Disrupting routines, facilitating control: exploring a change towards healthier food purchasing behaviour using a health app

Background: Unhealthier food consumption patterns constitute a leading risk factor for ill health. As an important step in the food consumption process, changing food purchasing may improve the healthfulness of dietary patterns. Changing behaviour towards healthier food purchasing may be viewed as effortful by consumers due to inadequate nutrition knowledge and skills which may inhibit their ability to make healthy choices within the supermarket. A dominance of routines and habits further impedes the use of deliberative decision-making, which makes information provision and goal-setting less effective. Behaviour change may be supported by disrupting undesirable behavioural patterns, building of personal resources, and reframing behavioural outcomes. This should prompt a greater use of reflective cognitive processes during food purchasing and aid healthier behaviour. However, there is limited evidence in relation to food purchasing. Given recent technological advances, apps offer a potential tool to facilitate such change. The high use of apps across social groups suggests that they may be appropriate for supporting behaviour change in lower socioeconomic groups. It is unclear if existing apps are appropriately designed or acceptable for use for the necessary time period, particularly for individuals from a lower socioeconomic background. Such knowledge gaps must be addressed to inform intervention design. This thesis aims to contribute to the theoretical understanding of the interplay between mobile app technology and behaviour change with food purchasing as the behaviour of interest, and a particular focus on women from a lower socioeconomic background. Methods: This thesis was grounded in a pragmatic philosophical perspective and consisted of four phases. In phase one, structural equation modelling was undertaken to examine the individual-level determinants of a healthy eating habit and the extent to which personal goals and self-control are linked to a healthy eating habit. A content analysis of existing apps was undertaken in phase two to examine their capacity to support healthier food purchasing behaviour. A structured analytical matrix was employed where relevant literature and theory was drawn upon. A phenomological methodology was used for the remaining two research phases. In phase three, the researcher explored the experience of using a health app to support healthier food purchasing behaviour. Women from a lower socioeconomic background were recruited and asked to use two, of three possible, apps over a two-week period. Subsequent semi-structured interviews explored the experience of using an app including those personal and app-related factors of importance. Inductive thematic analysis was conducted to explore common patterns across participants’ experiences. In the fourth research phase, the lived experience of changing purchasing behaviour was explored in women from a lower socioeconomic background using a health app over an 8-11 week period. Participants were asked to use one, of two possible, apps. Multiple data collection methods were employed to capture the lived experience of behaviour change and app use. At baseline, an accompanied shop, incorporating the use of think-aloud protocol and researcher observations, was conducted, followed by an in-depth interview and questionnaire completion. At the midway point, participants were asked to complete a reflective account of their experience thus far. They were also asked to share their till receipts for the study duration. At follow-up, an accompanied shop, in-depth interview, and questionnaire completion was again employed. Interpretative phenomenological analysis was conducted to gain insight into the behaviour change experience. Theoretical thematic analysis was employed to examine app use through the lens of engagement theory. Findings: Self-control and deliberative cognitive processes were central to maintaining a healthy eating habit. This challenges the current conceptualisation and suggests the need to view complex food behaviours as highly routinised; this is an important consideration for behaviour change. Food purchasing behaviour was not a primary focus of existing apps with behavioural outcomes, such as weight-loss, as their main goal. While existing apps have the potential to support healthier purchasing behaviour, there is an opportunity to broaden their capacity. Health apps, through the process of self-monitoring, problem solving, and behavioural prompts, disrupted existing purchasing patterns. This prompted the use of reflective cognitive processes such that purchasing behaviour was directed by personal resources and healthy food goals. However, the extent to which reflective cognition continued to be employed during behaviour change was influenced by the broader goal system in which healthy food goals resided. The importance of user engagement was highlighted through this exploratory research. Engagement was expressed at an intrinsic level as a sense of personal autonomy, an increased perceived capacity to change, and viewing the app as a confidential and empathetic ally. App features that facilitated their expression were considered to result in optimal engagement. Findings suggest that an individual’s involvement, in relation to healthy food, may act as a trigger for different phases of engagement as variations in goal saliency lead to flux in involvement levels. The importance of individual characteristics on app engagement was evident which emphasises the need to integrate tailored features into health apps to ensure that it is congruent with personal goals. Conclusions The present findings add to the existing understanding of the interplay between app technology and behaviour change. If appropriately designed health apps may facilitate a more conscious approach to food purchasing and support healthier purchasing behaviour. An individual’s goal system architecture may influence the extent to which the reflective cognitive system is employed during behaviour change, which progresses existing knowledge of the influence of goal systems on behaviour change. The present research contributes to the extant literature in relation to user engagement. The intrinsic expressions of engagement are proposed to result from different configurations of engagement dimensions which suggests an interaction between these dimensions rather than an isolated existence. The potential role of involvement as a trigger of engagement phases further challenges the current conceptualisation of engagement. Such findings add to the call for the use of alternative non-quantitative, context-specific means of measurement to adequately capture the engagement process. In conclusion, findings suggest the potential to expand existing behaviour change theory, to integrate components of engagement, for improved relevance in the app technology space. Future health app design must consider the individual user and incorporate tailored features to ensure user self-congruence and support continued engagement to facilitate change. Health apps may be an effective tool to support healthier food behaviours in women from a lower socioeconomic background but they may be most effective when implemented as part of a range of individual, community, and broader structural measures

