Engaging with the pragmatics of relational thinking, leverage points and transformations – Reply to West et al.

Peer reviewe

Use of behavioral economics and social psychology to improve treatment of acute respiratory infections (BEARI): rationale and design of a cluster randomized controlled trial [1RC4AG039115-01] - study protocol and baseline practice and provider characteristics

Background: Inappropriate antibiotic prescribing for nonbacterial infections leads to increases in the costs of care, antibiotic resistance among bacteria, and adverse drug events. Acute respiratory infections (ARIs) are the most common reason for inappropriate antibiotic use. Most prior efforts to decrease inappropriate antibiotic prescribing for ARIs (e.g., educational or informational interventions) have relied on the implicit assumption that clinicians inappropriately prescribe antibiotics because they are unaware of guideline recommendations for ARIs. If lack of guideline awareness is not the reason for inappropriate prescribing, educational interventions may have limited impact on prescribing rates. Instead, interventions that apply social psychological and behavioral economic principles may be more effective in deterring inappropriate antibiotic prescribing for ARIs by well-informed clinicians. Methods/design The Application of Behavioral Economics to Improve the Treatment of Acute Respiratory Infections (BEARI) Trial is a multisite, cluster-randomized controlled trial with practice as the unit of randomization. The primary aim is to test the ability of three interventions based on behavioral economic principles to reduce the rate of inappropriate antibiotic prescribing for ARIs. We randomized practices in a 2 × 2 × 2 factorial design to receive up to three interventions for non-antibiotic-appropriate diagnoses: 1) Accountable Justifications: When prescribing an antibiotic for an ARI, clinicians are prompted to record an explicit justification that appears in the patient electronic health record; 2) Suggested Alternatives: Through computerized clinical decision support, clinicians prescribing an antibiotic for an ARI receive a list of non-antibiotic treatment choices (including prescription options) prior to completing the antibiotic prescription; and 3) Peer Comparison: Each provider’s rate of inappropriate antibiotic prescribing relative to top-performing peers is reported back to the provider periodically by email. We enrolled 269 clinicians (practicing attending physicians or advanced practice nurses) in 49 participating clinic sites and collected baseline data. The primary outcome is the antibiotic prescribing rate for office visits with non-antibiotic-appropriate ARI diagnoses. Secondary outcomes will examine antibiotic prescribing more broadly. The 18-month intervention period will be followed by a one year follow-up period to measure persistence of effects after interventions cease. Discussion The ongoing BEARI Trial will evaluate the effectiveness of behavioral economic strategies in reducing inappropriate prescribing of antibiotics. Trials registration ClinicalTrials.gov: NCT0145494

Taking patient and public involvement online: qualitative evaluation of an online forum for palliative care and rehabilitation research.

PLAIN ENGLISH SUMMARY: Patient and public involvement (PPI) is increasingly recognised as important in research. Most PPI takes place face-to-face, but this can be difficult for people who are unwell or have caring responsibilities. As these challenges are particularly common in palliative care and rehabilitation research, we developed an online forum for PPI: www.csipublicinvolvement.co.uk. In this study, we explored how well the online forum worked, if it is a suitable method for PPI, and how PPI members and researchers reacted to using it. We used an existing theory about online interventions to help choose the 'right' questions to ask participants. We invited PPI members and researchers who had used the online forum to participate in focus groups, and identified the most important themes discussed. Within this study, PPI members have helped with the interview questions, analysis, and write up. Overall, four PPI members and five researchers participated in the focus groups. Participants felt the online forum worked well and had multiple benefits. From the discussions, we identified four key questions to consider when developing online methods for PPI: how does the forum work, how does it engage people, how does it empower people, and what is the impact? Participants suggested the forum could be improved by being more PPI and less researcher focused. We conclude that when developing online methods of PPI, a functioning forum is not enough: it also needs to be engaging and empowering to have an impact. Future work can use these four domains when developing their own online PPI methods. BACKGROUND: Patient and public involvement (PPI) in research is increasingly recognised as important. Most PPI activities take place face-to-face, yet this can be difficult for people with ill health or caring responsibilities, and may exclude people from hard-to-reach populations (e.g. living in vulnerable social circumstances and/or remote geographical locations). These challenges are particularly pertinent in palliative care and rehabilitation research where people often live with, or care for someone with, advanced illness. In response to this, we aimed to test the functionality, feasibility, and acceptability of an online forum for PPI for palliative care and rehabilitation research (www.csipublicinvolvement.co.uk). METHODS: We conducted separate focus groups with PPI members and researchers who had used the online forum. Data collection was underpinned by DeLone and Mclean's model of information systems success. Focus groups were recorded, transcribed, and analysed using inductive thematic analysis. Dual coding by two authors ensured rigour, and attention was paid to divergent cases. RESULTS: Four PPI members and five researchers participated in the focus groups (two PPI focus groups, one researcher focus group). The online forum was perceived as functional, feasible, and acceptable. Our analysis identified four key questions to consider when developing online methods for PPI: (1) how does the forum work, (2) how does it engage people, (3) how does it empower people, and (4) what is the impact? PPI members felt that the online forum was too researcher led, and needed to be more PPI focussed. CONCLUSIONS: When developing online methods of PPI, a functioning forum is not enough: it also needs to be engaging and empowering to have an impact. To optimise online involvement, future work should refer to these four domains and balance the needs of researchers and PPI members

