title: Barriers and Recommended Interventions to Prevent Melioidosis in Northeast Thailand: A Focus Group Study Using the Behaviour Change Wheel.
abstract: Melioidosis, an often fatal infectious disease in Northeast Thailand, is caused by skin inoculation, inhalation or ingestion of the environmental bacterium, Burkholderia pseudomallei. The major underlying risk factor for melioidosis is diabetes mellitus. Recommendations for melioidosis prevention include using protective gear such as rubber boots and gloves when in direct contact with soil and environmental water, and consuming bottled or boiled water. Only a small proportion of people follow such recommendations.
  
  
  
  Nine focus group discussions were conducted to evaluate barriers to adopting recommended preventive behaviours. A total of 76 diabetic patients from northeast Thailand participated in focus group sessions. Barriers to adopting the recommended preventive behaviours and future intervention strategies were identified using two frameworks: the Theoretical Domains Framework and the Behaviour Change Wheel.
  
  
  
  Barriers were identified in the following five domains: (i) knowledge, (ii) beliefs about consequences, (iii) intention and goals, (iv) environmental context and resources, and (v) social influence. Of 76 participants, 72 (95%) had never heard of melioidosis. Most participants saw no harm in not adopting recommended preventive behaviours, and perceived rubber boots and gloves to be hot and uncomfortable while working in muddy rice fields. Participants reported that they normally followed the behaviour of friends, family and their community, the majority of whom did not wear boots while working in rice fields and did not boil water before drinking. Eight intervention functions were identified as relevant for the intervention: (i) education, (ii) persuasion, (iii) incentivisation, (iv) coercion, (v) modeling, (vi) environmental restructuring, (vii) training, and (viii) enablement. Participants noted that input from role models in the form of physicians, diabetic clinics, friends and families, and from the government via mass media would be required for them to change their behaviours.
  
  
  
  There are numerous barriers to the adoption of behaviours recommended for melioidosis prevention. We recommend that a multifaceted intervention at community and government level is required to achieve the desired behaviour changes.
authors.affiliation: Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.
authors.forename: Pornpan
authors.initials: P
authors.lastname: Suntornsut
authors.affiliation: Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.
authors.forename: Nittayasee
authors.initials: N
authors.lastname: Wongsuwan
authors.affiliation: Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.
authors.forename: Mayura
authors.initials: M
authors.lastname: Malasit
authors.affiliation: Department of Disease Control, Ministry of Public Health, Nonthaburi, Thailand.
authors.forename: Rungreung
authors.initials: R
authors.lastname: Kitphati
authors.affiliation: Centre for Outcomes Research Effectiveness, Research Department of Clinical, Educational and Health Psychology, University College London, London, United Kingdom.
authors.forename: Susan
authors.initials: S
authors.lastname: Michie
authors.affiliation: Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.|London School of Hygiene and Tropical Medicine, London, United Kingdom.
authors.forename: Sharon J
authors.initials: SJ
authors.lastname: Peacock
authors.affiliation: Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.|Department of Tropical Hygiene, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.|Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom.
authors.forename: Direk
authors.identifier: 0000-0001-7240-5320
authors.initials: D
authors.lastname: Limmathurotsakul
mesh_terms: D000293:Adolescent; D000328:Adult; D016957:Burkholderia pseudomallei / Q000235:genetics / Q000302:isolation & purification* / Q000502:physiology; D005260:Female; D017144:Focus Groups; D006801:Humans; D008297:Male; D008554:Melioidosis / Q000453:epidemiology / Q000382:microbiology / Q000523:psychology*; D008875:Middle Aged; D013785:Thailand / Q000453:epidemiology; D055815:Young Adult