Dr Benjamin Gardner

BackgroundEveningness chronotype—the tendency for later sleep and wake times—arises from a confluence of psychosocial, behavioral, and biological factors. With the onset and progression of puberty, many young people develop an eveningness chronotype, which remains prevalent through the transition into adulthood. Eveningness has been associated with increased risk for poorer health. While eveningness is modifiable, maintaining the necessary behavior changes can be challenging. The science on habits demonstrates that habit formation is a key mechanism for maintaining behavior change over time. Learning theory o!ers schedules of reinforcement that also hold promise for enhancing the maintenance of behavior change. The present study will evaluate the Habit-based Sleep Health Intervention (HABITs)—which combines the Transdiagnostic Intervention for Sleep and Circadian Dysfunction (TranS-C) with the science of habits—and a text message intervention informed by learning theory to attempt to sustainably modify the contributors to eveningness among young adults (18–30 years of age).MethodsParticipants (N = 160) will be randomly allocated to HABITs and HABITs + Texts. Both interventions include HABITs which involves three 50-min sessions followed by six 30-min sessions. Alongside the latter six sessions, HABITs + Texts will concurrently receive the text message intervention. Aims 1–3 will compare HABITs + Texts to HABITs on improvements in the outcomes of (1) utilization of sleep health behaviors and habit formation, (2) sleep and cir-cadian functioning, and (3) functioning in five health-relevant domains, in the short (post-treatment) and longer (6-month and 12-month follow-up) term. Exploratory analysis will (1) compare HABITs and HABITs + Texts on (a) if sleep health behavior habit formation mediates the e!ects of intervention on improvement in outcomes and (b) if intervention effects are moderated by select variables, and (2) to evaluate if HABITs (regardless of the text message intervention) is associated with an improvement in outcomes in the short and longer term.DiscussionThis study has the potential to advance knowledge on (1) the value of leveraging the science of habits and learning theory in behavior change interventions, (2) the use of a low-cost and efficient intervention for habit formation and maintenance, (3) interventions that address eveningness chronotype, and (4) processes related to behavior change during emerging adulthood.Trial registrationClinicaltrials.gov NCT05167695. Registered on December 22, 2021.

When self-regulatory resources are depleted, people tend to act more on ‘autopilot’, with minimal forethought. It follows that when sleepy, people should be more likely to act habitually, based on learned cue-behaviour associations that trigger behaviour automatically when the cue is encountered. This ecological momentary assessment study investigated whether, over the course of a week, between-person differences and momentary within-person variation in daytime sleepiness were associated with the reported habit strength of behaviours. Participants (N = 105, 71% female, M age = 35) completed a baseline assessment of sleep quality and, six times daily over seven days, momentary assessments in which they reported the habit strength of the behaviour they were doing when prompted and their momentary sleepiness. Multilevel modelling revealed that people who were more sleepy than others were not more or less likely to act habitually, but on occasions when people were more sleepy than was typical for them, the behaviour they were engaging in tended to be more habitual (Pseudo-R2 = 2%). Our results suggest that sleepiness causes people to rely on non-reflective processes such as habit to regulate their behaviour. Interventions should promote habit formation for desirable behaviours so that when people are sleepy, they can rely on the efficiency of habits to ensure they continue to enact wanted behaviours. Conversely, interventions promoting behaviours that require deliberative thought might encourage performance during times of day when people are more alert.

It is challenging to predict long-term outcomes of interventions without understanding how they work. Health economic models of public health interventions often do not incorporate the many determinants of individual and population behaviours that influence long term effectiveness. The aim of this paper is to draw on psychology, sociology, behavioural economics, complexity science and health economics to: (a) develop a toolbox of methods for incorporating the influences on behaviour into public health economic models (PHEM-B); and (b) set out a research agenda for health economic modellers and behavioural/ social scientists to further advance methods to better inform public health policy decisions. A core multidisciplinary group developed a preliminary toolbox from a published review of the literature and tested this conceptually using a case study of a diabetes prevention simulation. The core group was augmented by a much wider group that covered a broader range of multidisciplinary expertise. We used a consensus method to gain agreement of the PHEM-B toolbox. This included a one-day workshop and subsequent reviews of the toolbox. The PHEM-B toolbox sets out 12 methods which can be used in different combinations to incorporate influences on behaviours into public health economic models: collaborations between modellers and behavioural scientists, literature reviewing, application of the Behaviour Change Intervention Ontology, systems mapping, agent-based modelling, differential equation modelling, social network analysis, geographical information systems, discrete event simulation, theory-informed statistical and econometric analyses, expert elicitation, and qualitative research/process tracing. For each method, we provide a description with key references, an expert consensus on the circumstances when they could be used, and the resources required. This is the first attempt to rigorously and coherently propose methods to incorporate the influences on behaviour into health economic models of public health interventions. It may not always be feasible or necessary to model the influences on behaviour explicitly, but it is essential to develop an understanding of the key influences. Changing behaviour and maintaining that behaviour change could have different influences; thus, there could be benefits in modelling these separately. Future research is needed to develop, collaboratively with behavioural scientists, a suite of more robust health economic models of health-related behaviours, reported transparently, including coding, which would allow model reuse and adaptation.

Understanding the influence of habit on health behaviour, or the formation or disruption of health habits over time, requires reliable and valid measures of automaticity. The most used measure, the Self-Report Behavioural Automaticity Index (SRBAI; derived from the Self-Report Habit Index [SRHI]) comprises four items, which may be impractical in some research contexts. Responding to demand from fellow researchers, this study sought to identify whether and which single items from the SRBAI adequately detect hypothesised effects of automaticity, via secondary analysis of 16 datasets, incorporating 16,838 participants and seven different behaviours. We assessed construct validity through correlations between each item and the full SRBAI (and where possible, the SRHI) and predictive validity by examining correlations with behaviour. All four single-item measures independently met construct and predictive validity criteria. We recognise compelling conceptual and methodological arguments regarding why people should not attempt to assess automaticity via a single, self-report item. However, where circumstances require brief measures, three SRBAI items each offer a credible and practical one-item measure that can substitute for the SRBAI or SRHI. We recommend one item in particular – ‘Behaviour X is something I do automatically’ – because it tended to most closely replicate the effects of the four-item SRBAI.

Meeting the needs of the growing number of older people is a challenge for health and social care services. Home-based interventions aiming to modify health-related behaviours of frail older people have the potential to improve functioning and well-being. Previous reviews have focused on whether such interventions are effective, rather than what might make them effective. Recent advances in behavioural science make possible the identification of potential 'active ingredients' of effective interventions, such as component behaviour change techniques (BCTs), and intended intervention functions (IFs; e.g. to educate, to impart skills). This paper reports a protocol for a systematic review that seeks to (a) identify health behaviour change interventions for older frail people, (b) describe the content of these interventions, and (c) explore links between intervention content and effectiveness. The protocol is reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) 2015 guidelines. Studies will be identified through a systematic search of 15 electronic databases, supplemented by citation tracking. Studies will be retained for review where they report randomised controlled trials focusing on home-based health promotion delivered by a health professional for frail older people in community settings, written in English, and either published from 1980 onwards, or, for registered trials only, unpublished but completed with results obtainable from authors. Interventions will be coded for their content (BCTs, IFs) and for evidence of effectiveness (outcome data relating to behavioural and health outcomes). Analyses will describe characteristics of all interventions. Interventions for which effectiveness data are available will be categorised into those showing evidence of effectiveness versus those showing no such evidence. The potential for each intervention characteristic to contribute to change in behaviour or health outcomes will be estimated by calculating the percentage of all interventions featuring those characteristics that have shown effectiveness. Results will reveal the strategies that have been drawn on within home-based interventions to modify the health behaviours of frail older people, and highlight those more associated with positive changes in behaviour and health. Findings from this review will provide a useful basis for understanding, developing, and implementing behaviour change interventions in this field. PROSPERO CRD42014010370.

The influence of habit on physical activity is computationally modelled as the aggregated influence of past behavioral choices a person makes in a given context. Hypotheses include that the influence of habit on behavior can be enhanced through engagement of the target behavior in a particular context or weakened through engagement of alternative behaviors in that context.

Abstract Issue Addressed Interventions targeting health care professionals' behaviours are assumed to support them in learning how to give behavioural advice to patients, but such assumptions are rarely examined. This study investigated whether key assumptions were held regarding the design and delivery of physical activity interventions among health care professionals in applied health care settings. This study was part of the ‘Physical Activity Tailored intervention in Hospital Staff’ randomised controlled trial of three variants of a web‐based intervention. Methods We used data‐prompted interviews to explore whether the interventions were delivered and operated as intended in health care professionals working in four hospitals in Western Australia ( N = 25). Data were analysed using codebook thematic analysis. Results Five themes were constructed: (1) health care professionals' perceived role in changing patients' health behaviours; (2) work‐related barriers to physical activity intervention adherence; (3) health care professionals' use of behaviour change techniques; (4) contamination between groups; and (5) perceptions of intervention tailoring. Conclusions The intervention was not experienced by participants, nor did they implement the intervention guidance, in the way we expected. For example, not all health care professionals felt responsible for providing behaviour change advice, time and shift constraints were key barriers to intervention participation, and contamination effects were difficult to avoid. So What? Our study challenges assumptions about how health care professionals respond to behaviour change advice and possible knock‐on benefits for patients. Applying our learnings may improve the implementation of health promotion interventions in health care settings.

OBJECTIVES Interventions promoting habitual fruit consumption have the potential to bring about long-term behaviour change. Assessing the effectiveness of such interventions requires adequate habit and behaviour measures. Habits are based on learned context-behaviour associations, so measures that incorporate context should be more sensitive to expected habit and behaviour changes than context-free measures. This study compared context-specific and context-free measures of fruit consumption habit and behaviour following a 3-week habit formation intervention. DESIGN Prospective online study (n = 58). METHODS Behaviour frequency was assessed across five timepoints, retrospectively (Time 1 [T1], T5) or via daily diary data (uploaded weekly at T2, T3 and T4). Habit strength was assessed before (T1) and immediately after the intervention (T4), and again 2 weeks later (T5). Analyses of variance were run, with time and context specificity as within-subject factors, and habit and behaviour frequency as dependent measures. RESULTS An interaction between time and context specificity was found in both analyses (habit: F(2,114) = 12.848, p < .001, part.η2 = .184; behaviour: F(2,114) = 6.714, p = .002, part.η2 = .105). Expected habit formation patterns 5 weeks post-baseline were only detected by the context-specific habit measure. Likewise, increased behaviour frequency was only found when the target context was specified (p's < .001). CONCLUSIONS Assessments of purposeful dietary habit and behaviour change attempts should incorporate context-specific measurement.

Background Mild frailty or pre-frailty is common and yet is potentially reversible. Preventing progression to worsening frailty may benefit individuals and lower health/social care costs. However, we know little about effective approaches to preventing frailty progression. Objectives (1) To develop an evidence- and theory-based home-based health promotion intervention for older people with mild frailty. (2) To assess feasibility, costs and acceptability of (i) the intervention and (ii) a full-scale clinical effectiveness and cost-effectiveness randomised controlled trial (RCT). Design Evidence reviews, qualitative studies, intervention development and a feasibility RCT with process evaluation. Intervention development Two systematic reviews (including systematic searches of 14 databases and registries, 1990–2016 and 1980–2014), a state-of-the-art review (from inception to 2015) and policy review identified effective components for our intervention. We collected data on health priorities and potential intervention components from semistructured interviews and focus groups with older people (aged 65–94 years) (n = 44), carers (n = 12) and health/social care professionals (n = 27). These data, and our evidence reviews, fed into development of the ‘HomeHealth’ intervention in collaboration with older people and multidisciplinary stakeholders. ‘HomeHealth’ comprised 3–6 sessions with a support worker trained in behaviour change techniques, communication skills, exercise, nutrition and mood. Participants addressed self-directed independence and well-being goals, supported through education, skills training, enabling individuals to overcome barriers, providing feedback, maximising motivation and promoting habit formation. Feasibility RCT Single-blind RCT, individually randomised to ‘HomeHealth’ or treatment as usual (TAU). Setting Community settings in London and Hertfordshire, UK. Participants A total of 51 community-dwelling adults aged ≥ 65 years with mild frailty. Main outcome measures Feasibility – recruitment, retention, acceptability and intervention costs. Clinical and health economic outcome data at 6 months included functioning, frailty status, well-being, psychological distress, quality of life, capability and NHS and societal service utilisation/costs. Results We successfully recruited to target, with good 6-month retention (94%). Trial procedures were acceptable with minimal missing data. Individual randomisation was feasible. The intervention was acceptable, with good fidelity and modest delivery costs (£307 per patient). A total of 96% of participants identified at least one goal, which were mostly exercise related (73%). We found significantly better functioning (Barthel Index +1.68; p = 0.004), better grip strength (+6.48 kg; p = 0.02), reduced psychological distress (12-item General Health Questionnaire –3.92; p = 0.01) and increased capability-adjusted life-years [+0.017; 95% confidence interval (CI) 0.001 to 0.031] at 6 months in the intervention arm than the TAU arm, with no differences in other outcomes. NHS and carer support costs were variable but, overall, were lower in the intervention arm than the TAU arm. The main limitation was difficulty maintaining outcome assessor blinding. Conclusions Evidence is lacking to inform frailty prevention service design, with no large-scale trials of multidomain interventions. From stakeholder/public perspectives, new frailty prevention services should be personalised and encompass multiple domains, particularly socialising and mobility, and can be delivered by trained non-specialists. Our multicomponent health promotion intervention was acceptable and delivered at modest cost. Our small study shows promise for improving clinical outcomes, including functioning and independence. A full-scale individually RCT is feasible. Future work A large, definitive RCT of the HomeHealth service is warranted.

To improve health and wellbeing, it is crucial that people regularly interrupt their sitting. In this paper, we propose a framework for examining and changing sitting behavior that addresses two key steps in the process towards developing effective interventions. First, we suggest that research should move away from its current focus on sitting time, which is an outcome of behavior. Rather, researchers should focus on stand-to-sit and sit-to-stand transitions, which are discrete units of behavior. Second, drawing on goal hierarchy models, we suggest that people rarely engage in stand-to-sit and sit-to-stand transitions for the purpose of being in a sitting or standing position; rather, we suggest that these transitions are means to higher-order goals (e.g., to complete work tasks, to watch television, to eat dinner). To improve adherence to and effectiveness of sitting behavior interventions, intervention designers should aim to increase the frequency of sit-to-stand (and stand-to-sit) transitions. To achieve this aim, intervention designers should capitalize on the higher-order goals that are typically served by these transitions. We suggest four concrete intervention strategies to increase sit-to-stand transitions in congruence with people’s everyday goals. We also describe implications of our framework for theory and methods in sitting behavior research.

Background and Aims. Student mental health is of increasing concern: over a quarter of UK students report a mental health issue, and reactive support services cannot cope with increasing demand. Physical activity (PA) is associated with improved mental health in higher education settings. Universities are well placed to offer PA to promote students’ mental health and wellbeing. This study represents the first attempt to establish how many UK universities offer PA-based interventions to improve mental health and wellbeing of students, and what these interventions entail. We sought to identify, and code the characteristics of, interventions regarding how to encourage regular PA. Methods. All UK universities were contacted and asked to report PA provisions available to students. We extracted key information from intervention descriptions, including using the Behaviour Change Technique (BCT) Taxonomy v1, to characterise component behaviour change strategies. Results. Of 143 public UK universities identified, 125 (87%) responded to our request. Of these, only 45 (36%) universities had PA provisions in place, with a total of 54 interventions available across the country, each delivered for between 6-12 weeks. Most interventions were tailored (82%) and used BCTs focused on instructing students on how to perform physical activity (61%), restructuring the environment to facilitate activity (54%), and behavioural goal setting (46%). Conclusions. Only a minority of UK universities offer PA interventions to students. These offerings focus on enhancing students’ capabilities and giving greater opportunities for PA. Universities should consider offering greater PA provision to students, and address students’ motivation to engage in PA.

Purpose: Adherence to swallowing exercises prescribed to improve swallow function after head and neck cancer has been reported to be suboptimal or poor in several studies. In this study, we identify the barriers and facilitators to performing exercises, and determine the likely strategies to reduce the barriers and enhance the facilitators. Method(s): Semi-structured face to face in-depth interviews were conducted on 13 patients post treatment for head and neck cancer. A comprehensive framework (Theoretical Domains Framework) was used to probe reasons for patients' adherent and non-adherent exercise behaviour. Findings were analysed using Content Analysis. The emergent categories were mapped onto a theory-based model of behaviour change. This facilitated the process of selecting strategies that are most likely to improve patient adherence based on insights from psychological theory and behavioural science. Result(s): Key barriers included inadequate knowledge of the impact of treatment on own swallow function, forgetting to do exercises, overwhelmed by information at a difficult time, pain and fatigue. Key facilitators included social support, knowing how to do the exercises, desire to prevent negative consequences and having a trigger to do exercises. Conclusions (Including Clinical Relevance): This study has used a behavioural science lens to examine head and neck patients adherence to swallowing exercises. The strategies likely to improve adherence will be included in the design of a new swallowing intervention package. The methodology employed in this study could have wider application for other patient groups. Relevant Financial Relationships: Roganie Govender: Has affiliations to disclose; National Institute of Health Research: Grant: Other Activities; Caroline Wood: Nothing to Disclose; Stuart Taylor: Nothing to Disclose; Benjamin Gardner: Nothing to Disclose; Christina Smith: Nothing to Disclose. Relevant Non-Financial Relationships: Roganie Govender: Nothing to Disclose; Caroline Wood: Nothing to Disclose; Stuart Taylor: Nothing to Disclose; Benjamin Gardner: Nothing to Disclose; Christina Smith: Nothing to Disclose.

Adjuvant endocrine therapy (AET) reduces breast cancer recurrence and mortality in women with early-stage breast cancer. Unintentional nonadherence to AET is common (eg, forgetting to take medication). Forming habits surrounding medication taking could reduce reliance on memory and improve AET adherence. SMS text messaging interventions may offer a low-cost approach for promoting medication-taking habits. To optimize the likely effectiveness of such SMS text messages, the content should be developed using a transparent approach to ensure fidelity to relevant psychological theory and with user input to increase acceptability. This study aimed to develop a pool of brief SMS text messages promoting habit formation to support AET adherence, which are acceptable to women with breast cancer and show fidelity to theory-based behavior change techniques (BCTs). According to published literature, we selected 6 BCTs derived from the habit formation model: action planning, habit formation, restructuring the physical environment, adding objects to the environment, prompts/cues, and self-monitoring of behavior. In study 1, behavior change experts (n=10) created messages, each based on 1 of the 6 BCTs, in a web-based workshop and rated the fidelity of the messages to the intended BCT. In study 2, women with experience of taking AET discussed the acceptability of the messages in a focus group (n=5), and the messages were refined following this. In study 3, women with breast cancer rated the acceptability of each message in a web-based survey (n=60). In study 4, additional behavior change experts rated the fidelity of the remaining messages to the intended BCT in a web-based survey (n=12). Finally, a consultant pharmacist reviewed a selection of messages to ensure that they did not contradict general medical advice. In study 1, 189 messages were created targeting the 6 BCTs. In total, 92 messages were removed because they were repetitious, unsuitable, or >160 characters, and 3 were removed because of low fidelity (scoring

Physical activity (PA) has numerous health benefits. However, individuals may depend on it for health reasons or lose control over it to the point of addiction, resulting in adverse health effects. Automatic reactions to cues related to addictive behavior have been identified as a hallmark of addiction. However, the extent to which these automatic reactions are associated with exercise dependence is unknown. This study aimed to examine the associations between exercise dependence and automatic reactions toward PA-related cues. Two studies were conducted on physically active individuals with low-to-moderate levels of exercise dependence. Study 1 (N=65) used a dot-probe task with eye-tracking to examine the association between attentional bias toward PA and exercise dependence scores as measured by the Exercise Dependence Scale–Revised (EDS-R). Study 2 (N=125) used a manikin task and a single-category implicit association test to assess the association of approach-avoidance tendencies and implicit affective attitudes toward PA with exercise dependence scores, respectively. Results showed that exercise dependence scores were positively associated with behavioral indicators of attentional bias (i.e., reaction times), but not with more direct eye-tracking indicators (i.e., first-gaze localization, gaze duration) (Study 1). Similarly, exercise dependence scores were unrelated to approach-avoidance tendencies or implicit affective attitudes toward PA (Study 2). Therefore, our study provides limited evidence supporting the hypothesis that automatic reactions to PA may reflect a “signature” of exercise dependence. Our findings do not robustly support the link between automatic processes and exercise dependence, which raises the question of whether the psychological mechanisms involved in the development of exercise dependence might differ from those typically observed in other addictive behaviors where automatic processes play a significant role. However, due to our sample's low-to-moderate levels of exercise dependence, definitive conclusions cannot be drawn. Further research with individuals exhibiting harmless and addiction-related dependence, incorporating personalized stimuli, and using neurophysiological methods is needed.

Background Frailty is a condition resulting from a decline in physiological reserves caused by an accumulation of several deficits, which progressively impairs the ability to recover from health adverse events. Following a promising feasibility study, the HomeHealth trial assessed a holistic tailored intervention for older adults with mild frailty to promote independence in their own homes, compared with usual care. We aimed to understand how goal setting worked among older people with mild frailty. Methods This study was a process evaluation alongside the HomeHealth randomised trial in older adults with mild frailty. The intervention was delivered at participants’ homes, either in person or by telephone or videoconferencing. We carried out semi-structured interviews with older participants who had received the intervention (between three and six appointments), on average 233 days (range 68–465) after their last appointment, purposively sampled according to age, gender, number of sessions attended, adverse events, ethnicity, Index of Multiple Deprivation, Montreal Cognitive Assessment (MoCA) and Barthel scores, research site, and HomeHealth worker. We also conducted interviews with HomeHealth workers who delivered the intervention (n=7). Interviews explored the experience and process of goal setting, benefits and challenges, perceived progress, and behaviour change maintenance after the service had finished. Ethics approval was obtained, and all participants gave informed consent. Interviews were thematically analysed. HomeHealth workers kept formal records of goals set and assessed progress towards goals (0–2 rating scale) during six monthly-sessions, which were descriptively summarised. Findings 56 interviews were completed between July 15, 2022, and May 18, 2023. Study participants (n=49) had a mean age of 80 years (range 66–94), including 32 (65%) women and 17 (35%) men. Participants self-identified as White (n=42), Asian (n=3), Black (n=2), Mixed (n=1), and other ethnic (n=1) backgrounds. Findings suggested goal setting could be both a challenge and a motivator for older participants with mild frailty. Goal setting worked well when the older person could identify a clear need and set realistic goals linked to functioning, which led to a positive sense of achievement. Challenges occurred when older people were already accessing multiple resources and health services, or where the terminology of “goals” was off-putting due to work or school connotations. Average progress towards goals was 1·15/2. Most participants set goals around improving mobility (or a combination of mobility and another goal type such as socialising), and there was evidence of participants sustaining these behaviour changes after the intervention. Interpretation Older people with mild frailty can engage well with goal setting to promote independence. The lapse between receiving the intervention and being interviewed limited recall for some participants. However, the acceptability and adherence to the intervention for older people with mild frailty, and their moderate progress towards goals, should encourage further tailored and person-centred practices to promote their independence. Funding National Institute for Health Research (NIHR) Health Technology Assessment.

The COVID-19 pandemic saw promotion of novel virus transmission-reduction behaviours, and discouragement of familiar transmission-conducive behaviours. Understanding changes in the automatic nature of such behaviours is important, because habitual behaviours may be more easily reactivated in future outbreaks and disrupting old habits may discontinue unwanted behaviours. A repeated-measures, multi-national design tracked virus-transmission habits and behaviour fortnightly over six months (Apr-Sept 2020) among 517 participants (age M = 42 ± 16y, 79% female). Within-participant habit trajectories across all timepoints, and engagement in transmission-reduction behaviours (handwashing when entering home; handwashing with soap for 20 seconds; physical distancing) and transmission-conducive behaviours (coughing/sneezing into hands; making physical contact) summed over the final two timepoints. Three habit trajectory types were observed. Habits that remained strong ('stable strong habit') and habits that strengthened ('habit formation') were most common for transmission-reduction behaviours. Erosion of initially strong habits ('habit degradation') was most common for transmission-conducive behaviours. Regression analyses showed 'habit formation' and 'stable strong habit' trajectories were associated with greater behavioural engagement at later timepoints. Participants typically maintained or formed transmission-reduction habits, which encouraged later performance, and degraded transmission-conducive habits, which decreased performance. Findings suggest COVID-19-preventive habits may be recoverable in future virus outbreaks.