Can existing mobile apps support healthier food purchasing behaviour? Content analysis of nutrition content, behaviour change theory and user quality integration

To assess the quality of nutrition content and the integration of user quality components and behaviour change theory relevant to food purchasing behaviour in a sample of existing mobile apps. Descriptive comparative analysis of eleven mobile apps comprising an assessment of their alignment with existing evidence on nutrition, behaviour change and user quality, and their potential ability to support healthier food purchasing behaviour. Mobile apps freely available for public use in GoogePlay were assessed and scored according to agreed criteria to assess nutrition content quality and integration of behaviour change theory and user quality components. A sample of eleven mobile apps that met predefined inclusion criteria to ensure relevance and good quality. The quality of the nutrition content varied. Improvements to the accuracy and appropriateness of nutrition content are needed to ensure mobile apps support a healthy behaviour change process and are accessible to a wider population. There appears to be a narrow focus towards behaviour change with an overemphasis on behavioural outcomes and a small number of behaviour change techniques, which may limit effectiveness. A significant effort from the user was required to use the mobile apps appropriately which may negatively influence user acceptability and subsequent utilisation. Existing mobile apps may offer a potentially effective approach to supporting healthier food purchasing behaviour but improvements in mobile app design are required to maximise their potential effectiveness. Engagement of mobile app users and nutrition professionals is recommended to support effective design

Healthy eating habit: A role for goals, identity, and self-control?

Supporting healthier eating habits is crucial for improving population health outcomes. Underpinning everyday eating patterns are recurring actions that may lead to positive or negative health outcomes depending on the healthfulness of such actions. The aim of this research was to explore individual-level determinants of a healthy eating habit and consider to what extent personal goals and self-control are linked to a healthy eating habit. One thousand one hundred nine adults completed a survey focusing on a range of factors that potentially sway food choice behaviors. A structural model, developed based on a review of existing literature, was tested using self-reported healthy eating habit (Verplanken & Orbell, 2003 ) as the dependent variable. Analysis suggests that along with health-conscious identity and food hedonism, self-control was one of the strongest determinants of a healthy eating habit. Furthermore, while healthy eating goals had a direct significant effect, other goals, economizing and emotional, did not. However, all three goals along with food hedonism had a significant indirect effect that was mediated through self-control. In revealing the role of self-control, this work questions the underlying assumption of automaticity in a healthy eating habit. This leads to the questions: what is a healthy eating habit and to what extent can healthy eating behaviors ever be truly characterized as controlled by heuristics and automaticity? This analysis suggests that healthy eating is an ongoing behavioral project that requires the continued engagement of deliberative processes; thus habit within this context, and as measured using self-reported habit, may be a misnomer. The use of healthy eating routines, as opposed to habits, may be more appropriate to acknowledge the role of both automatic and deliberative processes with self-control being central in everyday decision making. Important practical and theoretical implications are discussed along with potential approaches for health and food sectors to support healthier eating behavior in the future

Exploring engagement with health apps: the emerging importance of situational involvement and individual characteristics

Purpose: Health apps offer a potential approach to support healthier food behaviours but a lack of sufficient engagement may limit effectiveness. This study aims to use a user engagement theoretical lens to examine the factors that influence app engagement over time and may prompt disengagement. Design/methodology/approach: A phenomenological exploration of the lived experience was used. Women from a lower socioeconomic background (based on the occupation and employment status of the household’s primary income earner) were randomly assigned to use one of two apps for a minimum of eight weeks. Multiple data collection methods, including accompanied shops, researcher observations, interviews, participant reflective accounts and questionnaires, were used at different time-points to examine engagement. Theoretical thematic analysis was conducted to explore the engagement experience and relevant social, personal and environmental influences. Findings: Healthy food involvement appears to drive app engagement. Changes in situational involvement may contribute to fluctuation in engagement intensity over time as the saliency of personal goals change. Negatively valenced engagement dimensions may contribute to the overall expression of engagement. A lack of congruency with personal goals or an imbalance between perceived personal investment and value was expressed as the primary reasons for disengagement. Research limitations/implications: Situational involvement may act as a trigger of different engagement phases. There is a need to better distinguish between enduring and situational involvement in engagement research. Practical implications: Individual characteristics may shape engagement and propensity for disengagement, which highlights the practical importance of incorporating tailored features into app design. Originality/value: Findings broaden the current conceptualisation of engagement within the digital space and prompt a reconsideration of the role of situational involvement and negatively valenced dimensions throughout the engagement process

