The results reported below represent the application of the BCW method. A summary of the BCW method employed is illustrated in Figure 1.
Step 1- Define the Problem in Behavioural Terms
Following a consensus meeting, the problem was defined as (a) the low level of awareness regarding drug-use decision making, (b) the poor insight as to the consequences of drug-use behaviours, and (c) the lack of opportunities to consider alternatives to fulfil personal enhancement. Therefore, the group decided that the intervention should focus on (a) increasing mindful decision-making in relation to illicit drug-use behaviours, and (b) enhancing individuals’ insight for alternatives to drug-use behaviours as means to fulfil the students’ personal enhancement. In relation to the context where the intervention should target, the group decided that the social events which involve alcohol consumption and students’ grouping who either declare occasional drug-use or non-use as targeted contextual features.
Some of the identified influences on drug-use are related to the physical and social opportunities that may be afforded by the university context. Other factors are related to students’ reflective motivation (e.g., how their peers would view them, feelings of shame) and automatic motivation (e.g., a desired outcome from the use). Finally, capabilities are not identified in the context of students’ drug-use behaviours. The scoping review (MRP) identified two contextual variables as potentially risky factors: the university context and the transition period from the second level (i.e., high school) to higher education. These factors require harm-reduction strategies at a systemic/policy-level (e.g., new public health responses to illicit drugs and alcohol use) (49). However, our analyses of behavioural diagnostics indicated the value of individual-level focus.
Step 2- Select the Target Behaviour
A long list of 67 potential behaviours (items) was derived from the synthesis of all the relevant literature review. Figure 2 illustrates five potential targets relevant to drug-use behaviours that can increase students’ awareness in relation to their decision to take drugs and can increase understanding of alternatives as means to fulfil the students’ personally relevant enhancements (the entire list is shown in Supplementary Table S1). In refining the long list of potential targets, one can see that current university service provisions address some of the targeting behaviours. For example, psychoeducation about the consequences of illicit drug-use (domain C) is service universities often provide as part of their health care policies (49). The advisory group participated in a Delphi-type exercise with two ranks.
In round one from the 67 items identified, only 24 items reached the agreement point of 70% (see Supplementary Table S1). Seventeen items were from the targeted behaviour A (increase awareness of current illicit drug-use behaviours), four from B (maximize self-regulatory capacity and skill), one from C (resilient-related skills), and two from E (address personalized-contextual factors). None of the items from domain D (provide psychoeducation relevant to drug-use) reached the agreement point and this behavioural target was excluded from round two.
In round two, from the 24 items selected, 15 items reached the agreement point of the median score, using the APEASE criteria (values > 3.25), as potential drug-use behaviours to target (10 from A; 4 for B; and one from E; see Supplementary Table S2). Finally, of these 15 items, only 4 reached the agreement of the mean score of the APEASE criteria (ranked > 70%) and these were selected as potential behaviours to target. All four items (targets relevant to drug-use behaviours) were from the behavioural target A (see Table 1 for the four identified behaviours). These items indicate that the targeted behaviours should increase awareness in relation to contextual factors (e.g., peers) that influence drug-use decision making and enhance insight as to the internal motivations of the students to use drugs (e.g., expectations).
Step 3- Specify the Target Behaviour
Table 1 presents the specifications of the targeted behaviours and the four selected items derived from the Delphi-type exercise.
Step 4- Identify What Needs to Change
Below, we first present an overview of the findings from the on-line survey. We then present the findings from mapping the 25 identified patterns of drug-use behaviours into the COM-B components. We finally present the findings from the discourse-based analysis that shows what needs to change for the targeted behaviours to occur, using the TDF domains. Table 2 shows the patterns of drug-use related behaviours that were mapped on the COM-B components and the TDF domains. Table 3 summarizes the findings of the whole analyses arising from the step 4.
Table 2: Mapping patterns of drug-use related behaviours within COM-B components and the TDF domains
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Motivation
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Opportunity
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Capability
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Reflective
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Automatic
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Social
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Physical
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Physical
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Psychological
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25 Patterns of influences on drug-use related behaviours (identified)
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Identity
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Belief about capabilities
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Optimism
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Intentions
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Goals
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Belief about Consequences
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Reinforcement
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Emotions
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Social Influences
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Environmental context & resources
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Physical skills
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Knowledge
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Cognitive/interpersonal skills
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Memory, attention & decision proc.
