1 00:00:00,060 --> 00:00:11,690 Hi, everyone. It's my first lecture for a while, so please let me know if I am mumbling or coughing or doing much about it, 2 00:00:11,690 --> 00:00:17,970 but yeah, I'm Ben and I'm going to talk about this intervention called Jen. 3 00:00:17,970 --> 00:00:29,000 Defence isn't entitled by any respect and. It was a psychological tension during COVID 19. 4 00:00:29,000 --> 00:00:37,760 And I'm going to talk, it's kind of I'm going to treat it like a big case study of the beginning to look back to the end. 5 00:00:37,760 --> 00:00:47,900 But wherever we are now in the pandemic and including the development of it, the evaluation of it and the ongoing implementation and it's turned into, 6 00:00:47,900 --> 00:00:54,080 is it I mean, it started before I I probably was just about started in my undergrad degree. 7 00:00:54,080 --> 00:01:02,210 But how was he had nothing to do with it then? In people, the leader, the current team. 8 00:01:02,210 --> 00:01:13,730 But we do like that people say and cope tomorrow, I don't know if they're going to know. 9 00:01:13,730 --> 00:01:17,540 My role is in this green box health psychology. 10 00:01:17,540 --> 00:01:23,030 I don't know if that's being talked about this week or not, if anyone's discussed health psychology. 11 00:01:23,030 --> 00:01:34,640 Does anyone have any experience of it or can I know what it is? One thing I know is going to say, You know, I have experience, but not of my father. 12 00:01:34,640 --> 00:01:43,730 OK, cool. So explain it anyway. So you probably heard loads about in the last 18 months about behaviour, medicine. 13 00:01:43,730 --> 00:01:46,440 Certainly what I read in the news quite a lot. 14 00:01:46,440 --> 00:01:52,790 And Susan McVie and Wilbur West and people like that saying this is what people should do, stuff like that. 15 00:01:52,790 --> 00:01:58,700 So health psychology is most similar to behaviour, medicine, I think anyway. 16 00:01:58,700 --> 00:02:07,760 And behavioural medicine is kind of getting people to do things through changing their behaviour. 17 00:02:07,760 --> 00:02:14,390 Health psychology is very, very similar, except we are particularly concerned with the psychology of what people are doing in that change. 18 00:02:14,390 --> 00:02:21,890 So that change is not behaviour. Medicine might be getting them to change their behaviour without them, 19 00:02:21,890 --> 00:02:25,910 even knowing that they're doing it through changing a bridge that they walk along on 20 00:02:25,910 --> 00:02:29,840 the way to work or something and giving them no option to walk or longer run rate. 21 00:02:29,840 --> 00:02:34,910 But if we make them want to change to walk a different route, they have different options. 22 00:02:34,910 --> 00:02:41,000 They will to make that kind of security. It's more concerned with what people are thinking and why they're doing what they're doing. 23 00:02:41,000 --> 00:02:44,360 So how can we make them want to take that idea? That's one difference. 24 00:02:44,360 --> 00:02:51,740 I have to say the very reason it is not the kind of typical psychology, anxiety, depression, 25 00:02:51,740 --> 00:02:56,480 a cognitive behavioural therapy that the psychology that I wanted to do when I came to 26 00:02:56,480 --> 00:03:01,620 do a psychology degree with no idea of what it was about any questions on that so far. 27 00:03:01,620 --> 00:03:09,860 That's cool. OK, cool. So what this talk is about is that this intervention called gen defence. 28 00:03:09,860 --> 00:03:12,140 I'll explain what that is. 29 00:03:12,140 --> 00:03:20,000 It's about how we developed it and how we updated it and the challenges of working in behavioural medicine health psychology during COVID 19, 30 00:03:20,000 --> 00:03:25,280 which obviously accelerated everything in that period. 31 00:03:25,280 --> 00:03:30,170 Am I in the way, by the way? I can all. All right. 32 00:03:30,170 --> 00:03:33,020 And then what I think is potentially the most interesting stuff, 33 00:03:33,020 --> 00:03:40,010 which is the subsequent dissemination implementation of that intervention and working within the current UK. 34 00:03:40,010 --> 00:03:45,050 I'm going to say health care, but public health, whatever the systems that we were, we were very pragmatic. 