was already widely implemented in routine practice when the research project and PPIE group were established. This commentary provides us with a unique opportunity to reflect on experiences of being part of a PPIE group in the context of a longer-term evaluation of a national programme, where the scope for involvement in the intervention design was more constrained, compared to PPIE within researcher-led intervention programmes. We reflect on PPIE in the design, analysis and dissemination of the research, including lessons learned for future PPIE work in large-scale commissioned evaluations of national programmes. Important considerations for this type of PPIE work include: ensuring the role of public contributors is clarified from the outset, the complexities of facilitating PPIE over longer project timeframes, and providing adequate support to public contributors and facilitators (including training, resources and flexible timelines) to ensure an inclusive and considerate approach. These findings can inform future PPIE plans for stakeholders involved in commissioned research.

"I don't know what I'm feeling for": young women's beliefs about breast cancer risk and experiences of breast awareness.

BACKGROUND: Younger women are often diagnosed with advanced breast cancer. Beliefs about risk are instrumental in motivating many health protective behaviours, but there may be confusion around which behaviour is appropriate to detect breast cancer earlier. Breast awareness, defined as an understanding of how the breasts look and feel so changes can be identified early, is widely recommended. In contrast, breast self-examination involves palpation using a specified method. We aimed to investigate young women's beliefs about their risk and experiences of breast awareness. METHODS: Thirty-seven women aged 30-39 years residing in a North West region of England with no family or personal history of breast cancer participated in seven focus groups (n = 29) and eight individual interviews. Data were analysed using reflexive thematic analysis. RESULTS: Three themes were generated. "Future me's problem" describes why women perceive breast cancer as an older woman's disease. Uncertainty regarding checking behaviours highlights how confusion about self-checking behaviour advice has resulted in women infrequently performing breast checks. Campaigns as a missed opportunity highlights the potential negative effects of current breast cancer fundraising campaigns and the perceived absence of educational campaigning about breast cancer for this demographic. CONCLUSIONS: Young women expressed low perceived susceptibility to developing breast cancer in the near future. Women did not know what breast self-checking behaviours they should be performing and expressed a lack of confidence in how to perform a breast check appropriately due to limited knowledge about what to look and feel for. Consequently, women reported disengagement with breast awareness. Defining and clearly communicating the best strategy for breast awareness and establishing whether it is beneficial or not are essential next steps.

Preventing type 2 diabetes: A research agenda for behavioural science.

AIMS: The aim of this narrative review was to identify important knowledge gaps in behavioural science relating to type 2 diabetes prevention, to inform future research in the field. METHODS: Seven researchers who have published behaviour science research applied to type 2 diabetes prevention independently identified several important gaps in knowledge. They met to discuss these and to generate recommendations to advance research in behavioural science of type 2 diabetes prevention. RESULTS: A total of 21 overlapping recommendations for a research agenda were identified. These covered issues within the following broad categories: (a) evidencing the impact of whole population approaches to type 2 diabetes prevention, (b) understanding the utility of disease-specific approaches to type 2 diabetes prevention such as Diabetes Prevention Programmes (DPPs) compared to generic weight loss programmes, (c) identifying how best to increase reach and engagement of DPPs, whilst avoiding exacerbating inequalities, (d) the need to understand mechanism of DPPs, (e) the need to understand how to increase maintenance of changes as part of or following DPPs, (f) the need to assess the feasibility and effectiveness of alternative approaches to the typical self-regulation approaches that are most commonly used, and (g) the need to address emotional aspects of DPPs, to promote effectiveness and avoid harms. CONCLUSIONS: There is a clear role for behavioural science in informing interventions to prevent people from developing type 2 diabetes, based on strong evidence of reach, effectiveness and cost-effectiveness. This review identifies key priorities for research needed to improve existing interventions.

Description of the nationally implemented National Health Service digital diabetes prevention programme and rationale for its development: mixed methods study.

