Designing Better Behavior Change Interventions: A Case Study on Selecting Components with Dr. Susan Brown

Interviewed by Michele L. Patel, PhD, Optimization of Behavioral and Biobehavioral Interventions SIG Co-Chair

The Society of Behavioral Medicine’s Optimization of Behavioral and Biobehavioral Interventions Special Interest Group (OBBI SIG) recently interviewed Susan D. Brown, PhD, FSBM, a clinical psychologist and Associate Professor at the University of California, Davis School of Medicine. She walks us through the four components used in her ongoing R01-funded SUNRISE optimization trial (n=2000), which seeks to optimize a brief digital outreach intervention to improve uptake of recommended type 2 diabetes screening for postpartum adults who had gestational diabetes mellitus (GDM) during pregnancy. The project is a collaboration with MPI Assiamira Ferrara, MD, PhD at Kaiser Permanente Northern California and Co-Investigator Michaela Kiernan, PhD at Stanford University School of Medicine.

How do you deliver the intervention?

Brown: The trial is fully remote. Once participants enroll, are randomized, and complete the baseline survey, they receive a link to a mobile-friendly interactive website. Depending on what components people are randomized to receive, they will see different modules. It’s quite brief, about 10 minutes. That was part of our goal to design an intervention that moves the needle on preventive health care and is feasible for patients to do, and for health systems to implement. It had to be short. It had to be self-directed. It had to be something that people can access.

How did you come up with your 4 components?

Brown: Patients with GDM are at high risk for type 2 diabetes after delivery. Yet uptake of the recommended postpartum diabetes screening is poor. We used the literature, theory, and preliminary work we had done to see what levers we could pull to improve uptake of that screening. We looked at barriers and facilitators, what things get in the way, to develop a conceptual model and a set of four candidate components.

Tell me about the ‘Values Affirmation’ component.

Brown: The first barrier we wanted to address is that many patients avoid diabetes screening due, in part, to fear of getting a diabetes diagnosis. So, we wanted to test whether values affirmation could be a sort of psychological buffer against scary or difficult stuff. In this component, developed with expert Geoffrey Cohen, PhD at Stanford University, participants are guided through prompts about their most important values and why those values are important to them.

Tell me about the ‘Tailored Risk Information’ component.

Brown: Another barrier we are trying to address that people have varying perceptions of their risk for type 2 diabetes after they’ve had GDM. Some people feel like “I’m healthy, I’m relatively young, I don’t feel at risk, so I don’t think I need to do this screening.” We’re testing whether providing people with information to understand their own risk might change screening behavior.

Tell me about the ‘Motivational Interviewing (MI)-based’ component.

Brown: MI is typically done with a trained counselor, but we wanted to test if there are elements of MI that we could administer in a scalable way through this intervention website. The website guides people to consider both the pros and cons of screening—having people reflect on their own preferences and consider their personal decision about screening.

Tell me about the ‘Action Planning’ component.

Brown:  One thing we hear from pregnant and postpartum adults is that “This is a really crazy time of life!” Screening is recommended between 4-12 weeks postpartum. Getting into a lab to do this important screening is no small feat. So, the action planning idea was to test whether guiding people to create a plan to manage these logistical barriers could improve screening outcomes.

Are there constant components in the intervention received by all participants?

Brown: Yes, there’s standard health information that everyone receives about postpartum screening after GDM—why it’s important, how to do it, and so on. We also make sure people know that there is no cost for the screening.

Anything else to know about selecting components?

Brown: Spend a lot of time on your conceptual model. How can you use theory to identify levers of behavior change? What do you think the mechanisms of action are? Draw on as many types of research as possible—qualitative work but also on the epidemiology of the phenomenon. What do you think the barriers are? Really consider health equity—there’s potential for our interventions to actually widen disparities if they improve things for one group and not another.

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Relevant articles:

Dr. Brown’s pilot study to test feasibility and acceptability of components used in the subsequent R01-funded SUNRISE trial: Brown, S. D., Garcia, B. L., Ritchie, J. L., Tsai, A. L., Millman, A., Greenberg, M., ... & Ferrara, A. (2024). Digital health outreach to promote postpartum screening after gestational diabetes: A randomized factorial pilot study. PEC innovation, 4, 100256.

Dr. Brown’s secondary analysis of postpartum screening rates that informed this work: Brown, S. D., Hedderson, M. M., Zhu, Y., Tsai, A. L., Feng, J., Quesenberry, C. P., & Ferrara, A. (2022). Uptake of guideline-recommended postpartum diabetes screening among diverse women with gestational diabetes: Associations with patient factors in an integrated health system in the USA. BMJ Open Diabetes Research and Care, 10(3), e002726.

An overview on intervention optimization: Collins, L. M., Nahum-Shani, I., Guastaferro, K., Strayhorn, J. C., Vanness, D. J., & Murphy, S. A. (2024). Intervention optimization: A paradigm shift and its potential implications for clinical psychology. Annual Review of Clinical Psychology, 20.

Checklist for reporting MOST studies in the Preparation Phase: Landoll, R. R., Vargas, S. E., Samardzic, K. B., Clark, M. F., & Guastaferro, K. (2022). The preparation phase in the multiphase optimization strategy (MOST): A systematic review and introduction of a reporting checklist. Translational behavioral medicine, 12(2), 291-303.

Strategy for identifying components: O’Hara, K. L., Knowles, L. M., Guastaferro, K., & Lyon, A. R. (2022). Human-centered design methods to achieve preparation phase goals in the multiphase optimization strategy framework. Implementation Research and Practice, 3, 26334895221131052.