35 00:03:45,050 --> 00:03:50,120 So whatever systems we were working within, it's about the time to do that. 36 00:03:50,120 --> 00:04:00,680 So x the rationale behind it and this was started actually a long, long time ago in pre swine flu. 37 00:04:00,680 --> 00:04:08,420 But I mean, it's just generally true for influenza and infectious diseases within the home is a key transmission pathway. 38 00:04:08,420 --> 00:04:14,090 So even in lockdown, well, especially in lockdown, when people aren't travelling anywhere, 39 00:04:14,090 --> 00:04:19,550 when people are staying at home, if someone has a virus again, we have to be coronavirus. 40 00:04:19,550 --> 00:04:25,040 It can be anything and they bring it home. You know, you and you and you share your household with people. 41 00:04:25,040 --> 00:04:26,930 If you don't live alone, 42 00:04:26,930 --> 00:04:34,490 there's loads of different ways and there's multiple opportunities to transmit that virus or that infection to someone else in your household. 43 00:04:34,490 --> 00:04:44,630 You're kind of in this group, but. Similarly, if there's a lot of movement going on, if you're going to work, if you're a healthcare professional, 44 00:04:44,630 --> 00:04:52,010 you go to work, you know, you go to a lecture at the university and then you come home. 45 00:04:52,010 --> 00:04:57,170 There's also opportunity to spread it to the people that you live with when you're out and about. 46 00:04:57,170 --> 00:05:01,880 One of you is shielding and the other person is going to work at home. 47 00:05:01,880 --> 00:05:10,670 As I am well aware, if you have a young child going to nursery and Nancy, we don't have no clue about infection control whatsoever. 48 00:05:10,670 --> 00:05:22,730 It's as if they've been trained to spread infection. They, you know you're at risk because it's very, very hard within the home to. 49 00:05:22,730 --> 00:05:29,300 Exposure to infected. Now the key thing, and this is something that was written about by the team in The BMJ. 50 00:05:29,300 --> 00:05:41,120 This is so commentary I so funny is actually that infects your chances of developing symptoms of having a strong or 51 00:05:41,120 --> 00:05:54,350 substantial infection increased by your viral load that you experience the more virus that you come into contact with. 52 00:05:54,350 --> 00:06:00,680 It can kind of overwhelm your immune system so that humans are able to come into contact with very small amounts of virus, 53 00:06:00,680 --> 00:06:04,860 whether it's a cold, whether it's things like that and not to get sick. 54 00:06:04,860 --> 00:06:15,650 Basically, this is not, you know, many people don't know this and therefore don't bother reducing that viral load. 55 00:06:15,650 --> 00:06:23,780 So for example, if you go into a small room with someone who's very sick, you're very likely because it gives them the virus. 56 00:06:23,780 --> 00:06:31,850 Whereas if you're outside, it's very hard to have that extensive exposure to your muscles that much. 57 00:06:31,850 --> 00:06:39,610 And you can reduce the chance of getting the infection, but also the subsequent severity of impact. 58 00:06:39,610 --> 00:06:50,690 And you are overwhelmed. I would note that I am a psychologist thanks to the people that help me. 59 00:06:50,690 --> 00:06:58,670 And yet I think the biggest fear is that people tend to be fatalistic. So they're like, Oh, well, I am very guilty of this. 60 00:06:58,670 --> 00:07:09,080 If my little boy has a snotty nose and he is rubbing his face into my ear or something, I tend to be like, Oh, well, there's nothing I can do. 61 00:07:09,080 --> 00:07:10,850 However, with that in mind, 62 00:07:10,850 --> 00:07:24,170 I can reduce virus transmission in viral load and therefore have a less severe impact on factors that can increase my motivation, change my behaviour. 63 00:07:24,170 --> 00:07:30,830 With that in mind, and around the capability of just the ability to buy and also live with an at risk grandparent, 64 00:07:30,830 --> 00:07:40,340 it would be that sort of germ defence was originally trialled like or developed in this once that stuff. 