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Potentially modifiable risk factors account for approximately 23% of breast cancer cases. In the United Kingdom, alcohol consumption alone is held responsible for 8% to 10% of cases diagnosed every year. Symptomatic breast clinics focus on early detection and treatment, but they also offer scope for delivery of low-cost lifestyle interventions to encourage a cancer prevention culture within the cancer care system. Careful development work is required to effectively translate such interventions to novel settings.
The aim of this study was to develop a theory of change and delivery mechanism for a context-specific alcohol and lifestyle brief intervention aimed at women attending screening and symptomatic breast clinics.
A formative study combined evidence reviews, analysis of mixed method data, and user experience research to develop an intervention model, following the 6 Steps in Quality Intervention Development (6SQuID) framework.
A Web app focused on improving awareness, encouraging self-monitoring, and reframing alcohol reduction as a positive choice to improve health was found to be acceptable to women. Accessing this in the clinic waiting area on a tablet computer was shown to be feasible. An important facilitator for change may be the heightened readiness to learn associated with a salient health visit (a teachable moment). Women may have increased motivation to change if they can develop a belief in their capability to monitor and, if necessary, reduce their alcohol consumption.
Using the 6SQuID framework supported the prototyping and maximized acceptability and feasibility of an alcohol brief intervention for women attending symptomatic breast clinics, regardless of their level of alcohol consumption.
Breast cancer is the most common type of cancer worldwide, and its incidence is rising [
Systematic reviews of alcohol interventions indicate that, outside of regulatory interventions, alcohol brief interventions (ABIs) demonstrate the greatest effectiveness and cost effectiveness [
The use of “teachable moments” is increasingly advocated to encourage modification of lifestyle determinants of cancers [
Previous research has criticized the premature trialing of ABIs in new environments, with recommendations that “applications of brief intervention to novel settings should begin with foundational research and developmental studies” [
The 6SQuID framework [
The 6 steps of the Quality Intervention Development framework as applied in the development of Abreast of Health (adapted from the study by Wight et al [
Step and data provenance | Methods | |
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Attitudes literature (Ea) | Scoping review |
Scoping study [ |
Scoping review | |
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Risk attitude literature (E) | Scoping review and theory mapping |
Scoping study [ |
Scoping review and theory mapping | |
Review of existing apps (Nb) | Scoping review and theory mapping | |
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Behavior change technique review (E) | Theory and concept mapping |
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Behavior change technique review (E) | Concept mapping |
User testing (N) | Agile prototyping | |
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User testing (N) | “Think aloud” and “teach me back” cognitive interviewing |
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To be addressed in future publication (N) | —c |
a(E): existing data from the public domain.
b(N): new data generated during this study.
cNot applicable.
The academic and gray literature were reviewed iteratively in 3 different areas relevant to the intervention (
Knowledge and social attitudes to alcohol among women (particularly in the United Kingdom) and among health care staff—this included information on knowledge of alcohol volumes, effect of alcohol on health, and confidence in managing alcohol-related health risks.
Knowledge and social attitudes in relation to modifiable risk factors for cancer—particular attention was paid to interaction with social determinants of health, including health literacy, socioeconomic status, and social deprivation.
Findings from existing reviews on behavior change mechanisms and techniques for reducing alcohol consumption—in addition to reviews from the Cochrane library, we focused on systematic and narrative reviews of features of digitally delivered ABIs [
A mixed method study was undertaken to complement evidence from the literature reviews, with data from the target environment: symptomatic breast clinics and an NHS Breast Screening Programme unit in Southampton, United Kingdom. A total of 205 women attending appointments were recruited to take part in (1) a survey of knowledge of risk factors for breast cancer and alcohol beverage content and (2) 5 focus groups. Moreover, 33 health professionals took part in a similar survey, of whom 8 also participated in semistructured interviews. The full detail is reported separately [
As part of 6SQuID steps 3 to 4, relevant theories and behavior change constructs were reviewed and mapped onto harmonized constructs from 2 systematic collations of health psychology theories commonly used in meta-analyses. These were (1) the 26 mechanisms of action [
The structure and content (both textual and visual) of the intervention prototype were designed by JMAS, PDM, and CKP in an Agile approach [
The research team scoped, reviewed, and appraised existing alcohol information leaflets, Web, and mobile phone apps. This involved mapping BCTs and appraising the language, tone, and focus of different approaches to consolidate a view of the most adapted content. A particular focus was placed on identifying features that were deemed difficult to understand, that were insufficiently relevant, or that could be perceived by some women as scary and/or judgmental. Similarly, features that appeared most helpful at implementing target mechanisms of change were also noted.
