Study design and rationale for a cluster randomized trial of a safe child feces management intervention in rural Odisha, India

Background Poor child feces management (CFM) is believed to be an important source of exposure to enteric pathogens that contribute to a large disease burden in low-income settings. While access to sanitation facilities is improving, national surveys indicate that even households with latrines often do not safely dispose of their child’s feces. Working with caregivers in rural Odisha, India, we co-developed an intervention aimed at improving safe disposal of child feces and encouraging child latrine use at an earlier age. We describe the rationale for the intervention and summarize the protocol for a cluster randomized trial (CRT) to evaluate its effectiveness at changing CFM practices. Methods The intervention consists of six behavior change strategies together with hardware provision: wash basin and bucket with lid to aid safe management of soiled nappies and a novel latrine training mat to aid safe disposal and latrine training. The intervention will be offered at the village level to interested caregivers of children < 5 years of age by a community-based organization. Following a baseline survey, 74 villages were randomly allocated to either intervention or control arm. The primary outcome is caregiver reported safe disposal of child feces after last defecation, either by the caregiver disposing of the child’s feces into the latrine or the child using the latrine, measured approximately four to six months following intervention delivery. Secondary outcomes include fecal contamination of household drinking water and the childs’ hands. A process evaluation will also be conducted to assess intervention fidelity and reach, and explore implementer and participant feedback. Discussion This study addresses a crucial knowledge gap in sanitation by developing a scalable intervention to improve safe management of child feces. The behavior change strategies were designed following the Risks, Attitudes, Norms, Abilities and Self-Regulation (RANAS) approach, which has shown to be effective for other environmental behavior change interventions in low-income settings. The latrine training mat hardware is a novel design developed cooperatively and manufactured locally. The evaluation follows a rigorous CRT study design assessing the impact of the intervention on CFM behavior change, as well as fecal contamination of two sources of potential exposure. Trial registration This trial is registered at ISRCTN: ISRCTN15831099.

MIA

Since online discussion platforms can limit the perception of social cues, effective collaboration over videochat requires additional attention to conversational skills. However, self-affirmation and defensive bias theories indicate that feedback may appear confrontational, especially when users are not motivated to incorporate them. We develop a feedback chatbot that employs Motivational Interviewing (MI), a directive counseling method that encourages commitment to behavior change, with the end goal of improving the user's conversational skills. We conduct a within-subject study with 21 participants in 8 teams to evaluate our MI-agent 'MIA' and a non-MI-agent 'Roboto'. After interacting with an agent, participants are tasked with conversing over videochat to evaluate candidate résumés for a job circular. Our quantitative evaluation shows that the MI-agent effectively motivates users, improves their conversational skills, and is likable. Through a qualitative lens, we present the strategies and the cautions needed to fulfill individual and team goals during group discussions. Our findings reveal the potential of the MI technique to improve collaboration and provide examples of conversational tactics important for optimal discussion outcomes.

Bridging Community, History, and Culture in Personal Informatics Tools

A healthy diet and increased physical activity are essential for reducing the prevalence of cardiovascular disease and related deaths, a worldwide public health concern that disproportionately affects Black American communities. Still, Black Americans can face unique challenges meeting dietary and physical activity requirements due to inequities in access and quality of care, environmental and local factors, and difficulties in changing individual health behaviors. Personal informatics and self-tracking tools are one way of increasing awareness of health behaviors to motivate behavior change. However, there are still gaps in knowledge about what encourages different users to engage with personal informatics tools over time, particularly when used in collaborative, community-health settings. This paper contributes a nuanced understanding of fifteen participants' reasons for engaging in an existing community-based health education and behavior change program that combines collaborative self-tracking with culturally relevant content and social engagement to motivate heart-healthy behaviors. We illustrate participants' positive and negative experiences engaging in self-tracking and collaborative tasks during the program. We also discuss how participants envision that integrating technology might support or hinder participant engagement and the work of deploying community-based public health interventions. Finally, we discuss design implications for culturally informed, community-based personal informatics tools that engage Black American's in heart-healthy activities.