Ethical frameworks for quality improvement activities: An analysis of international practice

Purpose: To examine international approaches to the ethical oversight and regulation of quality improvement and clinical audit in healthcare systems. Data sources: We searched grey literature including websites of national research and ethics regulatory bodies and health departments of selected countries. Study selection: National guidance documents were included from six countries: Ireland, England, Australia, New Zealand, the United States of America and Canada. Data extraction: Data were extracted from 19 documents using an a priori framework developed from the published literature. Results: We organised data under five themes: ethical frameworks; guidance on ethical review; consent, vulnerable groups and personal health data. Quality improvement activity tended to be outside the scope of the ethics frameworks in most countries. Only New Zealand had integrated national ethics standards for both research and quality improvement. Across countries, there is consensus that this activity should not be automatically exempted from ethical review, but requires proportionate review or organisational oversight for minimal risk projects. In the majority of countries, there is a lack of guidance on participant consent, use of personal health information and inclusion of vulnerable groups in routine quality improvement. Conclusion: Where countries fail to provide specific ethics frameworks for quality improvement, guidance is dispersed across several organisations which may lack legal certainty. Our review demonstrates a need for appropriate oversight and responsive infrastructure for quality improvement underpinned by ethical frameworks that build equivalence with research oversight. It outlines aspects of good practice, especially The New Zealand framework that integrates research and quality improvement ethics

An international perspective on definitions and terminology used to describe serious reportable patient safety incidents: A systematic review

Objectives: Patients are unintentionally, yet frequently, harmed in situations that are deemed preventable. Incident reporting systems help prevent harm, yet there is considerable variability in how patient safety incidents are reported. This may lead to inconsistent or unnecessary patterns of incident reporting and failures to identify serious patient safety incidents. This systematic review aims to describe international approaches in relation to defining serious reportable patient safety incidents. Methods: Multiple electronic and gray literature databases were searched for articles published between 2009 and 2019. Empirical studies, reviews, national reports, and policies were included. A narrative synthesis was conducted because of study heterogeneity. Results: A total of 50 articles were included. There was wide variation in the terminology used to represent serious reportable patient safety incidents. Several countries defined a specific subset of incidents, which are considered sufficiently serious, yet preventable if appropriate safety measures are taken. Terms such as “never events,” “serious reportable events,” or “always review and report” were used. The following dimensions were identified to define a serious reportable patient safety incident: (1) incidents being largely preventable; (2) having the potential for significant learning; (3) causing serious harm or have the potential to cause serious harm; (4) being identifiable, measurable, and feasible for inclusion in an incident reporting system; and (5) running the risk of recurrence. Conclusions: Variations in terminology and reporting systems between countries might contribute to missed opportunities for learning. International standardized definitions and blame-free reporting systems would enable comparison and international learning to enhance patient safety

Level of agreement between frequently used cardiovascular risk calculators in people living with HIV

Objectives The aim of the study was to describe agreement between the QRISK2, Framingham and Data Collection on Adverse Events of Anti‐HIV Drugs (D:A:D) cardiovascular disease (CVD) risk calculators in a large UK study of people living with HIV (PLWH). Methods PLWH enrolled in the Pharmacokinetic and Clinical Observations in People over Fifty (POPPY) study without a prior CVD event were included in this study. QRISK2, Framingham CVD and the full and reduced D:A:D CVD scores were calculated; participants were stratified into ‘low’ ( 20%) categories for each. Agreement between scores was assessed using weighted kappas and Bland–Altman plots. Results The 730 included participants were predominantly male (636; 87.1%) and of white ethnicity (645; 88.5%), with a median age of 53 [interquartile range (IQR) 49–59] years. The median calculated 10‐year CVD risk was 11.9% (IQR 6.8–18.4%), 8.9% (IQR 4.6–15.0%), 8.5% (IQR 4.8–14.6%) and 6.9% (IQR 4.1–11.1%) when using the Framingham, QRISK2, and full and reduced D:A:D scores, respectively. Agreement between the different scores was generally moderate, with the highest level of agreement being between the Framingham and QRISK2 scores (weighted kappa = 0.65) but with most other kappa coefficients in the 0.50–0.60 range. Conclusions Estimates of predicted 10‐year CVD risk obtained with commonly used CVD risk prediction tools demonstrate, in general, only moderate agreement among PLWH in the UK. While further validation with clinical endpoints is required, our findings suggest that care should be taken when interpreting any score alone