The growing tendency towards "urbanization" is promoting an increase in resource consumption and waste generation, which requires proper waste separation management with active participation of the population. To this end, it is essential to know the personal modifiable factors that predict recycling. The primary aim of the present study is to develop and evaluate the psychometric properties of a Spanish language questionnaire designed to measure determinants of household waste separation for recycling purposes (ReDom Questionnaire). A cross-cultural adaptation, translation, and psychometric evaluation was undertaken of an extant questionnaire originally developed in Swedish, and the resultant Spanish questionnaire was then subjected to reliability and validity testing. The questionnaire was developed using survey data from 759 respondents and 33 participants performed the re-test to assess reliability. The resultant 'ReDom Questionnaire' is composed of 3 factors that draw on relevant elements of the COMB framework: motivation (7 items), physical opportunity (3 items) and social opportunity (3 items). The accuracy of the scores is adequate both in terms of internal consistency (factorial weights >0.60; CFI= 0.994; RMSEA= 0.049; RMSR=0.053) and reliability (Pearson correlation >0.65; Cronbach's alpha >0.75). In conclusion, the Spanish ReDom Questionnaire showed adequate psychometric properties and appears useful for assessing the determinants of household waste separation. Abstract With the urbanization growing the resource consumption and the waste generation

Background: Growing evidence suggests that sitting is activated automatically on exposure to associated environments, yet no study has yet sought to identify in what ways sitting may be automatic. Methods: This study used data from a 12-month sitting-reduction intervention trial to explore discrete dimensions of sitting automaticity, and how these dimensions may be affected by an intervention. 194 office workers reported sitting automaticity at baseline, and 3, 6, 9 and 12 months after receiving one of two sitting-reduction intervention variants. Results: Principal component analysis extracted two automaticity components, corresponding to a lack of awareness and a lack of control. Scores on both automaticity scales decreased over time post-intervention, indicating that sitting became more mindful, though lack of awareness scores were consistently higher than lack of control scores. Conclusions: Attempts to break office workers' sitting habits should seek to enhance conscious awareness of alternatives to sitting and afford office workers a greater sense of control over whether they sit or stand.

Background. Attempts to improve evening sleep hygiene have overlooked that sleep preparation behaviours are often undertaken automatically with little awareness; that is, habitually. This mixed-methods study assessed aspects of the feasibility and acceptability of a novel behavioural intervention procedure ('script elicitation'), which encourages reflection on and reorganisation of the content and sequencing of habitual evening pre-sleep routines. Methods. The study was advertised via social media, and circular lists at a UK university. Twenty-four UK-based adults, reporting

OBJECTIVE The Spring 2020 UK COVID-19 lockdown required normally-office-based workers to modify their work-related practices to work at home. This study explored workers' experiences of adapting to home-working, health behaviours and wellbeing. METHODS Twenty-seven home-working employees (19 female; aged 23-57y), from various industry sectors, gave individual semi-structured interviews. Topics focused on home-working experiences, routine adaptations, and changes in health behaviours and wellbeing. RESULTS Four themes were extracted: changes to the work interface; adaptations to a new workspace; changes to work-life balance; and adjustments to a new social context. Notably, participants reported greater reliance on computer-based interactions, which they felt discouraged physical activity and increased sitting. Working in a domestic environment reportedly challenged work-home boundaries. CONCLUSIONS Work practices can incidentally detrimentally impact health-related behaviours and wellbeing. Organisations should develop policies and procedures to promote health-conducive home-working.

BackgroundUniversity students typically face acute financial pressure, which can adversely impact mental health, wellbeing, and academic outcomes. This scoping review of qualitative and quantitative studies aimed to identify distinct money-management behaviours, and psychological determinants, to inform future interventions.MethodsTwo electronic databases were searched for observational studies focusing on money-management behaviours and their correlates (in quantitative studies) or reflections on experiences of such behaviours (qualitative studies). Of 789 unique papers identified, 12 papers, reporting 10 distinct studies (six quantitative, two qualitative, two mixed-methods), were entered into review. We inductively categorised all behaviours and psychological correlates, and narratively synthesised findings.ResultsWe documented 15 distinct money-management behaviours, which fitted five higher-order categories: budgeting, saving (i.e., building funds), spending, borrowing, and settling debts. Twenty-two distinct potential correlates were observed, which fitted six categories: personality characteristics, financial beliefs and knowledge, attitudes, affective responses, self-efficacy and control, and social influences. Financial beliefs and knowledge, attitudes, self-efficacy and control, and social support from parents and peers were generally associated with ‘better’ money management practices.ConclusionHeterogeneity in behaviours and correlates studied precluded definitive conclusions. Future studies should more comprehensively adopt theories and concepts from behavioural science, to distinguish between different money-management behaviours, identify which behaviours have most impact on students, and establish which specific determinants are most related to which money-management behaviours.nd

Background Mild cognitive impairment (MCI) affects 5–20% of older people in the UK, but often goes undiagnosed and is associated with increased risk of dementia. Targeting risk factors such as physical inactivity and social isolation through behaviour-change interventions could reduce this risk. However, it is unclear how MCI impacts engagement with these interventions. We aimed to explore how MCI affects goal-setting priorities and progress towards these goals in a behaviour-change intervention (HomeHealth). Methods This was a secondary analysis of a completed randomised controlled trial, HomeHealth, which started in January 2021 and recruited 386 participants aged 65 years and older with mild frailty according to the Clinical Frailty Scale from general practices and the community in England. Participants were randomly assigned (1:1) to receive either the HomeHealth intervention (n=195) or treatment as usual (n=191) for 6 months. An evidence-based behaviour change intervention supported older people to work on goals to maintain independence, addressing factors affecting capability, opportunity, and motivation. Goal setting and progress information was available for 167 (86%) of 195 participants who received the intervention. The type of goal set and goal progress (scale 0–2) were compared between participants with healthy cognition, those with potential MCI, and those with probable dementia (rated with Montreal Cognitive Assessment [MoCA]). Qualitative semi-structured interviews were conducted between Aug 16, 2022, and May 18, 2023, with 29 people with MCI who received the intervention, to explore the perceived impact of MCI on goal setting, progress, and maintenance. Data were analysed using codebook thematic analysis. Findings The mean age of participants was 80·8 years, 105 (63%) of 167 were women and 158 (95%) were white. 54 (32%) of 167 participants had healthy cognition, 94 (56%) had potential MCI, and 19 (11%) probable dementia. Distribution of goal type was similar across the three groups, with most participants setting mobility goals. Progress towards goals (scale 0–2) was similar in people with healthy cognition and potential MCI (1·24 and 1·18, respectively) but lower in those with probable dementia (0·76). However, all met the moderate progress cutoff (0·66–1·32). People with MCI recognised their cognition was getting worse but did not feel the HomeHealth intervention could help. Rather than setting new goals, people with MCI built on existing behaviours. Many did not initially understand the intervention and felt they would have benefitted from contact in between sessions or from more sessions to help goal progress. Once the sessions ended, less than a quarter of participants maintained the goal progress. Interpretation Interventions to help older adults age well can be successfully delivered in people with MCI, to help them set and make progress towards goals. However, to maintain changes, more intense support is needed. Funding National Institute for Health and Care Research (NIHR) School for Primary Care Research, NIHR Health Technology Assessment.

In the wake of Covid-19, the prevalence of working from home ('home-working') is expected to rise. Yet, working from home can have negative health and wellbeing impacts. Interventions are needed to promote effective ways of working that also protect workers' health and wellbeing. This study explored the feasibility and acceptability of an intervention intended to promote home-working practices that would protect and promote health behaviour and wellbeing. An uncontrolled, single-arm mixed-methods trial design was employed. Forty-two normally-office-based UK workers, working from home between January-February 2021 (during the Covid pandemic), consented to receive the intervention. The intervention: a digital document offering evidence-based recommendations for home-working in ways conducive to health behaviour and wellbeing. Feasibility and acceptability were quantitatively indexed by: expressions of interest within 1 week (target threshold ≥ 35); attrition across the one-week study period (threshold ≤ 20%); and the absence of any apparent detriments in self-reported physical activity, sedentary behaviour, snacking, and work-related wellbeing prior to and one week after receiving the intervention. Qualitative think-aloud data, obtained while participants read through the intervention, and analysed using reflexive thematic analysis, explored acceptability. Semi-structured interviews conducted one week after intervention exposure were content-analysed to identify whether and which behaviour changes were adopted. Two feasibility criteria were met: 85 expressions of interest indicated satisfactory intervention demand, and no detriments were observed in health behaviours or wellbeing. Forty-two participants (i.e., maximum capacity for the study; 26 females, 16 males, aged 22-63) consented to take part. 31% dropped out over the one-week study period leaving a final sample of 29 (18 females, 11 males, aged 22-63), exceeding identified attrition thresholds. Think-aloud data showed that participants concurred with intervention guidance, but felt it lacked novelty and practicality. Follow-up interviews produced 18 (62%) participant reports of intervention adherence, where nine recommendations reportedly prompted behaviour change in at least one participant. Mixed evidence was found for intervention feasibility and acceptability. Whilst the information was deemed relevant and of value, further development is required to increase its novelty. It may also be more fruitful to provide this information via employers, to encourage and emphasise employer endorsement.

A vegan diet, which excludes all animal-derived products, has been associated with some improvements in health, while also conferring environmental benefits. Understanding the psychological determinants of successfully switching to a vegan diet will help to inform the design of interventions supporting long-term dietary change. Studies to date have tended to focus on reasoned motives underlying the decision to initiate such a dietary shift. Yet, focusing on reasons for switching may overlook the importance of a broader range of psychological factors that may help or hinder attempts to maintain a vegan diet. This qualitative interview study, the timing of which coincided with UK Covid-19 lockdowns, documented experiences of 20 young adults (17 female; mean age 22y) who attempted to adopt a vegan diet in the past nine months and had or had not successfully maintained this change. Reflexive Thematic Analysis identified five themes surrounding initiation and maintenance. A theme of ‘motives, expectations and cues to switching’ showed that switching was motivated by ethical or health concerns, and cued by Veganuary, lockdown or health issues. ‘The effortfulness of switching’ captured experiences of the perceived burden imposed by adhering to the diet due to, for example, a perceived lack of accessible vegan options. The ‘flexibility of dietary rules’ theme showed that many found the ‘no animal products’ rule clear but restrictive, so allowed themselves occasional non-meat animal products. ‘Social acceptability concerns’ captured the importance of acceptance from vegan and non-vegan family and friends, and ‘satisfaction with the switch’ described the perceived benefits that sustained maintenance for many. Our findings suggest that interventions should seek to support people to overcome potentially unforeseen practical and social challenges to adhering to a vegan diet.

Car emissions have significant detrimental environmental and health impacts, and many journeys could be undertaken using alternative transport. Effective transport policy necessitates identification of potentially modifiable determinants of driving. This thesis identified psychological underpinnings of decisions to drive. Study 1 used qualitative ‘grounded theory’ analysis to detail commuters’ reasons for driving, and highlighted misconceptions and biases underpinning these motives. In study 2, we developed quantitative measures of the concepts identified in study 1, and tested these as determinants of decisions to commute by public transport alongside variables from the Theory of Planned Behaviour (TPB; Ajzen, 1991). Results showed that the inductive concepts were best modelled as determinants of attitude and control perceptions, and demonstrated the superiority of established deductive concepts. A meta-analysis of the extant literature (study 3) showed a dearth of available evidence of correlates of driving. Strong associations with behaviour were found for intention and habit, and TPB cognitions relating to not driving showed stronger effects on intentions than did TPB variables relating to driving. There were also effects for descriptive and personal norms. Using an extended TPB model, study 4 demonstrated that the motivation to make local journeys by car was informed by cognitions relating to car and to non-car travel, and descriptive and personal norms. Environmental beliefs informed personal norms and attitudes to non-car travel. Studies 5-7 explored habit in commuting mode choice: study 5 developed a new self-report habit measure, which in studies 6 and 7 was used in comparison with existing habit indices to predict car and bicycle commuting among UK and Dutch samples respectively. Findings revealed the superiority of an existing habit measure, and pointed to the habitual nature of commuting mode choice. The seven studies highlighted motivational and volitional determinants of driving, and suggest various intervention strategies to reduce car use.

Sustaining physical activity may require incorporating activity into everyday routines. Yet, many such routines are executed habitually, so people may not recognise physical activity opportunities. ‘Script Elicitation’ – a novel intervention method whereby participants detail the content and structure of their routines, and are supported to plan modifications to those routines – has not yet been applied to physical activity. This mixed-methods study assessed the acceptability of Script Elicitation for increasing physical activity among office workers. Eleven UK office workers completed the one-to-one Script Elicitation procedure, describing their typical before-, during-, or after-work routines, and receiving guidance on incorporating activity into those routines. One week later, they rated acceptability of the method and completed a semi-structured interview. Physical activity was self-reported at baseline and one-week follow-up. Acceptability was descriptively assessed on two quantitative criteria (no clear decrease in physical activity; above-midpoint acceptability scores) and qualitatively explored via Thematic Analysis. Acceptability criteria were met, and participants reported raised awareness of routines and physical activity increases. Script Elicitation appears potentially suitable for promoting activity within everyday routines. If effectiveness is shown in a more rigorous trial, future work will need to develop script-based methods for efficient delivery at scale as a public health intervention.

Background NHS frailty services commonly target more severely frail older people, despite evidence suggesting frailty can be prevented or reversed when addressed at an earlier stage. HomeHealth is a new home-based, manualised voluntary sector service supporting older people with mild frailty to maintain their independence through behaviour change. Over six appointments, a trained HomeHealth worker discusses what matters to the older person and supports them to set and achieve goals around mobility, nutrition, socialising and/or psychological wellbeing. The service showed promising effects in a feasibility trial. We aimed to test the clinical and cost-effectiveness of HomeHealth for maintaining independence in older people with mild frailty compared with treatment as usual. Methods In this single-blind multicentre randomised controlled trial, we recruited community-dwelling older people aged 65 years or older with mild frailty from 27 general practices, community groups and sheltered housing in London, Yorkshire, and Hertfordshire. Participants were randomly assigned (1:1) to receive either HomeHealth monthly for 6 months or treatment as usual (usual GP and outpatient care, no specific frailty services). Our primary outcome was independence in activities of daily living, measured by blinded outcome assessors using the modified Barthel Index, and analysed using linear mixed models, including 6-month and 12-month data and controlling for baseline Barthel score and site. The study was approved by the Social Care Research Ethics Committee, and all participants provided written or orally recorded informed consent. This study is registered with the ISRCTN registry, ISRCTN54268283. Findings This trial took place between Jan 18, 2021, and July 4, 2023. We recruited 388 participants (mean age 81·4 years; 64% female [n=250], 94% White British/European [n=364], 2·5% Asian [n=10], 1·5% Black [n=6], 2·0% other [n=8]). We achieved high retention for 6-month follow-up (89%, 345/388), 12-month follow-up (86%, 334/388), and medical notes data (89%, 347/388). 182 (93%) of 195 participants in the intervention group completed the intervention, attending a mean of 5·6 appointments. HomeHealth had no effect on Barthel Index scores at 12 months (mean difference 0·250, 95% CI –0·932 to 1·432). At 6 months, there was a small reduction in psychological distress (–1·237, –2·127 to –0·348) and frailty (–0·124, –0·232 to –0·017), and at 12 months, we found small positive effects on wellbeing (1·449, 0·124 to 2·775) in those receiving HomeHealth. Other outcomes in analysis to date showed no significant difference. Health economic outcomes (including quality of life, capability, health services use and care needs or burden) are pending. Interpretation This high-quality trial showed that HomeHealth did not maintain independence in older people with mild frailty, and had limited effects upon secondary outcomes. Future studies need to explore different ways to promote health in this population. Funding National Institute for Health and Care Research Health Technology Assessment (NIHR HTA).

Background Adjuvant endocrine therapy (AET) reduces the risk of breast cancer recurrence and mortality. However, up to three-quarters of women with breast cancer do not take AET as prescribed. Existing interventions to support adherence to AET have largely been unsuccessful, and have not focused on the most salient barriers to adherence. This paper describes the process of developing four theory-based intervention components to support adherence to AET. Our aim is to provide an exemplar of intervention development using Intervention Mapping (IM) with guidance from the Multiphase Optimisation Strategy (MOST). Methods Iterative development followed the six-stage IM framework with stakeholder involvement. Stage 1 involved a literature review of barriers to adherence and existing interventions, which informed the intervention objectives outlined in Stage 2. Stage 3 identified relevant theoretical considerations and practical strategies for supporting adherence. Stage 4 used information from Stages 1-3 to develop the intervention components. Stages 1-4 informed a conceptual model for the intervention package. Stages 5 and 6 detailed implementation considerations and evaluation plans for the intervention package, respectively. Results The final intervention package comprised four individual intervention components: Short Message Service to encourage habitual behaviours surrounding medication taking; an information leaflet to target unhelpful beliefs about AET; remotely delivered Acceptance and Commitment Therapy-based guided self-help to reduce psychological distress; and a website to support self-management of AET side-effects. Considerations for implementation within the NHS, including cost, timing and mode of delivery were outlined, with explanation as to how using MOST can aid this. We detail our plans for the final stage of IM which involve feasibility testing. This involved planning an external exploratory pilot trial using a 2(4-1) fractional factorial design, and a process evaluation to assess acceptability and fidelity of intervention components. Conclusions We have described a systematic and logical approach for developing a theoretically informed intervention package to support medication adherence in women with breast cancer using AET. Further research to optimise the intervention package, guided by MOST, has the potential to lead to more effective, efficient and scalable interventions.

Habit change is often seen as key to successful long-term behaviour change. Making ‘good’ behaviours habitual – i.e., ensuring a behaviour is prompted automatically on exposure to situational cues, based on cue-response associations learned through context-consistent repetition – is portrayed as a mechanism for sustaining such behaviours over time. Conversely, disrupting ‘bad’ habits is expected to terminate longstanding unwanted actions. Yet, some commentators have suggested that the role of habit in real-world behaviour and behaviour change has been overstated. Such critiques highlight a gap between habit theory and the reality of human behaviour ‘in the wild’. This state-of-the-field review aims to narrow this gap. Building on a core distinction between habit and habitual behaviour, our review seeks to offer interpretations of habit theory and evidence that will better manage intervention designers’ expectations regarding how modifying habit can realistically be expected to promote behaviour change. We emphasise that habit is just one potential influence on behaviour at any given moment, and highlight instances in which habit may dominate over intention, and in which intention may dominate over habit, in determining behaviour frequency. We suggest that, while it may assist behaviour maintenance, habit formation may be neither necessary nor sufficient to sustain real-world behaviour change. We draw attention to the various ways in which habit may be ‘broken’ (i.e., disrupted), and discern the implications of each habit disruption mechanism for long-term cessation of unwanted behaviours.

The Handbook on Implementation Science provides an overview of the field’s multidisciplinary history, theoretical approaches, key concepts, perspectives, and methods. By drawing on knowledge concerning learning, habits, organizational theory, improvement science, and policy research, the Handbook offers novel perspectives from a broad group of international experts in the field representing diverse disciplines. The editors seek to advance implementation science through careful consideration of current thinking and recommendations for future directions.

BackgroundThe Live Well with Parkinson’s Self-Management Toolkit is designed for use in the NHS to support people with Parkinson’s, their carers and health professionals in managing motor and non-motor symptoms and promoting well-being. The Toolkit was developed based on theory-based behaviour change and self-management techniques in consultation with people living with Parkinson’s and health and social care practitioners. There are digital (e-Toolkit) and paper (manual) versions.MethodsSingle-blind two-arm randomised controlled trial RCT of clinical effectiveness and cost-effectiveness of the Toolkit, facilitated by up to six sessions with a trained non-specialist supporter, in improving quality of life. People with Parkinson’s will be assessed at baseline, 6 and 12 months. Assessors will be blind to the treatment group. The primary outcome measure is the Parkinson’s Disease Questionnaire (PDQ-39, Parkinson’s related quality of life) score at 12 months. Secondary outcome measures include the MDS Unified Parkinson’s Disease Rating Scale (Part I, II, III, IV), EQ-5D, and a Client Service Receipt Inventory shortened, adapted for Parkinson’s. Carer outcomes include the Zarit Carer Burden Inventory and Carer Quality of Life Questionnaire for Parkinsonism. A total of 338 people with Parkinson’s, and their carers if appropriate, will be recruited from diverse settings across England. Those with advanced dementia, at end-of-life or with atypical Parkinsonism will be excluded. A parallel mixed methods process evaluation will explore the factors promoting or inhibiting implementation, uptake, use, effectiveness and cost-effectiveness of the Toolkit and sessions.DiscussionIf successful, the Live Well with Parkinson’s Toolkit could be used as a model for other complex long-term disorders, including dementia. This would bridge existing gaps in the NHS (as shown by the national Parkinson’s audit data), by enabling patients and carers to access personalised information, advice and support on symptom management and ‘living well’ with Parkinson’s.Trial registrationISRCTN92831552. Registered on 26th Oct 2021.

Objective: Habit is thought to be conducive to health behavior maintenance, because habits prompt behavior with minimal cognitive resources. The precise role of habit in determining complex behavioral sequences, such as exercise, has been underresearched. It is possible that the habit process may initiate a behavioral sequence (instigation habit) or that, after instigation, movement through the sequence is automated (execution habit). We hypothesized that exercise instigation habit can be empirically distinguished from exercise execution habit and that instigation habit strength is most predictive of future exercise and reflective of longitudinal exercise behavior change. Further, we evaluated whether patterned exercise action—that is, engaging in the same exercise actions from session to session—can be distinct from exercise execution habit. Method: Healthy adults (N = 123) rated their exercise instigation and execution habit strengths, patterned exercise actions, and exercise frequency in baseline and 1-month follow-up surveys. Participants reported exercise engagement via electronic daily diaries for 1 month. Hypotheses were tested with regression analyses and repeated-measures analyses of variance. Results: Exercise instigation habit strength was the only unique predictor of exercise frequency. Frequency profiles (change from high to low or low to high, no change high, no change low) were associated with changes in instigation habit but not with execution habit or patterned exercise action. Conclusions: Results suggest that the separable components of exercise sessions may be more or less automatic, and they point to the importance of developing instigation habit for establishing frequent exercise.

Abstract Introduction Frailty is a condition that makes it increasingly difficult for individuals to recover from adverse health events and gradually erodes independence. NHS interventions in England have focused on those with more severe frailty. We tested HomeHealth, a home-based, tailored, multi-domain (six-session) behaviour change intervention to promote independence in the over-65s living with mild frailty, in a RCT recruiting 388 people (intervention 195; control 193). HomeHealth was delivered by the voluntary sector in three diverse areas and addressed mobility, nutrition, socialising, and psychological goals, among other domains. We aimed to explore acceptability, participant engagement, and experiences of delivering and receiving the service. Methods Following a mixed-methods approach, we extracted quantitative data on types of goals and progress towards goals from Health and Wellbeing plans and appointment checklists. Between July 2022 and May 2023, we interviewed 49 older participants, 7 HomeHealth workers and 8 stakeholders. Older people were purposively sampled for diversity in socio-demographic characteristics, cognitive and physical functioning, intervention adherence and allocated HomeHealth worker. Interviews explored their motivations to engage; experience of participation, delivery and study support followed by their suggestions for improvement. We analysed qualitative data thematically and quantitative data descriptively. Results Most participants set mobility goals (49%), followed by a combination of goals (31%), and made moderate progress towards these. The intervention (completed by 93.3% participants) was positively received, boosted participants’ confidence, and provided emotional support. Participants reported that sometimes behaviour was maintained post-intervention, but further appointments would have been welcomed to fill the gap in other services. However, some people found it difficult to identify goals to work on, particularly when they already felt independent and well supported. Conclusions Services to support older people with mild frailty are acceptable, have good engagement, and can lead to behaviour change, particularly among those who self-identify a need for change.