“Sometimes You Get Good Ones, and Sometimes You Get Not-so-Good Ones”: Vendors’ and Consumers’ Strategies to Identify and Mitigate Food Safety Risks in Urban Nigeria

This paper uses detailed data from in-depth interviews with consumers (n = 47) and vendors (n = 37) in three traditional markets in Birnin Kebbi, Nigeria. We used observations from those markets to examine how consumers and vendors identify and avoid or manage food safety risks and whom they hold responsible and trust when it comes to ensuring food safety. At the level of the vendor, consumers mentioned seeking “clean” or “neat” vendors or stalls. Cleanliness was primarily related to the appearance of the vendor, stall, and surroundings; reliance on trusted, known vendors was also noted. Food products themselves were largely evaluated based on visual cues: insects, holes, and colors—with some reliance on smell, also. Similarly, vendors assessed safety of food from suppliers based on a visual assessment or reliance on trusted relationships. On the second research question, both consumers and vendors largely placed responsibility for ensuring food safety on government; when asked specifically, consumers also named specific steps that vendors could take to ensure food safety. Consumers and vendors also generally felt that they could limit many food safety risks through identifying the “good” products in the market or from suppliers. The paper discusses the implications of these results for behavior change interventions.

Tapping into Residents’ Perceptions to Diffuse Landscape Water Conservation and Protection Practices

This new 4-page article provides real examples of how university researchers used the Diffusion of Innovations theory to analyze Florida residents’ perceptions of landscape conservation and fertilizer behaviors and identify barriers and opportunities to encourage widespread adoption. The information and recommendations are intended for Extension professionals and other practitioners to promote behavior change in household landscaping practices. Written by Colby Silvert, Laura Warner, Matt Benge, and John Diaz and published by the Department of Agricultural Education and Communication.https://edis.ifas.ufl.edu/wc405

On the need to investigate the barriers to physical activity that are specific to stigmatized individuals

Understanding what predicts behavior change is a hot topic in health psychology, especially with regard to physical activity. While existing research has revealed key factors of physical activity (e.g., reasoned cognitions, automatic processes), it fails to accurately identify those that are specific to the most inactive populations (e.g., older adults, obese individuals, women, people living with chronic disease). In this commentary, we propose to articulate current approaches of health behavior change with the social psychology of stereotypes, based on the observation that inactive groups are often targeted by negative stereotypes. This articulation may allow to better identify the barriers to physical activity that are specific to individuals from the most inactive groups. More particularly, we propose that low self-control resources and self-perceptions may be key factors of physical inactivity in these individuals. This proposition could in turn help to explain why some behavioral change techniques that are efficient in healthy or young adults are inefficient in other individuals.

Implementation and Evaluation of a Digitally Enabled Precision Public Health Intervention to Reduce Inappropriate Gabapentinoid Prescription: Cluster Randomized Controlled Trial

Background Digital technologies can enable rapid targeted delivery of audit and feedback interventions at scale. Few studies have evaluated how mode of delivery affects clinical professional behavior change and none have assessed the feasibility of such an initiative at a national scale. Objective The aim of this study was to develop and evaluate the effect of audit and feedback by digital versus postal (letter) mode of delivery on primary care physician behavior. Methods This study was developed as part of the Veterans’ Medicines Advice and Therapeutics Education Services (MATES) program, an intervention funded by the Australian Government Department of Veterans’ Affairs that provides targeted education and patient-specific audit with feedback to Australian general practitioners, as well as educational material to veterans and other health professionals. We performed a cluster randomized controlled trial of a multifaceted intervention to reduce inappropriate gabapentinoid prescription, comparing digital and postal mode of delivery. All veteran patients targeted also received an educational intervention (postal delivery). Efficacy was measured using a linear mixed-effects model as the average number of gabapentinoid prescriptions standardized by defined daily dose (individual level), and number of veterans visiting a psychologist in the 6 and 12 months following the intervention. Results The trial involved 2552 general practitioners in Australia and took place in March 2020. Both intervention groups had a significant reduction in total gabapentinoid prescription by the end of the study period (digital: mean reduction of 11.2%, P=.004; postal: mean reduction of 11.2%, P=.001). We found no difference between digital and postal mode of delivery in reduction of gabapentinoid prescriptions at 12 months (digital: –0.058, postal: –0.058, P=.98). Digital delivery increased initiations to psychologists at 12 months (digital: 3.8%, postal: 2.0%, P=.02). Conclusions Our digitally delivered professional behavior change intervention was feasible, had comparable effectiveness to the postal intervention with regard to changes in medicine use, and had increased effectiveness with regard to referrals to a psychologist. Given the logistical benefits of digital delivery in nationwide programs, the results encourage exploration of this mode in future interventions.