65 00:07:40,340 --> 00:07:48,950 And so I think it's funded by fund and we see it with the leaves that Professor Lucy Yardley, 66 00:07:48,950 --> 00:07:52,220 who both stayed involved with the project throughout the week. 67 00:07:52,220 --> 00:08:03,950 And now at the time we just focussed on hand-washing is no good evidence actually start to say, Wait, I was involved with that. 68 00:08:03,950 --> 00:08:10,760 There was no good evidence at home, no scalable interventions to support hand-washing at the home. 69 00:08:10,760 --> 00:08:17,000 It was kind of this paper, which is pretty much ignored. And so the germ defence team developed, 70 00:08:17,000 --> 00:08:24,740 it was a really good virus and such back in the day developed to try and increase handwashing 71 00:08:24,740 --> 00:08:30,260 digitally and 2005 2010 for digital whole digital thing was really novel as well. 72 00:08:30,260 --> 00:08:36,060 That just wasn't how you will not be surprised when you look into what it looked like. 73 00:08:36,060 --> 00:08:46,610 That's right. And we used what I'm sure you've been speaking about and maybe to adjust people's behaviour and evaluate the individual side. 74 00:08:46,610 --> 00:08:56,060 I think with the data we print to meet you and I'm not going to go into detail about your theory, class behaviour, 75 00:08:56,060 --> 00:09:04,280 common sense, but revealing that the most basic reason brought in all of these theories of infection control for everything. 76 00:09:04,280 --> 00:09:10,480 And the main thing we did or they did was to focus on increasing well-being, emphasising. 77 00:09:10,480 --> 00:09:12,160 Social consequences. 78 00:09:12,160 --> 00:09:20,170 And this is evidence that they live in the that price of stature comes up to the minute that we did this qualitative interviews and questionnaires, 79 00:09:20,170 --> 00:09:28,160 I found out actually where the key target, what things are possible to change, what motivations are possible to change. 80 00:09:28,160 --> 00:09:34,870 So, for example, social health consequences was something that was particularly important to people. 81 00:09:34,870 --> 00:09:42,370 Therefore, it could be effectively targeted in the kind of informative intervention, 82 00:09:42,370 --> 00:09:48,730 increasing people's skills and confidence on how to reduce that exposure to the virus. 83 00:09:48,730 --> 00:09:56,470 And again, it was primarily on hand washing at the primary point. 84 00:09:56,470 --> 00:10:09,040 Importantly, if you like the fact that this tool invented that it was exactly the same as this mindset and personalised context 85 00:10:09,040 --> 00:10:15,940 wanting to help people sort of set up having to ask them to put in their current behaviour over the last week. 86 00:10:15,940 --> 00:10:19,700 I wash my hands this month in this situation to think about it. 87 00:10:19,700 --> 00:10:22,090 And I mean, these are things that actually quite fit you don't think about. 88 00:10:22,090 --> 00:10:30,730 Like, how often do you wash your hands before you see me over 40 Panopto now it might be more like that, 89 00:10:30,730 --> 00:10:36,070 but we're not necessarily asking everyone to do this all the time. 90 00:10:36,070 --> 00:10:43,830 What germ defence does? Because if you say if you give people an impossible behaviour to adhere to, then we do it. 91 00:10:43,830 --> 00:10:54,310 Basically, you just think, Well, that's ludicrous. But what we're doing is trying to tap into, OK, what is your risk? 92 00:10:54,310 --> 00:11:00,680 What do you mean if you live with someone who's vulnerable? If you do it, if someone has been to a crowded place, 93 00:11:00,680 --> 00:11:06,210 so being to the point of being to get the vaccine and being surprised when they have been of the hospital, 94 00:11:06,210 --> 00:11:10,840 well, perhaps then you'll be at more risk and you may want to do something. 95 00:11:10,840 --> 00:11:18,550 And if you do it, then can you build a habit on it? So we had this whole plan about how often people do it. 96 00:11:18,550 --> 00:11:23,260 We then gave people feedback, said, OK, that you don't do in this area, make your weapon. 