BACKGROUND: The National Health Service (NHS) Digital Diabetes Prevention Programme (DDPP) is a behaviour change programme for adults in England who are at high risk of developing type 2 diabetes. Four independent providers deliver the NHS-DDPP following a competitive tendering process. Although providers work to a single service specification, there is potential for some variation in the service across providers. This study (1) assesses fidelity of the structural features of the design of the NHS-DDPP compared to the service specification, (2) describes the structural features of delivery of the NHS-DDPP as implemented (3) reports developers' views on how the structural components of the NHS-DDPP were developed and why changes were made following implementation. METHODS: Using mixed methods, we conducted a document review of providers' NHS-DDPP design and delivery documentation, and extracted information using the Template for Intervention Description and Replication checklist, which was adapted to capture features of digital delivery. Documentation was supplemented by content analysis of interviews with 12 health coaches involved in delivering the NHS-DDPP. Semi-structured interviews were also conducted with 6 programme developers employed by the digital providers. RESULTS: Provider plans for the NHS-DDPP show relatively high fidelity to the NHS service specification. Despite this, there was wide variation in structural features of delivery of the NHS-DDPP across providers, particularly for delivery of 'support' (e.g. use, dose and scheduling of health coaching and/or group support). Interviews with developers of the programmes showed that much of this variation is likely to be attributable to the origin of each provider's programme, which was usually a pre-existing programme that was adapted to conform to the NHS-DDPP service specification. The NHS-DDPP is continually improved and developed based on user experience feedback and research conducted by the providers. CONCLUSION: Indirect evidence suggests that variation in delivery of support could affect effectiveness of the NHS-DDPP. A priority for future research is ascertaining whether the variation in delivery of the NHS-DDPP across providers is related to any differences in health outcomes. It is recommended that future rounds of commissioning the NHS-DDPP pre-specify the type of support participants should receive, including expected dose and scheduling.

Optimising the delivery of breast cancer risk assessment for women aged 30-39 years: A qualitative study of women's views.

BACKGROUND: Identifying women aged 30-39 years at increased risk of developing breast cancer could allow them to consider screening and preventive strategies. Research is underway to determine the feasibility of offering breast cancer risk assessment to this age group. However, it is unclear how best to deliver and communicate risk estimates to these women, in order to avoid potential harms such as undue anxiety and increase benefits such as informed decision-making. OBJECTIVES: This study aimed to investigate women's views on, and requirements for, this proposed novel approach to risk assessment. DESIGN: A cross-sectional qualitative design was used. METHODS: Thirty-seven women aged 30-39 years with no family history or personal history of breast cancer participated in seven focus groups (n = 29) and eight individual interviews. Data were analysed thematically using a framework approach. RESULTS: Four themes were developed. Acceptability of risk assessment service concerns the positive views women have towards the prospect of participating in breast cancer risk assessment. Promoting engagement with the service describes the difficulties women in this age group experience in relation to healthcare access, including mental load and a lack of cultural awareness, and the implications of this for service design and delivery. Impact of receiving risk results focuses on the anticipated impacts of receiving different risk outcomes, namely, complacency towards breast awareness behaviours following low-risk results, an absence of reassurance following average-risk results and anxiety for high-risk results. Women's information requirements highlights women's desire to be fully informed at invite including understanding why the service is needed. In addition, women wanted risk feedback to focus on plans for management. CONCLUSION: The idea of breast cancer risk assessment was received favourably among this age group, providing that a risk management plan and support from healthcare professionals is available. Determinants of acceptability of a new service included minimising effort required to engage with service, co-development of invitation and risk feedback materials and the importance of educational campaigning about the potential benefits of participation in risk assessment.

How the Behavior Change Content of a Nationally Implemented Digital Diabetes Prevention Program Is Understood and Used by Participants: Qualitative Study of Fidelity of Receipt and Enactment.

