Dr Benjamin Gardner


Reader in Psychology
BA (Hons) Social Psychology, MRes Psychological Methods, DPhil Social Psychology
+44 (0)1483 686863
01 AC 05

Biography

Areas of specialism

Habit; Behaviour change; Social psychology; Health psychology

My qualifications

2008
DPhil Social Psychology
University of Sussex
2004
MRes Psychological Methods (Distinction)
University of Sussex
2003
BA (Hons) Social Psychology (First Class)
University of Sussex

Previous roles

2021 - 2022
Reader in Social Psychology
King's College London
2014 - 2021
Senior Lecturer
King's College London
2009 - 2014
Lecturer in Health Psychology
University College London
2007 - 2009
Research Associate
University College London

Affiliations and memberships

British Psychological Society
Associate Fellow (2014-)
Chartered Psychologist (2011-)
Member (2006-)
Higher Education Academy
Senior Fellow (2019-)

Research

Research interests

Indicators of esteem

  • Deputy Editor, British Journal of Health Psychology (2022-)

  • Associate Editor, International Journal of Behavioral Medicine and Physical Activity (2019-)

  • Advisory Editor, Social Science & Medicine (2018-)

  • Editorial Board member, Health Psychology Review (2017-)

My publications

Publications

Roganie Govender, Christina H Smith, Stuart A Taylor, Daphne Grey, Jane Wardle, BENJAMIN GARDNER (2015)Identification of behaviour change components in swallowing interventions for head and neck cancer patients: protocol for a systematic review, In: Systematic reviews4(1)pp. 89-89 BMC

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.

BENJAMIN GARDNER, LJ Smith, Daniel Aggio, Steve Iliffe, Kenneth R Fox, Barbara J Jefferis, M Hamer (2015)'On Your Feet to Earn Your Seat': update to randomised controlled trial protocol, In: Trials16(1)pp. 330-330 BIOMED CENTRAL LTD

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.,

BENJAMIN GARDNER (2015)A review and analysis of the use of 'habit' in understanding, predicting and influencing health-related behaviour, In: Health psychology review9(3)pp. 277-295 Routledge

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.

M Tang, L Shahab, Kathryn A. Robb, BENJAMIN GARDNER (2016)Are parents more willing to vaccinate their children than themselves?, In: Journal of health psychology21(5)pp. 781-787

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.

Crystal Rolfe, BENJAMIN GARDNER (2016)Experiences of hearing loss and views towards interventions to promote uptake of rehabilitation support among UK adults, In: International journal of audiology55(11)pp. 666-673 Taylor & Francis

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.

BENJAMIN GARDNER (2015)Defining and measuring the habit impulse: response to commentaries, In: Health psychology review9(3)pp. 318-322 Routledge
BENJAMIN GARDNER, Sharon Corbridge, L McGowan (2015)Do habits always override intentions? Pitting unhealthy snacking habits against snack-avoidance intentions, In: BMC Psychology3(1)pp. 8-8 BioMed Central
Jean Adams, Belinda Bateman, F Becker, Tricia Cresswell, D Flynn, Rebekah McNaughton, Yemi Oluboyede, Shannon Robalino, Laura Ternent, S Michie, BENJAMIN GARDNER, Janet Shucksmith, Falko F Sniehotta, Sarah Wigham (2015)Effectiveness and acceptability of parental financial incentives and quasi-mandatory schemes for increasing uptake of vaccinations in preschool children: systematic review, qualitative study and discrete choice experiment, In: Health technology assessment (Winchester, England)19(94)pp. 1-176 Nihr Journals Library

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.

Lee Smith, Alexia Sawyer, Benjamin Gardner, Katri Seppala, Marcella Ucci, Alexi Marmot, Pippa Lally, Abi Fisher (2018)Occupational Physical Activity Habits of UK Office Workers: Cross-Sectional Data from the Active Buildings Study, In: International Journal of Environmental Research and Public Health15(6)1214 MDPI

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.

