Literature review
The review identified eight papers of relevance (Table 3) which tested five engagement strategies: monetary incentives [20–23]; a prize draw [24]; professional testimonial [5]; text message reminders [25]; and smaller time commitment [26]. The majority tested interventions for parenting programmes [5, 21, 22, 25, 27], two were substance abuse prevention programmes [20, 26] and one smoking cessation programme [24]. None tested interventions in the UK. Two strategies demonstrated effectiveness; financial incentives [28] [23]; and text message reminders. Although Diaz et al. and Heinrichs et al. observed positive effects with a financial incentive, Dumas et al. and Gross et al. did not. This is consistent with the wider literature that suggests financial incentives are not always effective. Further, this approach is unlikely to be feasible at population level and so was not considered in the present study. Text message reminders were effective at promoting programme completion. This method is widely used to promote uptake of clinical interventions or appointments, and are a low cost and low resource strategy which indicated potential for this intervention [29–32]. The findings of this review were presented to the intervention development team to summarise the current literature.
Table 3 Studies that have tested a strategy to promote engagement with a public health programme
|
Study
|
Public health programme
|
Sample
|
Evaluation design
|
Engagement intervention
|
Measures
|
Outcome
|
|
Diaz et al. 2009
|
Family drug use prevention programme delivered in secondary school setting in Spain
|
197 families invited from three participating secondary schools in different localities with high risk factors of drug use
|
Quasi-experimental design
One school randomly selected (n=3) to receive intervention condition
|
Financial incentive
I= €10 shopping voucher received for each session attended (up to 7 sessions)
C=no shopping voucher
|
Attendance
|
I>C attendance (6.2 vs 2.0 mean sessions attended from study sample) p=0
|
|
Dumas et al. 2010
|
Parenting programme delivered in day-care setting in US
|
610 parents that completed a survey at participating daycare centre invited to enrol
|
Experimental design
Daycare centres (n=50) randomised to incentive intervention or control condition
|
Financial incentive
I= up to $68 received depending on number of sessions attended
C=no financial incentive
|
Enrolment
Attendance
|
I>C enrolled (52.3 vs 47.7%) p=n.s.
I<C enrolled and attended first session (46.0 vs 54.0%) p=n.s.
I>C attended all sessions (30.5 vs 20.7%) p=n.s.
|
|
Emont and Cummings, 1992
|
Worksite smoking cessation programme at car dealership in US
|
56 smokers from car dealership work sites
|
Quasi-experimental design
Worksites (n=25) randomised to “prize draw” intervention or control condition
|
Prize draw (“dinner for two”)
I=participants offered a chance to win a dinner for two in a local restaurant if they attended the first session
C=no prize draw offered
|
Attendance
|
I<C (6.3% vs 6.7% participation rate) p=n.s
|
|
Gross et al. 2011
|
Parenting programme delivered in childcare setting in US
|
174 parents using participating “low income” childcare centre
|
Experimental design
Childcare centres (n=8) randomised to discount condition or control condition
|
Financial incentive
I=parents offered a discount on their childcare bill contingent with weekly attendance at programme
C=no financial incentive
|
Enrolment
Attendance
|
I>C enrolled (93 vs 81) p=n.s.
I>C mean attendance (6.26 vs 5.86 sessions) p=n.s.
|
|
Study
|
Public health programme
|
Sample
|
Evaluation design
|
Engagement intervention
|
Measures
|
Outcome
|
|
Heinrichs et al. 2006
|
Parenting programme in preschool setting in Germany
|
248 parents whose children attended participating preschools
|
Experimental design
Preschools (n=15) matched on size then randomly assigned to four incentive conditions
|
Financial incentive and either group or individual format
15 preschools randomise to four intervention conditions
Incentive= up to $145 depending on how many sessions attended
Individual or group format….
I1=Individual format + no incentive
I2=Group format + no incentive
I3=Indvidual format +incentive
I4=Group format + incentive
|
Initial enrolment
Completers
|
I1=26.8% enrolled
I2=25.8% enrolled
I3=52.7% enrolled
I4=38.3% enrolled
I1=58% completers
I2=85% completers
I3=65% completers
I4=81% completers
Main effect between incentive and non-incentive p=<.05
|
|
Morawska et al. 2011
(Study 2)
|
Parenting programme delivered in Australia
|
73 parents recruited from primary schools around Australia via email
|
Experimental design
Participants randomly assigned to one of three conditions
|
Professional testimonial
I1=non-fear expert testimonial…….