The impact of a demand-side sanitation and hygiene promotion intervention on sustained behavior change and health in Amhara, Ethiopia: A cluster-randomized trial

Behaviors related to water, sanitation, and hygiene (WASH) are key drivers of infectious disease transmission, and experiences of WASH are potential influencers of mental well-being. Important knowledge gaps exist related to the content and delivery of effective WASH programs and their associated health impacts, particularly within the contexts of government programs implemented at scale. We developed and tested a demand-side intervention called Andilaye, which aimed to change behaviors related to sanitation, personal hygiene, and household environmental sanitation. This theory-informed intervention was delivered through the existing Ethiopian Health Extension Programme (HEP). It was a multilevel intervention with a catalyzing event at the community level and behavior change activities at group and household levels. We randomly selected and assigned 50 kebeles (sub-districts) from three woredas (districts), half to receive the Andilaye intervention, and half the standard of care sanitation and hygiene programming (i.e., community-led total sanitation and hygiene [CLTSH]). We collected data on WASH access, behavioral outcomes, and mental well-being. A total of 1,589 households were enrolled into the study at baseline; 1,472 households (94%) participated in an endline assessment two years after baseline, and approximately 14 months after the initiation of a multi-level intervention. The intervention did not improve construction of latrines (prevalence ratio [PR]: 0.99; 95% CI: 0.82, 1.21) or handwashing stations with water (PR: 0.96; 95% CI: 0.72, 1.26), or the removal of animal feces from the compound (PR: 1.10; 95% CI: 0.95, 1.28). Nor did it impact anxiety (PR: 0.90; 95% CI: 0.72, 1.11), depression (PR: 0.83; 95% CI: 0.64, 1.07), emotional distress (PR: 0.86; 95% CI: 0.67, 1.09) or well-being (PR: 0.90; 95% CI: 0.74, 1.10) scores. We report limited impact of the intervention, as delivered, on changes in behavior and mental well-being. The effectiveness of the intervention was limited by poor intervention fidelity. While sanitation and hygiene improvements have been documented in Ethiopia, behavioral slippage, or regression to unimproved practices, in communities previously declared open defecation free is widespread. Evidence from this trial may help address knowledge gaps related to challenges associated with scalable alternatives to CLTSH and inform sanitation and hygiene programming and policy in Ethiopia and beyond. Trial registration: This trial was registered with clinicaltrials.gov (NCT03075436) on March 9, 2017.

Smokers' Engagement Behavior on Facebook regarding to Smoking Cessation Verbalization and Facebook Reaction Usage: Content Analysis (Preprint)

BACKGROUND The Transtheoretical Model recommends "processes of change", while the Motivational Interviewing approach offers “motivational language” as indicators of health behavior change. The relationship between these indicators and the usage of Facebook reaction buttons is little known. However, this relationship may highlight how to evaluate one of the most popular engagement indicators (Facebook reactions) in online health behavior change interventions. OBJECTIVE The study aim was to understand the relationship between processes of change, motivational language, Facebook users’ gender, and the Facebook reaction buttons. METHODS A total of 821 comments were analyzed in the current study (N=821), which came from different Facebook users, and responded to image-based, smoking cessation support contents. The processes of change (experiential and behavioral processes) and the motivational language (change talk and sustain talk) in the investigated comments were identified. The presence, the number, and the proportion of these linguistic categories were compared with the Facebook users’ gender and the usage of reaction buttons. RESULTS The Facebook users who used the “Haha” reaction button wrote significantly higher proportion of sustain talk than those who used the “Like” or “Love” reaction (P=.011). No significant difference in the number or proportion of linguistic categories was found between those who used the "Like" reaction button, and those who did not use reaction buttons. The Facebook users who combined the comment and “Love” reaction wrote significantly more change talk than those who used the “Haha” and “Like” reactions, or those who did not utilize these buttons (P<.001). Significant female dominance was observed in the presence, the number, and the proportion of experiential processes and change talk (P<.05). In addition, significant male predominance was found in the presence, the number, and the proportion of sustain talk (P<.05). CONCLUSIONS The "Haha" reaction may be a negative engagement indicator, the "Like" reaction may be a neutral engagement indicator, and the "Love" reaction may be a positive engagement indicator in terms of the smoking cessation during Facebook-based interventions. Furthermore, female engagement may be characterized by utilizing the terms of experiential processes and change talk, while the usage of sustain talk can be typical for male engagement. We recommend the evaluation of processes of change and motivational utterances in participants' comments during online public health interventions.