97 00:11:23,260 --> 00:11:30,520 We ask people to set an intention. How often are you going to do that over the next week? 98 00:11:30,520 --> 00:11:36,920 And that individual trial? People then don't do it over the course of 16 weeks, so we really try to set an automatic habit. 99 00:11:36,920 --> 00:11:45,100 And that was something that I could talk about that I will really just mention is that 100 00:11:45,100 --> 00:11:49,090 we used what's called the person based approach to make it as effective as possible. 101 00:11:49,090 --> 00:11:55,830 And this is really a hallmark of the research that the team does. And I know that there are many people out of it who are it. 102 00:11:55,830 --> 00:12:06,550 In many situations, the health care debate and based approach aims to understand exactly what it is that stops people doing it, 103 00:12:06,550 --> 00:12:13,070 but how you just get that whatever the behaviour is, whatever the population is in this case, 104 00:12:13,070 --> 00:12:19,870 the behaviour in the public to make interventions acceptable. 105 00:12:19,870 --> 00:12:25,450 So it might be that, you know, people don't like the look of it. 106 00:12:25,450 --> 00:12:33,170 It might be that the words they don't like and might be this fundamental conceptual ideas that people need to understand. 107 00:12:33,170 --> 00:12:39,400 For example, that issue about viral load helped me because I have family as possible and overcoming 108 00:12:39,400 --> 00:12:45,670 various pursuit to really get people engaged in the event in slightly different ways and, 109 00:12:45,670 --> 00:12:52,720 to be honest, will continue to update this person based approach and make it practical and acceptable possible side effects, 110 00:12:52,720 --> 00:13:03,160 except that it involves extensive and get qualitative interviews with your target group users or PTI stakeholders. 111 00:13:03,160 --> 00:13:09,160 In this case, they might be clinicians. It might be vulnerable people living at home. 112 00:13:09,160 --> 00:13:15,250 It might be helpful. You know, anyone who uses the intervention. 113 00:13:15,250 --> 00:13:20,770 We also did a qualitative quantitative data from the using where they're using it. 114 00:13:20,770 --> 00:13:24,730 Who is dropping out of what state intervention and stuff like that. 115 00:13:24,730 --> 00:13:31,680 And we just couldn't be. The picture of engagement, why people using it, how can we help people, 116 00:13:31,680 --> 00:13:36,750 what happens if that's acceptable as possible and therefore how can we increase the uptake in the hearings? 117 00:13:36,750 --> 00:13:53,370 And ultimately the aim is to make the outcomes? So the doctor who basically at the state level, but she's been working on defence since its inception, 118 00:13:53,370 --> 00:14:06,570 and she really ultimately developed the only way in the beginning and that takes qualitative interviews in a questionnaire. 119 00:14:06,570 --> 00:14:21,780 And she found some relatively boring kind of you just central one that people wanted to see that interaction to be engaged in prevention layout. 120 00:14:21,780 --> 00:14:28,770 They wanted. And but the point that they detached from the standard that could lead to change and they want to illustrate it. 121 00:14:28,770 --> 00:14:37,260 So that's kind of simple stuff. Fundamentally, more conceptually, there was that viral. 122 00:14:37,260 --> 00:14:43,580 People really need. That was a key message we needed to understand in order to motivate them to engage in behaviour change. 123 00:14:43,580 --> 00:14:50,520 And that was a key one to try and get them to this look like effect. 124 00:14:50,520 --> 00:14:54,340 So you can see yet be that. 125 00:14:54,340 --> 00:15:04,680 You know that we highlighted in Bow emphasises the naked photos and everything, I think Claire should know this was filed in primary minutes. 126 00:15:04,680 --> 00:15:12,290 So actually, a lot of the demographic that we're using it and where it's really likely to make a difference to health care often is older people. 