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Behavioural regulation
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Frequencies (number of times each domain coded in the analysis)
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10
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7
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9
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11
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10
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18
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13
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8
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8
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10
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0
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3
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4
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7
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5
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Perceived reasons for using drugs
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Perceived consequences from drug-use in users’ daily functioning (immediate)
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Perceived consequences from drug-use in users’ daily functioning (distal)
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Perceived reasons for never use
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Norm correction
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Perceived concerns from the absence of use
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Perceived differences from use between the general and student population
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Questioning future use
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Planning to use drugs
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Time proximity of drug-use
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Perceived drug-use when alternative, non-use behaviours, are present
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Intention to use drugs
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Reasons for reducing drug-use
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Noticeable effects of drugs in students’ daily functioning resulting in increasing students’ motivation for change
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Perceived attitudes of students as risky population when compared with the general population
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Recognition of valued activities as an antidote to drug-use
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Perceived ability to implement harm-reduction practices when needed
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Perceived capability to reduce or stop taking drugs
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Perceived knowledge about the risk of drug-use
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Methods used to reduce or stop using drugs
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Perceived ability to influence others on drug-use decision making
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Contextual forces-A: Recognition of peers influence in reducing drug-use
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Contextual forces-B: Recognition of students’ users as contributors to drug-use
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Contextual forces-C: Recognition of the physical environment as an influencing factor for drug-use
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Contextual forces-D: Recognition of sources (suppliers) as an influencing factor for drug-use
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Note 1: we identified the following TDF domains, expanded on the COM-B components; motivation [86]: social/professional role and identity (10), beliefs about capabilities (7), optimism (9), intentions (11), goals (10), beliefs about consequences (18), reinforcement (13) and emotion (8); opportunity [18]: social influences (8), environment (10); capability [19]: physical skills (0), knowledge (3), cognitive and interpersonal skills (4), memory attention and decision processes (4), behavioural regulation (5).
Note 2: Id.: Social/Professional Role and Identity, Bel cap.: beliefs about capabilities, Opt.: optimism, Int.: Intentions, Bel cons.: Beliefs about consequences, Reinf.: reinforcements, Em.: Emotions, Env.: Environmental context & resources, know.: knowledge, cog.: cognitive and interpersonal skills, mem.: memory, attention and decision processes, Beh. Reg.: behavioural regulation. The shaded squares highlight evidence or consensus that these identifiers map on a specific TDF domain.
Table 3: Intervention components targeting the eight identified patterns of drug-use related behaviours
Pattern of drug-use related target behaviours
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COM-B mapped elements targeted
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Intervention Function served
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Coded identified
(from BCTTv1)
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BCTs selected
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Translation of BCTs within X intervention
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Cluster 1: Increase awareness about the real vs. anticipated effects drug-use can have on students’ personally desired behaviours
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Reflective motivation
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Education
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5.1.
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Information about health consequences
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Provide a personalized animated feedback explaining the possible health-related risks and harms per drug-use type and frequency.
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5.3.
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Information about social and environmental consequences
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Present a gamified quiz showing the possible consequences of drugs in students’ academic and emotional area of living (e.g., legal problems, etc.).
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5.6.
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Information about emotional consequences
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6.3.
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Information about others’ approval
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Provide a subjunctive norm correction, in a gamified quiz way.
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13.4.
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Valued self-identity
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Include a story-telling exercise requesting from students to produce self-statements of their life they want while in college.
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Cluster 2: Promote identification of personally relevant activities (which are they?) which lead to positive expected outcomes in students’ desired behaviours (fun & enjoyment)
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Education
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1.3.
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Goal setting (outcome)
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Present an interactive value’s identification and committed action exercise.
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7.2.
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Cue signalling reward
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Present a reflective- non-judgmental rhetorical question, prompting students to consider how their values match with drug-use behaviours.
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13.2.
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Framing/reframing
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Suggest the adoption of alternative to drug-use activities as means to enhance fun and enjoyment.
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Modeling
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5.6.
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Information about emotional consequences
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Present a mindful-based exercise (“how fully present am I?”), prompting students to visualize (mental representation) how they would feel after achieving college-related goals.
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15.1
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Verbal persuasion about capability
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Use motivational cards to show how students can pursue value committed actions.
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16.3.
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Vicarious learning
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Present a scenario-based story showing a student pursuing his/her goals while enjoying college’s years.
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Training
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1.4.
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Action planning
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Prompt students to use their e-calendar to plan implementing SMART defined goals.
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Cluster 3: Increase perceived competence & optimism that an implementation plan of alternatives to drug-use activities can induce positive expected experiences (fun & enjoyment)
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Education
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1.3
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Goal setting (outcome)
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Use an animation to educate how commitment to SMART goals can work as alternative to drug-use behaviours and reinforce the deliberate adoption of several, non-drug-use behaviours, asserting that these behaviours can elicit as fun as drugs can, without putting students into risks or harms.