A total of 10 women recruited from symptomatic breast clinics were invited to test and comment on a range of existing health apps in 1 focus group, adding to findings from the team’s own analysis.
The research team sketched the visual layout of small components of the intervention.
Immediate comments and reactions on early versions of wording and visual features of these components were invited from 161 women recruited from symptomatic breast clinics. Participants took part in face-to-face cognitive interviews, which invited them to “think aloud” and “teach back” information gathered while testing the prototype to the researcher [
New findings were discussed by the research team on a weekly basis, setting objectives for the next data collection cycle the following week. Conclusions from these activities were mapped to a particular component of the emerging prototype intervention and recorded on a Kanban board (using the Trello software) [
All participants were recruited from the women attending the symptomatic breast clinics at Southampton General Hospital on referral from their primary care physician. All participants were approached in the waiting room, and having given consent, they either participated at that time and/or agreed to take part in a focus group/testing session at a later date. Activities (2) and (3) above were approved by Health Research Authority Research Ethics Committees as part of 2 independent studies (references: 17/LO/0953 and 18/SC/0120).
Having identified alcohol consumption as a potentially modifiable lifestyle cause of breast cancer, we undertook a broad review of underpinning factors (
Key findings were that although 60% to 72% of women attending breast screening appointments or symptomatic breast clinics drink alcohol, only 20% of women were aware that it was a risk factor for breast cancer [
From steps 1 to 2, we concluded that the greatest scope for change resides in increasing awareness of alcohol’s role in promoting chronic conditions such as cancer, even at low levels. This interacts with other behavioral predictors listed in
Thematic summary of social and psychological determinants of knowledge, attitudes, and behavior around alcohol consumption.
Domain | Evidence |
Knowledge: low alcohol literacy | Only 20% of women in breast clinics [ |
Knowledge: low alcohol numeracy | Individuals do not always accurately recall the frequency, volume, and concentration of alcohol they drink [ |
Social role and identity of health professionals | In addition to lacking in time and relevant training on lifestyle interventions, health care staff may not believe it is part of their clinical role to discuss lifestyle factors in relation to modifiable risk factors for cancer [ |
Beliefs about capability and readiness to learn | Patients are more concerned by genetic determinants rather than modifiable risk factors for breast cancer [ |
Health beliefs: cancer predeterminism and fatalism | A proportion of the population believes that incidence of cancer is purely down to “fate” or known genetic causes. “Cancer fatalism” is thought to have a negative impact on health behaviors, including screening uptake. Evidence suggests that it is more prevalent among women from black and minority ethnic backgrounds and that beliefs that cancer is predetermined are strongest among women: (1) born outside the United Kingdom, (2) whose main language is not English, or (3) exhibiting lower levels of health literacy [ |
Exposure to fear appeal messages | Alcohol and cancer are health themes in which public health campaigns have traditionally appealed to fear processes, seeking impact by evoking a strong emotional response. Alcohol harm reduction video advertisements, in particular, tend to have a negative emotional tone (74%) and focus on short-term risks (53%), with only 18% focusing on how to adapt lifestyle to improve long-term health [ |
Perceived relevance of alcohol prevention | Generalist alcohol brief interventions are rarely tailored to individuals’ drinking behavior. We found that many leaflets contain messages and recommendations that are aimed at higher-risk drinkers; therefore, these are not relevant to many recipients’ level of alcohol consumption or lifestyles. These messages may, therefore, be easily dismissed by the majority of readers as irrelevant [ |
Beyond the need to increase knowledge of the long-term health effects of alcohol (commonly invoked as a necessary mechanism of action to promote behavior change) [
The teachable moment model [
Danger control processes predict an enhanced “readiness to learn,” which we define as the propensity to absorb information on health risks, reflect on its meaning, and use it in relation to everyday lifestyle choices. An ABI could capitalize on danger control processes by establishing an association between alcohol and the risk of breast cancer and redirecting the individual’s attention toward achievable methods of reducing alcohol consumption.