Background: Frailty is clinically associated with multiple adverse outcomes, including reduced quality of life and functioning, falls, hospitalisations, moves to long-term care and mortality. Health services commonly focus on the frailest, with highest levels of need. However, evidence suggests that frailty is likely to be more reversible in people who are less frail. Evidence is emerging on what interventions may help prevent or reduce frailty, such as resistance exercises and multi-component interventions, but few interventions are based on behaviour change theory. There is little evidence of cost-effectiveness. Previously, we co-designed a new behaviour change health promotion intervention (“HomeHealth”) to support people with mild frailty. HomeHealth is delivered by trained voluntary sector support workers over six months who support older people to work on self-identified goals to maintain their independence, such as strength and balance exercises, nutrition, mood and enhancing social engagement. The service was well received in our feasibility randomised controlled trial and showed promising effects upon outcomes. Aim: To test the clinical and cost-effectiveness of the HomeHealth intervention on maintaining independence in older people with mild frailty in comparison to treatment as usual (TAU). Methods: Single-blind individually randomised controlled trial comparing the HomeHealth intervention to TAU. We will recruit 386 participants from general practices and the community across three English regions. Participants are included if they are community-dwelling, aged 65+, with mild frailty according to the Clinical Frailty Scale. Participants will be randomised 1:1 to receive HomeHealth or TAU for 6 months. The primary outcome is independence in activities of daily living (modified Barthel Index) at 12 months. Secondary outcomes include instrumental activities of daily living, quality of life, frailty, wellbeing, psychological distress, loneliness, cognition, capability, falls, carer burden, service use, costs and mortality. Outcomes will be analysed using linear mixed models, controlling for baseline Barthel score and site. A health economic analysis and embedded mixed-methods process evaluation will be conducted. Discussion: This trial will provide definitive evidence on the effectiveness and cost-effectiveness of a home-based, individualised intervention to maintain independence in older people with mild frailty in comparison to TAU, that could be implemented at scale if effective.

Around 40% of US university students use cannabis, 25% of whom present with cannabis use disorder, which endangers health. We investigated the concurrent contribution of reflective processes, which generate action via conscious deliberation, and non-reflective processes, which prompt behavior automatically, to undergraduates' cannabis consumption. Eighteen UK undergraduates who regularly consume cannabis (11 female, 7 male; mean age 20 y). Semi-structured interviews explored cannabis motives, routines, cues, and decision points. Thematic analysis identified themes, in each of which reflective and non-reflective dimensions were coded. Four themes were identified: cannabis use for relaxation, social bonding, and symbolic-affective significance, and contexts and triggers. Some influences guided cannabis use reflectively in some settings, and non-reflectively in others. Even when cannabis use was consciously driven, non-reflective processes were deployed to execute subservient acts, such as rolling joints. Findings highlight specific processes and pathways that might be targeted to reduce cannabis-related harm.

Skin cancer is highly burdensome, but preventable with regular engagement in sun protective behaviors. Despite modest effectiveness of sun-protective behavior promotional efforts thus far, rates of engagement in sun-protective behaviors remain low. More is needed to understand motivation for using sunscreen, wearing sun-protective clothing, and seeking shade. This study tested whether the links of intention and habit strength with behavior differed between sun-protective behaviors. It was hypothesized that sun protective behaviors would be predicted by both habit and intention and that intention-behavior associations would be weaker for people with stronger habits. Participants residing in Queensland, Australia (N = 203; 75.96% female; M age = 37.16 years, SD = 14.67) self-reported their intentions and habit strength about sun-protective behavior for the next 7 days. Participants were followed-up 7 days later to self-report their sun-protective behavior. Multilevel modeling, accounting for nesting of multiple behaviors within-person, revealed that habit moderated the intention strength - behavior association and this moderation effect did not differ as a function of which behavior was being predicted. People with strong or moderate habit strength tended to act in line with their intentions; however, for people with very weak habits (2 SD 

To help implement behavior change interventions (BCIs) it is important to be able to characterize their key components and determine their effectiveness. This study assessed and compared the components of BCIs in terms of intervention functions identified using the Behaviour Change Wheel Framework (BCW) and in terms of their specific behavior change techniques (BCTs) identified using the BCT TaxonomyV1, across six behavioral domains and the association of these with cost-effectiveness. BCIs in 251 studies targeting smoking, diet, exercise, sexual health, alcohol and multiple health behaviors, were specified in terms of their intervention functions and their BCTs, grouped into 16 categories. Associations with cost-effectiveness measured in terms of incremental cost-effectiveness ratio (ICER) upper and lower estimates were determined using regression analysis. The most prevalent functions were increasing knowledge through education (72.1%) and imparting skills through training (74.9%). The most prevalent BCT groupings were shaping knowledge (86.5%), changing behavioral antecedents (53.0%), supporting self-regulation (47.7%), and providing social support (44.6%). Intervention functions associated with better cost-effectiveness were those based on training (βlow = -15044.3; p = .002), persuasion (βlow = -19384.9; p = .001; βupp = -25947.6; p < .001) and restriction (βupp = -32286.1; p = .019), and with lower cost-effectiveness were those based on environmental restructuring (β = 15023.9low; p = .033). BCT groupings associated with better cost-effectiveness were goals and planning (βlow = -8537.3; p = .019 and βupp = -12416.9; p = .037) and comparison of behavior (βlow = -13561.9, p = .047 and βupp = -30650.2; p = .006). Those associated with lower cost-effectiveness were natural consequences (βlow = 7729.4; p = .033) and reward and threat (βlow = 20106.7; p = .004). BCIs that focused on training, persuasion and restriction may be more cost-effective, as may those that encourage goal setting and comparison of behaviors with others.

Lecture capture is popular within Higher Education, but previous research suggests that students do not always optimally select content to review, nor do they make the most of specific functions. In the current study conducted in the 2019/20 academic year, we used a repeated-measures crossover design to establish the effects of transcripts with closed captioning, and email reminders, on use (self-reported and system analytics), perceptions of lecture capture and student performance, as measured by multiple-choice question (MCQ) tests designed to assess the module learning outcomes. System analytics (N = 129) and survey data (N = 42) were collected from students alongside qualitative data from semi-structured interviews (N = 8). We found that students value lecture capture highly, but do not access it extensively during the teaching period. The availability of transcripts and closed captions did not impact the amount of capture use or performance on MCQ tests, but did result in more positive perceptions of capture, including increased likelihood of recommending it to others. The use of email reminders referring students to specific segments of capture and reminding them of the functionality had no impact on any measure, although qualitative data suggested that the content of reminders may be used in revision rather than during the teaching period, which fell outside the period we investigated. Collectively, these data suggest that the use of captions and transcripts may be beneficial to students by allowing dual processing of visual and audio content, and a searchable resource to help consolidate their learning but there is little evidence to support reminders.

COVID-19 forced the closure of UK universities. One effect of this was a change in how lectures, and their recordings, were made and used. In this research, we aimed to address two related research questions. Firstly, we aimed to understand how UK universities replaced in-person lectures and, secondly, to establish what academic staff believed the post-pandemic lecture would look like. In a mixed-methods study, we collected anonymous quantitative and qualitative data from 87 academics at 36 UK institutions. Analysis revealed that respondents recognised the value and importance of interactive teaching and indicated that the post-pandemic lecture would and should make greater use of this. Data also revealed positive views of lecture capture, in contrast to pre-pandemic studies, and demonstrated that staff recognised their value for those who were unable to attend, or who had specific learning differences. However, staff also recognised the value of asynchronous lecture videos within a blended or flipped approach. This study provides evidence that the pandemic has engendered changes in attitudes and practices within UK higher education that are conducive to educational reform.

People with stroke experience falls at more than twice the rate of the general older population resulting in high fall-related injuries. However, there are currently no effective interventions that prevent falls after stroke. To determine the effect and cost-benefit of an innovative, home-based, tailored intervention to reduce falls after stroke. A total of 370 participants will be recruited in order to be able to detect a clinically important between-group difference of a 30% lower rate of falls with 80% power at a two-tailed significance level of 0.05. alls fter troke rial (FAST) is a multistate, Phase III randomized trial with concealed allocation, blinded assessment, and intention-to-treat analysis. Ambulatory stroke survivors within five years of stroke who have been discharged from formal rehabilitation to the community and who have no significant language impairment will be randomly allocated to receive habit-forming exercise, home safety, and community mobility training or usual care. The primary outcome is the rate of falls over the previous 12 months. Secondary outcomes are the risk of falling (proportion of fallers), community participation, self-efficacy, balance, mobility, physical activity, depression, and health-related quality of life. Health care utilization will be collected retrospectively at baseline and prospectively to 6 and 12 months. The results of FAST are anticipated to directly influence intervention for stroke survivors in the community. ANZCTR 12619001114134.

Maintaining weight loss requires long-term behaviour change. Theory and evidence around habitual behaviour ? i.e., action triggered by impulses that are automatically activated upon exposure to cues, due to learned cueaction associations ? can aid development of interventions to support weight loss maintenance. Specifically, weight loss is more likely to be sustained where people develop new habits that support weight management, and break old habits that may undermine such efforts. Interventions seeking to break ?bad? weight-related habits have focused on inhibiting unwanted impulses or avoiding cues. This paper draws attention to the possibility that while such approaches may discontinue habitual behaviour, underlying habit associations may remain. We use evidence from existing qualitative studies to demonstrate that, left unchecked, unwanted habit associations can render people prone to lapsing into old patterns of unhealthy behaviours when motivation or willpower is momentarily weakened, or when returning to familiar settings following temporarily discontinued exposure. We highlight six behaviour change techniques especially suited to disrupting habit associations, but show that these techniques have been underused in weight loss maintenance interventions to date. We call for intervention developers and practitioners to adopt techniques conducive to forming new habit associations to directly override old habits, and to use the persistence of unwanted habit associations as a potential indicator of longterm weight loss intervention effectiveness.

Many universities use lecture capture to record live lectures and make them available online, although this practice is not without controversy. We used an online survey to investigate perceptions of lectures and their capture in staff (N = 95) and students (N = 522). We found that they valued lectures and perceived capture differently, despite similar views on the type of learning lectures best support. Students were more positive about capture, utilising the online platform effectively. Exact use differed depending on whether students were substituting or supplementing attendance. Use of lecture capture was predicted by several factors including: demand of live lectures, attendance, and performance. Student attendance ratings were predicted by the availability of online resources and difficulty in getting to lectures, whilst staff felt only availability of online resources was critical in determining student attendance. Differing views of lectures and the importance of attendance may contribute to the different overall perceptions of lecture capture in these two groups. •Students value lectures more highly but perceive less need for participation. •Students perceive capture positively with little impact on the live lecture.•Use of capture is predicted by factors relating to the individual student.•Use of capture is also predicted by factors relating to the live lecture e.g. speed.•Lecture capture is one of several variables that negatively impacts attendance.

Habitual behaviours are elicited when a familiar context activates cue-behaviour associations that have been learned through previous performance. A core hypothesis within habit theory is that, by virtue of its automaticity, habit weakens the impact of intention on action, such that in facilitating conditions, action will be guided more by habit than momentary intentions. This has led to recommendations that habit formation be harnessed as a mechanism for sustaining desirable behaviour over time, when people would otherwise relapse due to loss of motivation. This article reviews theory and evidence around the hypothesized interaction between habit and intention as determinants of behaviour. We first qualify the hypothesis by clarifying that it pertains only to determinants of the instigation of action, rather than execution. Next, drawing on a systematic review of 52 behaviour-prediction studies, we highlight mixed empirical support for the interaction. We argue that ostensibly inconsistent findings can be reconciled by recognizing the distinction between the direction and strength of intention, and identifying the "facilitating conditions" that may determine the relative influence of habit and intention on behaviour. Evidence demonstrates that when self-control is diminished, people act habitually regardless of intention direction or strength. When people possess self-control, habits can help people to act on favourable but weakened intentions, but intentions that oppose habitual tendencies can override habitual influence. This has important implications for behaviour change: even if habit has formed, a minimal level of favourable conscious motivation may be required to sustain behaviours over time. Social psychology might fruitfully move beyond askingwhetherhabit moderates the intention-behaviour relationship, and instead probehowandin which conditionshabits and intentions interact.

Hagger (2019) offers an insightful synthesis of recent theoretical and empirical developments in understanding of habit and its relevance to physical activity. This commentary extends coverage of one such advance, namely the distinction between two manifestations of habit in physical activity: habitually ‘deciding’ to engage in activity (i.e. habitual instigation), and habitually ‘doing’ the activity (habitual execution). We explore the rationale for this distinction and argue that most contemporary theory and evidence around habitual physical activity – and by extension, Hagger’s review – implicitly focuses on instigation and neglects execution. We offer hypotheses around the potential roles that habitual execution may play in physical activity. Broadening the scope of inquiry within the field to more fully encompass habitual performance would achieve a more comprehensive and informative account that incorporates concepts of skill acquisition and mastery.

IntroductionRegular physical activity (PA) participation has many important physical and psychological health benefits, managing and preventing over 25 chronic conditions. Being more physically active as a child is associated with being more active as an adult, but less than 10% of Canadian children are achieving the recommended PA guidelines of 60 minutes per day of moderate to vigorous PA. Parental support is a predictor of child PA, but parent intention to support child PA does not always predict enacted support. Targeting factors that assist in the sustainability of parent support behaviour of child PA may have an impact on child PA. The purpose of this study is to evaluate an intervention designed to promote habit formation of parental support (HABIT, independent variable) on child PA (dependant variable) compared with a planning and education group (PLANNING) and an education only group (EDUCATION).Methods and analysisThe three conditions will be compared using a 6-month longitudinal randomised trial. Eligible families have at least one child aged 6–12 years who is not meeting the 2011 Canadian PA Guidelines. Intervention materials are delivered at baseline, with check-in sessions at 6 weeks and 3 months. Child’s moderate-to-vigorous PA, measured by accelerometry, is assessed at baseline, 6 weeks, 3 months and 6 months as the primary outcome. At baseline and 6 months, children perform fitness testing. Parents and children complete questionnaires at all timepoints. So far, 123 families have been recruited from the Greater Victoria and surrounding area. Recruitment will be continuing through 2020 with a target of 240 families.Ethics and disseminationThis protocol has been approved by the University of Victoria Human Research Ethics Board (Victoria, Canada). Results will be shared at conferences as presentations and as published manuscripts. Study findings will be made available to interested participants.Trial registration numberNCT03145688; Pre-results

Contextual cues play an important role in facilitating behaviour change. They not only support memory but may also help to make the new behaviour automatic through the formation of new routines. However, previous research shows that when people start a new behaviour, they tend to select cues that lack effectiveness for prompting behaviour. Therefore, it is important to understand what influences cue selection, as this can help to identify acceptable cues, which in turn could inform future behaviour change interventions to help people select cues that best fit their context and so ensure continued repetition. We conducted a qualitative study to investigate what cues people select, how, and what influences their decisions. We recruited 39 participants and asked them to take vitamin C tablets daily for 3 weeks and later interviewed them about their experience. Quantitative habit strength and memory measures were taken for descriptive purposes. Cue selection was primarily influenced by a desire to minimise effort, e.g. keeping related objects at hand or in a visible place; prior experience with similar behaviours (regardless of whether the cues used in the past were reliable or not); and beliefs about effective approaches. In addition, we found that suboptimal remembering strategies involved reliance on a single cue and loosely defined plans that do not specify cues. Moreover, for many participants, identifying optimal cues required trial and error, as people were rarely able to anticipate in advance what approach would work best for them. Future behaviour change interventions that rely on routine behaviours might fruitfully include the provision of educational information regarding what approaches are suboptimal (single factors, vaguely defined plans) and what is most likely to work (combining multiple clearly defined cues). They should also assess people's existing beliefs about how to best remember specific behaviours as such beliefs can either enhance or inhibit the cues they select. Finally, interventions should account for the fact that early failures to remember are part of the process of developing a reliable remembering strategy and to be expected.

Many universities now use lecture capture. We used focus groups to investigate perceptions of lectures and their capture in staff ( N  = 8) and students ( N  = 17). We found that staff and students held different views of lectures and this impacted on their perceptions of lecture capture. Our findings confirmed a range of previously identified uses of lecture capture and additionally demonstrated its use to model expert behaviour. Furthermore, we report here that students felt lecture capture reduced anxiety, particularly for those with disabilities, indicating that lecture capture may be a useful tool in creating an environment that supports mental wellbeing. Despite this potential value of lecture capture, it was still perceived to have some negative impact on the live lecture; reducing the interaction with students and prevent staff using anecdotes and humour in their teaching, which could reduce the value of the lecture capture.

Growing evidence suggests that prolonged uninterrupted sitting can be detrimental to health. Much sedentary behaviour research is reliant on self-reports of sitting time, and sitting-reduction interventions often focus on reducing motivation to sit. These approaches assume that people are consciously aware of their sitting time. Drawing on Action Identification Theory, this paper argues that people rarely identify the act of sitting as 'sitting' per se, and instead view it as an incidental component of more meaningful and purposeful typically-seated activities. Studies 1 and 2 explored whether people mentioned sitting in written descriptions of actions. Studies 3-5 compared preferences for labelling a typically desk-based activity as 'sitting' versus alternative action identities. Studies 6 and 7 used card-sort tasks to indirectly assess the prioritisation of 'sitting' relative to other action descriptions when identifying similar actions. Participants rarely spontaneously mentioned sitting when describing actions (Studies 1-2), and when assigning action labels to a seated activity, tended to offer descriptions based on higher-order goals and consequences of action, rather than sitting or other procedural elements (Studies 3-5). Participants primarily identified similarities in actions based not on sitting, but on activities performed while seated (e.g. reading; Studies 6-7). 'Sitting' is a less accessible cognitive representation of seated activities than are representations based on the purpose and implications of seated action. Findings suggest that self-report measures should focus on time spent in seated activities, rather than attempting to measure sitting time via direct recall. From an intervention perspective, findings speak to the importance of targeting behaviours that entail sitting, and of raising awareness of sitting as a potential precursor to attempting to reduce sitting time.

Many of the most pressing societal issues—e.g., health, illness, and associated costs; climate change—are rooted in behavior. Even small changes to everyday behaviors can bring considerable benefits. Many people successfully adopt new behaviors but fail to maintain them over time. This problem has inspired interest in habit. Within psychology, habitual behaviors are defined as actions triggered automatically when people encounter situations in which they have consistently done them in the past. Repeating behavior in the same context reinforces mental associations between the context and behavior. Habit is said to have formed when exposure to the context non-consciously activates the association, which in turn elicits an urge to act, influencing behavior with minimal conscious forethought. As an initially goal-directed behavior becomes habitual, control over behavior is transferred from a reasoned, reflective processing system, which elicits behavior relatively slowly based on conscious motivation, to an impulsive system, which elicits behavior rapidly and efficiently, based on learned context-behavior associations. Habitual behaviors thus become detached from conscious motivational processes. Spurred by development of self-report habit measures, studies have modeled the relationship between behavioral repetition and the strengthening of habit, showing that habit is characterized by initially rapid growth, which decelerates until a plateau is reached. Theories propose that habit has two effects on behavior in the associated context: habit will prompt frequent performance, and will override motivational tendencies in doing so, unless self-control is particularly strong in that moment. People may therefore continue to perform a habitual action even when they lack motivation. These characteristics have generated interest in the potential for habit to support long-term adoption of new behaviors. People often fail to maintain behavior changes because they lose motivation, but if people were to form habits for new behaviors, they should in theory continue to perform them despite losing motivation. This has prompted calls for interventions to move beyond merely promoting new behaviors, toward advocating context-dependent habitual performances. Some have also argued that habit formation may be fruitful for stopping unwanted behaviors, because new, “good” habits can be directly substituted for existing “bad” habits. Realistically, habit formation is not a viable standalone behavior change technique, as it requires that people first adopt a new behavior, which through repetition will become habitual. The promotion of context-dependent repetition should complement techniques that reinforce the motivation and action control required for behavioral initiation and maintenance prior to habit forming. Real-world behavior change interventions based on these principles have been found to be acceptable and appealing, and show promise for changing behavior, though few have used long-term follow-up periods. This entry highlights leading work in the application of habit formation to behavior change interventions, drawing on the most methodologically and conceptually rigorous empirical research available. Most of the development and application of habit theory to real-world social contexts has been undertaken in health and pro-environmental domains. This entry thus focuses most heavily on these domains, but the principles outlined are thought to be applicable across behaviors and settings.

Within psychology, the term habit refers to a process whereby contexts prompt action automatically, through activation of mental context–action associations learned through prior performances. Habitual behavior is regulated by an impulsive process, and so can be elicited with minimal cognitive effort, awareness, control, or intention. When an initially goal-directed behavior becomes habitual, action initiation transfers from conscious motivational processes to context-cued impulse-driven mechanisms. Regulation of action becomes detached from motivational or volitional control. Upon encountering the associated context, the urge to enact the habitual behavior is spontaneously triggered and alternative behavioral responses become less cognitively accessible.By virtue of its cue-dependent automatic nature, theory proposes that habit strength will predict the likelihood of enactment of habitual behavior, and that strong habitual tendencies will tend to dominate over motivational tendencies. Support for these effects has been found for many health-related behaviors, such as healthy eating, physical activity, and medication adherence. This has stimulated interest in habit formation as a behavior change mechanism: It has been argued that adding habit formation components into behavior change interventions should shield new behaviors against motivational lapses, making them more sustainable in the long-term. Interventions based on the habit-formation model differ from non-habit-based interventions in that they include elements that promote reliable context-dependent repetition of the target behavior, with the aim of establishing learned context–action associations that manifest in automatically cued behavioral responses. Interventions may also seek to harness these processes to displace an existing “bad” habit with a “good” habit.Research around the application of habit formation to health behavior change interventions is reviewed, drawn from two sources: extant theory and evidence regarding how habit forms, and previous interventions that have used habit formation principles and techniques to change behavior. Behavior change techniques that may facilitate movement through discrete phases in the habit formation trajectory are highlighted, and techniques that have been used in previous interventions are explored based on a habit formation framework. Although these interventions have mostly shown promising effects on behavior, the unique impact on behavior of habit-focused components and the longevity of such effects are not yet known. As an intervention strategy, habit formation has been shown to be acceptable to intervention recipients, who report that through repetition, behaviors gradually become routinized. Whether habit formation interventions truly offer a route to long-lasting behavior change, however, remains unclear.

Purpose Patients newly diagnosed with head and neck cancer should be informed of the ramifications of cancer treatment on swallowing function during their pretreatment consultation. The purpose of this study was to explore (a) the usefulness and (b) the acceptability of video-animation in helping patients to understand the basics of the swallowing mechanism and dysphagia. Method Thirteen patients treated for head and neck cancer participated in this study. Think-aloud, a type of qualitative methodology, was used to encourage patients to verbalize their thoughts while watching two short video-animations showing the process of normal/abnormal swallowing. Transcripts were analyzed using thematic analysis. Results Four main themes were identified as follows: (a) patient interest and engagement, (b) acceptability of visual imagery and narration, (c) information provision and learning, and (d) personal relevance and intended action. Patients appeared interested and engaged in the video-animations, asking several spontaneous questions about how to maintain or improve swallowing function. Learning was evident from patients' recognition and verbalizations of grossly disordered swallowing patterns. Most patients reported the images to be visually acceptable and could often relate what they were seeing to their own swallowing experience. Many patients also verbalized recognition of the need to keep muscles active through exercises. Conclusions These results suggest that the video-animations of swallowing were acceptable, interesting, informative, and relevant for most patients. It was therefore useful not only as an education tool, but also showed potential to influence patients' intentions to undertake preventative interventions that may preserve better swallowing function after cancer treatment.

Among adults with cystic fibrosis (CF), medication adherence is low and reasons for low adherence are poorly understood. Our previous exploratory study showed that stronger ‘habit’ (ie, automatically experiencing an urge to use a nebuliser) was associated with higher nebuliser adherence. We performed a secondary analysis of pilot trial data (n=61) to replicate the earlier study and determine whether habit–adherence association exists in other cohorts of adults with CF. In this study, high adherers also reported stronger habit compared with low adherers. Habit may be a promising target for self-management interventions.Trial registration numberACtiF pilot, ISRCTN13076797.

Habit, a psychological process that automatically generates urges to perform a behavior in associated settings, is potentially an important determinant of medication adherence. Habit is challenging to measure because, as a psychological construct, it cannot be directly observed. We describe a method of using routinely available objective adherence data from electronic data capture (EDC) to generate a behavior-based index of adherence habit and demonstrate how this index can be applied. Our proposed habit index is a "frequency in context" measure. It estimates habit as a multiplicative product of behavior frequency (generated from weekly percentage adherence) and context stability (inferred from time of nebulizer use). Although different timescales can be used, we chose to generate weekly habit scores since we believe that this is the most granular level at which context stability can be reasonably calculated. A hallmark of habit is to predict future behavior, hence we used time series method to cross-correlate the habit index with nebulizer adherence in the subsequent week among 123 adults with cystic fibrosis (52, 42.3% female; median age 25 years) over a median duration of 153 weeks (IQR 74-198 weeks). The mean cross-correlation coefficient ( ) between the habit index and subsequent adherence was 0.40 (95% CI 0.36-0.44). Adjusting for current adherence, the unstandardized regression coefficient ( ) for the habit index was 0.30 (95% CI -1.04 to 1.65). We have described a pragmatic method to infer "habit" from adherence data routinely captured with EDC and provided proof-of-principle evidence regarding the feasibility of this concept. The continuous stream of data from EDC allows the habit index to unobtrusively assess "habit" at various time points over prolonged periods, and hence the habit index may be applicable in habit formation studies.