Patient and public involvement in palliative care research: What works, and why? A qualitative evaluation.

BACKGROUND: Public involvement is increasingly considered a prerequisite for high-quality research. However, involvement in palliative care is impeded by limited evidence on the best approaches for populations affected by life-limiting illness. AIM: To evaluate a strategy for public involvement in palliative care and rehabilitation research, to identify successful approaches and areas for improvement. DESIGN: Co-produced qualitative evaluation using focus groups and interviews. Thematic analysis undertaken by research team comprising public contributors and researchers. SETTING/PARTICIPANTS: Researchers and public members from a palliative care and rehabilitation research institute, UK. RESULTS: Seven public members and 19 researchers participated. Building and maintaining relationships, taking a flexible approach and finding the 'right' people were important for successful public involvement. Relationship building created a safe environment for discussing sensitive topics, although public members felt greater consideration of emotional support was needed. Flexibility supported involvement alongside unpredictable circumstances of chronic and life-limiting illness, and was facilitated by responsive communication, and opportunities for in-person and virtual involvement at a project- and institution-level. However, more opportunities for two-way feedback throughout projects was suggested. Finding the 'right' people was crucial given the diverse population served by palliative care, and participants suggested more care needed to be taken to identify public members with experience relevant to specific projects. CONCLUSION: Within palliative care research, it is important for involvement to focus on building and maintaining relationships, working flexibly, and identifying those with relevant experience. Taking a strategic approach and developing adequate infrastructure and networks can facilitate public involvement within this field.The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by the National Institute for Health Research (NIHR) Collaboration for Leadership and Applied Health Research and Care South London (NIHR CLAHRC South London) Involvement Activity Funding and Research Capability Funding at King’s College Hospital NHS Foundation Trust. Support was also provided by the NIHR Applied Research Collaboration (ARC) South London at King’s College Hospital Foundation Trust. LJB is supported through a National Institute for Health Research (NIHR) Career Development Fellowship (CDF-2017-10-009). CE is funded by HEE/NIHR Senior Clinical Lectureship. The views expressed in this publication are those of the author(s) and not necessarily those of the funders, the NHS, the National Institute for Health Research or the Department of Health

Behavioral interventions to reduce inappropriate antibiotic prescribing: a randomized pilot trial

Background: Clinicians frequently prescribe antibiotics inappropriately for acute respiratory infections (ARIs). Our objective was to test information technology-enabled behavioral interventions to reduce inappropriate antibiotic prescribing for ARIs in a randomized controlled pilot test trial. Methods: Primary care clinicians were randomized in a 2 × 2 × 2 factorial experiment with 3 interventions: 1) Accountable Justifications; 2) Suggested Alternatives; and 3) Peer Comparison. Beforehand, participants completed an educational module. Measures included: rates of antibiotic prescribing for: non-antibiotic-appropriate ARI diagnoses, acute sinusitis/pharyngitis, all other diagnoses/symptoms of respiratory infection, and all three ARI categories combined. Results: We examined 3,276 visits in the pre-intervention year and 3,099 in the intervention year. The antibiotic prescribing rate fell for non-antibiotic-appropriate ARIs (24.7 % in the pre-intervention year to 5.2 % in the intervention year); sinusitis/pharyngitis (50.3 to 44.7 %); all other diagnoses/symptoms of respiratory infection (40.2 to 25.3 %); and all categories combined (38.7 to 24.2 %; all p < 0.001). There were no significant relationships between any intervention and antibiotic prescribing for non-antibiotic-appropriate ARI diagnoses or sinusitis/pharyngitis. Suggested Alternatives was associated with reduced antibiotic prescribing for other diagnoses or symptoms of respiratory infection (odds ratio [OR], 0.62; 95 % confidence interval [CI], 0.44–0.89) and for all ARI categories combined (OR, 0.72; 95 % CI, 0.54–0.96). Peer Comparison was associated with reduced prescribing for all ARI categories combined (OR, 0.73; 95 % CI, 0.53–0.995). Conclusions: We observed large reductions in antibiotic prescribing regardless of whether or not study participants received an intervention, suggesting an overriding Hawthorne effect or possibly clinician-to-clinician contamination. Low baseline inappropriate prescribing may have led to floor effects. Trial Registration ClinicalTrials.gov: NCT01454960. Electronic supplementary material The online version of this article (doi:10.1186/s12879-016-1715-8) contains supplementary material, which is available to authorized users

