title: Using an Analysis of Behavior Change to Inform Effective Digital Intervention Design: How Did the PRIMIT Website Change Hand Hygiene Behavior Across 8993 Users?
abstract: BACKGROUND
  In designing digital interventions for healthcare, it is important to understand not just whether interventions work but also how and for whom-including whether individual intervention components have different effects, whether a certain usage threshold is required to change behavior in each intervention and whether usage differs across population subgroups.
  
  
  OBJECTIVE
  We investigated these questions using data from a large trial of the digital PRimary care trial of a website based Infection control intervention to Modify Influenza-like illness and respiratory tract infection Transmission) (PRIMIT) intervention, which aimed to reduce respiratory tract infections (RTIs) by increasing hand hygiene behavior.
  
  
  METHODS
  Baseline and follow-up questionnaires measured behaviors, intentions and attitudes in hand hygiene. In conjunction with objective measures of usage of the four PRIMIT sessions, we analysed these observational data to examine mechanisms of behavior change in 8993 intervention users.
  
  
  RESULTS
  We found that the PRIMIT intervention changed behavior, intentions and attitudes, and this change was associated with reduced RTIs. The largest hand hygiene change occurred after the first session, with incrementally smaller changes after each subsequent session, suggesting that engagement with the core behavior change techniques included in the first session was necessary and sufficient for behavior change. The intervention was equally effective for men and women, older and younger people and was particularly effective for those with lower levels of education.
  
  
  CONCLUSIONS
  Our well-powered analysis has implications for intervention development. We were able to determine a 'minimum threshold' of intervention engagement that is required for hand hygiene change, and we discuss the potential implications this (and other analyses of this type) may have for further intervention development. We also discuss the application of similar analyses to other interventions.
authors.affiliation: Centre for Clinical and Community Applications of Health Psychology, Psychology, Faculty of Social and Human Sciences, University of Southampton, Southampton, SO17 1BJ, UK. ben.ainsworth@southampton.ac.uk.|Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK. ben.ainsworth@southampton.ac.uk.
authors.forename: B
authors.identifier: http://orcid.org/0000-0002-5098-1092
authors.initials: B
authors.lastname: Ainsworth
authors.affiliation: Centre for Clinical and Community Applications of Health Psychology, Psychology, Faculty of Social and Human Sciences, University of Southampton, Southampton, SO17 1BJ, UK.
authors.forename: M
authors.initials: M
authors.lastname: Steele
authors.affiliation: Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.
authors.forename: B
authors.initials: B
authors.lastname: Stuart
authors.affiliation: Centre for Clinical and Community Applications of Health Psychology, Psychology, Faculty of Social and Human Sciences, University of Southampton, Southampton, SO17 1BJ, UK.
authors.forename: J
authors.initials: J
authors.lastname: Joseph
authors.affiliation: Centre for Clinical and Community Applications of Health Psychology, Psychology, Faculty of Social and Human Sciences, University of Southampton, Southampton, SO17 1BJ, UK.
authors.forename: S
authors.initials: S
authors.lastname: Miller
authors.affiliation: Centre for Clinical and Community Applications of Health Psychology, Psychology, Faculty of Social and Human Sciences, University of Southampton, Southampton, SO17 1BJ, UK.|Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.
authors.forename: L
authors.initials: L
authors.lastname: Morrison
authors.affiliation: Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.
authors.forename: P
authors.initials: P
authors.lastname: Little
authors.affiliation: Centre for Clinical and Community Applications of Health Psychology, Psychology, Faculty of Social and Human Sciences, University of Southampton, Southampton, SO17 1BJ, UK.
authors.forename: L
authors.initials: L
authors.lastname: Yardley
mesh_terms: D000328:Adult; D001521:Behavior Therapy; D005260:Female; D063373:Hand Hygiene; D006801:Humans; D007251:Influenza, Human / Q000517:prevention & control*; D033182:Intention; D008297:Male; D008875:Middle Aged; D011795:Surveys and Questionnaires
keywords: Behavior change; Digital interventions; Engagement; Hand hygiene; Usage