Isabelle White, Lee Smith, Daniel Aggio, Sahana Shankar, Saima Begum, Raluca Matei, Kenneth R Fox, Mark Hamer, Steve Iliffe, Barbara J Jefferis, Nick Tyler, Benjamin Gardner (2017)On Your Feet to Earn Your Seat: pilot RCT of a theory-based sedentary behaviour reduction intervention for older adults, In: Pilot and Feasibility Studies3(1)23 BioMed Central

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.

Kate Walters, Rachael Frost, Kalpa Kharicha, Christina Avgerinou, Benjamin Gardner, Federico Ricciardi, Rachael Hunter, Ann Liljas, Jill Manthorpe, Vari Drennan, John Wood, Claire Goodman, Ana Jovicic, Steve Iliffe (2017)Home-based health promotion for older people with mild frailty: the HomeHealth intervention development and feasibility RCT Background, In: Health Technology Assessment21(73) NIHR Journals Library

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.

Per Nilsen, Margit Neher, Per-Erik Ellstrom, Benjamin Gardner (2017)Implementation of Evidence-Based Practice From a Learning Perspective, In: Worldviews on Evidence-Based Nursing14(3)pp. 192-199 Wiley

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.

Ai Koyanagi, B Stubbs, LJ Smith, Benjamin Gardner, Davy Vancampfort (2017)Correlates of physical activity among community-dwelling adults aged 50 or over in six low- and middle-income countries, In: PLoS ONE12(10)e0186992

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 (

Roganie Govender, Caroline E Wood, Stuart A Taylor, Christina H Smith, Helen Barratt, Benjamin Gardner (2017)Patient Experiences of Swallowing Exercises After Head and Neck Cancer: A Qualitative Study Examining Barriers and Facilitators Using Behaviour Change Theory, In: Dysphagia32pp. 559-569 Springer

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.

Roganie Govender, Christina H Smith, Stuart A Taylor, Helen Barratt, Benjamin Gardner (2017)Swallowing interventions for the treatment of dysphagia after head and neck cancer: a systematic review of behavioural strategies used to promote patient adherence to swallowing exercises, In: BMC Cancer17(1)43 Springer Nature

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.

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.

Benjamin Gardner, Ana Jovicic, Celia Belk, Kalpa Kharicha, Steve Iliffe, Jill Manthorpe, C Goodman, VM Drennan, Kate Walters (2017)Specifying the content of home-based health behaviour change interventions for older people with frailty or at risk of frailty: an exploratory systematic review, In: BMJ Open7(2)e014127

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.

Rachael Frost, Celia Belk, Ana Jovicic, Federico Ricciardi, Kalpa Kharicha, Benjamin Gardner, Steve Iliffe, Claire Goodman, Jill Manthorpe, Vari M. Drennan, Kate Walters (2017)Health promotion interventions for community-dwelling older people with mild or pre-frailty: a systematic review and meta-analysis, In: BMC Geriatrics17157 BMC

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.

Dominika Kwasnicka, Corneel Vandelanotte, Amanda L Rebar, Benjamin Gardner, Camille Short, Mitch Duncan, Dawn Crook, Martin S. Hagger (2017)Comparing motivational, self-regulatory and habitual processes in a computer-tailored physical activity intervention in hospital employees - protocol for the PATHS randomised controlled trial, In: BMC Public Health17(1)pp. 518-518 Springer Nature

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.

Rachael Frost , Kalpa Kharicha, Ana Jovicic, Ann Liljas, Steve Iliffe, Jill Manthorpe, BENJAMIN GARDNER, Christina Avgerinou, Claire Goodman, Vari M. Drennan, Kate Walters (2018)Identifying acceptable components for home-based health promotion services for older people with mild frailty: A qualitative study, In: Health & social care in the community26(3)pp. 393-403 Wiley

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.

BENJAMIN GARDNER, Vari Drennan, Kate Walters, Christina Avgerinou (2018)Moving upstream in health promoting policies for older people with early frailty in England? A policy analysis, In: Journal of health services research & policy23(3)pp. 168-175

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.

Anders Broström, Amir H Pakpour, Per Nilsen, BENJAMIN GARDNER, Martin Ulander (2018)Promoting CPAP adherence in clinical practice: A survey of Swedish and Norwegian CPAP practitioners' beliefs and practices, In: Journal of sleep research27(6)e12675

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.