BACKGROUND: The National Health Service Digital Diabetes Prevention Programme (NHS-DDPP) is a program for adults in England at risk of developing type 2 diabetes mellitus (T2DM). It is based on NHS England specifications that stipulate specific behavior change techniques (BCTs), that is, active ingredients to produce behavior change to target diet and physical activity. Now rolled out nationally, the NHS-DDPP is being delivered by 4 independent providers as a 9-month intervention via apps, educational material, and remote health coaching. To optimize effectiveness, participants need to be able to understand and use behavior change content (eg, goal setting and problem solving) of an intervention delivered to them digitally. Previous research has shown that people benefit from support to aid the understanding and use of BCTs. OBJECTIVE: The objectives of this qualitative study were to evaluate how participants in the NHS-DDPP understand and use BCT content, investigate how participants describe the role of health coaches in supporting their behavior change, and examine how the understanding and use of behavior change content of the NHS-DDPP varies across providers. METHODS: In total, 45 service users were interviewed twice by telephone at 2 to 4 months into, and at the end of, the program. Topics included participants' understanding and use of key BCTs to support self-regulation (eg, goal setting) and the support they received via the program. Transcripts were analyzed thematically, informed by the framework method. RESULTS: Participants described their understanding and use of some behavior change content of the program as straightforward: use of BCTs (eg, self-monitoring of behavior) delivered digitally via provider apps. Participants valued the role of health coaches in supporting their behavior change through the emotional support they offered and their direct role in delivery and application of some BCTs (eg, problem solving) to their specific circumstances. Participants expressed frustration over the lack of monitoring or feedback regarding their T2DM risk within the program. Variations in the understanding and use of behavior change content of the NHS-DDPP were present across provider programs. CONCLUSIONS: Health coaches' support in delivery of key components of the program seems to be pivotal. To improve the understanding and use of BCTs in digital interventions, it is important to consider routes of delivery that offer additional interactive human support. Understanding of some self-regulatory BCTs may benefit from this support more than others; thus, identifying the optimal mode of delivery for behavior change content is a priority for future research. The NHS-DDPP could be improved by explicitly setting out the need for health coaches to support understanding of some self-regulatory BCT content such as problem solving in the service specification and amending the discharge process so that knowledge of any change in T2DM risk is available to participants.

What behaviour change technique content is offered to service users of the nationally implemented English NHS Digital Diabetes Prevention Programme: Analysis of multiple sources of intervention content.

The National Health Service Digital Diabetes Prevention Programme (NHS-DDPP) is a behavioural intervention for adults in England at risk of developing Type 2 diabetes, rolled out nationally via independent providers and their digital partners. The NHS England programme specification indicated 19 behaviour change techniques (BCTs) which should be present in the intervention, including BCTs to support self-regulation. A previous evaluation of the face-to-face service found an under-delivery of some self-regulatory BCTs. This study assessed whether those 19 BCTs were offered in the different interventions delivered by four digital providers. A cross-sectional analysis of BCT content in the NHS-DDPP was elicited from the following sources: (a) online platforms (e.g. apps), (b) educational materials, and (c) health coaching (assessed via interviews with health coaches and audio-recorded telephone consultations). All materials were coded using the Behaviour Change Technique Taxonomy v1. A total of 17, 15, 15 and 14 of the 19 specified BCTs were identified across the four digital provider programmes. A mean proportion of 43% of specified BCTs were present via providers' apps, 74% via educational materials, and 62% via health coaching. An additional 41 BCTs were included in at least one of the four providers' programmes. Fidelity of BCT content in the NHS-DDPP was better than previously identified for the face-to-face DPP service. However, BCTs were offered via multiple modalities, thus the degree to which users engage with the modalities will impact on their exposure to BCTs and likely effectiveness of the digital programme.

Changes in a Digital Type 2 Diabetes Self-management Intervention During National Rollout: Mixed Methods Study of Fidelity.