127 00:15:12,290 --> 00:15:17,730 And so older people may want to keep this clear accessible. 128 00:15:17,730 --> 00:15:33,360 And it was also as a note of that, and you can see we have messages on that message before the bill comes together. 129 00:15:33,360 --> 00:15:40,250 And then, yeah, I do want to emphasise that the qualitative stuff, the to me, 130 00:15:40,250 --> 00:15:51,060 the important messages are not that Typekit around the neck and the feel of it and highlight these fundamental but where to target your key messages. 131 00:15:51,060 --> 00:15:55,950 Why are people not engaging with it? Do they fundamentally not believe in what it's saying? 132 00:15:55,950 --> 00:16:00,520 You know, do they have a belief that you need to read? 133 00:16:00,520 --> 00:16:14,490 So, for example, in the qualitative interviews, people thought again, this virus, but the virus can go airborne. 134 00:16:14,490 --> 00:16:20,710 It was all that often there was no need to wash your hands at all. 135 00:16:20,710 --> 00:16:26,940 I would say I don't want to be obsessive that this isn't about constantly washing my hands. 136 00:16:26,940 --> 00:16:35,160 So we would put the messages to address that component, and then it dissipated. 137 00:16:35,160 --> 00:16:47,550 I forgot to do it again in things like that to really get into the nuts and bolts of why people might see these behaviours. 138 00:16:47,550 --> 00:17:02,440 The key behaviour that you have in terms of generating evidence over 20000 people and climbing in the pool while I was going The Lancet. 139 00:17:02,440 --> 00:17:12,510 And there was a positive effect. I think effect size, whether it's a documentary, was about 10 15 percent. 140 00:17:12,510 --> 00:17:17,850 Reducing respiratory infections reduced the frequency of them, the severity of them. 141 00:17:17,850 --> 00:17:26,960 The people in the firm had less consultations with a. 142 00:17:26,960 --> 00:17:31,400 We'll prescribe. And also there was a benefit for their family members, 143 00:17:31,400 --> 00:17:41,330 so people there were less household infections and there were also less other infections that were the primary target and programme. 144 00:17:41,330 --> 00:17:45,380 And we did some subgroup analysis that said is particularly effective. 145 00:17:45,380 --> 00:17:54,590 And it was equally effective across most of household variances that we could find like gender, age and things like that. 146 00:17:54,590 --> 00:18:00,470 So that was that was Bob. And of course, one of the questions what we got. 147 00:18:00,470 --> 00:18:03,170 So we did this big trial. I don't know if you've been discussing this, 148 00:18:03,170 --> 00:18:07,820 but where do you go with something like this outside of a trial outside of like a tremendous amount of funding that 149 00:18:07,820 --> 00:18:17,490 it takes to run a trial like this and do a to people and have teams ringing up and reminding them to complete? 150 00:18:17,490 --> 00:18:29,700 I have to say it wasn't being used by loads of people, so Sasha was happy to have adapted it to be useful outside of the swine flu pandemic. 151 00:18:29,700 --> 00:18:35,250 And so it was pushed. We updated it to make it look a bit more modern, and this is when I got the call. 152 00:18:35,250 --> 00:18:44,670 And then we're kind of hosting it and trying to implement it in there with the W.H.O. Handwashing Week, they had for a while. 153 00:18:44,670 --> 00:18:49,350 So we tried to advertise it then and then we were in the process of getting it 154 00:18:49,350 --> 00:18:55,500 up into nice guidelines that everything related barriers that that I mean, 155 00:18:55,500 --> 00:18:56,960 we have some news. 156 00:18:56,960 --> 00:19:03,420 So it was a resource that was being used, so it was making some difference, but it certainly didn't have loads of uptake outside of a chance. 157 00:19:03,420 --> 00:19:08,970 For me, always being one of the big challenges of Western Hemisphere is even in, you know, 158 00:19:08,970 --> 00:19:15,150 targeted and effective interventions that you might develop to be increased from asthma. 