EHPS/DHP Conference 2016: Summary of DHP Award for ‘Outstanding MSc Thesis’ and reflections on conference highlights

As a winner of the DHP award for ‘Outstanding MSc Thesis’, I was invited to present my work at the joint EHPS/DHP Conference 2016 in Aberdeen, Scotland. In this brief report, I provide a summary of my thesis, entitled ‘Understanding user engagement with a novel smoking cessation smartphone application in UK- based adult smokers: An exploratory analysis of usage data from a randomised controlled trial’, and my reflections on the positive aspects of the conference

Engagement with Digital Behaviour Change Interventions: Conceptualisation, Measurement and Promotion

Digital behaviour change interventions (DBCIs) can help people change various health behaviours; however, engagement is low on average and there is a positive association of engagement with intervention effectiveness. The extent to which this relationship is confounded or subject to reverse causality is unclear, and evidence-based models of how to promote engagement are lacking. Progress is hindered by the existence of multiple definitions and measures of engagement; this hampers attempts to aggregate data in meta-analyses. Using smartphone applications (apps) for smoking cessation and alcohol reduction as case studies, this thesis investigated how to conceptualise and measure engagement and identified factors that influence engagement with DBCIs in general, and with apps for smoking cessation and alcohol reduction in particular. Six studies using qualitative and quantitative methods were conducted. Study 1 was a systematic, interdisciplinary literature review, which synthesised existing conceptualisations and generated an integrative definition of engagement with behavioural and experiential dimensions, and a conceptual framework of factors that influence engagement with DBCIs. Studies 3 and 4 involved the development and evaluation of a self-report measure of the behavioural and experiential dimensions of engagement. Studies 2, 5 and 6 used mixed-methods to identify factors that influence engagement with apps for smoking cessation and alcohol reduction. Engagement with DBCIs can usefully be defined in both behavioural and experiential terms: the self-report measure demonstrated promising psychometric properties and was underpinned by two distinct factors, labelled ‘Experiential Engagement’ and ‘Behavioural Engagement’. Design features that support users’ motivation to change, foster their beliefs about the perceived usefulness and relevance of the technology, and spark their interest were found to be most important in the promotion of engagement with apps for smoking cessation and alcohol reduction. These findings can be used to inform the design of new, or modification of existing, apps for these behaviours

Acceptability of digital health interventions: embracing the complexity

Acceptability is a core concept in digital health. Available frameworks have not clearly articulated why and how researchers, practitioners and policy makers may wish to study the concept of acceptability. Here, we aim to discuss (i) the ways in which acceptability might differ from closely related concepts, including user engagement; (ii) the utility of the concept of acceptability in digital health research and practice; (iii) social and cultural norms that influence acceptability; and (iv) pragmatic means of measuring acceptability, within and beyond the research process. Our intention is not to offer solutions to these open questions but to initiate a debate within the digital health community. We conducted a narrative review of theoretical and empirical examples from the literature. First, we argue that acceptability may usefully be considered an emergent property of a complex, adaptive system of interacting components (e.g., affective attitude, beliefs), which in turn influences (and is influenced by) user engagement. Second, acceptability is important due to its ability to predict and explain key outcomes of interest, including user engagement and intervention effectiveness. Third, precisely what people find acceptable is deeply contextualized and interlinked with prevailing social and cultural norms. Understanding and designing for such norms (e.g., through drawing on principles of user centered design) is therefore key. Finally, there is a lack of standard acceptability measures and thresholds. Star ratings coupled with free-text responses may provide a pragmatic means of capturing acceptability. Acceptability is a multifaceted concept, which may usefully be studied with a complexity science lens

Association between changes in harm perceptions and e-cigarette use among current tobacco smokers in England: A time series analysis

Background: There is a decreasing trend in the proportion of individuals who perceive e-cigarettes to be less harmful than conventional cigarettes across the UK, Europe and the US. It is important to assess whether this may influence the use of e-cigarettes. We aimed to estimate, using a time series approach, whether changes in harm perceptions among current tobacco smokers have been associated with changes in the prevalence of e-cigarette use in England, with and without stratification by age, sex and social grade. Methods: Respondents were from the Smoking Toolkit Study, which involves monthly cross-sectional household surveys of individuals aged 16+ years in England. Data were aggregated monthly on ~ 300 current tobacco smokers between 2014 and 2019. The outcome variable was the prevalence of e-cigarette use. The explanatory variable was the proportion of smokers who endorsed the belief that e-cigarettes are less harmful than combustible cigarettes. Covariates were cigarette (vs. non-cigarette combustible) current smoking prevalence, past-year quit attempt prevalence and national smoking mass media expenditure. Unadjusted and adjusted autoregressive integrated moving average with exogeneous variables (ARIMAX) models were fitted. Results: For every 1% decrease in the mean prevalence of current tobacco smokers who endorsed the belief that e-cigarettes are less harmful than combustible cigarettes, the mean prevalence of e-cigarette use decreased by 0.48% (βadj = 0.48, 95% CI = 0.25–0.71, p < .001). Marginal age and sex differences were observed, whereby significant associations were observed in older (but not in young) adults and in men (but not in women). No differences by social grade were detected. Conclusions: Between 2014 and 2019 in England, at the population level, monthly changes in the prevalence of accurate harm perceptions among current tobacco smokers were strongly associated with changes in e-cigarette use