•The presence of bodily pain is associated with increased sedentary time in people with anxiety.•Lack of social cohesion is associated with being more sedentary in people with anxiety.•Being unemployed is associated with being more sedentary in people with anxiety. We investigated correlates of sedentary behavior (SB) among community-dwelling adults with elevated anxiety symptoms in six low- and middle-income countries (LMICs). Cross-sectional data from the World Health Organization's Study on Global Ageing and Adult Health (2007–2010) were analyzed. Associations between SB levels and the correlates were examined using multivariable linear and logistic regressions. Out of 42,469 individuals aged ≥ 18 years, there were 2630 participants with anxiety (47.6 ± 16.5 years; 66.6% female). Correlates significantly associated with being sedentary ≥ 8 h/day were being male, older age, a lower income, never married (vs. married/cohabiting), being unemployed, poor self-related health, alcohol consumption, and less social cohesion (highest quartile vs. lowest). Disability and bodily pain were associated with more time spent (min/day) sedentary. Future intervention research should target the risk groups based on identified sociodemographic correlates. Also, whether the promotion of social cohesion increases the efficacy of public health initiatives should be examined with prospective data.

Sitting time is associated with adverse physical and mental health outcomes, and premature mortality. Office workers sit for prolonged periods, so are at particular risk. Scientific advances in public health threats are predominantly communicated to the public through media reports. This study aimed to examine office workers' impromptu responses to media coverage of scientific evidence related to the health risks of sedentary behaviour. Semi-structured interviews were run with 26 office workers (mean age 35 years), recruited from four organizations in southern England. Within the interview, each participant provided a 'think-aloud' narrative as they read three real-world news reports relating to sedentary behaviour. Thematic analysis was conducted on verbatim transcripts. Three themes were extracted from the data: gauging the personal relevance of the news reports; questioning their trustworthiness and challenging the feasibility of proposed sitting-reduction strategies. Participants voiced scepticism about the applicability of the reports to their personal circumstances, and the validity of the reports and the scientific evidence underpinning them. Researchers, press officers and journalists should emphasise the ways in which participants in research studies represent the broader population of office workers, and offer greater transparency in reporting study methods, when reporting scientific advances in sedentary behaviour.

Objectives Fly-in fly-out (FIFO) work involves commuting long distances to the worksite and living in provided accommodation for 1-4 weeks while on shift. While the potentially detrimental impact of FIFO work on the health and well-being of workers has been documented, little attention has been paid to how workers, or their partners, cope with this impact. This study sought to investigate how workers and their partners negotiate the impact of FIFO on their mental health and well-being. Design The study design was qualitative. FIFO workers arid partners responded to open-ended questions on concerns about the FIFO lifestyle arid the support they use. Setting Australian FIFO workers arid partners responded to the questions via email. Participants Participants were 34 FIFO workers (25 men, M age=41 years) and 26 partners of FIFO workers (26 women, Mage=40 years). Results Participant-validated thematic analysis generated three main themes: managing multiple roles, impact on mental health and well-being, and social support needs. Results revealed difficulties in adjusting between the responsibilities of perceptually distinct on-shift and off shift lives, and managing potential psychological distance that develops while workers are on site. Participants emphasised the importance of maintaining quality communication and support from family members. Workers and partners attempted to maintain mental health arid well-being by regularly engaging with support networks, although many felt organisational support was tokenistic, stigmatised or lacking. Conclusions Recommendations for enhancing support provided by FIFO organisations are offered. In particular, organisations should emphasise the irnportance of good mental health and well-being, maintain transparency regarding potential challenges of FIFO lifestyles, arid offer professional support for managing multiple social roles and effective communication.

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

Office workers spend most of their working day sitting, and prolonged sitting has been associated with increased risk of poor health. Standing in meetings has been proposed as a strategy by which to reduce workplace sitting but little is known about the standing experience. This study documented workers' experiences of standing in normally seated meetings. Twenty-five participants (18+ years), recruited from three UK universities, volunteered to stand in 3 separate, seated meetings that they were already scheduled to attend. They were instructed to stand when and for however long they deemed appropriate, and gave semi-structured interviews after each meeting. Verbatim transcripts were analysed using Framework Analysis. Four themes, central to the experience of standing in meetings, were extracted: physical challenges to standing; implications of standing for meeting engagement; standing as norm violation; and standing as appropriation of power. Participants typically experienced some physical discomfort from prolonged standing, apparently due to choosing to stand for as long as possible, and noted practical difficulties of fully engaging in meetings while standing. Many participants experienced marked psychological discomfort due to concern at being seen to be violating a strong perceived sitting norm. While standing when leading the meeting was felt to confer a sense of power and control, when not leading the meeting participants felt uncomfortable at being misperceived to be challenging the authority of other attendees. These findings reveal important barriers to standing in normally-seated meetings, and suggest strategies for acclimatising to standing during meetings. Physical discomfort might be offset by building standing time slowly and incorporating more sit-stand transitions. Psychological discomfort may be lessened by notifying other attendees about intentions to stand. Organisational buy-in to promotional strategies for standing may be required to dispel perceptions of sitting norms, and to progress a wider workplace health and wellbeing agenda.

Objectives. Fly-in, fly-out (FIFO) work involves long commutes, living on-site for consecutive days and returning home between shifts. This unique type of work requires constant transitioning between the roles and routines of on-shift versus off-shift days. This study aims to examine health behaviour patterns of FIFO workers and FIFO partners during on-shift and off-shift time frames. Design. This study used ecological momentary assessment and multilevel modelling to examine daily health behaviours. Setting. FIFO workers and FIFO partners from across Australia responded to daily online surveys for up to 7 days of on-shift and up to 7 days of off-shift time frames. Participants. Participants included 64 FIFO workers and 42 FIFO worker partners. Results. Workers and partners reported poorer sleep and nutrition quality for on-shift compared with off-shift days. Both workers and partners exercised less, smoked more cigarettes, took more physical health medication and drank less alcohol during on-shift compared with off-shift days. Conclusions. FIFO organisations should consider infrastructure changes and support services to enhance opportunities for quality sleep and nutrition, sufficient exercise, moderate alcohol consumption and cigarette cessation for workers on-site and their partners at home.

Habitual behaviours are learned responses that are triggered automatically by associated environmental cues. The unvarying nature of most workplace settings makes workplace physical activity a prime candidate for a habitual behaviour, yet the role of habit strength in occupational physical activity has not been investigated. Aims of the present study were to: (i) document occupational physical activity habit strength; and (ii) investigate associations between occupational activity habit strength and occupational physical activity levels. A sample of UK office-based workers (n = 116; 53% female, median age 40 years, SD 10.52) was fitted with activPAL accelerometers worn for 24 h on five consecutive days, providing an objective measure of occupational step counts, stepping time, sitting time, standing time and sit-to-stand transitions. A self-report index measured the automaticity of two occupational physical activities (being active (e.g., walking to printers and coffee machines) and stair climbing). Adjusted linear regression models investigated the association between occupational activity habit strength and objectively-measured occupational step counts, stepping time, sitting time, standing time and sit-to-stand transitions. Eighty-one per cent of the sample reported habits for being active, and 62% reported habits for stair climbing. In adjusted models, reported habit strength for being active were positively associated with average occupational sit-to-stand transitions per hour (B = 0.340, 95% CI: 0.053 to 0.627, p = 0.021). Stair climbing habit strength was unexpectedly negatively associated with average hourly stepping time (B = -0.01, 95% CI: -0.01 to -0.00, p = 0.006) and average hourly occupational step count (B = -38.34, 95% CI: -72.81 to -3.88, p = 0.030), which may reflect that people with stronger stair-climbing habits compensate by walking fewer steps overall. Results suggest that stair-climbing and office-based occupational activity can be habitual. Interventions might fruitfully promote habitual workplace activity, although, in light of potential compensation effects, such interventions should perhaps focus on promoting moderate-intensity activity.

Background: Handgrip strength is a valid indicator of broader physical functioning. Handgrip strength and weight status have been independently associated with depressive symptoms in older adults, but no study has yet investigated the relationships between all three in older US adults. This study investigated the relationship between physical function and depressive symptoms by weight status in older US adults. Methods: Cross-sectional data were analysed from the National Health and Nutrition Examination Survey waves 2011 to 2012 and 2013 to 2014. Physical function was assessed using a grip strength dynamometer. Depressive symptoms were assessed using the self-reported Patient Health Questionnaire-9. Weight status was assessed using Body Mass Index (BMI) and participants were categorised as normal weight (< 25 kg/m(2)), overweight (25 to< 30 kg/m(2) ), and obese (>= 30.0 kg/m(2)). Associations between depressive symptoms and hand grip strength were estimated by gender-specific multiple linear regressions and BMI stratified multivariable linear regression. Results: A total of 2,812 adults (54% female, mean age 69.2 years, mean BMI 29.2 kg/m(2)) were included. Women with moderate to severe depressive symptoms had 1.60 kg (95% CI: 0.91 to 2.30) lower hand grip strength compared to women with minimal or no depressive symptoms. No such association was observed in men. Among those with obesity, men (-3.72 kg, 95% CI: -7.00 to -0.43) and women (-1.83 kg, 95% CI: -2.87 to -0.78) with moderate to severe depressive symptoms both had lower handgrip strength. Conclusion: Among older US adults, women and people who are obese and depressed are at the greatest risk of decline in physical function.

Background Sedentary behavior (SB) is associated with diabetes, cardiovascular disease and low mood. There is a paucity of multi-national research investigating SB and depression, particularly among low- and middle-income countries. This study investigated the association between SB and depression, and factors which influence this. Methods Cross-sectional data were analyzed from the World Health Organization's Study on Global Ageing and Adult Health. Depression was based on the Composite International Diagnostic Interview. The association between depression and SB (self-report) was estimated by multivariable linear and logistic regression analyses. Mediation analysis was used to identify influential factors. Results A total of 42,469 individuals (50.1% female, mean 43.8 years) were included. People with depression spent 25.6 (95%CI8.5–42.7) more daily minutes in SB than non-depressed participants. This discrepancy was most notable in adults aged ≥ 65 y (35.6 min more in those with depression). Overall, adjusting for socio-demographics and country, depression was associated with a 1.94 (95%CI1.31–2.85) times higher odds for high SB (i.e., ≥ 8 h/day). The largest proportion of the SB-depression relationship was explained by mobility limitations (49.9%), followed by impairments in sleep/energy (43.4%), pain/discomfort (31.1%), anxiety (30.0%), disability (25.6%), cognition (16.1%), and problems with vision (11.0%). Other health behaviors (physical activity, alcohol consumption, smoking), body mass index, and social cohesion did not influence the SB-depression relationship. Conclusion People with depression are at increased risk of engaging in high levels of SB. This first multi-national study offers potentially valuable insight for a number of hypotheses which may influence this relationship, although testing with longitudinal studies is needed.

Background: Hearing and vision impairments/problems are associated with increased risk of premature mortality in adulthood. One potential pathway explaining this association is reduced levels of physical activity. Reductions in activity levels due to sensory impairments may commence earlier in life; however, associations between sensory impairments/problems and activity levels in childhood are not well understood. Objective: The objective of this study was to examine associations between hearing and vision problems and objectively measured activity levels in a representative sample of British children. Methods: Data were drawn from sweep 4 of the Millennium Cohort Study, a prospective cohort study among children aged 7. Child hearing and vision problems were reported by parents in a postal survey. Children were also invited to have their physical activity measured objectively via accelerometry. A total of 6410 children had valid accelerometry data accompanied by complete survey data on the variables of interest. The main outcomes were objectively measured moderate-to-vigorous physical activity, steps and sedentary time. Adjusted linear regression was used to examine associations between vision and hearing problems and objectively measured activity levels. Results: In this sample of 7-year old children, 16.7% (n = 1068) had a reported vision problem and 11.6% (n = 745) had a hearing problem. Reported vision problems in both eyes, but not one eye, was associated with 2 fewer minutes of moderate-to-vigorous physical activity per day (B = -2.1 95% Confidence Intervals [CI] -3.9 to -0.4) and almost 200 fewer steps per day (B= -198.4 95% CI, -398.4 to 1.6). Hearing problems were not associated with activity levels in either one or both ears. Conclusion: Children with visual problems affecting both eyes, but not one eye, are likely to have lower levels of physical activity. Strategies to promote physical activity in children with visual problems are warranted. (C) 2017 Elsevier Inc. All rights reserved.

Objectives Individuals with chronic conditions can benefit from formulating action plans to engage in regular physical activity. However, the content and the successful translation of plans into action, so-called plan enactment, are rarely adequately evaluated. The aim of this study was to describe the content of user-specified plans and to examine whether participants were more likely to enact their plans if these plans were highly specific, viable, and instrumental. Design and methods The study presents secondary analyses from a larger behavioural intervention in cardiac and orthopaedic rehabilitation. The content of 619 action plans from 229 participants was evaluated by two independent raters (i.e., qualitative analyses and ratings of specificity) and by participants themselves (i.e., instrumentality and viability). Plan enactment was also measured via self-reports. Multilevel analyses examined the relationship between these plan characteristics and subsequent plan enactment, and between plan enactment and aggregated physical activity. Results Participants preferred to plan leisure-time physical activities anchored around time-based cues. Specificity of occasion cues (i.e., when to act) and highly instrumental plans were positively associated with plan enactment. Interestingly, individuals who planned less specific behavioural responses (i.e., what to do) were more likely to enact their plans. Plan enactment was positively associated with aggregated behaviour. Conclusions Interventions should not only emphasize the importance of planning, but also the benefits of formulating specific contextual cues. Planning of the behavioural response seems to require less precision. Allowing for some flexibility in executing the anticipated target behaviour seems to aid successful plan enactment.

Background: Mild or pre-frailty is common and associated with increased risks of hospitalisation, functional decline, moves to long-term care, and death. Little is known about the effectiveness of health promotion in reducing these risks. This systematic review aimed to synthesise randomised controlled trials (RCTs) evaluating home and community-based health promotion interventions for older people with mild/pre-frailty. Methods: We searched 20 bibliographic databases and 3 trials registers (January 1990 - May 2016) using mild/pre-frailty and associated terms. We included randomised controlled and crossover trials of health promotion interventions for community-dwelling older people (65+ years) with mild/pre-frailty and excluded studies focussing on populations in hospital, long term care facilities or with a specific condition. Risk of bias was assessed by two reviewers using the Cochrane Risk of Bias tool. We pooled study results using standardised mean differences (SMD) where possible and used narrative synthesis where insufficient outcome data were available. Results: We included 10 articles reporting on seven trials (total n = 506 participants) and included five trials in a meta-analysis. Studies were predominantly small, of limited quality and six studies tested group exercise alone. One study additionally investigated a nutrition and exercise intervention and one evaluated telemonitoring. Interventions of exercise in groups showed mixed effects on functioning (no effects on self-reported functioning SMD 0.19 (95% CI -0.57 to 0.95) n = 3 studies; positive effects on performance-based functioning SMD 0.37 (95% CI 0.07 to 0.68) n = 3 studies). No studies assessed moves to long-term care or hospitalisations. Conclusions: Currently the evidence base is of insufficient size, quality and breadth to recommend specific health promotion interventions for older people with mild or pre-frailty. High quality studies of rigorously developed interventions are needed.

Background: Most people do not engage in sufficient physical activity to confer health benefits and to reduce risk of chronic disease. Healthcare professionals frequently provide guidance on physical activity, but often do not meet guideline levels of physical activity themselves. The main objective of this study is to develop and test the efficacy of a tailored intervention to increase healthcare professionals' physical activity participation and quality of life, and to reduce work-related stress and absenteeism. This is the first study to compare the additive effects of three forms of a tailored intervention using different techniques from behavioural theory, which differ according to their focus on motivational, self-regulatory and/or habitual processes. Methods/Design: Healthcare professionals (N = 192) will be recruited from four hospitals in Perth, Western Australia, via email lists, leaflets, and posters to participate in the four group randomised controlled trial. Participants will be randomised to one of four conditions: (1) education only (non-tailored information only), (2) education plus intervention components to enhance motivation, (3) education plus components to enhance motivation and self-regulation, and (4) education plus components to enhance motivation, self-regulation and habit formation. All intervention groups will receive a computer-tailored intervention administered via a web-based platform and will receive supporting text-messages containing tailored information, prompts and feedback relevant to each condition. All outcomes will be assessed at baseline, and at 3-month follow-up. The primary outcome assessed in this study is physical activity measured using activity monitors. Secondary outcomes include: quality of life, stress, anxiety, sleep, and absenteeism. Website engagement, retention, preferences and intervention fidelity will also be evaluated as well as potential mediators and moderators of intervention effect. Discussion: This is the first study to examine a tailored, technology-supported intervention aiming to increase physical activity in healthcare professionals. The study will evaluate whether including additional theory-based behaviour change techniques aimed at promoting motivation, self-regulation and habit will lead to increased physical activity participation relative to information alone. The online platform developed in this study has potential to deliver efficient, scalable and personally-relevant intervention that can be translated to other occupational settings.

Sedentary behaviour - i.e., low energy-expending waking behaviour while seated or lying down - is a health risk factor, even when controlling for physical activity. This review sought to describe the behaviour change strategies used within interventions that have sought to reduce sedentary behaviour in adults. Studies were identified through existing literature reviews, a systematic database search, and hand-searches of eligible papers. Interventions were categorised as very promising', quite promising', or non-promising' according to observed behaviour changes. Intervention functions and behaviour change techniques were compared across promising and non-promising interventions. Twenty-six eligible studies reported thirty-eight interventions, of which twenty (53%) were worksite-based. Fifteen interventions (39%) were very promising, eight quite promising (21%), and fifteen non-promising (39%). Very or quite promising interventions tended to have targeted sedentary behaviour instead of physical activity. Interventions based on environmental restructuring, persuasion, or education were most promising. Self-monitoring, problem solving, and restructuring the social or physical environment were particularly promising behaviour change techniques. Future sedentary reduction interventions might most fruitfully incorporate environmental modification and self-regulatory skills training. The evidence base is, however, weakened by low-quality evaluation methods; more RCTs, employing no-treatment control groups, and collecting objective data are needed.

Objective: Effective hearing loss rehabilitation support options are available. Yet, people often experience delays in receiving rehabilitation support. This study aimed to document support-seeking experiences among a sample of UK adults with hearing loss, and views towards potential strategies to increase rehabilitation support uptake. People with hearing loss were interviewed about their experiences of seeking support, and responses to hypothetical intervention strategies, including public awareness campaigns, a training programme for health professionals, and a national hearing screening programme. Design: Semi-structured qualitative interview design with thematic analysis. Study sample: Twenty-two people with hearing loss, aged 66-88. Results: Three themes, representing barriers to receiving rehabilitation support and potential areas for intervention, were identified: making the journey from realization to readiness, combatting social stigma, and accessing appropriate services. Barriers to receiving support mostly focused on appraisal of hearing loss symptoms. Interventions enabling symptom appraisal, such as routine screening, or demonstrating how to raise the topic effectively with a loved one, were welcomed. Conclusions: Interventions to facilitate realization of hearing loss should be prioritized. Raising awareness of the symptoms and prevalence of hearing loss may help people to identify hearing problems and reduce stigma, in turn increasing hearing loss acceptance.

Risk perception studies have focused on personal risks; yet many decisions are taken for others. Some studies have suggested that parents are especially sensitive to risks to their children. We compared 245 parents' willingness to vaccinate their child versus themselves in nine hypothetical scenarios relating to influenza strains. Scenarios varied according to non-vaccination risk (low, medium and high) and 'risk target' (oneself, one's child or, as a comparator, one's elderly parent). Participants were more willing to vaccinate their child (61% acceptance) than themselves (54%) or their parent (56%). Parents may be more risk-sensitive when deciding for their child than for themselves.

Background: Uptake of preschool vaccinations is less than optimal. Financial incentives and quasi-mandatory policies (restricting access to child care or educational settings to fully vaccinated children) have been used to increase uptake internationally, but not in the UK. Objective: To provide evidence on the effectiveness, acceptability and economic costs and consequences of parental financial incentives and quasi-mandatory schemes for increasing the uptake of preschool vaccinations. Design: Systematic review, qualitative study and discrete choice experiment (DCE) with questionnaire. Setting: Community, health and education settings in England. Participants: Qualitative study - parents and carers of preschool children, health and educational professionals. DCE - parents and carers of preschool children identified as 'at high risk' and 'not at high risk' of incompletely vaccinating their children. Data sources: Qualitative study - focus groups and individual interviews. DCE - online questionnaire. Review methods: The review included studies exploring the effectiveness, acceptability or economic costs and consequences of interventions that offered contingent rewards or penalties with real material value for preschool vaccinations, or quasi-mandatory schemes that restricted access to 'universal' services, compared with usual care or no intervention. Electronic database, reference and citation searches were conducted. Results: Systematic review - there was insufficient evidence to conclude that the interventions considered are effective. There was some evidence that the quasi-mandatory interventions were acceptable. There was insufficient evidence to draw conclusions on economic costs and consequences. Qualitative study - there was little appetite for parental financial incentives. Quasi-mandatory schemes were more acceptable. Optimising current services was consistently preferred to the interventions proposed. DCE and questionnaire - universal parental financial incentives were preferred to quasi-mandatory interventions, which were preferred to targeted incentives. Those reporting that they would need an incentive to vaccinate their children completely required around 110 pound. Those who did not felt that the maximum acceptable incentive was around 70 pound. Limitations: Systematic review - a number of relevant studies were excluded as they did not meet the study design inclusion criteria. Qualitative study - few partially and non-vaccinating parents were recruited. DCE and questionnaire - data were from a convenience sample. Conclusions: There is little current evidence on the effectiveness or economic costs and consequences of parental financial incentives and quasi-mandatory interventions for preschool vaccinations. Universal incentives are likely to be more acceptable than targeted ones. Preferences concerning incentives versus quasi-mandatory interventions may depend on the context in which these are elicited. Future work: Further evidence is required on (i) the effectiveness and optimal configuration of parental financial incentive and quasi-mandatory interventions for preschool vaccinations - if effectiveness is confirmed, further evidence is required on how to communicate this to stakeholders and the impact on acceptability; and (ii) the acceptability of parental financial incentive and quasi-mandatory interventions for preschool vaccinations to members of the population who are not parents of preschool children or relevant health professionals. Further consideration should be given to (i) incorporating reasons for non-vaccination into new interventions for promoting vaccination uptake; and (ii) how existing services can be optimised.

Understanding human behavior lies at the heart of responses to climate change. Many environmentally relevant behavior patterns are frequent, stable, and persistent. There is an increasing focus on understanding these patterns less in terms of deliberative processes and more in terms of habits and routines embedded in everyday life. Examinations of the habitual' nature of environmentally consequential activities have been approached from two theoretically distinct perspectives. From a social psychological perspective, habit' is studied as an intra-individual psychological construct that sustains ingrained behavior patterns in stable settings and obstructs adoption of more environmentally friendly alternatives. Sociologists from the social practice tradition, in contrast, have sought to highlight the ways in which resource-intensive habitual practices' become established and maintained in society through a commingling of material, procedural, and socio-discursive elements. We reflect critically upon key theoretical differences underpinning these two approaches to repetitive behaviors and review empirical work from both traditions that speaks to the relevance of habitual behavior patterns' central to addressing climate change. Finally, we examine how changes in habits are theorized and operationalized within both social psychological and social practice approaches, and practical implications for promoting environmentally sustainable societies. (C) 2014 The Authors. WIREs Climate Change published by John Wiley & Sons, Ltd.