159 00:19:15,150 --> 00:19:24,510 Inhaler use in primary care outside of a trial is incredibly hard to implement them at a scale that is useful for digital interventions. 160 00:19:24,510 --> 00:19:32,490 If these interventions they don't like, I wonder what that motivation is when you have time to sit down and try to change that one person's behaviour. 161 00:19:32,490 --> 00:19:39,600 They tend to work at scale with relatively modest behavioural effects that don't work for everyone. 162 00:19:39,600 --> 00:19:49,650 But the idea is because it's a cheap and it cost literally nothing to do it on 10 people versus doing it with one person. 163 00:19:49,650 --> 00:19:55,050 Over time, they will have a hopefully a phenomenal, and they can reach many more people for less cost. 164 00:19:55,050 --> 00:20:05,060 But like you do need to have that support and you like how if you have a fantastic app, how do you apply that app in the real world? 165 00:20:05,060 --> 00:20:10,080 It's incredibly challenging and it's so much fun to do it. 166 00:20:10,080 --> 00:20:23,280 And so one of the things that we looked at was when does the effect come to people in this trial? 167 00:20:23,280 --> 00:20:28,980 We're doing over 16 weeks and they do it in every four weeks to complete a questionnaire from that. 168 00:20:28,980 --> 00:20:34,770 And what you can see is I don't have a laser pointer, but if you see this is the bottom, 169 00:20:34,770 --> 00:20:39,900 this is like every week they knock it off and they've done an intervention. 170 00:20:39,900 --> 00:20:47,460 They do the full intervention fully, but in intensive care. 171 00:20:47,460 --> 00:21:02,410 So well, yeah. And so if you look to the green, this is what we did is we look at how many sessions people did. 172 00:21:02,410 --> 00:21:15,290 Three or four? And what you can see is the effect basically the same, whether they did one to three or four sets or anything in their hands. 173 00:21:15,290 --> 00:21:18,430 Now it's not, it's not massive. It goes, it goes from light. 174 00:21:18,430 --> 00:21:26,150 It's about nought point five or something goes from three to four, but that's on a scale of zero to five. 175 00:21:26,150 --> 00:21:32,830 So it's taking on average it takes to go from like quite good to very good. 176 00:21:32,830 --> 00:21:36,670 Actually, that's quite impressive if you think the average people are quite good at playing 177 00:21:36,670 --> 00:21:41,030 people who've been taking and taking from that one to five and what people think. 178 00:21:41,030 --> 00:21:50,470 But is this something you look at its effect size change after one session effect size is huge. 179 00:21:50,470 --> 00:21:56,650 Like the big 15 is big and then almost all of the changes in that first session. 180 00:21:56,650 --> 00:22:02,530 So in terms of how do we apply this learnings, we've got to take the evidence of what happened. 181 00:22:02,530 --> 00:22:11,290 Anyone. They don't have any idea how we might adapt and defence based on it from a full assessment function. 182 00:22:11,290 --> 00:22:19,420 Yeah, exactly. Basically, if you ask me to log in and over a four week period, it's a massive hassle. 183 00:22:19,420 --> 00:22:25,090 You have to like, sign in and put your email address in and like, remember a password? 184 00:22:25,090 --> 00:22:29,140 And I mean, at the time, that was that was a hassle for people. 185 00:22:29,140 --> 00:22:32,890 It's now not only a hassle, but also there's legit Typekit issues of anyone else. 186 00:22:32,890 --> 00:22:39,580 But I'm always like, if people say, can you put in a fake occupant thinking like, I'm not yet great. 187 00:22:39,580 --> 00:22:50,140 And then I think my problem better. So what we did there was we think we better update based on context the evidence we made in one session only. 188 00:22:50,140 --> 00:22:57,790 So it didn't have to lock in and think about the extra information. And actually, we could make that first that much more than half that. 189 00:22:57,790 --> 00:23:02,710 We don't have a trust issue and we can give people the key messages and. 190 00:23:02,710 --> 00:23:07,630 That was an example and making it snappy. 