I2=fear expert testimonial………
|
Recruitment
|
I1<I2participated (58.92 vs 59.09) p=n.s.
|
|
Murray et al. 2015
|
Parenting programme delivered in community setting in US
|
117 parents from area where children are at high-risk of malnutrition
|
Randomised controlled trial
Participants randomised to receive SMS message reminder or no message
|
SMS reminder
I=text message reminders sent to participants on the day before each class
C=no text message
|
Attendance
Completion
|
I>C mean sessions attended (7.0 vs 7.0) p=n.s
I>C completed the class (79% vs 63%) p=.049
|
|
Spoth et al. 1994
|
Family substance abuse prevention programme delivered in school setting in the US
|
208 families from six school districts in two rural counties that were eligible for state supported school lunch
|
Quasi-experimental design
Participants randomised to intervention or control condition
|
Recruitment strategy (reduced time commitment)
I=project overview with programme summary received, participant invited to in-home interview only, at initial in-home interview participant invited to 2nd in-home interview and full programme participation
C=full programme brochure received, participant invited to participate in full programme, participant invited to commit to full programme
|
Attendance
|
I<C participants (88.2 vs 98.2 families) p=n.s
|
|
Stage 1:
Defining the problems in behavioural terms
The findings of the ethnography were consistent with what has previously been reported in the literature regarding participant level barriers to engagement with parenting programmes e.g. programme acceptability, group dynamics and the personal attributes of the group facilitator [33–38]. However, the study also revealed that engagement with HENRY was influenced by implementation factors that were present across multiple operational levels within the children’s centre/local authority context. This was consistent with what is known about the effective implementation of public health programmes. In particular, a hierarchical spill-over affect was observed, whereby local authority ‘buy-in’ of HENRY cascaded down to children’s centre implementation of the programme which subsequently influenced how participants perceived and experienced the programme. During each intervention development meeting, the findings of the ethnography study were discussed and the team considered whether the findings acted as a barrier or lever to engagement. For example, in one centre some staff members had poor understanding of what HENRY entailed which hindered their efforts to recruit to the programme and therefore was a barrier to engagement. In contrast, in a different centre, all centre staff had received training in the HENRY approach which gave them confidence when approaching parents to attend which was a facilitator to engagement. However, a further finding of the ethnography study revealed that, although stakeholders acknowledged that some behaviours were likely to facilitate participant engagement with HENRY (e.g. HENRY training for all staff), practical barriers such as funding availability and capacity limited their ability to adopt them. Therefore, the problem defined in behavioural terms as to why centres struggled to recruit and retain participants on the HENRY programmes was that Children’s centre stakeholders (commissioners, managers and centre staff) did not (or were not able to) adopt behaviours that were likely to promote participant engagement.
Selecting the target behaviour
The intervention development team used the findings of the ethnography study, the literature and professional experience to develop a list of broad intervention targets that were proposed to promote participant engagement with HENRY if adopted by children’s centre stakeholders (Table 4); for example, delivering a taster session prior to each session. They then narrowed these down by determining who would be able to deliver these interventions and whether this was dependent on the behaviours of other people within the children’s centre/local authority setting. For example, establishing whether managers would have the autonomy to provide HENRY training for staff without agreement from the local authority decision makers. With this in mind, the optimisation development team specified a ‘long list’ of 33 target behaviours aimed at individuals from across the children’s centre hierarchy (local authority commissioners, centre managers, centre staff, HENRY facilitators and parents that had attended the HENRY programme) that would facilitate the broader intervention targets to be met. The long list of 33 behaviours was then narrowed down to 16 using the BCW exercise of prioritising behaviours into very promising, quite promising, and worth considering and team ranking of the behaviours.
Identifying what needs to change
The COM-B behavioural analysis determined the direction of the intervention at each level (Table 5).
Table 4 Recommended behaviours for promoting parent engagement with HENRY
Table 5 Summary of behavioural analysis to identify which components of the COM-B model would need to be influenced in the Participant Engagement Intervention.