Habit formation is thought to lead to long-term maintenance of fruit and vegetable consumption. Habits develop through context-dependent repetition, but additional variables such as intrinsic reward of behaviour may influence habit strength. Drawing upon the Associative-Cybernetic Model, this exploratory study tested different pathways by which intrinsic reward may influence fruit and vegetable consumption habit strength. In a three-wave study of fruit and vegetable intake in adults (N = 127) from the general population, intrinsic reward, intention, and self-efficacy were assessed at baseline, fruit and vegetable consumption and intrinsic reward two weeks later, and habit strength another two weeks later. Direct, indirect, and moderation effects of intrinsic reward on habit strength were tested simultaneously in a moderated mediation model. Intrinsic reward had a positive indirect effect on habit strength through its influence on the frequency of fruit and vegetable consumption. Further, the relationship between fruit and vegetable consumption and habit was stronger where consumption was considered more intrinsically rewarding. Findings highlight the potential relevance of intrinsic reward to habit. We suggest that intrinsic rewards from behaviour may not only facilitate habit via behaviour frequency, but also reinforce the relationship between behavioural repetition and habit strength.

Background: The twelve-item Self-Report Habit Index (SRHI) is the most popular measure of energy-balance related habits. This measure characterises habit by automatic activation, behavioural frequency, and relevance to self-identity. Previous empirical research suggests that the SRHI may be abbreviated with no losses in reliability or predictive utility. Drawing on recent theorising suggesting that automaticity is the 'active ingredient' of habit-behaviour relationships, we tested whether an automaticity-specific SRHI subscale could capture habit-based behaviour patterns in self-report data. Methods: A content validity task was undertaken to identify a subset of automaticity indicators within the SRHI. The reliability, convergent validity and predictive validity of the automaticity item subset was subsequently tested in secondary analyses of all previous SRHI applications, identified via systematic review, and in primary analyses of four raw datasets relating to energy-balance relevant behaviours (inactive travel, active travel, snacking, and alcohol consumption). Results: A four-item automaticity subscale (the 'Self-Report Behavioural Automaticity Index'; 'SRBAI') was found to be reliable and sensitive to two hypothesised effects of habit on behaviour: a habit-behaviour correlation, and a moderating effect of habit on the intention-behaviour relationship. Conclusion: The SRBAI offers a parsimonious measure that adequately captures habitual behaviour patterns. The SRBAI may be of particular utility in predicting future behaviour and in studies tracking habit formation or disruption.

Gardner B., Croker H., Barr S., Briley A., Poston L. & Wardle J. on behalf of the UPBEAT Trial. (2012) Psychological predicators of dietary intentions in pregnancy. J Hum Nutr Diet. 25, 345353 Abstract Background: Consuming a healthy diet in pregnancy has the potential to improve obstetric outcome, including minimising the risk of macrosomia. Effective promotion of dietary change depends on identifying and targeting determinants of gestational diet. The present study aimed to model psychological predictors of intentions to reduce intake of high-fat and high-sugar foods, and increase fruit and vegetable consumption, among pregnant women. Methods: One hundred and three pregnant women completed questionnaire measures of intentions to modify the consumption of the target foods, current intake, perceived vulnerability to and severity of adverse outcomes of unhealthful consumption of these foods (i.e. threat), benefits of dietary change to mother and baby, barriers to dietary changes, and social approval for dietary change (subjective norms). A cross-sectional design was used. Logistic regression analyses were undertaken to model dietary change intentions. Results: Participants who reported excessive current intake of high-fat and high-sugar foods were more likely to intend to reduce the intake of these foods. Perceived benefits for mother and baby enhanced intentions to eat more fruit and vegetables and eat less high-fat, and marginally significantly increased high-sugar reduction intentions. There were no effects of threat, barriers or subjective norms. Conclusions: Lack of effects for barriers, threat and subjective norms may indicate that pregnant women discount barriers to health-promoting behaviour, understand the threat posed by unhealthy eating and perceive social approval from others. Dietary change interventions for pregnant women should emphasise likely positive outcomes for both mother and child.

Objectives. Repeated action can lead to the formation of habits and identification as the kind of person that performs the behaviour. This has led to the suggestion that identity-relevance is a facet of habit. This study explores conceptual overlap between habit and identity, and examines where the two constructs fit into an extended Theory of Planned Behaviour (TPB) model of binge-drinking among university students. Design. Prospective, questionnaire-based correlational design. Methods. A total of 167 UK university students completed baseline measures of past behaviour, self-identity, the Self-Report Habit Index (SRHI), and TPB constructs. One week later, 128 participants completed a follow-up behaviour measure. Results. Factor analyses of the SRHI and four identity items revealed two correlated but distinct factors, relating to habit and identity, respectively. Hierarchical regression analyses of intention and behaviour showed that identity contributed over and above TPB constructs to the prediction of intention, whereas habit predicted behaviour directly, and interacted with intentions in predicting behaviour. Habits unexpectedly strengthened the intentionbehaviour relation, such that strong intenders were more likely to binge-drink where they also had strong habits. Conclusions. Identity and habit are conceptually discrete and impact differently on binge-drinking. Findings have implications for habit theory and measurement. Recommendations for student alcohol consumption reduction initiatives are offered.

Background Health behaviour models typically neglect habitual action. The Self-Report Habit Index (SRHI) permits synthesis of evidence of the influence of habit on behaviour. Purpose The purpose of this study is to review evidence around mean habit strength, habit–behaviour correlations, and habit × intention interactions, from applications of the SRHI to dietary, physical activity, and active travel behaviour. Method Electronic database searches identified 126 potentially relevant papers. Twenty-two papers (21 datasets) passed eligibility screening. Mean scores and correlations were meta-analysed using fixed, random and mixed effects, and interactions were synthesised via narrative review. Results Twenty-three habit–behaviour correlations and nine habit × intention interaction tests were found. Typical habit strength was located around the SRHI midpoint. Weighted habit–behaviour effects were medium-to-strong (fixed: r+ = 0.44; random: r+ = 0.46). Eight tests found that habit moderated the intention–behaviour relation. Conclusion More comprehensive understanding of nutrition and activity behaviours will be achieved by accounting for habitual responses to contextual cues.

Transport accounts for nearly a quarter of current energy-related carbon dioxide emissions with car travel constituting more than three quarters of all vehicle kilometres travelled. Interventions to change transport behaviour, and especially to reduce car use, could reduce CO2 emissions from road transport more quickly than technological measures. It is unclear, however, which interventions are effective in reducing car use and what the likely impact of these interventions would be on CO2 emissions. A two-stage systematic search was conducted focusing on reviews published since 2000 and primary intervention evaluations referenced therein. Sixty-nine reviews were considered and 47 primary evaluations found. These reported 77 intervention evaluations, including measures of car-use reduction. Evaluations of interventions varied widely in the methods they employed and the outcomes measures they reported. It was not possible to synthesise the findings using meta-analysis. Overall, the evidence base was found to be weak. Only 12 of the 77 evaluations were judged to be methodologically strong, and only half of these found that the intervention being evaluated reduced car use. A number of intervention approaches were identified as potentially effective but, given the small number of methodologically strong studies, it is difficult to draw robust conclusions from current evidence. More methodologically sound research is needed in this area.

Annual increments in measles, mumps and rubella (MMR) vaccination coverage in England have halted, with uptake rates (mean 85%) remaining below the 95% rate needed for herd immunity. 1 Some commentators have called for vaccination to be made compulsory, or otherwise heavily incentivised. Health visitors were also concerned that making MMR vaccination compulsory, where other child health decisions are subject to parental free choice, would introduce inconsistency to healthcare policy and practice, and overemphasise the importance of MMR relative to other vaccinations.

A grounded theory analysis of reasons for driving to work was undertaken following semi-structured interviews with 19 regular private car commuters in a small English city. Five core motives were identified: journey time concerns; journey-based affect; effort minimisation; personal space concerns; and monetary costs. An underlying desire for control underpinned many of these motives. The analysis revealed misconceptions regarding journey times and control in relation to car and public transport use, systematic underestimation of car-related monetary costs, and the importance of self- and identity-relevant consequences in relation to transport policy acceptance. Drivers' motives and misconceptions are discussed in light of transport demand management policies. (c) 2006 Elsevier Ltd. All rights reserved.

This chapter presents the benefits of exercise benefits. Stronger exercise habit is beneficial because it should increase the likelihood of frequent exercise, as is supported by the commonly observed association between self‐reported habit and exercise frequency. Having strongly formed exercise habits makes it less likely that people will seek out or be tempted by opposing unhealthy alternative behavioral options. The formation of exercise habits also has the benefit that it is less cognitively demanding than non‐habitual exercise. The chapter explores how exercise habits are formed. Helping people to form exercise habits requires encouraging people to exercise regularly and in the same contexts, so that habit associations develop. Factors can impact habit formation in several ways: by increasing or maintaining the motivation to become physically active, by aiding the translation of motivation into repeated action, or by strengthening the reinforcing value of each repetition on the formation of cue‐behavior associations.

Habitual actions are elicited automatically in associated settings, bypassing conscious motivation. This has prompted interest in habit formation as a mechanism for sustaining behaviour change when conscious motivation erodes. Promoting habit depends on understanding how habit develops. This chapter reviews theory and evidence around the habit formation process. First, we describe the few, recent studies that have explicitly sought to study habit development for meaningful activities in humans. Next, we outline a framework for understanding the habit formation process, and narratively review evidence regarding the factors that may directly facilitate or impede habit development, generating hypotheses for future studies. We offer practical suggestions for optimal modelling of habit formation and its determinants.

Translating research evidence into clinical practice to improve care involves healthcare professionals adopting new behaviours and changing or stopping their existing behaviours. However, changing healthcare professional behaviour can be difficult, particularly when it involves changing repetitive, ingrained ways of providing care. There is an increasing focus on understanding healthcare professional behaviour in terms of non-reflective processes, such as habits and routines, in addition to the more often studied deliberative processes. Theories of habit and routine provide two complementary lenses for understanding healthcare professional behaviour, although to date, each perspective has only been applied in isolation. To combine theories of habit and routine to generate a broader understanding of healthcare professional behaviour and how it might be changed. Sixteen experts met for a two-day multidisciplinary workshop on how to advance implementation science by developing greater understanding of non-reflective processes. From a psychological perspective ‘habit’ is understood as a process that maintains ingrained behaviour through a learned link between contextual cues and behaviours that have become associated with those cues. Theories of habit are useful for understanding the individual's role in developing and maintaining specific ways of working. Theories of routine add to this perspective by describing how clinical practices are formed, adapted, reinforced and discontinued in and through interactions with colleagues, systems and organisational procedures. We suggest a selection of theory-based strategies to advance understanding of healthcare professionals' habits and routines and how to change them. Combining theories of habit and routines has the potential to advance implementation science by providing a fuller understanding of the range of factors, operating at multiple levels of analysis, which can impact on the behaviours of healthcare professionals, and so quality of care provision. •Improving the quality of care involves changing healthcare professional behaviour.•Professional behaviour is driven by both reflective and non-reflective processes.•Changing non-reflective, habitual, or routine clinical behaviours is difficult.•Theory-based strategies can help address non-reflective clinical behaviours.•Future directions for research on non-reflective clinical behaviour are provided.

Objective Many adolescents report a lack of physical activity (PA) and excess screen time (ST). Psychological theories aiming to understand these behaviours typically focus on predictors of only one behaviour. Yet, behaviour enactment is often a choice between options. This study sought to examine predictors of PA and ST in a single model. Variables were drawn from dual process models, which portray behaviour as the outcome of deliberative and automatic processes. Design 411 Finnish vocational school students (age 17-19) completed a survey, comprising variables from the Reasoned Action Approach (RAA) and automaticity pertaining to PA and ST, and self-reported PA and ST four weeks later. Main outcome measures Self-reported time spent on PA and ST and their predictors. Results PA and ST correlated negatively (r = -.17, p = .03). Structural equation modelling revealed that intentions and habit for PA predicted PA while ST was predicted by intentions and habit for ST and negatively by PA intentions. RAA-cognitions predicted intentions. Conclusion PA and ST and their psychological predictors seem to be weakly interlinked. Future studies should assess more behaviours and related psychological influences to get a better picture of connections between different behaviours.

Habitual behaviours are triggered automatically, with little conscious forethought. Theory suggests that making healthy behaviours habitual, and breaking the habits that underpin many ingrained unhealthy behaviours, promotes long-term behaviour change. This has prompted interest in incorporating habit formation and disruption strategies into behaviour change interventions. Yet, notable research gaps limit understanding of how to harness habit to change real-world behaviours. Discussions among health psychology researchers and practitioners, at the 2019 European Health Psychology Society 'Synergy Expert Meeting', generated pertinent questions to guide further research into habit and health behaviour. In line with the four topics discussed at the meeting, 21 questions were identified, concerning: how habit manifests in health behaviour (3 questions); how to form healthy habits (5 questions); how to break unhealthy habits (4 questions); and how to develop and evaluate habit-based behaviour change interventions (9 questions). While our questions transcend research contexts, accumulating knowledge across studies of specific health behaviours, settings, and populations will build a broader understanding of habit change principles and how they may be embedded into interventions. We encourage researchers and practitioners to prioritise these questions, to further theory and evidence around how to create long-lasting health behaviour change.

Advances in understanding how habit forms can help people change their behaviour in ways that make them happier and healthier. Making behaviour habitual, such that people automatically act in associated contexts due to learned context-response associations, offers a mechanism for maintaining new, desirable behaviours even when conscious motivation wanes. This has prompted interest in understanding how habit forms in the real world. To reliably inform intervention design, habit formation studies must be conceptually and methodologically sound. This paper proposes methodological criteria for studies tracking real-world habit formation, or potential moderators of the effect of repetition on formation. A narrative review of habit theory was undertaken to extract essential and desirable criteria for modelling how habit forms in naturalistic settings, and factors that influence the relationship between repetition and formation. Next, a methodological review identified exemplary real-world habit formation studies according to these criteria. Fourteen methodological criteria, capturing study design (four criteria), measurement (six criteria), and analysis and interpretation (four criteria), were derived from the narrative review. Five extant studies were found to meet our criteria. Adherence to these criteria should increase the likelihood that studies will offer revealing conclusions about how habits develop in real-world settings.

Background Our thoughts impact our mental health and there is a distinction between thought content (what we think) and thought process (how we think). Habitual thinking has been proposed as one such process. Habits, which are cue-dependent automatic responses, have primarily been studied as behavioural responses. Methods The current scoping review investigated the extent to which the thinking patterns important for mental health have been conceptualized as habits. Using systematic search criteria and nine explicit inclusion criteria, this review identified 20 articles and 24 empirical studies examining various mental habits, such as negative self-thinking, self-criticism, and worry. Results All of the included empirical studies examined maladaptive (negative) mental habits and no study investigated adaptive (positive) mental habits. We categorized the characteristics of each study along several dimensions including how mental habits were defined, measured, and which constructs were studied as habitual. Conclusions Although mental habits appear to be relevant predictors of mental health, habitual thinking has not been well-integrated with psychological constructs related to mental health, such as automatic thoughts. We discuss the implications of mental habits for future research and clinical practice.

Abstract Background We aimed to establish what core elements were required in a group therapy programme for men who disclose perpetrating intimate partner abuse in a substance use setting and develop, and test the feasibility of delivering an intervention in this setting. Methods We describe the theoretical development and feasibility testing of an integrated substance use and intimate partner abuse intervention (‘ADVANCE’) for delivery in substance use services. We employed a comprehensive eight-stage process to guide this development applying the ‘COM-B’ (‘capability’, ‘opportunity’, ‘motivation’ and ‘behaviour’) model for intervention design which specifies the following: (1) define the problem, (2) select the target behaviour, (3) specify the target behaviour, (4) identify what needs to change, (5) identify intervention functions, (6) identify policy categories, (7) select behaviour change techniques, and (8) design a mode of delivery. The development was informed by primary research conducted by the authors, consulting with organisation steering groups and by those with personal experiences. The identified targets for intervention and mode and method of delivery were then refined over 4 intervention development meetings, using the nominal group technique with the ADVANCE experts, then further refined following consultation with service user groups and wider expert groups via a learning alliance meetings. Results Our final intervention, the ADVANCE intervention consisted of a group intervention comprising of up to four pre-group individual interviews, followed by 12 × 2-h group sessions supported by integrated safety work for victim/survivors, and risk and safety support and integrity support for the professionals. The main targets for change were personal goal planning, self-regulation, and attitudes and beliefs supporting intimate partner abuse. The intervention was regarded as very acceptable to both staff and clients in substance use services, with group attendees reported positive behaviour changes and development of new skills. Conclusion We have demonstrated the ability to employ a structured eight-step process to develop an integrated intervention to address substance use-related intimate partner abuse that is acceptable to staff and clients in substance use services. This led to a feasibility study (ISRCTN 79435190) involving 104 men and 30 staff at three different locations across the UK was conducted to assess the feasibility and acceptability of the intervention and to refine the content and approach to delivery (BMC Public Health, 21: 980, 2021).

OBJECTIVE: Habits, defined as well-learned associations between cues and behaviours, are essential for health-related behaviours, including physical activity (PA). Despite the sensitivity of habits to context changes, little remains known about the influence of a context change on the interplay between PA habits and behaviours. We investigated the evolution of PA habits amidst the spring COVID-19 lockdown, a major context change. Moreover, we examined the association of PA behaviours and autonomous motivation with this evolution. DESIGN: Three-wave observational longitudinal design. METHODS: PA habits, behaviours, and autonomous motivation were collected through online surveys in 283 French and Swiss participants. Variables were self-reported with reference to three time-points: before-, mid-, and end-lockdown. RESULTS: Mixed effect modelling revealed a decrease in PA habits from before- to mid-lockdown, especially among individuals with strong before-lockdown habits. Path analysis showed that before-lockdown PA habits were not associated with mid-lockdown PA behaviours (β = -.02, p = .837), while mid-lockdown PA habits were positively related to end-lockdown PA behaviours (β = .23, p = .021). Autonomous motivation was directly associated with PA habits (ps 

Cognitive enhancers (CE) are prescription drugs taken, either without a prescription or at a dose exceeding that which is prescribed, to improve cognitive functions such as concentration, vigilance or memory. Previous research suggests that users believe the drugs to be safer than non-users and that they have sufficient knowledge to judge safety. However, to date no research has compared the information sources used and safety knowledge of users and non-users. This study compared users and non-users of CE in terms of i) their sources of knowledge about the safety of CE and ii) the accuracy of their knowledge of possible adverse effects of a typical cognitive enhancer (modafinil); and iii) how the accuracy of knowledge relates to their safety beliefs. Students (N = 148) from King's College London (UK) completed an anonymous online survey assessing safety beliefs, sources of knowledge and knowledge of the safety of modafinil; and indicated whether they used CE, and, if so, which drug(s). The belief that the drugs are safe was greater in users than non-users. However, both groups used comparable information sources and have similar, relatively poor drug safety knowledge. Furthermore, despite users more strongly believing in the safety of CE there was no relationship between their beliefs and knowledge, in contrast to non-users who did show correlations between beliefs and knowledge. These data suggest that the differences in safety beliefs about CE between users and non-users do not stem from use of different information sources or more accurate safety knowledge.

Sedentary behaviour research to date has been predominantly based on self-reported sitting time, yet little attention has been paid to how respondents interpret sitting questionnaire items. 25 office workers participated in qualitative, ‘think-aloud’ interviews, describing their thoughts while completing 43 items derived from 9 existing questionnaires. Inductive Thematic Analysis identified four potential interpretation or response problems: misinterpretation and uncertainty; the mental calculation process involved in formulating responses; self-presentation concerns; and the affective and motivational impact of questionnaire completion. Results not only show that lay representations of sitting may diverge from those of researchers, but also highlight potential errors and biases encountered when generating sitting estimates. Additionally, reporting sitting may generate a desire to reduce sitting time. Findings suggest that domain-specific measures that estimate sitting across different settings may better correspond with participants’ perceptions. Future research should investigate the potential for sedentary behaviour questionnaire completion to change behaviour. •Little is known about how people understand sitting time questionnaire items.•25 office workers gave ‘think aloud’ responses while completing 43 items.•Results highlighted a process of converting seated activity into total sitting time.•Some items were misinterpreted and some biases were found.•Completing items motivated some to reduce their sitting, so may change behaviour.

Dysphagia or difficulty in swallowing affects quality of life for most patients with head and neck cancer. SIP SMART - [Swallowing Intervention Package: Self-Monitoring, Assessment, Rehabilitation Training] aims to improve post-treatment swallowing outcomes through a targeted and tailored pre-treatment intervention. This feasibility study assessed 1) recruitment and retention, 2) patient acceptability of randomisation and participation, 3) patient adherence, and 4) sought to identify a suitable primary outcome for a definitive trial, including sample size estimation. This two-arm parallel group non-blinded randomised feasibility trial took place within a head and neck centre at a teaching hospital in London, UK. Patients newly diagnosed with stage III/IV head and neck cancer were recruited and underwent 6-month follow-up. Patients were randomised to SIP-SMART or usual care via an online web-based system. SIP SMART comprised two 45-min consultations including a baseline clinical and instrumental swallowing assessment, relevant educational information, targeted swallowing exercises, and specific behaviour change strategies to increase exercise adherence. Usual care comprised a single session including a baseline clinical assessment and generic information about the likely impact of treatment on swallowing. A total of 106 patients were identified at pre-screening, 70 were assessed for eligibility. Twenty-six patients did not meet eligibility criteria [0.37, 95% CI 0.27 to 0.49]. Five of 44 [0.11, 95% CI 0.05 to 0.24] eligible patients were not approached by researchers during clinic. Seven [0.18, 95% CI 0.08 to 0.33] of the 39 approached declined participation. Target recruitment (32 consented patients) was achieved within the timeframe. At 6-months 29/32 [0.91, 95% CI 0.76 to 0.97] patients remained in the trial. Acceptability of randomisation and participation in the intervention was favourable, and adherence to the exercises exceeded the pre-defined 35% minimum criterion. The MD Anderson Dysphagia Inventory swallow related quality of life measure was selected as the most suitable primary outcome for sample size estimation. No adverse effects arose from the intervention, or study participation. A definitive trial of the SIP SMART intervention compared to usual care is feasible and can be undertaken with patients with head and neck cancer treated within the NHS. ISRCTN40215425, registered retrospectively.

Regular physical activity (PA) is associated with many health benefits during childhood, and tracks into desirable PA patterns and health profiles in adulthood. Interventions designed to support these behaviours among young children are critical. Family-based interventions focusing on parent-child activities together (i.e., co-activity) among preschool-aged children are warranted. Targeting parental support practices can increase the frequency of co-activity, however interventions must move beyond merely building intention and planning skills for successful maintenance. Interventions designed to increase co-activity habit strength may facilitate the sustainability and thus impact child PA. The purpose of this study is to compare the effects of three intervention conditions designed to increase child PA through co-activity: a standard education condition (information about benefits), a planning (action planning, coping planning) + education condition and a habit (context-dependent repetition from prompts and cues) + planning +education condition. A longitudinal three-arm parallel design randomized trial will compare three conditions over six months. Families are eligible if they have at least one child between 3y and 5y that is not meeting 60mins/day of moderate to vigorous physical activity (MVPA). The primary outcome (child MVPA) is assessed via accelerometry at baseline, six weeks, three months and six months (primary endpoint). Intervention materials targeting co-activity are delivered post baseline assessment, with booster sessions at six weeks and three months. Parental co-activity habit, parent-child co-activity and other behavioural constructs are also assessed via questionnaire at all measurement occasions. As tertiary outcomes, parental PA is measured via accelerometry and co-activity is measured via a Bluetooth-enabled proximity feature. A total of 106 families have been recruited thus far from the Greater Victoria region. The study is ongoing with a minimum target of 150 families and an anticipated recruitment completion date of August 2022. This protocol describes the implementation of a randomized trial evaluating the effectiveness of a habit formation group compared with a planning group and an education only group to increase child PA through targeting parent-child co-activity. This information could prove useful in informing public health initiatives to promote PA among families with preschool-aged children. This trial was prospectively registered on clinicaltrials.gov in February 2016, identifier NCT03055871 .