191 00:23:07,630 --> 00:23:15,880 Investing is quite handy because obviously beginning anything and he begins by funny how the 19 192 00:23:15,880 --> 00:23:26,560 year old around and we got some funding to actually the funding was for this implementation, 193 00:23:26,560 --> 00:23:34,030 really. I mean, we were going to do an evaluation of our job evaluation, but really the funding was to get it out there as much as possible. 194 00:23:34,030 --> 00:23:37,330 And in fact, I would think that would do that. 195 00:23:37,330 --> 00:23:45,670 So we had the free copy co-design evaluation and we had a big collaborative, restless to Public Health England. 196 00:23:45,670 --> 00:23:54,520 Now UK HSA UK has great things and a few other people here just waiting because we basically, you know, you read, remember that. 197 00:23:54,520 --> 00:24:05,160 So every all hands on deck there. So that because that was the thing, this PBI approach, this sort of really rigorous, 198 00:24:05,160 --> 00:24:12,570 evidence based development updating approach that we did in getting hit a that came to 199 00:24:12,570 --> 00:24:21,390 over a five year you spent two years updating to make sure we didn't have time to do that. 200 00:24:21,390 --> 00:24:26,130 So what we did was we set out this process of really, really rapid adaptation. 201 00:24:26,130 --> 00:24:34,590 So we've got a stakeholder panel which had kind of people who would be able to weigh in on how to get people to get comfortable. 202 00:24:34,590 --> 00:24:42,540 And we met like once a week to email people all the time, and then we'd compromise and be willing to jam with people. 203 00:24:42,540 --> 00:24:51,060 Using it means that people who completed those questionnaires and surveys, we looked at data. 204 00:24:51,060 --> 00:24:56,160 So we had a constant iterative process to try and make it less invasive without any barriers. 205 00:24:56,160 --> 00:25:08,550 We met with people and we continued to do that constantly, and so we updated it in March 2020. 206 00:25:08,550 --> 00:25:12,520 We've kind of released it to the world when we were confident that were appropriate. 207 00:25:12,520 --> 00:25:23,310 That type of nineteen point three generation that people 2020 and you can see like this is in its simplest version. 208 00:25:23,310 --> 00:25:27,750 Now this business or infographic that lets people read into that. 209 00:25:27,750 --> 00:25:38,670 So we really updated it and tried to make you. It's a lot more appropriate for the modern world compared to that by mistake. 210 00:25:38,670 --> 00:25:45,180 And yeah, we like we we still kept updating it. So to be honest, the funding is just about finished now, so we don't have much capacity. 211 00:25:45,180 --> 00:25:47,430 I think it's still kind of keeping it going. 212 00:25:47,430 --> 00:25:56,220 But I would say that one of the key things at the beginning of the pandemic, everyone was very scared of COVID 19. 213 00:25:56,220 --> 00:26:00,780 Like people were like, If I get it, I might die everyone. 214 00:26:00,780 --> 00:26:06,300 We didn't really know the risks. So the key motivating risk was here is the risk. 215 00:26:06,300 --> 00:26:09,990 If you get the virus, this is what will happen. 216 00:26:09,990 --> 00:26:16,860 Is the risk to you and to your family and what are you trying to avoid it? 217 00:26:16,860 --> 00:26:19,920 By the end of the pandemic, people were not worried about the risk. 218 00:26:19,920 --> 00:26:25,530 To me, that was kind of a known quantity that some people were very concerned about some people. 219 00:26:25,530 --> 00:26:26,580 We're not concerned about it. 220 00:26:26,580 --> 00:26:33,690 On the whole, people knew that it wasn't going to be something that we could change their minds about and change their behaviour within that limit. 221 00:26:33,690 --> 00:26:40,530 So actually, actually what people didn't know was like, how easy it was, 222 00:26:40,530 --> 00:26:45,240 how much community transmission there was and how easy it was to catch the virus if you were out and about. 223 00:26:45,240 --> 00:26:50,550 So our messaging changed from here is the risk of you catching the virus. 