BACKGROUND: "Healthy Living for People with type 2 Diabetes (HeLP-Diabetes)" was a theory-based digital self-management intervention for people with type 2 diabetes mellitus that encouraged behavior change using behavior change techniques (BCTs) and promoted self-management. HeLP-Diabetes was effective in reducing HbA1c levels in a randomized controlled trial (RCT). National Health Service (NHS) England commissioned a national rollout of HeLP-Diabetes in routine care (now called "Healthy Living"). Healthy Living presents a unique opportunity to examine the fidelity of the national rollout of an intervention originally tested in an RCT. OBJECTIVE: This research aimed to describe the Healthy Living BCT and self-management content and features of intervention delivery, compare the fidelity of Healthy Living with the original HeLP-Diabetes intervention, and explain the reasons for any fidelity drift during national rollout through qualitative interviews. METHODS: Content analysis of Healthy Living was conducted using 3 coding frameworks (objective 1): the BCT Taxonomy v1, a new coding framework for assessing self-management tasks, and the Template for Intervention Description and Replication. The extent to which BCTs and self-management tasks were included in Healthy Living was compared with published descriptions of HeLP-Diabetes (objective 2). Semistructured interviews were conducted with 9 stakeholders involved in the development of HeLP-Diabetes or Healthy Living to understand the reasons for any changes during national rollout (objective 3). Qualitative data were thematically analyzed using a modified framework approach. RESULTS: The content analysis identified 43 BCTs in Healthy Living. Healthy Living included all but one of the self-regulatory BCTs ("commitment") in the original HeLP-Diabetes intervention. Healthy Living was found to address all areas of self-management (medical, emotional, and role) in line with the original HeLP-Diabetes intervention. However, 2 important changes were identified. First, facilitated access by a health care professional was not implemented; interviews revealed this was because general practices had fewer resources in comparison with the RCT. Second, Healthy Living included an additional structured web-based learning curriculum that was developed by the HeLP-Diabetes team but was not included in the original RCT; interviews revealed that this was because of changes in NHS policy that encouraged referral to structured education. Interviewees described how the service provider had to reformat the content of the original HeLP-Diabetes website to make it more usable and accessible to meet the multiple digital standards required for implementation in the NHS. CONCLUSIONS: The national rollout of Healthy Living had good fidelity to the BCT and self-management content of HeLP-Diabetes. Important changes were attributable to the challenges of scaling up a digital intervention from an RCT to a nationally implemented intervention, mainly because of fewer resources available in practice and the length of time since the RCT. This study highlights the importance of considering implementation throughout all phases of intervention development.

How is the NHS Low-Calorie Diet Programme expected to produce behavioural change to support diabetes remission: An examination of underpinning theory.

Background: In 2020, the National Health Service Low-Calorie Diet Programme (NHS-LCD) was launched, piloting a total diet (TDR) replacement intervention with behaviour change support for people living with Type 2 Diabetes (T2D) and excess weight. Four independent service providers were commissioned to design and deliver theoretically grounded programmes in localities across England. Aims: 1) to develop a logic model detailing how the NHS-LCD programme is expected to produce changes in health behaviour, and (2) to analyse and evaluate the use of behaviour change theory in providers' NHS-LCD Programme designs. Methods: A documentary review was conducted. Information was extracted from the NHS-LCD service specification documents on how the programme expected to produce outcomes. The Theory Coding Scheme (TCS) was used to analyse theory use in providers' programme design documents. Results: The NHS-LCD logic model included techniques aimed at enhancing positive outcome expectations of programme participation and beliefs about social approval of behaviour change, to facilitate programme uptake and behaviour change intentions. This was followed by techniques aimed at shaping knowledge and enhancing the ability of participants to self-regulate their health behaviours, alongside a supportive social environment and person-centred approach.Application and type of behaviour change theory within service providers' programme designs varied. One provider explicitly linked theory to programme content; two providers linked 63% and 70% of intervention techniques to theory; and there was limited underpinning theory identified in the programme design documents for one of the providers. Conclusion: The nature and extent of theory use underpinning the NHS-LCD varied greatly amongst service providers, with some but not all intervention techniques explicitly linked to theory. How this relates to outcomes across providers should be evaluated. It is recommended that explicit theory use in programme design and evidence of its implementation becomes a requirement of future NHS commissioning processes.

Assessing and ensuring fidelity of the nationally implemented English NHS diabetes prevention programme: lessons learned for the implementation of large-scale behaviour change programmes.

Background: Health services interventions are typically more effective in randomised controlled trials than in routine healthcare. One explanation for this 'voltage drop', i.e. reduction in effectiveness, is a reduction in intervention fidelity, i.e. the extent to which a programme is implemented as intended. This article discusses how to optimise intervention fidelity in nationally implemented behaviour change programmes, using as an exemplar the National Health Service Diabetes Prevention Programme (NHS-DPP); a behaviour change intervention for adults in England at increased risk of developing Type 2 diabetes, delivered by four independent provider organisations. We summarise key findings from a thorough fidelity evaluation of the NHS-DPP assessing design (whether programme plans were in accordance with the evidence base), training (of staff to deliver key intervention components), delivery (of key intervention components), receipt (participant understanding of intervention content), and highlight lessons learned for the implementation of other large-scale programmes. Results: NHS-DPP providers delivered the majority of behaviour change content specified in their programme designs. However, a drift in fidelity was apparent at multiple points: from the evidence base, during programme commissioning, and on to providers' programme designs. A lack of clear theoretical rationale for the intervention contents was apparent in design, training, and delivery. Our evaluation suggests that many fidelity issues may have been less prevalent if there was a clear underpinning theory from the outset. Conclusion: We provide recommendations to enhance fidelity of nationally implemented behaviour change programmes. The involvement of a behaviour change specialist in clarifying the theory of change would minimise drift of key intervention content. Further, as loss of fidelity appears notable at the design stage, this should be given particular attention. Based on these recommendations, we describe examples of how we have worked with commissioners of the NHS-DPP to enhance fidelity of the next roll-out of the programme.