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1.9.
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Commitment
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6.3.
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Information about others’ approval
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8.2.
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Behaviour substitutions
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8.6.
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Generalization of a target behaviour
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13.2
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Framing/reframing
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15.1.
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Verbal persuasion about capability
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Cluster 4: Increase awareness of the university context as a risk factor that increase the chances for drug-use behaviours and how this can restrict students from having positive college’s experiences
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Education
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2.3.
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Self-monitoring of behaviour
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Explain the role of cues (triggers of use) within an ABC analysis (behavioural analysis), prompting students to identify (self-monitoring) their own antecedent triggers in relation to the context of use.
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4.2.
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Information about antecedents
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Modeling
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7.1.
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Prompt/cues
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Show how self-talk can be used to help students recognize cues that can influence decision making in relation to drug-use.
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15.4
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Self-talk
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Cluster 5: Cultivate mindful awareness of the perceived reasons for using (why I use?) and increase insight as to whether the use leads to desired outcomes in goal-directed behaviours at a long-run
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Education
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1.6.
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Discrepancy between current behaviours and goals
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Present a personalized feedback showing students’ level of behavioural awareness and goal attainment (i.e. whether their decision to take drugs is influenced by others).Then, prompt students to monitor whether there is a discrepancy between goals and present behaviours.
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2.4.
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Self-monitoring of the outcomes of behaviours
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4.1.
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Instructions on how to perform a behaviour
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Introduce via an animation the mindful decision making skill (learn to pause step-back, notice and decide) and prompt students to think how this skill resonates with their role identity.
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8.1.
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Behavioural practice/rehearsal
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13.4
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Valued self-identity
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4.2.
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Information about antecedents
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Prompt students to apply the new skills to identify cues.
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Modelling
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4.1.
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Instructions on how to perform a behaviour
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Present via a story-narrative (a party house) how a student applying mindful decision making skill (pausing- noticing- deciding) in a situation requiring drug-use decision making.
Reinforce students’ capacity to apply the new skill in different situations
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6.1.
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Demonstration of the behaviour (modelling)
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8.1.
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Behavioural practice/rehearsal
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8.6.
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Generalization of a target behaviour
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15.1.
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Verbal persuasion about capability
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Training
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6.1.
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Demonstration of the behaviour
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Present a series of mindful cards demonstrating what mindful decision making skill does and advice for a gradual implementation of this skill building activity.
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8.7.
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Graded tasks
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Cluster 6: Resolve students’ misleading expectations about the expected outcomes of drug-use in students’ desired behaviours in the long-run
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Automatic motivation
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Education
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5.2.
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Salience of consequences
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Provide a general performance score in a drug-use quiz activity. Wrong- answered responses will provide feedback that will target at correcting students’ expectations about the effect of drugs in the long-run. They will also aim at increasing awareness about the potential regrets students may experience from the use of drugs
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13.2.
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Framing/reframing
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Persuasion
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5.5.
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Anticipated regret
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Cluster 7: Increase procedural knowledge and practice skills on how harm-reduction practices are implemented within the university context
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Capability Physical
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Education
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1.8.
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Behavioural contract
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Present a series of harm-reduction practices and invite students to select the ones that best fit with their experiences (personalized plan).
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4.1.
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Instructions on how to perform a behaviour
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Show instructions in detail on how to perform selected harm-reduction practices via a series of illustrative cards.
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8.6.
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Generalization of the target behaviour
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Prompts students to generalize the new harm-reduction practices, including awareness of exposure to cues, to multiple different situation.
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12.3.
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Avoidance/ reducing exposure to cues for the behaviour
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Modelling
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1.9.
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Commitment
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Show an animation illustrating a student to perform one harm reduction practice, highlighting his/her commitment.
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4.1.
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Instruction on how to perform a behaviour
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Training
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4.1.
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Instruction on how to perform a behaviour
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6.1.
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Demonstration of the behaviour
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Cluster 8: Promote behavioural awareness and behavioural regulation regarding drug-use decision making under the influence of peers
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Social Opportunity
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Education
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1.6.
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Discrepancy between current behaviour and goal
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Prompt students to reflect on their personalized feedback scores in questionnaires assessing levels of decision making influenced by others.
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4.1.
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Instruction on how to perform a behaviour
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Present instructions on how to promote behavioural awareness in relation to decision making.
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4.2.
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Information about antecedents
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Prompt students to think peers’ influences as antecedent (cues) for them to use drugs.
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5.2.
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Salience of consequences
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8.2.
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Behavioural substitution
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Promote a mindful decision-making, highlighting that influences from peers should be aware.