A Spectroscopic Road Map for Cosmic Frontier: DESI, DESI-II, Stage-5

In this white paper, we present an experimental road map for spectroscopic experiments beyond DESI. DESI will be a transformative cosmological survey in the 2020s, mapping 40 million galaxies and quasars and capturing a significant fraction of the available linear modes up to z=1.2. DESI-II will pilot observations of galaxies both at much higher densities and extending to higher redshifts. A Stage-5 experiment would build out those high-density and high-redshift observations, mapping hundreds of millions of stars and galaxies in three dimensions, to address the problems of inflation, dark energy, light relativistic species, and dark matter. These spectroscopic data will also complement the next generation of weak lensing, line intensity mapping and CMB experiments and allow them to reach their full potential.Comment: Contribution to Snowmass 202

Wnt signaling in triple-negative breast cancer

Wnt signaling regulates a variety of cellular processes, including cell fate, differentiation, proliferation and stem cell pluripotency. Aberrant Wnt signaling is a hallmark of many cancers. An aggressive subtype of breast cancer, known as triple-negative breast cancer (TNBC), demonstrates dysregulation in canonical and non-canonical Wnt signaling. In this review, we summarize regulators of canonical and non-canonical Wnt signaling, as well as Wnt signaling dysfunction that mediates the progression of TNBC. We review the complex molecular nature of TNBC and the emerging therapies that are currently under investigation for the treatment of this disease