Fidelity to Program Specification of the National Health Service Digital Diabetes Prevention Program Behavior Change Technique Content and Underpinning Theory: Document Analysis.

BACKGROUND: The National Health Service (NHS) Diabetes Prevention Program is a behavior change intervention for adults in England who are identified as being at high risk of developing type 2 diabetes. The face-to-face service was launched in 2016, followed by a digital service (NHS Digital Diabetes Prevention Program [NHS-DDPP]) in 2019. A total of 4 service providers were commissioned to deliver the NHS-DDPP and were required to deliver the digital service in line with a program specification detailing the key intervention content. The fidelity of the behavior change content in the digital service (ie, the extent to which the program is delivered as intended) is currently unknown. Digital interventions may allow higher fidelity as staff do not have to be trained to deliver all intervention content. Assessing fidelity of the intervention design is particularly important to establish the planned behavior change content in the NHS-DDPP and the extent to which this adheres to the program specification. This is the first known independent assessment of design fidelity in a large-scale digital behavior change intervention. OBJECTIVE: This study aims to assess the fidelity of the behavior change content in each of the 4 NHS-DDPP providers' intervention designs to the full program specification. METHODS: We conducted a document review of each provider's NHS-DDPP intervention design, along with interviews with program developers employed by the 4 digital providers (n=6). Providers' intervention design documents and interview transcripts were coded for behavior change techniques (BCTs; ie, the active ingredients of the intervention) using the Behavior Change Technique Taxonomy version 1 and underpinning theory using the Theory Coding Scheme framework. The BCTs identified in each digital provider's intervention design were compared with the 19 BCTs included in the program specification. RESULTS: Of the 19 BCTs specified in the program specification, the 4 providers planned to deliver 16 (84%), 17 (89%), 16 (84%), and 16 (84%) BCTs, respectively. An additional 41 unspecified BCTs were included in at least one of the 4 digital providers' intervention designs. By contrast, inconsistent use of the underpinning theory was apparent across providers, and none of the providers had produced a logic model to explain how their programs were expected to work. All providers linked some of their planned BCTs to theoretical constructs; however, justification for the inclusion of other BCTs was not described. CONCLUSIONS: The fidelity of BCT content in the NHS-DDPP was higher than that previously documented for the face-to-face service. Thus, if service users engage with the NHS-DDPP, this should increase the effectiveness of the program. However, given that a clear theoretical underpinning supports the translation of BCTs in intervention designs to intervention delivery, the absence of a logic model describing the constructs to be targeted by specific BCTs is potentially problematic.

How is the Behavior Change Technique Content of the NHS Diabetes Prevention Program Understood by Participants? A Qualitative Study of Fidelity, With a Focus on Receipt.