M Yusuf, A Jagatia, Z Mahmood, E McCabe, G-J de Bruijn, L Smith, BENJAMIN GARDNER (2019)How do office workers respond to media coverage of sitting?, In: Occupational medicine (Oxford)69(5)pp. 372-375

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.

Davy Vancampfort, Brendon Stubbs, Lee Smith, BENJAMIN GARDNER, Matthew P. Herring, Joseph Firth, Beta Ai Koyanagi (2019)Correlates of sedentary behavior among community-dwelling adults with anxiety in six low- and middle-income countries, In: Psychiatry research273pp. 501-508 Elsevier B.V

•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.

Amanda L. Rebar, Ryan E. Rhodes, BENJAMIN GARDNER (2019)How we are misinterpreting physical activity intention - behavior relations and what to do about it, In: The international journal of behavioral nutrition and physical activity16(1)71 Springer Nature

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.

Megan McKee, Barbara A. Mullan, Enrique Mergelsberg, BENJAMIN GARDNER, Kyra Hamilton, Ashley Slabbert, Emily Kothe (2019)Predicting what mothers feed their preschoolers: Guided by an extended theory of planned behaviour, In: Appetite137pp. 250-258 Elsevier Ltd

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.

Zhe Hui Hoo, Martin J Wildman, Michael J Campbell, Stephen J Walters, BENJAMIN GARDNER (2019)A pragmatic behavior-based habit index for adherence to nebulized treatments among adults with cystic fibrosis, In: Patient preference and adherence13pp. 283-294

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.

Zhe Hui Hoo, BENJAMIN GARDNER, Madelynne A. Arden, Simon Waterhouse, Stephen J Walters, Michael J Campbell, Daniel Hind, Chin Maguire, Jane Dewar, Martin J Wildman (2019)Role of habit in treatment adherence among adults with cystic fibrosis, In: Thorax74(2)pp. 197-199 BMJ

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.

BENJAMIN GARDNER, Amanda L. Rebar, Phillippa Lally (2019)A matter of habit: Recognizing the multiple roles of habit in health behaviour, In: British journal of health psychology24(2)pp. 241-249 WILEY
Amanda L. Rebar, BENJAMIN GARDNER (2019)Habit Formation and Behavior Change, In: Oxford Research Encyclopedia of Psychology Oxford University Press

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.

BENJAMIN GARDNER, Amanda L. Rebar (2019)Habit Formation and Behavior Change, In: Psychology Oxford University Press

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.

BENJAMIN GARDNER, Stuart Flint, Amanda L. Rebar, Stephen Dewitt, Sahana K Quail, Helen Whall, LJ Smith (2019)Is sitting invisible? Exploring how people mentally represent sitting, In: The international journal of behavioral nutrition and physical activity16(1)pp. 85-85

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.

Eleanor J Dommett, BENJAMIN GARDNER, Wijnand Van Tilburg (2019)Staff and student views of lecture capture: a qualitative study, In: International Journal of Educational Technology in Higher Education16(1)pp. 1-12 Springer International Publishing

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.

Eleanor J Dommett, Wijnand Van Tilburg, BENJAMIN GARDNER (2019)A case study: Views on the practice of opting in and out of lecture capture, In: Education and information technologies24(5)pp. 3075-3090 Springer US

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.

Benjamin Gardner, Stephen Dewitt, LJ Smith, John Buckley, Stuart J. H Biddle, L Mansfield (2017)The ReSiT study (reducing sitting time): rationale and protocol for an exploratory pilot study of an intervention to reduce sitting time among office workers, In: Pilot and Feasibility Studies3(1)pp. 47-47 BioMed Central

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.

Stephen Dewitt, Jennifer Hall, Lee Smith, John P. Buckley, Stuart J. H Biddle, Louise Mansfield, BENJAMIN GARDNER (2019)Office workers’ experiences of attempts to reduce sitting-time: an exploratory, mixed-methods uncontrolled intervention pilot study, In: BMC public health19(1)pp. 819-819 BioMed Central
Lena Fleig, Benjamin Gardner, Jan Keller, Sonia Lippke, Sarah Pomp, Amelie U Wiedemann (2017)What contributes to action plan enactment? Examining characteristics of physical activity plans, In: British Journal of Health Psychology22(4)pp. 940-957

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.