Estimated failure to report unsuccessful quit attempts by type of cessation aid: A population survey of smokers in England

Introduction. It has been estimated that smokers tend to fail to report unsuccessful quit attempts that lasted a short time and occurred a longer time ago. However, it is unclear whether the failure to report unsuccessful quit attempts varies by the type of cessation aid used. Methods. A total of 5,892 smokers aged 16+ years who had made 1+ quit attempts in the past year were surveyed between January 2014 and December 2020 as part of the Smoking Toolkit Study. Respondents indicated when their most recent quit attempt started, how long it lasted, and which cessation aid(s) were used (e.g., unaided, varenicline, and behavioural support). The percentage failure to report for each cessation aid and 95% bootstrap confidence intervals (CIs) were estimated with an established method. Test for equality of proportions was performed to examine whether quit attempts lasting between one day and one week and that started >6 months ago failed to be reported at a different rate depending on the cessation aid used. Results. We estimated that after three months, 97% (95% -98%) of unaided quit attempts lasting less than one day, 80% (95% -81%) of those lasting between one day and one week, and 60% (95% -61%) of those lasting between one week and one month fail to be reported. Compared with unaided attempts, the estimated percentage failure to report quit attempts that lasted between one day and one week and that started >6 months ago was significantly lower for attempts involving behavioural support (92% of unaided attempts vs. 75% of attempts involving behavioural support, , ). No other significant differences were detected. Conclusions. Smokers in England appear to fail to report a substantial proportion of unsuccessful quit attempts. This failure appears particularly prominent for attempts that last a short time or occurred longer ago and appears lower for attempts involving behavioural support compared with unaided attempts

Exploring views on alcohol consumption and digital support for alcohol reduction in UK-based Punjabi-Sikh men: A think aloud and interview study

Introduction and Aims: We aimed to explore UK‐based Punjabi‐Sikh men's views on: (i) alcohol consumption within the community; (ii) available support for alcohol reduction; and (iii) an evidence‐informed alcohol reduction app. Design and Methods: Semi‐structured interviews and a think aloud method were employed. Participants (n = 15) were male, aged 18–27 years, identified as Punjabi‐Sikh, were hazardous or harmful drinkers (i.e. had an Alcohol Use Disorders Identification Test‐Consumption score of ≥5) and interested in using an app to reduce drinking. Interviews were audio‐recorded, transcribed verbatim and analysed with inductive thematic analysis. Results: Six themes were developed: (i) fear of drinking to cope; (ii) clash between religious and cultural norms (i.e. an internal conflict between important values); (iii) stigmatisation of mental health issues and lack of knowledge as barriers to help seeking; (iv) perceived usefulness of goal setting, monitoring and feedback (i.e. beliefs about the utility of the app's components for reducing drinking); (v) concerns about accessibility of the app within the Punjabi‐Sikh community; and (vi) desire for human support for continued app engagement. Discussion and Conclusions: Among UK‐based, Punjabi‐Sikh men, clashing religious and cultural norms give rise to internal conflict about drinking. Stigmatisation of mental health issues and lack of knowledge of available support leads to reduced help seeking. Respondents believed an evidence‐informed alcohol reduction app could be useful, but were concerned about accessibility within the wider community and wanted an element of human support. The potential for a combination of digital and face‐to‐face support should be explored

Innovative methods for observing and changing complex health behaviors: Four propositions

Precision health initiatives aim to progressively move from traditional, group-level approaches to health diagnostics and treatments toward ones that are individualized, contextualized, and timely. This article aims to provide an overview of key methods and approaches that can help facilitate this transition in the health behavior change domain. This article is a narrative review of the methods used to observe and change complex health behaviors. On the basis of the available literature, we argue that health behavior change researchers should progressively transition from (i) low- to high-resolution behavioral assessments, (ii) group-only to group- and individual-level statistical inference, (iii) narrative theoretical models to dynamic computational models, and (iv) static to adaptive and continuous tuning interventions. Rather than providing an exhaustive and technical presentation of each method and approach, this article articulates why and how researchers interested in health behavior change can apply these innovative methods. Practical examples contributing to these efforts are presented. If successfully adopted and implemented, the four propositions in this article have the potential to greatly improve our public health and behavior change practices in the near future