BackgroundIncreasingly, national policy initiatives and programmes have been developed to increase physical activity (PA). However, challenges in implementing and translating these policies into effective local-level programmes have persisted, and change in population PA levels has been small. This may be due to insufficient attention given to the implementation context, and the limited interactions between local policy-makers, practitioners and researchers. In this paper we use a case study of a cross-sectoral network in Northeast England, to identify the local-level challenges and opportunities for implementing PA policies and programmes, particularly the updated 2019 UK PA guidelines.MethodsFive focus groups (n=59) were conducted with practice partners, local policy-makers and researchers during an initial workshop in April 2018. Through facilitated discussion, participants considered regional priorities for research and practice, along with barriers to implementing this agenda and how these may be overcome. During a second workshop in December 2018, overarching findings from workshop one were fedback to a similar group of stakeholders, along with national policy-makers, to stimulate feedback from delegates on experiences that may support the implementation of the UK PA guidelines locally, focusing on specific considerations for research, evidence and knowledge exchange.ResultsIn workshop one, three overarching themes were developed to capture local challenges and needs: (i) understanding complexity and context; (ii) addressing the knowledge and skills gap; and (iii) mismatched timescales and practices. In workshop two, participants' implementation plans encompassed: (i) exploring a systems approach to implementation; (ii) adapting policy to context; and (iii) local prioritising.ConclusionsOur findings suggest that academics, practitioners and policy-makers understand the complexities of implementing PA strategies, and the challenges of knowledge exchange. The updated UK PA guidelines policy presented an opportunity for multiple agencies to consider context-specific implementation and address enduring tensions between stakeholders. An organically derived implementation plan that prioritises PA, maps links to relevant local policies and supports a context-appropriate communication strategy, within local policy, practice and research networks, will help address these. We present 10 guiding principles to support transferable knowledge exchange activities within networks to facilitate implementation of national PA policy in local contexts.

Mild frailty is common among older people, but it is potentially reversible with health promotion interventions. Behaviour change may be a key to preventing progression of frailty; however, we know little about what interventions work best and how a behaviour change approach would be perceived by this group. The aim of this study was to explore how mildly frail older people perceive health promotion based on behaviour change and what factors affect engagement with this approach. We conducted semi-structured interviews with 16 older people with mild frailty who received a pilot home-based behaviour change health promotion service, including a dyad of older person/family carer, and two service providers delivering the service in two diverse areas of South England. Interviews were audio-recorded, transcribed and thematically analysed. The concept of goal setting was acceptable to most participants, though the process of goal setting needed time and consideration. Goals on maintaining independence, monitoring of progress and receiving feedback were reported to increase motivation. Physical/mental capability and knowledge/perception of own needs were main determinants of the type of goals chosen by participants as well as the approach used by the project workers. Older people with complex needs benefited from care coordination, with a combination of goal setting and elements of social, practical and emotional support in varying proportions. Mildly frail older people responded well to a behaviour change approach to promote health and well-being. Further consideration is needed of the most effective strategies based on complexity of needs, and how to overcome barriers among people with cognitive impairment.

Lecture capture use has increased in recent years. Research shows that staff and students view capture differently, but their views on the practice of opting-in and out has not been investigated previously, even though this element of practice can be specified in institutional policy and governance. Focus groups revealed that staff were unclear on issues around consent and both groups i) felt staff should determine whether to capture their lectures, although students felt opting-out should require approval from senior staff and ii) recognised the need to communicate in advance about capture provision. Survey data showed the two groups differed in policy preference, with student’s preferring Opt-out and staff wanting Opt-in, and in terms of whether approval should be needed to opt-out. However, there were similarities with both groups believing impact on lecture content was the most acceptable reason to opt-out and, if approval was needed, that this should be at the department level. While significant differences exist in how staff and students perceive opting in and out of capture, there is common ground which should inform the wider debate around the use of lecture capture. Furthermore, the current research identifies key issues on which staff and students should be consulted when introducing lecture capture such as consent and reasoning for use or non-use. Consultation on these topics may result in a policy more appealing to both groups.

Healthy eating behaviours are important for physical and mental well-being and developing healthy eating behaviours early in life is important. As parents are the main providers of preschool children's food the main objective of this study was to use the theory of planned behaviour, expanded to include habit and past behaviour, to predict parents' healthy feeding intention and behaviour. Theory of planned behaviour, habit strength, and past behaviour were reported at baseline by 443 mothers. One week later, 235 mothers completed a healthy feeding questionnaire on the eating behaviours of their 2–4 year old child. Data were analysed using hierarchical regression analyses to predict parent's general healthy feeding behaviour, and five sub-behaviours: parents' perceptions of their child's fruit and vegetable consumption, healthy and unhealthy snacking behaviour, as well as healthy and unhealthy drinking behaviour. Intention, perceived behavioural control, habit strength and past behaviour were all positively associated with parents' general healthy feeding (47% explained variance). Perceived behavioural control was the only variable positively associated with mothers' perception of their child's fruit and vegetable consumption and unhealthy snacking behaviour. The theory did not explain the other behaviours. Moreover, habit strength only strengthened the intention-behaviour link for fruit and vegetable consumption and child's age was only positively associated with the mothers' perception of their child's unhealthy snacking behaviour. The findings suggest important differences in the predictors of different feeding behaviours that can provide direction for future intervention development.

Background Studies of the physical activity intention-behavior gap, and factors that may moderate the gap (e.g., habit, perceived behavioral control), can inform physical activity promotion efforts. Yet, these studies typically apply linear modeling procedures, and so conclusions rely on linearity and homoscedasticity assumptions, which may not hold. Methods We modelled and plotted physical activity intention-behavior associations and the moderation effects of habit using simulated data based on (a) normal distributions with no shared variance, (b) correlated parameters with normal distribution, and (c) realistically correlated and non-normally distributed parameters. Results In the uncorrelated and correlated normal distribution datasets, no violations were unmet, and the moderation effects applied across the entire data range. However, because in the realistic dataset, few people who engaged in physical activity behavior had low intention scores, the intention-behavior association was non-linear, resulting in inflated linear moderation estimations of habit. This finding was replicated when tested with intention-behavior moderation of perceived behavioral control. Conclusions Comparisons of the three scenarios illustrated how an identical correlation coefficient may mask different types of intention-behavior association and moderation effects. These findings highlight the risk of misinterpreting tests of the intention-behavior gap and its moderators for physical activity due to unfounded statistical assumptions. The previously well-documented moderating effects of habit, whereby the impact of intention on behavior weakens as habit strength increases, may be based on statistical byproducts of unmet model assumptions.

The benefits of continuous positive airway pressure (CPAP) treatment for obstructive sleep apnea are well established, but adherence tends to be low. Research exploring CPAP practitioners' beliefs around determinants of CPAP adherence, and the actions they use in clinical practice to promote CPAP adherence is lacking. This study aimed to: (i) develop and validate a questionnaire to assess beliefs and current practices among CPAP practitioners; (ii) explore practitioners' beliefs regarding the main determinants of patient adherence, and the actions practitioners most commonly use to promote CPAP adherence; and (iii) explore the associations between perceived determinants and adherence-promotion actions. One-hundred and forty-two CPAP practitioners in Sweden and Norway, representing 93% of all Swedish and 62% of all Norwegian CPAP centres, were surveyed via a questionnaire exploring potential determinants (18 items) and adherence-promotion actions (20 items). Confirmatory factor analysis and second-order structural equational modelling were used to identify patterns of beliefs, and potential associations with adherence-promotion actions. Patients' knowledge, motivation and attitudes were perceived by practitioners to be the main determinants of CPAP adherence, and educating patients about effects, management and treatment adjustments were the most common practices. Knowledge was shown to predict educational and informational actions (e.g. education about obstructive sleep apnea and CPAP). Educational and informational actions were associated with medical actions (e.g. treatment adjustment), but knowledge, attitude and support had no association with medical actions. These findings indicate that a wide variety of determinants and actions are considered important, though the only relationship observed between beliefs and actions was found for knowledge and educational and informational actions.

Mild frailty is common in later life, increasing the risk of hospitalisation, loss of independence and premature death. Targeted health promotion services may reduce adverse outcomes and increase quality of life; however, effective, well-developed theory-based interventions are lacking. We aimed to explore perceptions of health promotion behaviours undertaken by older people with mild frailty, barriers and facilitators to engagement, and identify potential components for new home-based health promotion services. We carried out 17 semi-structured qualitative interviews and six focus groups with 53 stakeholders, including 14 mildly frail older people, 12 family carers, 19 community health and social care professionals, and 8 homecare workers, in one urban and one semi-rural area of England. Transcripts were thematically analysed. Older people with mild frailty reported engaging in a variety of lifestyle behaviours to promote health and well-being. Key barriers or facilitators to engaging in these included transport, knowledge of local services, social support and acceptance of personal limitations. Older people, carers and professionals agreed that any new service should address social networks and mobility and tailor other content to each individual. Services should aim to increase motivation through focussing on independence and facilitate older people to continue carrying out behaviours that improve their well-being, as well as provide information, motivation, psychological support and practical support. Stakeholders agreed services should be delivered over a sustained period by trained non-specialist workers. New services including these components are likely to be acceptable to older people with mild frailty.

Time spent outdoors is associated with higher levels of physical activity. To date, correlates of independent outdoor play have not been investigated. This study aimed to identify potential demographic, behavioural, environmental and social correlates of children's independent outdoor play. Data were from the Millennium Cohort Study when children were aged 7years. Parents reported whether their children played out unsupervised (yes/no) as well as the above mentioned correlates of unsupervised outdoor play. Children's physical activity levels were measured using waist worn accelerometry. Multiple logistic regression was used to examine associations between correlates and odds of independent (unsupervised) outdoor play. Adjusted multiple linear regression was used to estimate associations between independent outdoor play and objective measures of physical activity. Activity was measured as average daily moderate-to-vigorous activity, steps, and sedentary behaviour. 3856 (n=29%) participants were categorised as engaging in independent outdoor play. Older age, being white British, being in poverty, living in close proximity to both family friends and family, having fewer internalising problems, having more externalising conduct problems and fewer pro-social behaviours were associated with higher odds of independent outdoor play. Independent outdoor play was associated with >2 additional minutes of moderate-to-vigorous activity (B=2.21 95% CI, 1.09 to 3.34), >330 additional steps per day (B=336.66 95% CI 209.80 to 463.51), and nearly 5min less time spent sedentary per day (B=−4.91 95% CI −7.54, −2.29) Younger children, those from a higher socio-economic-status, those isolated in location from family friends and family, and those with high levels of prosocial behaviour have lower levels of independent outdoor play. Independent outdoor play was associated with higher levels of physical activity and less time sedentary. Future interventions to promote independent outdoor play should target such populations.

Background Desk-based workers engage in long periods of uninterrupted sitting time, which has been associated with morbidity and premature mortality. Previous workplace intervention trials have demonstrated the potential of providing sit-stand workstations, and of administering motivational behaviour change techniques, for reducing sitting time. Yet, few studies have combined these approaches or explored the acceptability of discrete sitting-reduction behaviour change strategies. This paper describes the rationale for a sitting-reduction intervention that combines sit-stand workstations with motivational techniques, and procedures for a pilot study to explore the acceptability of core intervention components among university office workers. Methods The intervention is based on a theory and evidence-based analysis of why office workers sit, and how best to reduce sitting time. It seeks to enhance motivation and capability, as well as identify opportunities, required to reduce sitting time. Thirty office workers will participate in the pilot study. They will complete an initial awareness-raising monitoring and feedback task and subsequently receive a sit-stand workstation for a 12-week period. They will also select from a ‘menu’ of behaviour change techniques tailored to self-declared barriers to sitting reduction, effectively co-producing and personally tailoring their intervention. Interviews at 1, 6, and 12 weeks post-intervention will explore intervention acceptability. Discussion To our knowledge, this will be the first study to explore direct feedback from office workers on the acceptability of discrete tailored sitting-reduction intervention components that they have received. Participants’ choice of and reflections on intervention techniques will aid identification of strategies suitable for inclusion in the next iteration of the intervention, which will be delivered in a self-administered format to minimise resource burden.

Background In June 2015, an expert consensus guidance statement was published recommending that office workers accumulate 2–4 h of standing and light activity daily and take regular breaks from prolonged sitting. This paper describes public responses to media coverage of the guidance, so as to understand public acceptability of the recommendations within the guidance, and perceptions of sitting and standing as health behaviours. Methods UK news media websites that had reported on the sedentary workplace guidance statement, and permitted viewers to post comments responding to the story, were identified. 493 public comments, posted in a one-month period to one of six eligible news media websites, were thematically analysed. Results Three themes were extracted: (1) challenges to the credibility of the sedentary workplace guidance; (2) challenges to the credibility of public health; and (3) the guidance as a spur to knowledge exchange. Challenges were made to the novelty of the guidance, the credibility of its authors, the strength of its evidence base, and its applicability to UK workplaces. Public health was commonly mistrusted and viewed as a tool for controlling the public, to serve a paternalistic agenda set by a conspiracy of stakeholders with hidden non-health interests. Knowledge exchanges focused on correcting others’ misinterpretations, raising awareness of historical or scientific context, debating current workplace health policies, and sharing experiences around sitting and standing. Conclusions The guidance provoked exchanges of health-promoting ideas among some, thus demonstrating the potential for sitting reduction messages to be translated into everyday contexts by lay champions. However, findings also demonstrated confusion, misunderstanding and misapprehension among some respondents about the health value of sitting and standing. Predominantly unfavourable, mistrusting responses reveal significant hostility towards efforts to displace workplace sitting with standing, and towards public health science more broadly. Concerns about the credibility and purpose of public health testify to the importance of public engagement in public health guidance development.

Introduction: The incidence of head and neck cancer (HNC) in the UK is rising, with an average of 31 people diagnosed daily. Patients affected by HNC suffer significant short-term and long-term post-treatment morbidity as a result of dysphagia, which affects daily functioning and quality of life (QOL). Pretreatment swallowing exercises may provide additional benefit over standard rehabilitation in managing dysphagia after primary HNC treatments, but uncertainty about their effectiveness persists. This study was preceded by an intervention development phase to produce an optimised swallowing intervention package (SIP). The aim of the current study is to assess the feasibility of this new intervention and research processes within a National Health Service (NHS) setting. Method and analysis: A two-arm non-blinded randomised controlled feasibility study will be carried out at one tertiary referral NHS centre providing specialist services in HNC. Patients newly diagnosed with stage III and IV disease undergoing planned surgery and/or chemoradiation treatments will be eligible. The SIP will be delivered pre treatment, and a range of swallowing-related and QOL measures will be collected at baseline, 1, 3 and 6 months post-treatment. Outcomes will test the feasibility of a future randomised controlled trial (RCT), detailing rate of recruitment and patient acceptance to participation and randomisation. Salient information relating to protocol implementation will be collated and study material such as the case report form will be tested. A range of candidate outcome measures will be examined for suitability in a larger RCT. Ethics and dissemination: Ethical approval was obtained from an NHS Research Ethics Committee. Findings will be published open access in a peer-reviewed journal, and presented at relevant conferences and research meetings.

Poor patient adherence to swallowing exercises is commonly reported in the dysphagia literature on patients treated for head and neck cancer. Establishing the effectiveness of exercise interventions for this population may be undermined by patient non-adherence. The purpose of this study was to explore the barriers and facilitators to exercise adherence from a patient perspective, and to determine the best strategies to reduce the barriers and enhance the facilitators. In-depth interviews were conducted on thirteen patients. We used a behaviour change framework and model [Theoretical domains framework and COM-B (Capability-opportunity-motivation-behaviour) model] to inform our interview schedule and structure our results, using a content analysis approach. The most frequent barrier identified was psychological capability. This was highlighted by patient reports of not clearly understanding reasons for the exercises, forgetting to do the exercises and not having a system to keep track. Other barriers included feeling overwhelmed by information at a difficult time (lack of automatic motivation) and pain and fatigue (lack of physical capability). Main facilitators included having social support from family and friends, the desire to prevent negative consequences such as long-term tube feeding (reflective motivation), having the skills to do the exercises (physical capability), having a routine or trigger and receiving feedback on the outcome of doing exercises (automatic motivation). Linking these findings back to the theoretical model allows for a more systematic selection of theory-based strategies that may enhance the design of future swallowing exercise interventions for patients with head and neck cancer.

Background Of all age groups, older adults spend most of the time sitting and are least physically active. This sequential, mixed-methods feasibility study used a randomised controlled trial design to assess methods for trialling a habit-based intervention to displace older adults’ sedentary behaviour with light activity and explore impact on behavioural outcomes. Methods Eligibility criteria were age 60–74 years, retired, and ≥6 h/day leisure sitting. Data were collected across four sites in England. The intervention comprised a booklet outlining 15 ‘tips’ for disrupting sedentary habits and integrating activity habits into normally inactive settings, and eight weekly self-monitoring sheets. The control was a non-habit-based factsheet promoting activity and sedentary reduction. A computer-generated 1:1 block-randomisation schedule was used, with participants blinded to allocation. Participants self-reported sedentary behaviour (two indices), sedentary habit, physical activity (walking, moderate, vigorous activity) and activity habit, at pre-treatment baseline, 8- and 12-week follow-ups and were interviewed at 12 weeks. Primary feasibility outcomes were attrition, adverse events and intervention adherence. The secondary outcome was behavioural change. Results Of 104 participants consented, 103 were randomised (intervention N = 52, control N = 51). Of 98 receiving allocated treatment, 91 (93%; intervention N = 45; control N = 46) completed the trial. One related adverse event was reported in the intervention group. Mean per-tip adherence across 7 weeks was ≥50% for 9/15 tips. Qualitative data suggested acceptability of procedures, and, particularly among intervention recipients, the allocated treatment. Both groups appeared to reduce sedentary behaviour and increase their physical activity, but there were no apparent differences between groups in the extent of change. Conclusions Trial methods were acceptable and feasible, but the intervention conferred no apparent advantage over control, though it was not trialled among the most sedentary and inactive population for whom it was developed. Further development of the intervention may be necessary prior to a large-scale definitive trial. One possible refinement would combine elements of the intervention with an informational approach to enhance effectiveness.

Objectives. 'Habit' is a process whereby situational cues generate behaviour automatically, via activation of learned cue-behaviour associations. This article presents a conceptual and empirical rationale for distinguishing between two manifestations of habit in health behaviour, triggering selection and initiation of an action ('habitual instigation'), or automating progression through subactions required to complete action ('habitual execution'). We propose that habitual instigation accounts for habit-action relationships, and is the manifestation captured by the Self-Report Habit Index (SRHI), the dominant measure in health psychology. Design. Conceptual analysis and prospective survey. Methods. Student participants (N = 229) completed measures of intentions, the original, non-specific SRHI, an instigation-specific SRHI variant, an execution-specific variant, and, 1 week later, behaviour, in three health domains (flossing, snacking, and breakfast consumption). Effects of habitual instigation and execution on behaviour were modelled using regression analyses, with simple slope analysis to test habit-intention interactions. Relationships between instigation, execution, and non-specific SRHI variants were assessed via correlations and factor analyses. Results. The instigation-SRHI was uniformly more predictive of behaviour frequency than the execution-SRHI and corresponded more closely with the original SRHI in correlation and factor analyses. Conclusions. Further, experimental work is needed to separate the impact of the two habit manifestations more rigorously. Nonetheless, findings qualify calls for habit-based interventions by suggesting that behaviour maintenance may be better served by habitual instigation and that disrupting habitual behaviour may depend on overriding habits of instigation. Greater precision of measurement may help to minimize confusion between habitual instigation and execution.

Objective: Habit is thought to be conducive to health behavior maintenance, because habits prompt behavior with minimal cognitive resources. The precise role of habit in determining complex behavioral sequences, such as exercise, has been underresearched. It is possible that the habit process may initiate a behavioral sequence (instigation habit) or that, after instigation, movement through the sequence is automated (execution habit). We hypothesized that exercise instigation habit can be empirically distinguished from exercise execution habit and that instigation habit strength is most predictive of future exercise and reflective of longitudinal exercise behavior change. Further, we evaluated whether patterned exercise action—that is, engaging in the same exercise actions from session to session—can be distinct from exercise execution habit. Method: Healthy adults (N = 123) rated their exercise instigation and execution habit strengths, patterned exercise actions, and exercise frequency in baseline and 1-month follow-up surveys. Participants reported exercise engagement via electronic daily diaries for 1 month. Hypotheses were tested with regression analyses and repeated-measures analyses of variance. Results: Exercise instigation habit strength was the only unique predictor of exercise frequency. Frequency profiles (change from high to low or low to high, no change high, no change low) were associated with changes in instigation habit but not with execution habit or patterned exercise action. Conclusions: Results suggest that the separable components of exercise sessions may be more or less automatic, and they point to the importance of developing instigation habit for establishing frequent exercise.

Dysphagia (difficulty in swallowing) is a predictable consequence of head and neck cancer and its treatment. Loss of the ability to eat and drink normally has a devastating impact on quality of life for survivors of this type of cancer. Most rehabilitation programmes involve behavioural interventions that include swallowing exercises to help improve swallowing function. Such interventions are complex; consisting of multiple components that may influence outcomes. These interventions usually require patient adherence to recommended behaviour change advice. To date, reviews of this literature have explored whether variation in effectiveness can be attributed to the type of swallowing exercise, the use of devices to facilitate use of swallowing muscles, and the timing (before, during or after cancer treatment). This systematic review will use a behavioural science lens to examine the content of previous interventions in this field. It aims to identify (a) which behaviour change components are present, and (b) the frequency with which they occur in interventions deemed to be effective and non-effective. Clinical trials of behavioural interventions to improve swallowing outcomes in patients with head and neck cancers will be identified via a systematic and comprehensive search of relevant electronic health databases, trial registers, systematic review databases and Web of Science. To ascertain behaviour change intervention components, we will code the content for its theory basis, intervention functions and specific behaviour change techniques, using validated tools: the Theory Coding Scheme, Behaviour Change Wheel and Behaviour Change Technique Taxonomy v1. Study quality will be assessed for descriptive purposes only. Given the specialisation and focus of this review, a small yield of studies with heterogeneous outcome measures is anticipated. Therefore, narrative synthesis is considered more appropriate than meta-analysis. We will also compare the frequency of behavioural components in effective versus non-effective interventions, where effectiveness is indicated by statistically significant changes in swallowing outcomes. This review will provide a synthesis of the behaviour change components in studies that currently represent best evidence for behavioural swallowing interventions for head and neck cancer patients. Results will provide some guidance on the choice of optimal behavioural strategies for the development of future interventions. PROSPERO CRD42015017048.

Objective: Few studies have examined how levels of activity intensity fluctuate throughout later life in older adults and no study has identified correlates of sustained activity levels in this age group. The aim of the present analysis was to investigate stability of activity over a 10-year period and identify potential correlates of sustained activity levels in older adults. Design: Analyses of data from the English Longitudinal Study of Ageing. Participant-reported physical activity data were collected in 2002 (baseline), 2004, 2006, 2008, 2010 and 2012. Participant age, sex, smoking, depressive symptoms, work status, wealth, and long-standing illness were recorded at baseline. Multiple logistic regression was used to examine associations between baseline exposure variables and persistent physical activity (reporting moderate and/or vigorous physical activity at least once a week at all 6 assessments over the 10-year time period). Results: A total of 5022 participants (mean age 61 years; 2114 male) were included in the analyses. There was reasonable stability in the physical activity measure over the 6 time points (Cronbach's alpha 0.85). There was an overall trend for increasing levels of inactivity and a reduction in vigorous activity. Age, female sex, having ever smoked, long-standing illness, arthritis, obesity, and depressive symptoms were associated with a lower likelihood of being persistently active (defined as reporting moderate and/or vigorous physical activity at least once a week over all 6 assessment points). Those with greater wealth were 4 times more likely to be persistently active. Conclusions: In the present analyses time spent in vigorous-intensity activity declined in later life. A range of sociodemographic and biomedical factors were associated with being persistently active in older adults.

Background To identify, using a longitudinal data set, parental and childhood correlates of adult television (TV) viewing time at 32-year follow-up. Method Data were derived from the 1970 British Cohort Study, a longitudinal observational study of 17 248 British people born in a single week of 1970. The present analyses incorporated data from the age 10 and 42-year surveys. When participants were aged 10 years, their mothers provided information on how often participants watched TV and played sports (never/sometimes/often), and parents' own occupation, as well as height and weight. A health visitor objectively assessed participants' height and weight at age 10. Thirty-two years later, when participants were aged 42 years, they reported their daily TV viewing hours (none/0

There is a growing body of research into the total amount and patterns of sitting, standing and stepping in office-based workers and few studies using objectively measured sitting and standing. Understanding these patterns may identify daily times opportune for interventions to displace sitting with activity. A sample of office-based workers (n = 164) residing in England were fitted with thigh-worn ActivPal accelerometers and devices were worn 24 hours a day for five consecutive days, always including Saturday and Sunday and during bathing and sleeping. Daily amounts and patterns of time spent sitting, standing, stepping and step counts and frequency of sit/stand transitions, recorded by the ActivPal accelerometer, were reported. Total sitting/standing time was similar on weekdays (10.6/4.1 hrs) and weekends (10.6/4.3 hrs). Total step count was also similar over weekdays (9682 ± 3872) and weekends (9518 ± 4615). The highest physical activity levels during weekdays were accrued at 0700 to 0900, 1200 to 1400, and 1700 to 1900; and during the weekend at 1000 to 1700. During the weekday the greatest amount of sitting was accrued at 0900 to 1200, 1400 to 1700, and 2000 to 2300, and on the weekend between 1800 and 2300. During the weekday the greatest amount of standing was accrued between 0700 and 1000 and 1700 and 2100, and on the weekend between 1000 and 1800. On the weekday the highest number of sit/stand transitions occurred between 0800 to 0900 and remained consistently high until 1800. On the weekend, the highest number occurred between 1000 to 1400 and 1900 to 2000. Office based-workers demonstrate high levels of sitting during both the working week and weekend. Interventions that target the working day and the evenings (weekday and weekend) to displace sitting with activity may offer most promise for reducing population levels of sedentary behaviour and increasing physical activity levels, in office-based workers residing in England.