B Stubbs, Davy Vancampfort, J Firth, Felipe B Schuch, Mats Hallgren, LJ Smith, Benjamin Gardner, Kai.G Kahl, Nicola Veronese, Marco Solmi, A Carvalho, Ai Koyanagi (2018)Relationship between sedentary behavior and depression: A mediation analysis of influential factors across the lifespan among 42,469 people in low- and middle-income countries, In: Journal of Affective Disorders229pp. 231-238 Elsevier

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.

Lee Smith, Stephanie White, Brendon Stubbs, Liang Hue, Nicola Veronese, Davy Vancampfort, Mark Hamer, Benjamin Gardner, Lin Yang (2018)Depressive symptoms, handgrip strength, and weight status in US older adults, In: Journal of Affective Disorders238pp. 305-310 Elsevier

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.

Amanda L. Rebar, Kristie-Lee Alfrey, Benjamin Gardner, Corneel Vandelanotte (2018)Health behaviours of Australian fly-in, fly-out workers and partners during on-shift and off-shift days: an ecological momentary assessment study, In: BMJ Open8(12)e023631 BMJ Publishing Group

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.

Louise Mansfield, Jennifer Hall, Lee Smith, Molly Rasch, Emily Reeves, Stephen Dewitt, Benjamin Gardner (2018)"Could you sit down please?" A qualitative analysis of employees' experiences of standing in normally-seated workplace meetings, In: PloS one13(6)e0198483

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.

Gaby Judah, Benjamin Gardner, Michael G. Kenward, Bianca DeStavola, Robert Aunger (2018)Exploratory study of the impact of perceived reward on habit formation, In: BMC Psychology662 BioMed Central

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.

Benjamin Gardner, Kristie-Lee Alfrey, Corneel Vandelanotte, Amanda L. Rebar (2018)Mental health and well-being concerns of fly-in fly-out workers and their partners in Australia: a qualitative study, In: BMJ Open8(3)e019516 BMJ Publishing Group

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.

Roganie Govender, Stuart A Taylor, Christina H Smith, Benjamin Gardner (2019)Helping Patients With Head and Neck Cancer Understand Dysphagia: Exploring the Use of Video-Animation, In: American Journal of Speech-Language Pathology28(2)pp. 697-705 American Speech-Language-Hearing Association

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.

Jacqueline Champagne, BENJAMIN GARDNER, Eleanor J Dommett (2019)Modelling predictors of UK undergraduates' attitudes towards smart drugs, In: Trends in neuroscience and education14pp. 33-39

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.

BENJAMIN GARDNER, E Beard, R West, F Lorencatto, Ben Gardner, S Michie, Lesley Owens, L Shahab (2019)What do cost-effective health behaviour-change interventions contain? A comparison of six domains, In: PloS one14(4)pp. e0213983-e0213983 PUBLIC LIBRARY SCIENCE

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.

Christina Avgerinou, BENJAMIN GARDNER, Kalpa Kharicha, RE Frost, Ann Liljas, Rekha Elaswarapu, Jill Manthorpe, VM Drennan, C Goodman, Steve Iliffe, Kate Walters (2019)Health promotion for mild frailty based on behaviour change: Perceptions of older people and service providers, In: Health & social care in the community27(5)pp. 1333-1343

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.

Katarzyna Stawarz, BENJAMIN GARDNER, Anna Cox, A Blandford (2020)What influences the selection of contextual cues when starting a new routine behaviour? An exploratory study, In: BMC Psychology8(1)pp. 29-29 BMC

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.

Benjamin P. Rigby, Peter van der Graaf, Liane B. Azevedo, Louise Hayes, BENJAMIN GARDNER, Caroline J. Dodd-Reynolds (2020)Challenges, opportunities and solutions for local physical activity stakeholders: an implementation case study from a cross-sectoral physical activity network in Northeast England, In: BMC public health20(1)pp. 1760-1760 BMC

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.