Make It Easier : A psychological perspective on sustainable behavior change

Human behavior is the cause of most environmental challenges we face today, and widespread behavioral change is urgently needed across actors and scales. Even though the public perception of the current ecological crisis has changed drastically in recent decades, a corresponding shift in behavior is lacking — unfortunately, mere belief in climate change is a poor predictor of taking action. In light of this knowledge-action gap, this thesis looks at behavior change from a psychological perspective and aims to explore how insights from the behavioral sciences can help understand and promote sustainable behavior change. This thesis mainly focuses on developing and testing interventions to promote pro-environmental behaviors. It studies the effectiveness of information-based nudges, manipulation of the physical environment, and the interaction between internal motivation to act and the immediate decision context. The thesis also explores the automatic and habitual aspects of behavior change. To this end, five studies were conducted. Four empirical studies in which interventions to promote pro-environmental behaviors were designed and implemented in different natural contexts. All interventions were evaluated using observed behavior and a mix of experimental designs, from lab experiments to natural field experiments. A fifth argument-driven conceptual paper was also written. Overall, the result from the studies highlights the potential (and complexity) of applying behavioral insights in intervention design: they indicate that the effect can be long-lasting and that relatively small changes in spatial layouts can produce significant behavior change. The results especially showcase the importance of the immediate decision context, and that if conditions are right, manipulating the physical environment can be a powerful, and potentially underutilized, tool to steer behavior. Notably, findings from a lab experiment showed that even when there are strong self-reported intentions to act, convenience to act sustainably might not be enough to spark change, as long as the alternative routine choice was equally convenient. Not until the more sustainable option was made to be the easier choice did significant change occur. The results also showcase the important role habit plays in our day-to-day actions and decisions, how habits can act as strong barriers to change, and that they link behavior to the physical environment. These insights complement the currently dominant narrative focused on intrinsic and rational motivation for acting sustainably and paves the way for a research agenda focused on exploring the manipulation of the physical environment and “habit architecture” as a way to spark sustainable behavior change.Människans beteende orsakar de flesta miljöutmaningar som vi står inför idag, vilken innebär att vi behöver se omfattande beteendeförändringar inom en nära framtid. Även fast kunskapen och den allmänna uppfattningen om den ekologiska kris vi nu befinner oss i har förändrats drastiskt under de senaste decennierna, saknas en motsvarande förändring i beteende – tyvärr är associationen mellan kunskap och ändrat beteende väldigt svag. I ljuset av det gapet, mellan kunskap och handling, utforskar denna avhandling beteendeförändringar ur ett psykologiskt perspektiv. Forskningen som presenteras här syftar till att undersöka hur insikter från beteendevetenskapen kan hjälpa oss att förstå och främja hållbara beteendeförändringar. Avhandlingen fokuserar främst på att utveckla och testa olika interventioner baserade på psykologiska insikter. Här studeras effektiviteten av informationsbaserade ”nudges”, förändringar i den fysiska miljön och interaktionen mellan inre motivation och den direkta omgivningen. Även de automatiska och vanemässiga aspekterna av beteendeförändringar utforskas. Fem studier genomfördes: i fyra empiriska studier utformades och implementerades interventioner för att främja miljövänliga beteenden i olika miljöer, dessa utvärderades med hjälp av olika experimentella designer: från laboratorieexperiment till naturliga fältexperiment, och effekten uppskattades med hjälp av observerat beteende. En femte konceptuell argumentdriven artikel skrevs också. Överlag belyser resultatet potentialen (men även komplexiteten) i att tillämpa insikter från beteendevetenskapen i designprocessen av olika interventioner: de visar att effekten kan vara långvarig och att relativt små ingripanden kan resultera i betydande beteendeförändring. Resultaten understryker även vikten av den omedelbara fysiska miljön, och att vid rätt förutsättningar – så kan manipulering av den fysiska miljön vara ett kraftfullt, och potentiellt underutnyttjat, verktyg för att styra beteenden mot hållbara val. Till exempelså visade resultaten från ett laboratorieexperiment att även om det fanns starka självrapporterade avsikter att agera hållbart och det samtidigt var ”lätt att göra rätt”, så var det inte tillräckligt — så länge det alternativa och mer vanemässiga beteendet var lika lätt eller lättare. Inte förrän den fysiska miljön gjorde det hållbara alternativet till det lättare valet, såg vi en betydande beteendeförändring. Resultaten belyser också den viktiga roll som vanor spelar för våra dagliga beslut och handlingar, hur vanor kan agera som barriärer mot förändring och hur de kopplar beteendet till den fysiska miljön. Dessa insikter kompletterar det dominerande narrativet inom dagens miljöforskning som främst fokuserar på rationellt beslutfattande och inre motivation att agera hållbart, och banar väg för en kompletterande forskningsagenda som fokuserar på manipulationen av den fysiska miljön och ”vanearkitektur” för att främja en hållbar beteendetransformation

Exploring tools to promote pro-environmental behaviour: : Can behavioural insights from psychology and behavioural economics be utilized to increase the recycling of food waste in Hökarängen, Sweden?

Human behaviour need to change in order to avoid potentially catastrophic global environmental changes, thus promoting pro-environmental behaviour amongst individuals is one of today’s greatest challenges. This thesis presents a methodological approach for developing and designing implementations to promote pro-environmental behaviour, using behaviour insights from psychology and behavioural economics, mainly by combining theories from nudging and social marketing. The method was tested on a case study in Hökarängen, - a suburb of Stockholm (Sweden) and was used to design an information hand-out aimed at encouraging the pro-environmental behaviour of recycling food waste. The effect of the implementation was then tested through a natural field experiment and evaluated using a difference-in-difference analysis. The results indicate a significant increase in food waste collected and a significant decrease in unsorted household waste compared to a control group in the research area. This study provides a promising methodological approach for fostering behaviour change: and contributes to advancing the scientific fields of green-nudges and social marketing to nurture pro-environmental behaviour. Insights from this study could be used to guide development of policy tools to help Stockholm and Sweden reach environmental policy goals