Implementation of corticosteroids in treating COVID-19 in the ISARIC WHO Clinical Characterisation Protocol UK:prospective observational cohort study

BACKGROUND: Dexamethasone was the first intervention proven to reduce mortality in patients with COVID-19 being treated in hospital. We aimed to evaluate the adoption of corticosteroids in the treatment of COVID-19 in the UK after the RECOVERY trial publication on June 16, 2020, and to identify discrepancies in care. METHODS: We did an audit of clinical implementation of corticosteroids in a prospective, observational, cohort study in 237 UK acute care hospitals between March 16, 2020, and April 14, 2021, restricted to patients aged 18 years or older with proven or high likelihood of COVID-19, who received supplementary oxygen. The primary outcome was administration of dexamethasone, prednisolone, hydrocortisone, or methylprednisolone. This study is registered with ISRCTN, ISRCTN66726260. FINDINGS: Between June 17, 2020, and April 14, 2021, 47 795 (75·2%) of 63 525 of patients on supplementary oxygen received corticosteroids, higher among patients requiring critical care than in those who received ward care (11 185 [86·6%] of 12 909 vs 36 415 [72·4%] of 50 278). Patients 50 years or older were significantly less likely to receive corticosteroids than those younger than 50 years (adjusted odds ratio 0·79 [95% CI 0·70–0·89], p=0·0001, for 70–79 years; 0·52 [0·46–0·58], p80 years), independent of patient demographics and illness severity. 84 (54·2%) of 155 pregnant women received corticosteroids. Rates of corticosteroid administration increased from 27·5% in the week before June 16, 2020, to 75–80% in January, 2021. INTERPRETATION: Implementation of corticosteroids into clinical practice in the UK for patients with COVID-19 has been successful, but not universal. Patients older than 70 years, independent of illness severity, chronic neurological disease, and dementia, were less likely to receive corticosteroids than those who were younger, as were pregnant women. This could reflect appropriate clinical decision making, but the possibility of inequitable access to life-saving care should be considered. FUNDING: UK National Institute for Health Research and UK Medical Research Council

Procalcitonin Is Not a Reliable Biomarker of Bacterial Coinfection in People With Coronavirus Disease 2019 Undergoing Microbiological Investigation at the Time of Hospital Admission

Abstract Admission procalcitonin measurements and microbiology results were available for 1040 hospitalized adults with coronavirus disease 2019 (from 48 902 included in the International Severe Acute Respiratory and Emerging Infections Consortium World Health Organization Clinical Characterisation Protocol UK study). Although procalcitonin was higher in bacterial coinfection, this was neither clinically significant (median [IQR], 0.33 [0.11–1.70] ng/mL vs 0.24 [0.10–0.90] ng/mL) nor diagnostically useful (area under the receiver operating characteristic curve, 0.56 [95% confidence interval, .51–.60]).</jats:p

Depression, lifestyle factors and cognitive function in people living with HIV and comparable HIV-negative controls

We investigated whether differences in cognitive performance between people living with HIV (PLWH) and comparable HIV-negative people were mediated or moderated by depressive symptoms and lifestyle factors. METHODS: A cross-sectional study of 637 'older' PLWH aged ≥ 50 years, 340 'younger' PLWH aged < 50 years and 276 demographically matched HIV-negative controls aged ≥ 50 years enrolled in the Pharmacokinetic and Clinical Observations in People over Fifty (POPPY) study was performed. Cognitive function was assessed using a computerized battery (CogState). Scores were standardized into Z-scores [mean = 0; standard deviation (SD) = 1] and averaged to obtain a global Z-score. Depressive symptoms were evaluated via the Patient Health Questionnaire (PHQ-9). Differences between the three groups and the effects of depression, sociodemographic factors and lifestyle factors on cognitive performance were evaluated using median regression. All analyses accounted for age, gender, ethnicity and level of education. RESULTS: After adjustment for sociodemographic factors, older and younger PLWH had poorer overall cognitive scores than older HIV-negative controls (P < 0.001 and P = 0.006, respectively). Moderate or severe depressive symptoms were more prevalent in both older (27%; P < 0.001) and younger (21%; P < 0.001) PLWH compared with controls (8%). Depressive symptoms (P < 0.001) and use of hashish (P = 0.01) were associated with lower cognitive function; alcohol consumption (P = 0.02) was associated with better cognitive scores. After further adjustment for these factors, the difference between older PLWH and HIV-negative controls was no longer significant (P = 0.08), while that between younger PLWH and older HIV-negative controls remained significant (P = 0.01). CONCLUSIONS: Poorer cognitive performances in PLWH compared with HIV-negative individuals were, in part, mediated by the greater prevalence of depressive symptoms and recreational drug use reported by PLWH