Amanda L. Rebar, A Reynolds, Sally A Ferguson, BENJAMIN GARDNER (2020)Accounting for automatic processes in sleep health, In: Journal of sleep research29(5)e12987 WILEY
Emily R Medd, Mark R Beauchamp, C Blanchard, Valerie Carson, BENJAMIN GARDNER, Darren E R Warburton, Ryan E. Rhodes (2020)Family-based habit intervention to promote parent support for child physical activity in Canada: protocol for a randomised trial, In: BMJ open10(4)e033732

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

Stina J. Grant, Mark R Beauchamp, Chris M. Blanchard, Valerie Carson, BENJAMIN GARDNER, Darren E R Warburton, Ryan E. Rhodes (2020)Parents and children active together: a randomized trial protocol examining motivational, regulatory, and habitual intervention approaches, In: BMC public health20(1)pp. 1436-1436 BMC

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 .

Roganie Govender, Christina H Smith, Helen Barratt, BENJAMIN GARDNER, Stuart A Taylor (2020)SIP SMART: a parallel group randomised feasibility trial of a tailored pre-treatment swallowing intervention package compared with usual care for patients with head and neck cancer, In: BMC cancer20(1)pp. 360-360 BMC

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.

BENJAMIN GARDNER, Amanda L. Rebar, Phillippa Lally (2020)‘Habitually deciding’ or ‘habitually doing’? A response to Hagger (2019), In: Psychology of sport and exercise47 Elsevier Ltd

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.

BENJAMIN GARDNER (2020)How do people interpret and respond to self-report sitting time questionnaires? a think-aloud study, In: Psychology of sport and exercise50 Elsevier Ltd

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.

BENJAMIN GARDNER, Phillippa Lally, Amanda L. Rebar (2020)Does habit weaken the relationship between intention and behaviour? Revisiting the habit-intention interaction hypothesis, In: Social and personality psychology compass14(8) WILEY

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.

Eleanor J Dommett, BENJAMIN GARDNER, Wijnand Van Tilburg (2020)Staff and students perception of lecture capture, In: The Internet and higher education46100732 Elsevier Inc

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.

BENJAMIN GARDNER, RR RICHARDS, Phillippa Lally, Amanda L. Rebar, Tanya Thwaite, RJ Beeken (2021)Breaking habits or breaking habitual behaviours? Old habits as a neglected factor in weight loss maintenance, In: Appetite162105183 ACADEMIC PRESS LTD- ELSEVIER SCIENCE LTD

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.

Silvio Maltagliati, Amanda Rebar, Layan Fessler, Cyril Forestier, Philippe Sarrazin, Aïna Chalabaev, David Sander, Hasmini Sivaramakrishnan, Dan Orsholits, Matthieu P Boisgontier, Nikos Ntoumanis, BENJAMIN GARDNER, Boris Cheval (2021)Evolution of physical activity habits after a context change: The case of COVID-19 lockdown, In: British journal of health psychology26(4)pp. 1135-1154 Wiley

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 

Elizabeth Gilchrist, AD Johnson, Mary McMurran, Danielle Stephens-Lewis, Sara Kirkpatrick, BENJAMIN GARDNER, C Easton, Gail Gilchrist (2021)Using the Behaviour Change Wheel to design an intervention for partner abusive men in drug and alcohol treatment, In: Pilot and feasibility studies7(1)pp. 1-14 BMC

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).

Ngoc Trai Nguyen, Tim Rakow, BENJAMIN GARDNER, Eleanor J Dommett (2021)Understanding the relationship between safety beliefs and knowledge for cognitive enhancers in UK university students, In: PloS one16(1)e0244865 Public Library of Science

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.

Catherine Dean, Lindy Clemson, Louise Ada, KL Scrivener, Natasha Lannin, Stefanie Mikolaizak, Sally Day, Anne Cusick, BENJAMIN GARDNER, Gillian Heller, Stephen Isbel, TD JONES, Virginia Mumford, Elisabeth Preston (2021)Home-based, tailored intervention for reducing falls after stroke (FAST): Protocol for a randomized trial, In: International journal of stroke16(9)pp. 1053-1058 Sage

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.