BACKGROUND: The National Health Service (NHS) Diabetes Prevention Program (DPP) is a nationally implemented behavioral intervention for adults at high risk of developing Type 2 diabetes in England, based on a program specification that stipulates inclusion of 19 specific behavior change techniques (BCTs). Previous work has identified drift in fidelity from these NHS England specifications through providers' program manuals, training, and delivery, especially in relation to BCTs targeting self-regulatory processes. PURPOSE: This qualitative study investigates intervention receipt, i.e., how the self-regulatory BCT content of the NHS-DPP is understood by participants. METHODS: Twenty participants from eight NHS-DPP locations were interviewed; topics included participants' understanding of self-monitoring of behavior, goal setting, feedback, problem solving, and action planning. Transcripts were analyzed thematically using the framework method. RESULTS: There was a wide variation in understanding among participants for some BCTs, as well as between BCTs. Participants described their understanding of "self-monitoring of behaviors" with ease and valued BCTs focused on outcomes (weight loss). Some participants learned how to set appropriate behavioral goals. Participants struggled to recall "action planning" or "problem solving" or found these techniques challenging to understand, unless additional support was provided (e.g., through group discussion). CONCLUSIONS: Participants' lack of understanding of some self-regulatory BCTs is consistent with the drift across fidelity domains previously identified from NHS design specifications. Behavioral interventions should build-in necessary support for participants to help them understand some BCTs such as action planning and problem solving. Alternatively, these self-regulatory BCTs may be intrinsically difficult to use for this population.

An evaluation of goal setting in the NHS England diabetes prevention programme.

ObjectiveWe know little about how goal setting is actually delivered in routine practice. The National Health Service Diabetes Prevention Programme (NHS-DPP) is a behavioural intervention aiming to prevent progression to Type 2 diabetes in those at risk. It has been delivered across England by four commercial providers. This study aimed to establish whether goal setting in the NHS-DPP was delivered in line with the current evidence base. Design: Observational study and document review. One-hundred-and-eighteen NHS-DPP sessions with 419 people were observed at eight sites (two sites per provider). Main outcome measures: Multiple characteristics of goal setting were reliably coded from each providers' programme plans (intended goal setting) and from audio-recorded NHS-DPP sessions (actual goal setting). Results: Providers intended to deliver goal setting in 88.3% of sessions, though goal setting was delivered in only 52.5% of sessions. During delivery, the observed goals set across providers were generally specific (62.5%), set privately (53.1%), with goal difficulty rarely mentioned (3.1%). Conclusions: Goal setting in the NHS-DPP is being under-delivered, and not in line with the evidence base for promoting behavioural change. Goal setting in national behaviour change programmes should be optimised and training provided specifically for goal setting.

Breast Cancer Risk Assessment and Primary Prevention Advice in Primary Care: A Systematic Review of Provider Attitudes and Routine Behaviours.

Implementing risk-stratified breast cancer screening is being considered internationally. It has been suggested that primary care will need to take a role in delivering this service, including risk assessment and provision of primary prevention advice. This systematic review aimed to assess the acceptability of these tasks to primary care providers. Five databases were searched up to July-August 2020, yielding 29 eligible studies, of which 27 were narratively synthesised. The review was pre-registered (PROSPERO: CRD42020197676). Primary care providers report frequently collecting breast cancer family history information, but rarely using quantitative tools integrating additional risk factors. Primary care providers reported high levels of discomfort and low confidence with respect to risk-reducing medications although very few reported doubts about the evidence base underpinning their use. Insufficient education/training and perceived discomfort conducting both tasks were notable barriers. Primary care providers are more likely to accept an increased role in breast cancer risk assessment than advising on risk-reducing medications. To realise the benefits of risk-based screening and prevention at a population level, primary care will need to proactively assess breast cancer risk and advise on risk-reducing medications. To facilitate this, adaptations to infrastructure such as integrated tools are necessary in addition to provision of education.

The theoretical basis of a nationally implemented type 2 diabetes prevention programme: how is the programme expected to produce changes in behaviour?

