Using an analysis of behavior change to inform effective digital intervention design: How did the PRIMIT website change hand hygiene behavior across 8993 users?

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.Purpose: We investigated these questions using data from a large trial of the digital PRIMIT intervention, which aimed to reduce respiratory tract infections (RTIs) by increasing hand hygiene behavior.Method: 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, olderand 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.