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8.7.
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Graded tasks
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Provide suggestions on building the new behavioural regulation skill (behavioural awareness).
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13.2.
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Framing/reframing
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Prompt students to consider their feedback on subjunctive norm correction (how behaviours are approved by others) in relation to their valued identity.
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15.2.
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Mental rehearsal of successful performance
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Advise students to imagine themselves taking a mindful decision, despite the presence of peers’ influence.
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Modelling
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4.1.
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Instruction on how to perform a behaviour
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Illustrate an animation (a narrative story) with a student denying using drugs, while recognizing the potential influence of peers.
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6.1.
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Demonstration of the behaviour
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Note1: Physical opportunity was not targeted.
Note 2: Translation of BCTs into digitally delivered components represent only concepts which are designed into ideations prototypes to be tested with students, rather than actual implementation practices for the X digital intervention.
Findings from the On-line Survey
Over half of the responders reported using an illicit drug in their lifetime (n=394), with a third reporting use in the last year (n=236). Cannabis was the most commonly reported drug (n=230; 31.25%), followed by ecstasy (n=139; 19%), cocaine (n=120;16.30%), ketamine (n=73;10%), mushrooms (n=53; 7.20%), and others (n= 121; 16.55%). The age of first use was 19-21 years for most drugs, except for cannabis which was 16-18 years old.
The majority (>77%) of respondents indicated experiencing negative effects from the use of any drug. They reported motivations to abstain from concerns raised regarding the impact of drugs in their psychological well-being, cognitive function, academic performance, and the lack of further pleasuring effects. The majority of responders (82%) also believed that students are much more likely to use drugs, compared to the general population, mostly due to opportunities for use, provided by the university context (e.g., acceptability, lack of control, and peer influences). Students reported social factors related to use, including peer pressures (54%) and at least one occasion (reported by 81%) where they were around people who were using drugs. The majority of students (72%) reported that they would be positively influenced to abstain if their friends reduced their usage. The primary reason for use was given as “fun and enjoyment” (86%), followed by “coping with daily academic stressors” (7.3%).
Students felt they possessed adequate knowledge of the risks associated with drug-use (89%), mentioning perceived deterioration in finances (9.5%), personal physical safety (42%), academic progress, physical activity (40% in both conditions), athletic performance (35%), and psychological wellbeing (32%) as the main areas that are affected by drug-use behaviours. Notably, students reported experiencing positive changes in several areas of functioning while taking drugs, including increases in confidence (95%), social interaction (92%), relaxation (86%), energy levels (62%), and decreases in irritability (70%), and distress (68%), with these effects reverting when the effects of the drugs wear off. For those declaring previous use, the five main motivations for change were: noticeable psychological impacts, financial burden, physical effects, impairments in executive functions, and concerns about how other people perceive their drug-use. Students also reported willingness to change their use if they were to socialize with other groups (18.7%), had alternatives to drug-use activities (24%) or had better ways to manage unwanted emotions (10.5%). The majority of students lack knowledge and present with low confidence in how to apply harm reduction practices.
Findings from the COM-B Mapping exercise
From the survey, we identified, coded, and mapped onto the COM-B and TDF a total of 25 patterns of drug-use behaviours (see Table 2). 23 items were coded into motivation (17 reflective and 6 automatic), 5 in capability (3 in physical and 2 in psychological), and 7 in opportunity (5 in social and 2 in physical).
Findings from the Grounded Discourse Theory Pattern-based Analysis
Using a grounded discourse theory pattern-based analysis, we identified eight clusters of drug-use behaviours. As presented in Table 3, five clusters target reflective motivation, one
Reflective Motivation
automatic motivation, one physical capability, and one social opportunity.
Beliefs about consequences: students have strong expectations as for the role of drug-use will play in enhancing personally relevant areas of interest. Given the immediate and potent effects of drugs (e.g., increased energy level, social interactions, confidence, reduction in anxiety, irritability, etc.), students’ beliefs about the positive consequences of drugs in fulfilling personal enhancement are strengthened, and thus maintained, at every drug-use experience. Using and non-using students voice concerns about the overall value of drug-use, tending to associate the use with negative effects in their life (i.e., more than 80% positively responded to the question). However, the presence of strongly held beliefs and other contextual variables (peers, the perceived expectation for use in higher education, positive immediate effects, absence of risks or control, etc.) serve to minimize students’ reflective motivation as to the potential negative longer-term effects of drugs. Increasing students’ awareness of the perceived long term consequences versus the perceived short term benefits may lead to an increase in students’ harm reduction practices and possibly reduce levels of drug-use.