BACKGROUND: It is considered best practice to provide clear theoretical descriptions of how behaviour change interventions should produce changes in behaviour. Commissioners of the National Health Service Diabetes Prevention Programme (NHS-DPP) specified that the four independent provider organisations must explicitly describe the behaviour change theory underpinning their interventions. The nationally implemented programme, launched in 2016, aims to prevent progression to Type 2 diabetes in high-risk adults through changing diet and physical activity behaviours. This study aimed to: (a) develop a logic model describing how the NHS-DPP is expected to work, and (b) document the behaviour change theories underpinning providers' NHS-DPP interventions. METHODS: A logic model detailing how the programme should work in changing diet and activity behaviours was extracted from information in three specification documents underpinning the NHS-DPP. To establish how each of the four providers expected their interventions to produce behavioural changes, information was extracted from their programme plans, staff training materials, and audio-recorded observations of mandatory staff training courses attended in 2018. All materials were coded using Michie and Prestwich's Theory Coding Scheme. RESULTS: The NHS-DPP logic model included information provision to lead to behaviour change intentions, followed by a self-regulatory cycle including action planning and monitoring behaviour. None of the providers described an explicit logic model of how their programme will produce behavioural changes. Two providers stated their programmes were informed by the COM-B (Capability Opportunity Motivation - Behaviour) framework, the other two described targeting factors from multiple theories such as Self-Regulation Theory and Self-Determination Theory. All providers cited examples of proposed links between some theoretical constructs and behaviour change techniques (BCTs), but none linked all BCTs to specified constructs. Some discrepancies were noted between the theory described in providers' programme plans and theory described in staff training. CONCLUSIONS: A variety of behaviour change theories were used by each provider. This may explain the variation between providers in BCTs selected in intervention design, and the mismatch between theory described in providers' programme plans and staff training. Without a logic model describing how they expect their interventions to work, justification for intervention contents in providers' programmes is not clear.

The Fidelity of Training in Behaviour Change Techniques to Intervention Design in a National Diabetes Prevention Programme.

BACKGROUND: The National Health Service Diabetes Prevention Programme (NHS-DPP) is a behavioural intervention for people identified as high risk for developing type 2 diabetes that has been rolled out across England. The present study evaluates whether the four commercial providers of the NHS-DPP train staff to deliver behaviour change technique (BCT) content with fidelity to intervention plans. METHOD: One set of mandatory training courses across the four NHS-DPP providers (seven courses across 13 days) was audio-recorded, and all additional training materials used were collected. Recordings and training materials were coded for BCT content using the BCT Taxonomy v1. BCTs and depth of training (e.g. instruction, demonstration, practice) of BCT content was checked against providers' intervention plans. RESULTS: Ten trainers and 78 trainees were observed, and 12 documents examined. The number of unique BCTs in audio recordings and associated training materials ranged from 19 to 44 across providers, and staff were trained in 53 unique BCTs across the whole NHS-DPP. Staff were trained in 66% of BCTs that were in intervention plans, though two providers trained staff in approximately half of BCTs to be delivered. The most common way that staff were trained in BCT delivery was through instruction. Training delivery style (e.g. experiential versus educational) varied between providers. CONCLUSION: Observed training evidences dilution from providers' intervention plans. NHS-DPP providers should review their training to ensure staff are trained in all key intervention components, ensuring thorough training of BCTs (e.g. demonstrating and practicing how to deliver) to enhance BCT delivery.

Is the NHS Diabetes Prevention Programme Intervention Delivered as Planned? An Observational Study of Fidelity of Intervention Delivery.

BACKGROUND: The NHS Diabetes Prevention Programme (NHS-DPP) has been delivered by four commercial organizations across England, to prevent people with impaired glucose tolerance developing Type 2 diabetes. Evidence reviews underpinning the NHS-DPP design specification identified 19 Behavior Change Techniques (BCTs) that are the intervention "active ingredients." It is important to understand the discrepancies between BCTs specified in design and BCTs actually delivered. PURPOSE: To compare observed fidelity of delivery of BCTs that were delivered to (a) the NHS-DPP design specification, and (b) the programme manuals of four provider organizations. METHODS: Audio-recordings were made of complete delivery of NHS-DPP courses at eight diverse sites (two courses per provider organization). The eight courses consisted of 111 group sessions, with 409 patients and 35 facilitators. BCT Taxonomy v1 was used to reliably code the contents of NHS-DPP design specification documents, programme manuals for each provider organization, and observed NHS-DPP group sessions. RESULTS: The NHS-DPP design specification indicated 19 BCTs that should be delivered, whereas only seven (37%) were delivered during the programme in all eight courses. By contrast, between 70% and 89% of BCTs specified in programme manuals were delivered. There was substantial under-delivery of BCTs that were designed to improve self-regulation of behavior, for example, those involving problem solving and self-monitoring of behavior. CONCLUSIONS: A lack of fidelity in delivery to the underlying evidence base was apparent, due to poor translation of design specification to programme manuals. By contrast, the fidelity of delivery to the programme manuals was relatively good. Future commissioning should focus on ensuring the evidence base is more accurately translated into the programme manual contents.