Conversely, an ABI could fail by triggering fear control processes, by exacerbating fatalistic thoughts in women attending clinic who believe that cancer risk is largely predetermined and beyond their control. Such beliefs are known to be more prevalent in populations with limited health literacy [
Data from our focus groups indicated that although fear control processes occur among women attending breast clinics (eg, “information overload,” avoidance of health literature), the desire to learn about modifiable risk factors is also present [
In addition to the findings from our reviews, qualitative evidence we collected [
From step 3, we concluded that the intervention is most likely to succeed if it provides reassurance that alcohol is a controllable determinant of cancer and that it promotes positive benefits of limiting alcohol use for long-term health and well-being.
Our previous work identified that the most feasible and scalable mode of delivering a lifestyle intervention in clinics was a Web app accessed by women in the clinic waiting area on a tablet computer [
Within the constraints set by a Web app, and with the help of the third review, we identified candidate BCTs to deliver the following mechanisms of action (see
Improving knowledge of the health benefits of low-risk drinking;
Increasing skills in relation to estimating the alcohol content of beverages;
Changing attitudes to, and beliefs about consequences of, alcohol consumption; and
Capitalizing on perceived susceptibility/vulnerability heightened by the symptomatic breast clinic attendance to increase motivation while emphasizing personal control and belief in the capability to reduce cancer risk.
The 4 BCTs employed with the highest degree of fidelity across the prototype were as follows: provision of information on health consequences of alcohol, feedback on behavior, discrepancy between current behavior and goals, and social comparison. Other techniques, for example, self-monitoring or instructions on how to perform the behavior, informed the design of prompts or suggestions deeper in the application interface available to those who were interested in exploring them rather than being delivered procedurally by the interface to all users.
Behavior change techniques and features identified for prototyping.
Behavior change techniques (taxonomy number) | Prototype features |
Information about health consequences (5.1) |
Information on alcohol’s dose-response association with breast cancer and the absence of a safe threshold Information on the proportion of breast cancer cases attributable to alcohol in the United Kingdom Information about benefits of low-risk drinking beyond lower risks of breast cancer (other types of cancers, mental health, dementia, liver, etc) “Myth busting” quiz on risk factors for breast cancer |
Feedback on behavior (2.2) and discrepancy between current behavior and goal (1.6) |
Assessment of current alcohol consumption in units per week Personalized feedback based on the UK Chief Medical Officers’ low-risk drinking guidance [ Automated suggestion of 1 of 3 goals in line with the same guidance [ |
Social comparison (6.2) |
Personalized feedback of current alcohol consumption compared with (1) other women in England and (2) other women in the clinic |
Framing/reframing (13.2) |
Frame alcohol as an easily controllable risk factor for breast cancer Focus messages on risk reduction by changing behavior rather than risk promotion by current behavior (gain framing) Frame alcohol as any other health risk factor by embedding alcohol within broader information on lifestyle determinants of health: physical activity, diet, and weight Offer ways to reduce alcohol consumption and promote them as simple and easy steps Emphasize choice, presenting change as an easy option, with advice on how to cut down |
Self-monitoring of behavior (2.3) |
“Top tips”: recommend keeping a diary of alcohol intake with a mobile phone app (hyperlink to National Health Service drinks tracker app) or a paper diary (hyperlink to a diary template) |
Credible source (9.1) |
“Myth busting” quiz challenging common misunderstandings on risk factors believed to promote breast cancer Breast Cancer Now charity logo and endorsement National Health Service branding of the app (requested by women, to be implemented subject to relevant authorizations) Delivery of the intervention within the clinic waiting room, endorsement by health care staff |
Instruction on how to perform a behavior (4.1); behavior substitution; and problem solving (1.2) |
“Top tips”: examples of techniques to reduce alcohol consumption on social occasions, by setting goals, self-monitoring, and involving relatives “Top tips”: advice on choosing beverages with lower alcohol content and/or smaller volume; alternating drinks with glasses of water Drink calculator: information on beverage sizes and alcohol content in UK units Hyperlinks to further resources: drinking diary template, Public Health England drink tracker app, “Soberistas,” and “Club Soda” |
Information related to consequences for the risk of breast cancer was designed to convey the dose-dependent nature of the association between alcohol and breast carcinogenesis, emphasizing that no “safe” threshold exists for alcohol consumption in relation to breast cancer risk. The material designed by the team is adapted from an existing information leaflet [
As women are often unsure about their alcohol risk levels (
The content of the intervention sought to reframe alcohol as one of the more controllable lifestyle risk factors for chronic illness (
Offer a new perspective on low-risk drinking as a positive choice (gain framing) made to improve future health prospects
Challenge binary stereotyping of alcohol use opposing “safe drinkers” and “alcoholics/boozers”; instead, represent the risks of drinking as a continuum. The language describing alcohol risks was kept as neutral as possible to adapt to a wide audience, and we excluded references to addiction or social harms of alcohol [
Some BCTs were potentially unhelpful in the context of the teachable moment within our target health settings because of their potential to trigger fear control reactions. In particular, we did not wish to enhance the
Finally, we identified other features likely to mediate the efficacy of the intervention, which required consideration as part of the iterative design and testing stage. As the usability of an electronic intervention is a predictor of engagement [
Following a phase of testing, with cycles of refinement of the prototype with 161 women in clinics, the final prototype consisted of the following:
An initial assessment of alcohol consumption, smoking, height, and weight.