Intention: the current users’ intention to abstain from drug-use, in contrast to the non-users, was found to be low. Students report confidence to use harm-reduction practices and use practices that are considered to be the most effective ones (e.g., avoid certain environments or people who frequently use). However, this expressed intention to use harm-reduction practices is buffered because contextual influences prevail. Low behavioural awareness, lack of planned alternatives, and long-term habitually established patterns of drug-use behaviours are thought to influence students’ motivation to engage with preventative or protective health behaviours. Harm reduction interventions should therefore aim to help students build personalized plans for alternatives to drug-use activities and reinforce their awareness of the long-term negative effects drugs can have on valued-based activities of importance in their lives.
Social/professional role and identity: although students present with sufficient awareness of the negative effects of drug-use in their social identity (e.g., academic disruptions, risks in physical safety, reductions in popularity levels, etc.), contextual forces (e.g., acceptability of drug-use, peer pressure, fear of not fitting in, etc.) minimize the effect of this awareness on their willingness to change behaviour (e.g., abstain or reduce the use). Increasing awareness of the negative effects of drugs on students’ identities (e.g., valued self-identity) can support harm-reduction interventions in higher education.
Goals: The goal of students who take drug is usually to fulfil some personal desires (e.g., such as induced fun and excitement while in college). This goal can become habitual, resulting in students to either planning specific actions to get drugs or prioritising activities around the drug-use. Findings showed that 50% of students plan to use drugs in the hours shortly before using, and 38% have a conscious plan (goal) several days in advance. Students report a willingness to abstain or reduce their drug-use if alternative activities will help them to achieve certain value-based outcomes (e.g., academic progress, secure physical safety, etc.). Therefore, altering the means via which students reach desired effects in personally relevant areas of interest (e.g., fun) can support harm-reduction interventions.
Automatic Motivation
Reinforcement: Students’ drug-use is associated with some positive effects in certain college’s areas (e.g., athletic performance, concentration enhancement, academic achievements). This “drug-use and positive effect” association strengthens every time students make use of drugs, increasing the likelihood of ongoing actual drug-use behaviour. Changing the association of seeing drug-use as an activity that can have a positive effect in certain college’s areas into the one that is seen as risky, could support harm reduction interventions.
Opportunity
Environmental context and resources (Physical): Contextual factors (e.g., perceived normalization/acceptability of drug-use within university settings) have a “synergetic” effect that influence students’ decision making. A harm reduction intervention should enhance students’ awareness about the “synergetic” effects of environmental antecedents (personal and interpersonal cues) and their role in increasing social opportunities for drug-use.
Step 5- Identify Intervention Functions
Five intervention functions were identified from the eight clusters of target behaviours, using the APEASE criteria. The overall reliability of agreement between the raters was satisfactory k= .47 (.95% CI, 33 to .60), p <.001. As seen in Table 4, we selected education, modelling, and persuasion as the predominant intervention functions. To address the possible low engagement with the new behavioural repertoires (skills), we included incentivisation, considering that the expectation of rewards in personally relevant behaviours, may have reinforcing effects on the target behaviours. Finally, in response to students’ lack of knowledge about implementing harm reduction practices, training was recognized as an important intervention function, mostly because it promotes procedural knowledge and practical skills (e.g., how to implement harm reduction practices).
Table 4: Links between the COM-B components and intervention functions
COM-B Components
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Intervention Functions
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Coercion
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Education
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Enablement
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Environmental Restructuring
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Incentivisation
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Modelling
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Persuasion
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Restriction
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Training
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Reflective motivation
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Automatic motivation
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Physical Capability
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Psychological Capability
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Physical Opportunity
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Social Opportunity
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Note: The shaded squares highlight evidence or consensus agreement among the members of the advisory group and shows that the identified clusters of target behaviours (8) can be targeted with a a particular intervention function or a combination of them.
Step 6- Identify Policy categories
We also decided that five policy categories could serve the five selected intervention functions: (a) communication/marketing, (b) guidelines, (c) regulation, (d) service provision, and (e) environmental/social planning. The first three policies were shared across at least four of the five intervention functions. Environmental/social planning was considered a supporting policy for the incentivisation as an intervention function. Both communication/marketing and service provision policies were selected to support post-design promotional and delivery activities of the X digital intervention, rather than to update its content.
Step 7- Identify Behaviour Change Techniques
We created a long list of potential BCTs (see Supplementary Table S3). Using the APEASE criteria, we identified 29 BCTs matched with the eight clusters of behaviour to change and COM-B components (see Table 3). In Figure 3, we illustrate the combination of the selected BCTs (BCCTv1) matched with the eight clusters of target behaviours.