E Beard, F Lorencatto, BENJAMIN GARDNER, S Michie, L. Owen, L Shahab (2022)Behavioral Intervention Components Associated With Cost-effectiveness: A Comparison of Six Domains, In: Annals of behavioral medicine56(2)pp. 176-192 OUP

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.

Richard Cooke, Olivia Bailey, JR Jennings, Chun Yuen, BENJAMIN GARDNER (2021)Do preparatory behaviours predict alcohol consumption among UK university students?, In: British journal of health psychology26(2)pp. 343-359 WILEY

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.

Louise Robson, BENJAMIN GARDNER, Eleanor J Dommett (2022)The Post-Pandemic Lecture: Views from Academic Staff across the UK, In: Education sciences12(2) MDPI AG

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.

Eamon Colvin, BENJAMIN GARDNER, P Labelle, Darcy Santor (2021)The Automaticity of Positive and Negative Thinking: A Scoping Review of Mental Habits, In: Cognitive therapy and research45(6)pp. 1037-1063 SPRINGER/PLENUM PUBLISHERS

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.

BENJAMIN GARDNER, Amanda L. Rebar, Phillippa Lally (2022)How does habit form? Guidelines for tracking real-world habit formation, In: Cogent psychology9(1) Cogent

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.

Eleanor J Dommett, Larisa M Dinu, Wijnand Van Tilburg, Samuel Keightley, BENJAMIN GARDNER (2022)Effects of captions, transcripts and reminders on learning and perceptions of lecture capture, In: International Journal of Educational Technology in Higher Education19(1) Springer International Publishing

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.

Amanda L. Rebar, Kyra Hamilton, Ryan E. Rhodes, BENJAMIN GARDNER (2021)Habit Facilitates Actioning Sun Protective Behavior Intentions, In: Behavioral medicine (Washington, D.C.) Taylor & Francis

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 

BENJAMIN GARDNER, Madelynne A. Arden, D Brown, Frank F. Eves, JAMES GREEN, Kyra Hamilton, Nelli Hankonen, Jennifer Inauen, Jan Keller, Dominika Kwasnicka, Sarah Labudek, Hans Marien, Radomír Masaryk, Nicola McCleary, Barbara A. Mullan, Efrat Neter, S Orbell, Sebastian Potthoff, Phillippa Lally (2021)Developing habit-based health behaviour change interventions: twenty-one questions to guide future research, In: Psychology & health Routledge

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.

Matthias Burkard Aulbach, Hanna Konttinen, BENJAMIN GARDNER, Emilia Kujala, Vera Araujo-Soares, Falko F Sniehotta, Taru Lintunen, Ari Haukkala, Nelli Hankonen (2021)A dual process model to predict adolescents' screen time and physical activity, In: Psychology & health Taylor & Francis

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.

Sebastian Potthoff, Dominika Kwasnicka, Leah Avery, Tracy Finch, BENJAMIN GARDNER, Nelli Hankonen, DG Johnston, MD Johnston, Gerjo Kok, Phillippa Lally, Gregory Maniatopoulos, Marta M Marques, Nicola McCleary, Justin Presseau, Tim Rapley, Tom Sanders, Gill ten Hoor, Luke Vale, Bas Verplanken, Jeremy M Grimshaw (2022)Changing healthcare professionals' non-reflective processes to improve the quality of care, In: Social science & medicine (1982)298114840 Elsevier Ltd

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.

Samuele Porche, BENJAMIN GARDNER (2022)Reflective and non-reflective influences on cannabis use among undergraduate students: A qualitative study, In: Journal of American college healthahead-of-print(ahead-of-print)pp. 1-7 Taylor & Francis

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.

Jennie Blicher-Hansen, Joseph Chilcot, BENJAMIN GARDNER (2022)Experiences of successful physical activity maintenance among adults with type 2 diabetes: a theory-based qualitative study, In: Psychology & healthahead-of-print(ahead-of-print)pp. 1-18 Routledge

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.