Long-term adherence to continuous positive airway pressure (CPAP) is low among patients with obstructive sleep apnea (OSA). The potential role of “habit” in sustaining adherence to CPAP use has not been studied. This study aimed to establish the relevance of habit to CPAP adherence, via validation of an adaptation of the Self-Report Habit Index (the CPAP Habit Index-5; CHI-5). Analyses focused on the homogeneity, reliability, and factor structure of the CHI-5 and, in line with theoretical predictions, its utility as a predictor of long-term CPAP adherence in middle-aged patients with OSA. A prospective longitudinal design was used. 117 patients with objectively verified OSA intended for CPAP treatment were recruited. Data was collected via clinical examinations, respiratory recordings, questionnaires, and CPAP devices at baseline, 2 weeks, 6 months, and 12 months. The CHI-5 showed satisfactory homogeneity interitem correlations (0.42–0.93), item-total correlations (0.58–0.91), and reliability ( α = 0.92). CHI-5 data at 6 months showed a one-factor solution and predicted 63% of variance in total CPAP use hours after 12 months. Based on the satisfactory measurement properties and the high amount of CPAP use variance it explained, the CHI-5 can be seen as a useful tool in clinical practice.

Background Internet-based interventions for smoking cessation could help millions of people stop smoking at very low unit costs; however, long-term biochemically verified evidence is scarce and such interventions might be less effective for smokers with low socioeconomic status than for those with high status because of lower online literacy to engage with websites. We aimed to assess a new interactive internet-based intervention (StopAdvisor) for smoking cessation that was designed with particular attention directed to people with low socioeconomic status. Methods We did this online randomised controlled trial between Dec 6, 2011, and Oct 11, 2013, in the UK. Participants aged 18 years and older who smoked every day were randomly assigned (1:1) to receive treatment with StopAdvisor or an information-only website. Randomisation was automated with an unseen random number function embedded in the website to establish which treatment was revealed after the online baseline assessment. Recruitment continued until the required sample size had been achieved from both high and low socioeconomic status subpopulations. Participants, and researchers who obtained data and did laboratory analyses, were masked to treatment allocation. The primary outcome was 6 month sustained, biochemically verified abstinence. The main secondary outcome was 6 month, 7 day biochemically verified point prevalence. Analysis was by intention to treat. Homogeneity of intervention effect across the socioeconomic subsamples was first assessed to establish whether overall or separate subsample analyses were appropriate. The study is registered as an International Standard Randomised Controlled Trial, number ISRCTN99820519. Findings We randomly assigned 4613 participants to the StopAdvisor group (n=2321) or the control group (n=2292); 2142 participants were of low socioeconomic status and 2471 participants were of high status. The overall rate of smoking cessation was similar between participants in the StopAdvisor and control groups for the primary (237 [10%] vs 220 [10%] participants; relative risk [RR] 1.06, 95% CI 0.89-1.27; p=0.49) and the secondary (358 [15%] vs 332 [15%] participants; 1.06,. 93-1.22; p=0.37) outcomes; however, the intervention effect differed across socioeconomic status subsamples (1.44, 0.99-2.09; p=0.0562 and 1.37, 1.02-1.84; p=0.0360, respectively). StopAdvisor helped participants with low socioeconomic status stop smoking compared with the information-only website (primary outcome: 90 [8%] of 1088 vs 64 [6%] of 1054 participants; RR 1.36, 95% CI 1.00-1.86; p=0.0499; secondary outcome: 136 [13%] vs 100 [10%] participants; 1.32, 1.03-1.68, p=0.0267), but did not improve cessation rates in those with high socioeconomic status (147 [12%] of 1233 vs 156 [13%] of 1238 participants; 0.95, 0.77-1.17; p=0.61 and 222 [18%] vs 232 [19%] participants; 0.96, 0.81-1.13, p=0.64, respectively). Interpretation StopAdvisor was more effective than an information-only website in smokers of low, but not high, socioeconomic status. StopAdvisor could be implemented easily and made freely available, which would probably improve the success rates of smokers with low socioeconomic status who are seeking online support. Funding National Prevention Research Initiative. Copyright (C) Brown et al. Open Access article distributed under the terms of CC BY.

Of all age groups, older adults spend the most time watching TV, which is one of the most common sedentary behaviours. Such sedentary activity in older adulthood is thought to risk deterioration of physical and mental functioning, health and wellbeing. Identifying the characteristics of older adults whose TV viewing increases over time may help to target sedentary behaviour reduction interventions to those in most urgent need. Yet, studies of the factors associated with TV viewing have predominantly been cross-sectional. This study used a prospective design to describe changes in TV viewing over a two-year follow-up period, and to model socio-demographic, behavioural and health factors associated with observed changes in viewing time. A two-year follow-up of 6,090 male and female older adults (mean age 64.9 ± 8.9 years) was conducted in the English Longitudinal Study of Ageing, a cohort of community dwelling older adults. TV viewing time was self-reported at baseline and at follow-up. The sample was categorised according to baseline TV viewing duration (

Habits are automatic behavioural responses to environmental cues, thought to develop through repetition of behaviour in consistent contexts. When habit is strong, deliberate intentions have been shown to have a reduced influence on behaviour. The habit concept may provide a mechanism for establishing new behaviours, and so healthy habit formation is a desired outcome for many interventions. Habits also however represent a potential challenge for changing ingrained unhealthy behaviours, which may be resistant to motivational shifts. This review aims to provide intervention developers with tools to help establish target behaviours as habits, based on theoretical and empirical insights. We discuss evidence-based techniques for forming new healthy habits and breaking existing unhealthy habits. To promote habit formation we focus on strategies to initiate a new behaviour, support context-dependent repetition of this behaviour, and facilitate the development of automaticity. We discuss techniques for disrupting existing unwanted habits, which relate to restructuring the personal environment and enabling alternative responses to situational cues.

Background: Internet-based interventions can help smokers to quit compared with brief written materials or no intervention. However, they are not widely used, particularly by more disadvantaged smokers, and there is significant variation in their effectiveness. A new smoking cessation website (‘StopAdvisor’) has been systematically developed on the basis of PRIME theory, empirical evidence, web-design expertise and user-testing with socio-economically disadvantaged smokers. This paper reports the protocol of a randomised controlled trial to evaluate the efficacy of StopAdvisor and determine whether it translates across the social spectrum. Methods: The trial has two arms with participants randomised to the offer of the interactive ‘StopAdvisor’ website (intervention condition) or a non-interactive, static website (control condition). Participants are adults from the UK, who smoke every day and are willing to make a serious quit attempt within a month of enrolment. At least 4260 participants will be recruited with a minimum of 2130 in each of two socio-economic sub-groups. The intervention comprises a structured quit plan and a variety of theory- and evidence-based behaviour change techniques for smoking cessation. Tailored support is offered in the form of a series of tunnelled sessions and a variety of interactive menus for use up to a month before, and then for one month after quitting (http://www.lifeguideonline.org/player/play/stopadvisordemonstration). The control is a static website that presents brief and standard advice on smoking cessation. Assessments are at baseline and 2-, 4- and 7-months post-enrolment. The primary outcome measure will be Russell Standard 6-months sustained abstinence, defined as self-reported continuous abstinence verified by saliva cotinine or anabasine at 7-month follow-up. Secondary outcome measures will include 7-day point-prevalence abstinence at 7-month follow-up, self-reported abstinence at 2- and 4-month follow-ups, satisfaction ratings of the website and quantitative indices of website interaction. All analyses will be by intention to treat and the main analysis will compare the two conditions on the primary outcome measure using a logistic regression model, adjusted for baseline characteristics. The efficacy of the intervention across the social spectrum will be assessed by a logistic regression focusing on the interaction between condition and socio-economic disadvantage. Trial registration: ISRCTN99820519.

Social disadvantage is associated with being overweight, a poor diet and physical inactivity. The NHS Health Trainer Service (HTS) is a national initiative designed to promote behaviour change among socially disadvantaged people in England and Wales. This study reports pre-post changes in Body Mass Index (BMI), associated behaviours and cognitions among service users who set dietary or physical activity goals during a 12-month period (2008-2009; N = 4418). Sixty-nine percent of clients were from the two most deprived population quintiles and 94.7% were overweight or obese. Mean BMI decreased from 34.03 to 32.26, with overweight/obesity prevalence decreasing by 3.7%. There were increases in fruit and vegetable consumption, reductions in fried snack consumption, increases in frequency of moderate or intensive activity and gains in self-efficacy and perceived health and wellbeing. Clients with higher BMI, poorer diet or less activity at baseline achieved greater change. Findings suggest that the NHS HTS has the potential to improve population health and reduce health inequalities through behaviour change.

Plug-in electric vehicles can potentially emit substantially lower CO2 emissions than internal combustion engine vehicles, and so have the potential to reduce transport emissions without curtailing personal car use. Assessing the potential uptake of these new categories of vehicles requires an understanding of likely consumer responses. Previous in-depth explorations of appraisals and evaluations of electric vehicles have tended to focus on ‘early adopters’, who may not represent mainstream consumers. This paper reports a qualitative analysis of responses to electric cars, based on semi-structured interviews conducted with 40 UK non-commercial drivers (20 males, 20 females; age 24–70 years) at the end of a seven-day period of using a battery electric car (20 participants) or a plug-in hybrid car (20 participants). Six core categories of response were identified: (1) cost minimisation; (2) vehicle confidence; (3) vehicle adaptation demands; (4) environmental beliefs; (5) impression management; and, underpinning all other categories, (6) the perception of electric cars generally as ‘work in progress’ products. Results highlight potential barriers to the uptake of current-generation (2010) plug-in electric cars by mainstream consumers. These include the prioritization of personal mobility needs over environmental benefits, concerns over the social desirability of electric vehicle use, and the expectation that rapid technological and infrastructural developments will make current models obsolete. Implications for the potential uptake of future electric vehicles are discussed.

Reviews of internet-based behaviour-change interventions have shown that they can be effective but there is considerable heterogeneity and effect sizes are generally small. In order to advance science and technology in this area, it is essential to be able to build on principles and evidence of behaviour change in an incremental manner. We report the development of an interactive smoking cessation website, StopAdvisor, designed to be attractive and effective across the social spectrum. It was informed by a broad motivational theory (PRIME), empirical evidence, web-design expertise, and user-testing. The intervention was developed using an open-source web-development platform, 'LifeGuide', designed to facilitate optimisation and collaboration. We identified 19 theoretical propositions, 33 evidence-or theory-based behaviour change techniques, 26 web-design principles and nine principles from user-testing. These were synthesised to create the website, 'StopAdvisor' (see http://www.lifeguideonline.org/player/play/stopadvisordemonstration). The systematic and transparent application of theory, evidence, web-design expertise and user-testing within an open-source development platform can provide a basis for multi-phase optimisation contributing to an 'incremental technology' of behaviour change.

Purpose. Habits may be a mechanism linking environmental variables with active commuting. This study investigated the role of habit strength in the explanation of active commuting across profiles based on current active commuting, motivation, and habit strength within the framework of the theory of planned behavior (TPB). Design. Cross-sectional survey using validated questionnaires. Setting. Undergraduate students who participated for course credits. Subjects. Five hundred and thirty-eight students (mean age = 21.19 [SD = 2.57]; 28.45% males; response rate = 86.36%). Measures. Questionnaire included TPB items, underlying beliefs, and a validated measure of habit strength. Active commuting was assessed with relevant items from the International Physical Activity Questionnaire. Analysis. Hierarchical regression and interaction analyses, discriminant function analysis, and analyses of variance. Results. Habit strength was the strongest correlate of active commuting and interacted with intention: at low and medium levels of habit strength, the intention–bicycle use relationship was more than twice as strong as at high levels. Beliefs regarding situational barriers were amongst the most discriminating beliefs, whereas beliefs regarding health benefits did not distinguish profiles. Conclusions. Stronger active commuting habits are associated with a lower association between intention and bicycle use. Persuasive health campaigns might more usefully instill a sense of confidence in various commuting situations rather than merely emphasizing health benefits of active commuting. (Am J Health Promot 2011;25[3]:e27–e36.)

This study sought to extract underlying beliefs towards measles, mumps and rubella (MMR) vaccination from UK parents' views towards potential motivational and organisational interventions to boost MMR vaccination. Thematic analysis of transcripts of five focus groups identified five underlying psychological themes: parents' information needs, distrust of government sources, trust of other parents, attentional biases towards risk information and problems of achieving "balance'' in MMR information provision. These are likely to represent important psychological barriers to or facilitators of the effectiveness of MMR promotion interventions.

Objective: Increasing the price of cigarettes reduces consumption, with a global price elasticity of approximately −0.4. In the UK where the cost of cigarettes is already relatively high, there is an issue surrounding public acceptance of further price rises ahead of the inflation rate. Previous research suggests that price increases may be supported where funds are dedicated to tobacco control. This study assessed public support in England for such a policy. Methods: A cross-sectional household survey was conducted in England between August 2008 and January 2009. A representative sample of 8736 respondents aged 16+, of whom 1900 (22%) were cigarette smokers at the time of the survey, was recruited. The primary outcome measure was support for a 20p (4%) price increase on a pack of cigarettes with proceeds going to fund tobacco control activities. Results: 6216 participants (71%), including half (47%) of current cigarette smokers, indicated that they would support a 20p price increase if funds were dedicated to tobacco control activities. Levels of support among smokers were similar across the social gradient and gender. Younger smokers were more likely to support the increase. Smokers who smoked 0–10 cigarettes per day were more supportive of the increase than heavier smokers. Conclusions: There is broad public support for raising the cost of cigarettes with funds being used for tobacco control activities. The absence of a social gradient among smokers concurs with other research showing that more disadvantaged smokers are as engaged with tobacco control objectives as more affluent smokers.

Evidence syntheses are used to inform health care policy and practice. Behaviour change theories offer frameworks for categorising and evaluating interventions and identifying likely mechanisms through which effects are achieved. Yet systematic reviews rarely explicitly classify intervention components using theory, which may result in evidence syntheses and health care practice recommendations that are less than optimal. This paper outlines a method for applying theory to evidence syntheses of behaviour change interventions. We illustrate this method with an analysis of ‘audit and feedback’ interventions, based on data from a Cochrane review. Our analysis is based on Control Theory, which suggests that behaviour change is most likely if feedback is accompanied by comparison with a behavioural target and by action plans, and we coded interventions for these three techniques. Multivariate meta-regression was performed on 85 comparisons from 61 studies. However, few interventions incorporated targets or action plans, and so meta-regression models were likely to be underfitted due to insufficient power. The utility of our approach could not be tested via our analysis because of the limited nature of the audit and feedback interventions. However, we show that conceptualising and categorising interventions using behaviour change theory can reveal the theoretical coherence of interventions and so point towards improvements in intervention design, evaluation and synthesis. The results demonstrate that a theory-based approach to evidence synthesis is feasible, and can prove beneficial in understanding intervention design, even where there is insufficient empirical evidence to reliably synthesise effects of specific intervention components.

The Expert Patient Programme (EPP) is a lay-led, group-based, self-management training course available through the UK National Health Service for persons with long-term health conditions. Thirty-two patients who attended EPP courses in East London were interviewed about their experiences. Grounded theory coding of transcripts was employed to identify recurring accounts. Thematic analysis was used to theorise and organise participants' accounts, identifying commonly reported changes, helpful techniques and disappointments and frustrations. Results highlighted the role of information provision, especially face-to-face information exchange as well as the impact of in-class instruction and modelling of physical skills. Personal goal setting, using graded tasks, self-monitoring and goal review were regarded as the most useful techniques. Adoption and use of these self-management techniques depended on the establishment of an empathic and self-validating interpersonal context. Findings also imply that EPP may not be ideal for all participants and suggested modifications and improvements are discussed.

The habitual action perspective Suggests that where transport users have strong travel choice habits, motivation will have no effect on behaviour. This has commonly been demonstrated in situations where travel habits and intentions conflict, but in stable decision settings intentions and habits will correspond. This paper reports two studies which demonstrate the moderating effect of habit on the intention-behaviour relationship within established commuting contexts. Results illustrate how motivational accounts of travel behaviour may be misleading if statistical significance of correlational data is the main criterion for model acceptance. Alternative methods for theory testing are discussed, and strategies for disrupting driving habits reviewed, (c) 2008 Elsevier Ltd. All rights reserved.

Background: Multidisciplinary guideline development groups (GDGs) have considerable influence on UK healthcare policy and practice, but previous research suggests that research evidence is a variable influence on GDG recommendations. The Evidence into Recommendations (EiR) study has been set up to document social-psychological influences on GDG decision-making. In this paper we aim to evaluate the relevance of existing qualitative methodologies to the EiR study, and to develop a method best-suited to capturing influences on GDG decision-making. Methods: A research team comprised of three postdoctoral research fellows and a multidisciplinary steering group assessed the utility of extant qualitative methodologies for coding verbatim GDG meeting transcripts and semi-structured interviews with GDG members. A unique configuration of techniques was developed to permit data reduction and analysis. Results: Our method incorporates techniques from thematic analysis, grounded theory analysis, content analysis, and framework analysis. Thematic analysis of individual interviews conducted with group members at the start and end of the GDG process defines discrete problem areas to guide data extraction from GDG meeting transcripts. Data excerpts are coded both inductively and deductively, using concepts taken from theories of decision-making, social influence and group processes. These codes inform a framework analysis to describe and explain incidents within GDG meetings. We illustrate the application of the method by discussing some preliminary findings of a study of a National Institute for Health and Clinical Excellence (NICE) acute physical health GDG. Conclusion: This method is currently being applied to study the meetings of three of NICE GDGs. These cover topics in acute physical health, mental health and public health, and comprise a total of 45 full-day meetings. The method offers potential for application to other health care and decision-making groups.

This meta-analysis synthesised quantitative research into potentially modifiable psychological correlates of car use and intentions to drive. Online psychology and transportation databases were searched, and inclusion criteria applied to potentially relevant records. An ancestry approach was also employed to search selected publications. Meta-analyses of effect size rs were performed on 23 unique study datasets. Results generally supported the predictive utility of variables derived from the Theory of Planned Behaviour, though cognitions towards not driving displayed uniformly larger effects than were observed for car use cognitions. There was also a strong effect of habit on behaviour. Support for effects of pro-environment cognitions on driving was weak. However, a dearth of available evidence limited our findings and precludes development of clear evidence-based recommendations for intervention design. Directions for future research are discussed. (C) 2008 Elsevier Ltd. All rights reserved.

Physical distancing remains an important initiative to curb COVID-19, and virus transmission more broadly. This exploratory study investigated how physical distancing behaviour changed during the COVID-19 pandemic and whether it was associated with identity with virus transmission avoidance and physical distancing habit strength. In a longitudinal, multinational study with fortnightly repeated-assessments, associations and moderation effects were considered for both overall (person-level means) and occasion-specific deviations in habit and identity. Participants (N=586, M age = 42, 79% female) self-reported physical distancing behavioural frequency, physical distancing habit strength, and identity with avoiding virus transmission. Physical distancing followed a cubic trajectory, with initial high engagement decreasing rapidly before increasing again near study end. Physical distancing was associated with both overall and occasion-specific virus transmission avoidant identity and physical distancing habit strength. People with strong virus transmission avoidant identity engaged in physical distancing frequently regardless of fluctuations in habit strength. However, for those with weaker virus transmission avoidant identity, physical distancing was strongly aligned with fluctuations in habit strength. To enhance engagement in physical distancing, public health messaging might fruitfully target greater or more salient virus-transmission avoidance identity, and stronger physical distancing habit.

Objectives To help implement behaviour change interventions (BCIs) in practice it is important to be able to characterize their key components. This study compared broad features of cost-effective BCIs that addressed smoking, diet, physical activity, alcohol and sexual health. It also assessed the association of these with the magnitude of the cost-effectiveness estimates. Methods A content analysis of 79 interventions based on 338 intervention descriptions was conducted, using the Behaviour Change Wheel (BCW) to classify intervention content in terms of intervention functions, and the BCT taxonomy to identify and categorise component Behaviour Change Techniques (BCT). Regression analysis identified the association of these with upper (pessimistic) and lower (optimistic) cost-effectiveness estimates. Results The most and least common functions and BCT clusters were education (82.3%) and shaping knowledge (79.7%), and coercion (3.8%) and covert learning (2.5%). Smoking interventions contained the largest ((M) over bar = 12) number of BCTs and were most cost-effective. Several other factors were associated with worse (coercion(function) beta(upper) = 36551.24; shaping knowledge(BCT) beta(lower) = 2427.78; comparison of outcomes(BCT) beta(upper) = 9067.32; repetition and substitution(BCT) beta(upper) = 7172.47) and better (modelling(function) beta(lower) = -2905.3; environmental restructuring(function) beta(upper) = -8646.28; reward and threat(BCT) beta(upper) = -5577.59) cost-effectiveness (p< 0.05). Discussion Cost-effective BCIs rely heavily on education with smoking interventions exhibiting the most comprehensive range of BCTs. Providing an example to aspire to, restructuring the environment and rewarding positive behaviour may be associated with greater cost-effectiveness.

Smart drug use is increasing but we have little insight into their use. We hypothesized that use is predicted by attitudes and various factors including incremental morality and entity intelligence beliefs would be associated with positive attitudes, whilst perception of unfairness would be associated with negative attitudes. UK undergraduates completed an online survey to establish attitudes towards smart drugs, previous use and likely future use as well as measures of several factors hypothesized to predict attitudes. Attitudes were found to predict previous and likely future use. Attitudes were more positive in those who believed that smart drugs were harmless and those who felt they knew enough to use them safely. By contrast, perceived unfairness was associated with negative attitudes. Interventions to reduce smart drug use should focus on attitudinal beliefs around potential harm and safety, as well as emphasizing the debate around unfairness.

Objectives Globally, populations are rapidly ageing and countries have developed health promotion and wellbeing strategies to address increasing demand for health care and old-age support. The older population is not homogeneous however, and includes a large group in transition between being active and healthy to being frail, i.e. with early frailty. This review explores the extent to which policy in England has addressed this group with a view to supporting independence and preventing further progression towards frailty. Methods A narrative review was conducted of 157 health and social care policy documents current in 2014-2017 at three levels of the health and social care system in England. Findings We report the policy problem analysis, the shifts over time in language from health promotion to illness prevention, the shift in target populations to mid-life and those most at risk of adverse outcomes through frailty, and changes to delivery mechanisms to incentivize attention to the frailest rather than those with early frailty. We found that older people in general were not identified as a specific population in many of these policies. While this may reflect a welcome lack of age discrimination, it could equally represent omission through ageism. Only at local level did we identify some limited attention to preventative actions with people with early frailty. Conclusion The lack of policy attention to older people with early frailty is a missed opportunity to address some of the demands on health and social care services. Addressing the individual and societal consequences of adverse experiences of those with the greatest frailty should not distract from a more distinct public health perspective which argues for a refocusing upstream to health promotion and illness prevention for those with early frailty.

Objectives: To identify trials of home-based health behaviour change interventions for frail older people, describe intervention content and explore its potential contribution to intervention effects. Design: 15 bibliographic databases, and reference lists and citations of key papers, were searched for randomised controlled trials of home-based behavioural interventions reporting behavioural or health outcomes. Setting: Participants' homes. Participants: Community-dwelling adults aged ≥65 years with frailty or at risk of frailty. Primary and secondary outcome measures: Trials were coded for effects on thematically clustered behavioural, health and well-being outcomes. Intervention content was described using 96 behaviour change techniques, and 9 functions (eg, education, environmental restructuring). Results: 19 eligible trials reported 22 interventions. Physical functioning was most commonly assessed (19 interventions). Behavioural outcomes were assessed for only 4 interventions. Effectiveness on most outcomes was limited, with at most 50% of interventions showing potential positive effects on behaviour, and 42% on physical functioning. 3 techniques (instruction on how to perform behaviour, adding objects to environment, restructuring physical environment) and 2 functions (education and enablement) were more commonly found in interventions showing potential than those showing no potential to improve physical function. Intervention content was not linked to effectiveness on other outcomes. Conclusions: Interventions appeared to have greatest impact on physical function where they included behavioural instructions, environmental modification and practical social support. Yet, mechanisms of effects are unclear, because impact on behavioural outcomes has rarely been considered. Moreover, the robustness of our findings is also unclear, because interventions have been poorly reported. Greater engagement with behavioural science is needed when developing and evaluating home-based health interventions.