Personalized feedback on alcohol intake integrated with other risk factors: A feedback page presents the estimated number of units per week, and drinking risk level, assisted by a graphic visualizing alcohol risk levels based on the UK Chief Medical Officers’ guidance [
An overview page linking to other health promotion information, including the following:
A myth-busting quiz testing knowledge on modifiable risk factors for breast cancer, including alcohol.
Information on the dose-response association between breast cancer and alcohol.
An interactive drink calculator providing alcohol units and calories of standard drinks as well as larger volumes (eg, bottles). This was refined to help participants add up, over any period, how many units of alcohol they may be consuming; how many kilocalories these drinks contain; food equivalents (in hamburgers and biscuits); and metabolic equivalents in minutes of tasks such as running, swimming, or housework.
Example goals for maintaining low-risk drinking or reducing alcohol consumption.
Specific information pages on the following: weight management, physical activity, diet, and smoking. A section on breast symptoms initially designed and tested was removed to refocus content on lifestyle promotion.
This study applied a rigorous intervention development framework, drawing on a suite of reviews of the risk factor literature, attitudes toward modifiable risk factors for cancer, and digital health interventions. We involved women attending breast clinics in the design, prototyping, and testing of a context-specific digital ABI in breast health settings with a potential to reach over 540,000 women per year in England alone, at very low costs, and where little information is currently provided in relation to modifiable risk factors for breast cancer. Coined as “teachable moments” in the cancer prevention literature [
The mechanisms of actions identified in this paper and our reviews of their evidence base suggest potential to achieve small reductions in alcohol consumption. Several moderators of the mechanisms of change for this intervention have been identified: acceptability to women, particularly those whose anxiety makes them potentially averse to health-related information; usability of the Web app delivering the intervention; and engagement with the subcomponents of the digital interface. The next phase of research will evaluate the feasibility, acceptability, and usability of the intervention in clinics with the target population and produce the necessary evidence on how to optimize the effect of such moderators.
The design of the proposed intervention differs from that of other digital ABIs, which focus either on student populations or longer-term engagement with mobile phone or Web apps [
This prototype intervention was developed in a single site in Southampton, United Kingdom. Feasibility and acceptability remain to be demonstrated in other sites, with different population demographics. The proposed intervention is also designed around the characteristics of the UK cancer detection model, and it may require adaptation to other health systems.
Breast cancer is the most common type of cancer in women, and alcohol is one of the most feasible risk factors to moderate for the prevention of breast cancer [
Scope of literature reviews.
Archive of five views of the prototype web application.
6 steps in quality intervention development
alcohol brief intervention
behavior change technique
National Health Service
National Institute for Health Research
This study was funded by the Medical Research Council (grant number MR/P016960/1) and an internal grant from the National Institute for Health Research (NIHR) Southampton Biomedical Research Centre. EK is a member of Fuse, the Centre for Translational Research in Public Health; the NIHR School of Public Health Research; and the NIHR School of Primary Care Research. MMcC holds a Medical Research Council/University fellowship supported by a Medical Research Council partnership grant (MC/PC/13027) and is supported by the Medical Research Council and Chief Scientist Office through the Complexity in Health Improvement program (MC_UU_12017/14/SPHSU14). The authors gratefully acknowledge the advice and comments throughout the project from the project partners Eluned Hughes of Breast Cancer Now and Lucy Rocca of Soberistas.
ERC declares honoraria, advisory board meetings, and support to attend educational meetings from the following: Roche, Astra-Zeneca, Lilly, Nanostring, and Pfizer.