Intervention level
|
Target behaviours
|
The COM-B construct that need to be influenced for target behaviours to occur.
|
Would need to be influenced for behaviour change to occur
|
Potential intervention function suggested by BCW
|
Commissioner
|
- Support/allow managers to implement recommended parent engagement strategies
|
Capability
(psychological)
|
Commissioners need greater understanding of HENRY outcomes to facilitate decision making around level of support they are willing to provide
|
✔
|
Education, training or enablement
|
Opportunity
(physical)
|
Strict budgets exist around how much money can be invested into participant engagement efforts. Therefore higher budgets would be required.
|
✔
|
Higher budgets would not be possible to influence within the intervention
|
Motivation
(reflective)
|
Motivation of commissioners need to be increased before additional resources are invested into participant engagement efforts.
|
✔
|
Education, persuasion, incentivisation, coercion
|
Managers
|
- Plan courses regularly and far in advance
- Provide further training for staff
- Allow self-referred parents to enrol
- Run taster sessions
- Promote HENRY using a variety of methods
- Implement peer to peer recruitment
|
Capability
(psychological)
|
Managers are already capable of performing the behaviours
|
X
|
N/A
|
Opportunity (social)
|
Managers need support from commissioners before investing greater resources into parent engagement efforts
|
✔
|
Restriction, environmental restructuring, modelling, enablement
|
Motivation
(reflective)
|
Prior to investing greater resources into HENRY, manager’s motivation would need to be increased due to restricted budgets and staff capacity.
|
✔
|
This would be influenced at the commissioner intervention level
|
HENRY facilitators
|
- Allow enough time in sessions to explore feelings
- Follow up on people that miss a session
- Consider characteristics of the group
- Put parents at ease during sessions
- Return outcome data promptly to allow prompt reporting
- Invite participants of HENRY to recruit their peers
|
Capability
(psychological)
|
Some facilitators may lack the relevant capability to perform the behaviours e.g. due to lack of experience
|
✔
|
Education, training or enablement
|
Opportunity
(physical)
|
A lack of time may present barriers to facilitators’ performing the behaviours
|
✔
|
Training, restriction, environmental restructuring or enablement
|
Motivation
(reflective)
|
The motivation of some facilitators could be increased to in order for them to invest additional time to HENRY planning.
|
✔
|
Education, persuasion, incentivisation, coercion
|
Intervention level
|
|
The COM-B construct that need to be influenced for target behaviours to occur.
|
Would need to be influenced for behaviour change to occur
|
Potential intervention function suggested by BCW
|
Children’s Centre staff
|
- Promote HENRY accurately to dispel myths
- Adopt whole centre approach to HENRY
|
Capability
(psychological)
|
Children’s centre staff often do not have the relevant capacity to perform the behaviours due to a lack of training.
|
✔
|
This would be influenced at the manager level of the intervention
|
Opportunity
(Social)
|
Staff would require adequate social support from managers and team members to perform the behaviours, along with physical resources to assist with promoting the programme.
|
✔
|
Restriction, environmental restructuring, modelling, enablement
|
Motivation
(reflective)
|
The motivation of some staff members would need to be increased in order for them to learn and implement new practices.
|
✔
|
Education, persuasion, incentivisation, coercion
|
HENRY parents
|
- Volunteer to be a peer recruiter
|
Capability
(psychological)
|
Previous participants of HENRY have the relevant capacity to be able to recruit their peers.
|
X
|
|
Opportunity
(physical)
|
The relevant physical resources would need to be provided in order for previous participants of HENRY to recruit their peers. In addition, social support from centre managers would also need to be influenced so that parents feel comfortable that their peers would be eligible and welcome to attend.
|
✔
|
Training, restriction, environmental restructuring or enablement
|
Motivation
(reflective)
|
Previous participants of HENRY that have enjoyed the programme would be likely to be motivate do recruit their peers. However, some may also worry about causing offense by inferring that the family/child needed to attend an obesity prevention programme.
|
✔
|
Education, persuasion, incentivisation, coercion
|
Stage 2: Identifying intervention options
Based on the findings of the behavioural analysis, experience of the optimisation development team and the literature, the team utilised APEASE criteria to agree on the most appropriate intervention functions. For example, although some potential functions were likely to be effective such as ‘enabling’ commissioners to support manager to adopt the recommended engagement strategies by providing additional funding, this would not have been affordable within the realms of the project. Whereas ‘education’ was agreed to be affordable, acceptable practicable and likely to be effective.