Make It Easier : A psychological perspective on sustainable behavior change

Human behavior is the cause of most environmental challenges we face today, and widespread behavioral change is urgently needed across actors and scales. Even though the public perception of the current ecological crisis has changed drastically in recent decades, a corresponding shift in behavior is lacking — unfortunately, mere belief in climate change is a poor predictor of taking action. In light of this knowledge-action gap, this thesis looks at behavior change from a psychological perspective and aims to explore how insights from the behavioral sciences can help understand and promote sustainable behavior change. This thesis mainly focuses on developing and testing interventions to promote pro-environmental behaviors. It studies the effectiveness of information-based nudges, manipulation of the physical environment, and the interaction between internal motivation to act and the immediate decision context. The thesis also explores the automatic and habitual aspects of behavior change. To this end, five studies were conducted. Four empirical studies in which interventions to promote pro-environmental behaviors were designed and implemented in different natural contexts. All interventions were evaluated using observed behavior and a mix of experimental designs, from lab experiments to natural field experiments. A fifth argument-driven conceptual paper was also written. Overall, the result from the studies highlights the potential (and complexity) of applying behavioral insights in intervention design: they indicate that the effect can be long-lasting and that relatively small changes in spatial layouts can produce significant behavior change. The results especially showcase the importance of the immediate decision context, and that if conditions are right, manipulating the physical environment can be a powerful, and potentially underutilized, tool to steer behavior. Notably, findings from a lab experiment showed that even when there are strong self-reported intentions to act, convenience to act sustainably might not be enough to spark change, as long as the alternative routine choice was equally convenient. Not until the more sustainable option was made to be the easier choice did significant change occur. The results also showcase the important role habit plays in our day-to-day actions and decisions, how habits can act as strong barriers to change, and that they link behavior to the physical environment. These insights complement the currently dominant narrative focused on intrinsic and rational motivation for acting sustainably and paves the way for a research agenda focused on exploring the manipulation of the physical environment and “habit architecture” as a way to spark sustainable behavior change.Människans beteende orsakar de flesta miljöutmaningar som vi står inför idag, vilken innebär att vi behöver se omfattande beteendeförändringar inom en nära framtid. Även fast kunskapen och den allmänna uppfattningen om den ekologiska kris vi nu befinner oss i har förändrats drastiskt under de senaste decennierna, saknas en motsvarande förändring i beteende – tyvärr är associationen mellan kunskap och ändrat beteende väldigt svag. I ljuset av det gapet, mellan kunskap och handling, utforskar denna avhandling beteendeförändringar ur ett psykologiskt perspektiv. Forskningen som presenteras här syftar till att undersöka hur insikter från beteendevetenskapen kan hjälpa oss att förstå och främja hållbara beteendeförändringar. Avhandlingen fokuserar främst på att utveckla och testa olika interventioner baserade på psykologiska insikter. Här studeras effektiviteten av informationsbaserade ”nudges”, förändringar i den fysiska miljön och interaktionen mellan inre motivation och den direkta omgivningen. Även de automatiska och vanemässiga aspekterna av beteendeförändringar utforskas. Fem studier genomfördes: i fyra empiriska studier utformades och implementerades interventioner för att främja miljövänliga beteenden i olika miljöer, dessa utvärderades med hjälp av olika experimentella designer: från laboratorieexperiment till naturliga fältexperiment, och effekten uppskattades med hjälp av observerat beteende. En femte konceptuell argumentdriven artikel skrevs också. Överlag belyser resultatet potentialen (men även komplexiteten) i att tillämpa insikter från beteendevetenskapen i designprocessen av olika interventioner: de visar att effekten kan vara långvarig och att relativt små ingripanden kan resultera i betydande beteendeförändring. Resultaten understryker även vikten av den omedelbara fysiska miljön, och att vid rätt förutsättningar – så kan manipulering av den fysiska miljön vara ett kraftfullt, och potentiellt underutnyttjat, verktyg för att styra beteenden mot hållbara val. Till exempelså visade resultaten från ett laboratorieexperiment att även om det fanns starka självrapporterade avsikter att agera hållbart och det samtidigt var ”lätt att göra rätt”, så var det inte tillräckligt — så länge det alternativa och mer vanemässiga beteendet var lika lätt eller lättare. Inte förrän den fysiska miljön gjorde det hållbara alternativet till det lättare valet, såg vi en betydande beteendeförändring. Resultaten belyser också den viktiga roll som vanor spelar för våra dagliga beslut och handlingar, hur vanor kan agera som barriärer mot förändring och hur de kopplar beteendet till den fysiska miljön. Dessa insikter kompletterar det dominerande narrativet inom dagens miljöforskning som främst fokuserar på rationellt beslutfattande och inre motivation att agera hållbart, och banar väg för en kompletterande forskningsagenda som fokuserar på manipulationen av den fysiska miljön och ”vanearkitektur” för att främja en hållbar beteendetransformation