Background: Dysphagia is a significant side-effect following treatment for head and neck cancers, yet poor adherence to swallowing exercises is frequently reported in intervention studies. Behaviour change techniques (BCTs) can be used to improve adherence, but no review to date has described the techniques or indicated which may be more associated with improved swallowing outcomes. Methods: A systematic review was conducted to identify behavioural strategies in swallowing interventions, and to explore any relationships between these strategies and intervention effects. Randomised and quasi-randomised studies of head and neck cancer patients were included. Behavioural interventions to improve swallowing were eligible provided a valid measure of swallowing function was reported. A validated and comprehensive list of 93 discrete BCTs was used to code interventions. Analysis was conducted via a structured synthesis approach. Results: Fifteen studies (8 randomised) were included, and 20 different BCTs were each identified in at least one intervention. The BCTs identified in almost all interventions were: instruction on how to perform the behavior, setting behavioural goals and action planning. The BCTs that occurred more frequently in effective interventions, were: practical social support, behavioural practice, self-monitoring of behaviour and credible source for example a skilled clinician delivering the intervention. The presence of identical BCTs in comparator groups may diminish effects. Conclusions: Swallowing interventions feature multiple components that may potentially impact outcomes. This review maps the behavioural components of reported interventions and provides a method to consistently describe these components going forward. Future work may seek to test the most effective BCTs, to inform optimisation of swallowing interventions.

Objectives: Adherence to nebulised treatment is typically low among people with cystic fibrosis (CF). This study sought to identify factors differentiating high or low nebuliser adherence patterns (i.e. ≥80% or

Background Considering that physical activity is associated with healthy ageing and helps to delay, prevent, or manage a plethora of non-communicable diseases in older adults, there is a need to investigate the factors that influence physical activity participation in this population. Thus, we investigated physical activity correlates among community-dwelling older adults (aged ≥50 years) in six low- and middle-income countries. Methods Cross-sectional data were analyzed from the World Health Organization’s Study on Global Ageing and Adult Health. Physical activity was assessed by the Global Physical Activity Questionnaire. Participants were dichotomized into low (i.e., not meeting 150 minutes of moderate physical activity per week) and moderate-to-high physically active groups. Associations between physical activity and a range of correlates were examined using multivariable logistic regressions. Results The overall prevalence (95%CI) of people not meeting recommended physical activity levels in 34,129 participants (mean age 62.4 years, 52.1% female) was 23.5% (22.3%-24.8%). In the multivariable analysis, older age and unemployment were significant sociodemographic correlates of low physical activity. Individuals with low body mass index (

Introduction For many nurses and other health care practitioners, implementing evidence-based practice (EBP) presents two interlinked challenges: acquisition of EBP skills and adoption of evidence-based interventions and abandonment of ingrained non-evidence-based practices. Aims The purpose of this study to describe two modes of learning and use these as lenses for analyzing the challenges of implementing EBP in health care. Methods The article is theoretical, drawing on learning and habit theory. Results Adaptive learning involves a gradual shift from slower, deliberate behaviors to faster, smoother, and more efficient behaviors. Developmental learning is conceptualized as a process in the “opposite” direction, whereby more or less automatically enacted behaviors become deliberate and conscious. Conclusion Achieving a more EBP depends on both adaptive and developmental learning, which involves both forming EBP-conducive habits and breaking clinical practice habits that do not contribute to realizing the goals of EBP. Linking Evidence to Action From a learning perspective, EBP will be best supported by means of adaptive learning that yields a habitual practice of EBP such that it becomes natural and instinctive to instigate EBP in appropriate contexts by means of seeking out, critiquing, and integrating research into everyday clinical practice as well as learning new interventions best supported by empirical evidence. However, the context must also support developmental learning that facilitates disruption of existing habits to ascertain that the execution of the EBP process or the use of evidence-based interventions in routine practice is carefully and consciously considered to arrive at the most appropriate response.

Background: Midwives are increasingly expected to promote healthy behaviour to women and pregnancy is often regarded as a 'teachable moment' for health behaviour change. This view focuses on motivational aspects, when a richer analysis of behaviour change may be achieved by viewing the perinatal period through the lens of the Capability-Opportunity-Motivation Behaviour framework. This framework proposes that behaviour has three necessary determinants: capability, opportunity, and motivation. Aim: To outline a broader analysis of perinatal behaviour change than is afforded by the existing conceptualisation of the 'teachable moment' by using the Capability-Opportunity-Motivation Behaviour framework. Findings: Research suggests that the perinatal period can be viewed as a time in which capability, opportunity or motivation naturally change such that unhealthy behaviours are disrupted, and healthy behaviours may be adopted. Moving away from a sole focus on motivation, an analysis utilising the Capability-Opportunity-Motivation Behaviour framework suggests that changes in capability and opportunity may also offer opportune points for intervention, and that lack of capability or opportunity may act as barriers to behaviour change that might be expected based solely on changes in motivation. Moreover, the period spanning pregnancy and the postpartum could be seen as a series of opportune intervention moments, that is, personally meaningful episodes initiated by changes in capability, opportunity or motivation. Discussion: This analysis offers new avenues for research and practice, including identifying discrete events that may trigger shifts in capability, opportunity or motivation, and whether and how interventions might promote initiation and maintenance of perinatal health behaviours. (C) 2015 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.

The term 'habit' is widely used to predict and explain behaviour. This paper examines use of the term in the context of health-related behaviour, and explores how the concept might be made more useful. A narrative review is presented, drawing on a scoping review of 136 empirical studies and 8 literature reviews undertaken to document usage of the term 'habit', and methods to measure it. A coherent definition of 'habit', and proposals for improved methods for studying it, were derived from findings. Definitions of 'habit' have varied in ways that are often implicit and not coherently linked with an underlying theory. A definition is proposed whereby habit is a process by which a stimulus generates an impulse to act as a result of a learned stimulus-response association. Habit-generated impulses may compete or combine with impulses and inhibitions arising from other sources, including conscious decision-making, to influence responses, and need not generate behaviour. Most research on habit is based on correlational studies using self-report measures. Adopting a coherent definition of 'habit', and a wider range of paradigms, designs and measures to study it, may accelerate progress in habit theory and application.

Background: This update describes changes to procedures for our randomised controlled trial of 'On Your Feet to Earn Your Seat', a habit-based intervention to reduce sedentary behaviour in older adults. Some of the amendments have arisen from the addition of new sites, each offering different possibilities and constraints for study procedures. Others have been made in response to problems encountered in administering intended recruitment procedures at the London sites described in our original protocol. All changes have received ethics and governance clearance, and were made before or during data collection and prior to analyses. Methods/design: Five non-London UK NHS-based sites (three general practices, one hospital, one NHS Foundation Trust) have been added to the study, each employing locally-tailored variations of recruitment and data collection procedures followed at the London sites. In contrast to the London sites, accelerometry data are not being collected nor are shopping vouchers being given to participants at the new sites. Data collection was delayed at the London sites because of technical difficulties in contacting participants. Subsequently, a below-target sample size was achieved at the London sites (n = 23), and recruitment rates cannot be estimated. Additionally, the physical inactivity inclusion criterion (i.e.,

Background: Adults aged 60 years and over spend most time sedentary and are the least physically active of all age groups. This early-phase study explored acceptability of a theory-based intervention to reduce sitting time and increase activity in older adults, as part of the intervention development process. Methods: An 8-week uncontrolled trial was run among two independent samples of UK adults aged 60-75 years. Sample 1, recruited from sheltered housing on the assumption that they were sedentary and insufficiently active, participated between December 2013 and March 2014. Sample 2, recruited through community and faith centres and a newsletter, on the basis of self-reported inactivity (< 150 weekly minutes of moderate-to-vigorous activity) and sedentary behaviour (>= 6 h mean daily sitting), participated between March and August 2014. Participants received a booklet offering 16 tips for displacing sitting with light-intensity activity and forming activity habits, and self-monitoring 'tick-sheets'. At baseline, 4-week, and 8-week follow-ups, quantitative measures were taken of physical activity, sedentary behaviour, and habit. At 8 weeks, tick-sheets were collected and a semi-structured interview conducted. Acceptability was assessed for each sample separately, through attrition and adherence to tips, ANOVAs for behaviour and habit changes, and, for both samples combined, thematic analysis of interviews. Results: In Sample 1, 12 of 16 intervention recipients completed the study (25 % attrition), mean adherence was 40 % (per-tip range: 15-61 %), and there were no clear patterns of changes in sedentary or physical activity behaviour or habit. In Sample 2, 23 of 27 intervention recipients completed (15 % attrition), and mean adherence was 58 % (per-tip range: 39-82 %). Sample 2 decreased mean sitting time and sitting habit, and increased walking, moderate activity, and activity habit. Qualitative data indicated that both samples viewed the intervention positively, found the tips easy to follow, and reported health and wellbeing gains. Conclusions: Low attrition, moderate adherence, and favourability in both samples, and positive changes in Sample 2, indicate the intervention was acceptable. Higher attrition, lower adherence, and no apparent behavioural impact among Sample 1 could perhaps be attributable to seasonal influences. The intervention has been refined to address emergent acceptability problems. An exploratory controlled trial is underway.

Objective. This study aimed to investigate whether active outdoor play and/or sports at age 10 is associated with sport/physical activity at 32 year follow-up using a birth cohort study. Methods. Data were from the 1970 British Cohort Study, a longitudinal observational study. The present paper included data from the age 10 years and age 42 years surveys. At age 10 the participant's mother provided information regarding how often their child played sports, and played outside on streets, parks or playgrounds. At age 42 participants reported frequency of participation in physical activities and sports. Associations between participation in sport/active outdoor play at age 10 years and adult sport/physical activity were investigated using adjusted (gender, fathers socio-occupational class, child's BMI, father's BMI, self-rated health at age 42, assessment of own weight at age 42, participant's education) Cox regression. Results. Final adjusted Cox regression models showed that participants (n = 6458) who often participated in sports at age 10 were significantly more likely to participate in sport/physical activity at age 42 (RR 1.10; 95% CI 1.01 to 1.19). Active outdoor play at age 10 was not associated with participation in sport/physical activity at age 42 (RR 0.99; 95% CI 0.91 to 1.07). Conclusion. Childhood activity interventions might best achieve lasting change by promoting engagement in sport rather than active outdoor play. (C) 2015 The Authors. Published by Elsevier Inc.

Habit formation has been proposed as a way to maintain behaviour over time. Recent evidence suggests that constructs additional to repeated performance may predict physical automaticity, but no research has yet explored possible direct impacts of intention, planning, affect, and perceived behavioural control (PBC) on automaticity. In a prospective study over a 2-week period amongst 406 undergraduate students (M (age) = 21.5 years [SD = 2.59], 27.4 % males), we investigated main and interaction effects of past exercise behaviour, PBC, intention, planning, and affect on exercise automaticity. Results showed that - controlling for past behaviour - PBC, affect, and planning were significant and positive predictors of exercise automaticity. Decomposing a significant interaction between PBC and planning when to exercise revealed that planning became less predictive of exercise automaticity at higher levels of PBC. Findings show that exercise automaticity is predicted by repeated performance and social-cognitive constructs. Further, interactions between social-cognitive predictors may be different for behavioural automaticity than for behavioural frequency.

Background: The Internet is an important tool to deliver health behavior interventions, yet little is known about Internet access and use of health-related information, or support, by the intended intervention recipients. Objective: Our aim was to evaluate whether health-related Internet use differed as a function of common health-risk behaviors (excessive alcohol consumption, smoking, low fruit/vegetable intake, inactive/sedentary lifestyle, unprotected sun exposure, or obesity). Methods: Sociodemographic, health behavior characteristics, and information on Internet access and use were assessed in the nationally representative US Health Information National Trends Survey (HINTS) 4. Data from 3911 participants collated in 2011/12 were included. Results: Of the 78.2% (95% CI 76.1-80.1) of participants who had ever accessed the Internet, approximately three-quarters (78.2%, 95% CI 75.4-80.7) had obtained health-related information online last year. About half had used the Internet as the first source of health-related information (47.8%, 95% CI 44.8-50.7) or to access behavioral support (56.9%, 95% CI 53.7-60.0) in the last year. Adjusting for sociodemographic determinants of going online (being younger, white, female, with at least college education) revealed few differences in Internet access and use between health-risk behaviors. Participants with inadequate sun protection were less likely to access the Internet (OR 0.59, 95% CI 0.04-0.88) and those with low fruit/vegetable intake were less likely to have gone online to obtain health-related information last year (OR 0.60, 95% CI 0.45-0.80). Smokers in particular were likely to use the Internet to obtain behavioral support (OR 1.90, 95% CI 1.35-2.68). Conclusions: Internet access and use to obtain health-related information and support is widespread and mostly independent of engagement in various health-risk behaviors. However, those with low fruit/vegetable intake or inadequate sun-protective behaviors may be more difficult to reach with Internet-based interventions. In addition, when developing online health promotions, relevant sociodemographic determinants of Internet use need to be targeted to maximize their impact.

Habit formation is thought to aid maintenance of physical activity, but little research is available into determinants of habit strength aside from repeated performance. Previous work has shown that intrinsically motivated physical activity, underpinned by inherent satisfaction derived from activity, is more likely to be sustained. We explored whether this might reflect a tendency for self-determined activity to become more strongly habitual. A sample of 192 adults aged 18-30 completed measures of motivational regulation, intention, behaviour, and habit strength. Results showed that self-determined regulation interacted with past behaviour in predicting habit strength: prior action was more predictive of habit strength among more autonomously motivated participants. There was an unexpected direct effect of self-determined regulation on habit strength, independently of past behaviour. Findings offer possible directions for future habit formation work.

Objectives Habit formation has been proposed as a means to promote maintenance of healthy behaviours, but there have been few investigations into how habits are formed. This exploratory study sought to model determinants of the formation of a dental flossing habit, including placement of the behaviour within the routine (before vs. after tooth-brushing), past behaviour, prospective memory ability, and motivational factors. Design and Method All participants (N=50) received a motivational intervention designed to initiate behaviour change and habit formation. Half of the participants were instructed to floss before brushing, and half after. Participants subsequently self-reported flossing behaviour daily and, 4weeks later, flossing automaticity. Automaticity and flossing frequency were also measured at 8-month follow-up. Results Participants with stronger prospective memory ability, higher levels of past behaviour, and a more positive attitude flossed more frequently during the study. Stronger automaticity was predicted by positive attitudes, and increased behaviour frequency during and prior to the study. Those who flossed after brushing (rather than before) tended to form stronger flossing habits and, at 8-month follow-up, had stronger habits and flossed more frequently. Conclusions Habit forming interventions might usefully consider features of everyday routines and how behaviour may be reinforced. Suggestions for further research using more methodologically rigorous designs are offered.

Background: As dietary gatekeepers for young children, parents are often the proximal target of family-based dietary interventions. Habit theory offers a novel approach to modifying parental feeding, based on "context-dependent repetition" to promote automatic responding and to reduce decisional conflict. Objective: This exploratory trial evaluated an intervention promoting habit formation for 3 parental feeding behaviors: serving fruit/vegetables, serving healthy snacks, and serving nonsweetened drinks. The primary outcome was parental habit strength for each behavior. The secondary outcome was children's food intake. Design: Parents of children aged 2-6 y (n = 126) were recruited from 6 children's centers in London and cluster-randomized to intervention (a = 3) or no-treatment control (n = 3) conditions. Parents in the intervention group (n = 58) received training on habit formation for 3 feeding behaviors; control participants (n = 68) were asked only to complete the measures. At baseline and after treatment, parents completed validated measures of subjective "automaticity" for feeding behaviors and a brief child food-frequency measure. Parents in the intervention group were interviewed about the program. The change between groups, after clustering was controlled for, was analyzed. Results: For all parental feeding behaviors, automaticity increased more in the intervention group than in the control group (P < 0.01 for all). Significant intervention effects on children's intake of vegetables (P = 0.003), healthy snacks (P = 0.009), and water (P = 0.032) were observed. Changes in children's food intake correlated with changes in parental automaticity of feeding behaviors, and program acceptability was high. Conclusions: A habit-based intervention successfully modified parental feeding behaviors, affected children's diets positively, and was well received by parents. Habit theory provides a promising new tool to support family-based obesity prevention. This trial was registered as ISRCTN09910187.

Background: Nutrition information (NI) on food packaging offers a public health tool that could be used to promote informed consumer choice and aid consumption of a healthy diet. Research indicates that the use of NI can lead to reduced energy intake and lower BMI, but little evidence is available regarding how, when or why people use NI when making everyday food choices. Methods: This qualitative study explored motivations and contexts surrounding the use of NI among 25 UK-based female NI users aged 23-35 years, using semi-structured individual interviews. Verbatim transcripts were analysed using thematic analysis. Results: Six themes were identified: (1) understanding and (2) functions of NI, (3) health versus appearance motives, NI use in (4) affective and (5) symbolic food episodes, and (6) competing point-of-purchase influences. Notable observations included a difficulty in understanding and converting NI into personally meaningful terms, and eschewal of NI in settings where food plays an affective or symbolic role (e. g. food consumption after a stressful day, buying food for a dinner party). Conclusions: We suggest evidence-based directions for future research and offer policy and practice recommendations, including the adoption of clear and consistent NI formats.

Background: This article reports a pilot study of a new smoking cessation website ('StopAdvisor'), which has been developed on the basis of PRIME theory, evidence, web-design expertise and user-testing. The aims were to i) evaluate whether cessation, website usage and satisfaction were sufficiently high to warrant a randomised controlled trial (RCT) and ii) assess whether outcomes were affected by socio-economic status. Methods: This was an uncontrolled pilot study. Two hundred and four adult daily smokers willing to make a serious quit attempt were included. All participants received support from 'StopAdvisor', which recommends a structured quit plan and a variety of evidence-based behaviour change techniques for smoking cessation. A series of tunnelled sessions and a variety of interactive menus provide tailored support for up to a month before quitting through until one-month post-quit (http://www.lifeguideonline.org/player/play/stopadvisordemonstration). The primary outcome was self-report of at least 1 month of continuous abstinence collected at 2 months post-enrolment and verified by saliva cotinine or anabasine. Usage was indexed by log-ins and page views. Satisfaction was assessed by dichotomous ratings of helpfulness, personal relevance, likelihood of recommendation and future use, which were collected using an online questionnaire at 2 months post-enrolment. Outcomes according to socio-economic status were assessed. Results: At 8 weeks post-enrolment, 19.6% (40/204) of participants were abstinent according to the primary outcome criteria (95% C.I. = 14.1% to 25.1%). Participants viewed a mean of 133.5 pages (median = 71.5) during 6.4 log-ins (median = 3). A majority of respondents rated the website positively on each of the four satisfaction 'ratings (range = 66.7% to 75.3%). There was no evidence of an effect of socio-economic status on abstinence (OR = 1.01, C.I. = 0.50-2.07), usage (page-views, t(202) = 0.11, p = .91; log-ins, t(202) = 0.21, p =.83), or satisfaction (helpfulness, OR = 1.09, C.I. = 0.41-2.88; personal relevance, OR = 0.55, C.I. = 0.20-1.56; recommendation, OR = 0.98, C.I. = 0.34-2.81; use in future, OR = 1.45, C.I. = 0.49-4.27). Conclusions: The systematic application of theory, evidence, web-design expertise, and user-testing has resulted in a website that shows sufficiently promising efficacy and usability to warrant evaluation in a RCT. The website appears to be similarly effective and acceptable to users across the social spectrum. (C) 2012 Elsevier Ltd. All rights reserved.

Habit formation is an important goal for behaviour change interventions because habitual behaviours are elicited automatically and are therefore likely to be maintained. This study documented experiences of habit development in 10 participants enrolled on a weight loss intervention explicitly based on habit-formation principles. Thematic analysis revealed three themes: Strategies used to support initial engagement in a novel behaviour; development of behavioural automaticity; and selecting effective cues to support repeated behaviour. Results showed that behaviour change was initially experienced as cognitively effortful but as automaticity increased, enactment became easier. Habits were typically formed in work-based contexts. Weekends and vacations temporarily disrupted performance due to absence of associated cues, but habits were reinstated on return to work. Implications for theory and practice are discussed.

A theory-of-planned-behavior-based model of intra-city driving incorporating cognitions concerning non-car transportation use, personal and descriptive norms, and the environment was tested. Participants were 190 residents of a UK city with good non-car travel infrastructure. Intention predicted 57% of the variance in behavior. In addition, 49% of intention variance was predicted by car-use attitudes, perceived behavioral control, descriptive norms, non-car-use attitudes, subjective norms, and personal norms. Concern and efficacy for reducing car-related environmental problems were associated with non-car attitudes and personal norms. Results demonstrate the importance of modeling transportation choice on cognitions relating to both car use and alternative transportation.

Recognized challenges in promoting long-term physical activity maintenance may be due to inconsistencies in the conceptualization and operationalization of behavior maintenance terminology in physical activity research. The overall goal of this paper is to propose a framework and agenda for the development of a common set of terms, definitions, and measures for physical activity maintenance concepts that can be widely tested and evaluated. To initiate this effort, this paper (1) provides an overview of conceptual and operational definitions of physical activity maintenance used in the empirical literature; (2) evaluates whether behavior maintenance terms used in addiction science can be translated to physical activity, (3) recommends research directions for developing consensus definitions of physical activity maintenance; and (4) proposes a conceptual model of physical activity maintenance with inflection points that require operational definitions to be decided upon through consensus efforts in the field. Consensus over the conceptualization and operationalization of physical activity maintenance is needed to draw conclusions regarding which policies and programs are best able to promote long-term behavior change.

Approximately 70% of adults with type 2 diabetes (T2D) fail to achieve the 150 minutes of weekly physical activity (PA) recommended for self-management. Interventions to promote PA adoption in T2D rarely achieve stable maintenance. Analysis of lived experiences of adults with T2D who have successfully transitioned to long-term PA maintenance can build understanding of factors influencing long-term maintenance. Semi-structured interviews were conducted among 18 adults with T2D who had transitioned to a lifestyle incorporating maintenance of recommended PA. Interview topics were informed by the three phases of the 'Multi-Process Action Control' (M-PAC) Framework, and explored attitudes, beliefs and experiences relating to PA decision, adoption and the transition to stable maintenance. Transcripts were thematically analysed. Seven themes emerged. Results variously showed that negative affect engendered by T2D diagnosis and inspiration from peers influenced intention formation, and that setting easy, fun goals, and experiencing biopsychosocial gains were important to behaviour adoption. PA maintenance was regulated by habit, expectations of positive affect, and a new sense of identity. Phase-based frameworks can help understand how regulation of behaviour evolves over time. PA promotion strategies for inactive adults with T2D should be phase-tailored, to help people transition from intentions to maintenance.

Objective This study explored whether the frequency and habitual nature of engagement in three behaviours that may serve as preparation for alcohol consumption on a night out with friends - that is, contacting friends to arrange a night out, buying alcohol, drinking alone at home before going out - predicted consumption on such nights. Design Prospective correlational design. Methods One hundred and twenty UK university students (68 female, 50 male, two non-binary, mean age = 20.78 years, SD = 1.52) completed a survey comprising intentions, habits, and frequency and habit for the three preparatory behaviours. One week later, a second survey measured the number of nights out with friends on which alcohol was drunk (i.e., drinking frequency) and the number on which four or more alcoholic drinks were consumed (i.e, excessive drinking). Regression models were run to predict drinking frequency and excessive drinking. Results Drinking frequency was predicted only by frequency of contacting friends (B = .28, SE = .12, p = .02), and habitually drinking alone before going out (B = .20, SE = .09, p = .03). Excessive drinking was only predicted by alcohol consumption habit (B = .67, SE = .23, p = .003). Conclusions Preceding actions may influence the frequency of alcohol consumption on nights out, independently of intentions and habits relating to alcohol consumption. While interventions to reduce consumption quantity in a single session might focus on disrupting the habits that sustain drinking episodes, efforts to reduce alcohol consumption frequency on nights out might focus on disrupting behaviours that precede alcohol consumption.