The outcome of this process is outlined in Table 5.
Stage 3: Identifying content and implementation options
Once it was agreed what the various functions of the interventions would be, APEASE criteria again facilitated structured group discussions around which behaviour change techniques had the potential to demonstrate effectiveness, balanced with which would be affordable, practicable, acceptable, equitable and present no side effects. Once agreed, the team considered how the behaviour change techniques could be incorporated into the intervention. The outcome of this stage is detailed in Table 6.
Intervention and delivery
The participant engagement intervention comprises the following components. The aim is to change behaviours of individuals across five levels of the local authority/children’s centre hierarchy: local authority commissioners, children’s centre managers, children’s centre staff, HENRY facilitators and previous participants of HENRY (summarised in Table 6)
- HENRY outcome report and leaflet: This is aimed at increasing local authority (or equivalent) commissioner support for HENRY implementation. The report outlines programme outcomes such as pre and post fruit and vegetable intake. The report will be produced and distributed by the central HENRY team. A HENRY overview leaflet will also be distributed to local authority commissioners which describes recommended strategies to promote recruitment and retention to HENRY, as well as describing the expected benefits of adopting the strategies.
- Dashboard report: A one page report summary will be circulated to children’s centre managers after each HENRY programme summarising the main participant and implementations outcomes (e.g. changes in dietary behaviour, parenting efficacy and recruitment and retention rates).The report aims to increase manager engagement with HENRY to encourage increased resource into promotion of the programme.
- Manager Information Days: Managers from of children’s centres delivering HENRY will be invited to attend a one day manager information workshop. During the workshop, strategies to promote participant engagement with HENRY will be recommended along with a discussion on the expected benefits of adopting them.
- Facilitator refresher training: Facilitators of HENRY will be invited to attend a one day refresher training session. Sessions will highlight and provide training on how to optimise the participant experience. The training session will also introduce the concept of peer recruitment.
- Revised promotional material will be utilised buy all centres recruiting to HENRY programmes which includes a new strapline for the HENRY programme; ‘Healthy family, happy home’ rather than Health, Exercise, Nutrition for the Really Young.
See additional file 1 for the logic model of how the intervention hoped to promote participant engagement with HENRY.
Table 6. Participant engagement intervention behaviour change technique and intervention component linked to intervention function
Intervention level
|
Intervention function
|
Behaviour change technique
|
Operationalised by
|
Intervention component
|
Commissioner
|
Enablement
|
12.5 Adding objects to the environment
|
Information about how HENRY supports families and the benefits of investing appropriate resources into participant engagement efforts
|
Commissioner report
|
Education
|
5.6 Information about social and environmental consequences
|
Regular outcome reports to enable decision making around HENRY
|
Commissioner leaflet
|
Managers
|
Persuasion
|
5.6 Information about social and environmental consequences
|
Information on how local families have benefited from attending HENRY and why it is beneficial to adopt target behaviours
|
Manager information day and dashboard report
|
HENRY facilitators
|
Training
|
4.1 Instruction on how to perform the behaviour
|
Instruction on how to incorporate target behaviours into HENRY session delivery
|
Facilitator refresher training
|
Persuasion
|
5.6 Information about social and environmental consequences
|
Information on why it is beneficial to adopt target behaviours
|
Facilitator refresher training
|
Children’s Centre staff
|
Environmental restructuring
|
12.5 Adding objects to the environment
|
Provision of promotional material which accurately depicts HENRY programme
|
Promotional material
|
Persuasion
|
5.6 Information about social and environmental consequences
|
Information on how HENRY supports families and how local families have benefitted from attending.
|
Dashboard report and promotional material
|
HENRY parents
|
Enablement
|
12.5 Adding objects to the environment
|
Resources to assist with peer recruitment such as promotional material and information on future course dates
|
Facilitator refresher training
|
Education
|
5.6 Information on social consequences
|
Information on why peer recruitment is effective for recruiting friends and families to the HENRY programme and therefore more people can benefit from the support it provides.
|
Promotional material
Facilitator refresher training
|