224 00:26:50,550 --> 00:26:56,730 So here is the risk if you pass the virus to here is the risk of contracting the virus. 225 00:26:56,730 --> 00:27:05,580 So it's changing that key risk message to try and fundamentally get people to engage in drought. 226 00:27:05,580 --> 00:27:09,720 And you're not going to talk about this intimidation rabbiting on all of that time. 227 00:27:09,720 --> 00:27:16,380 But we did like we added content to help people identify, 228 00:27:16,380 --> 00:27:23,040 know we're not trying to get someone who is fit and healthy and had their vaccines and at low risk, 229 00:27:23,040 --> 00:27:28,680 and then to stay at home and wear a mask in the house with their family. 230 00:27:28,680 --> 00:27:34,930 We're trying to get people to do to be motivated to understand what the risks are and 231 00:27:34,930 --> 00:27:39,580 then to be motivated to do the appropriate behaviours in the face of those risks. 232 00:27:39,580 --> 00:27:45,150 Again, because if you ask someone to do something really, really inconvenient, 233 00:27:45,150 --> 00:27:51,750 the most likely thing is they'll go, That's a waste of time and then just switch off. We really can't say this is how this like. 234 00:27:51,750 --> 00:27:55,440 These are reasons why you might want to engage in these behaviours and give people 235 00:27:55,440 --> 00:28:01,110 an active understanding of what adjusting their behaviour will do for them. 236 00:28:01,110 --> 00:28:07,800 And then they might engage in some of the behaviours to a level which is appropriate for them. 237 00:28:07,800 --> 00:28:08,910 So, for example, 238 00:28:08,910 --> 00:28:16,180 one of the quotes one of the great crises to a night from from an early participant because to a ninety five year old Typekit and more importantly, 239 00:28:16,180 --> 00:28:22,760 than worrying about whether you're going to die of a virus and this incredibly emotional. 240 00:28:22,760 --> 00:28:27,930 So we actually ended up putting in content that was like, how can you get around? 241 00:28:27,930 --> 00:28:34,140 How can you engage in behaviours or how can you do appropriate behaviours in the face of these risks? 242 00:28:34,140 --> 00:28:38,460 It was stuff like setting out your living room so you could watch films with if someone 243 00:28:38,460 --> 00:28:42,540 is more vulnerable in the same breath and how you can sit in the same type of far apart. 244 00:28:42,540 --> 00:28:49,920 It all comes down to reducing that with that, and you can see that this is what it looks like now. 245 00:28:49,920 --> 00:28:53,790 People log in. We've got like the first three pages on the app. 246 00:28:53,790 --> 00:28:58,400 I like the fundamentals, the motivational stuff you then get. 247 00:28:58,400 --> 00:29:01,250 The guy down when pathway, depending on your level of risk, 248 00:29:01,250 --> 00:29:07,310 and it kind of gives you this advice according to how vulnerable you are, a vulnerable, your family and things like that. 249 00:29:07,310 --> 00:29:16,180 And then we get it. So it's really trimmed down from like a stage website with about 50 pages and it takes, well, take about 10 minutes. 250 00:29:16,180 --> 00:29:22,340 But then and this is the stuff about the rest of it. 251 00:29:22,340 --> 00:29:25,700 How do we get it out to people? This has been for me. 252 00:29:25,700 --> 00:29:31,310 This has been a real like. I really don't actually think that as any other country in the world, 253 00:29:31,310 --> 00:29:39,530 we have a really good grip on this problem of dissemination and implementation of interventions like this. 254 00:29:39,530 --> 00:29:43,670 So it has been basically what I'm going to talk about for the remainder of the talk 255 00:29:43,670 --> 00:29:49,580 is the fact that we did everything we could to get it to as many people as possible. 256 00:29:49,580 --> 00:29:54,890 And because it's digital, we can look at what comes and we can look at usage and see how it goes. 257 00:29:54,890 --> 00:30:01,010 And so we have a fairly good grip on what works and what it is, mostly what it is. 258 00:30:01,010 --> 00:30:08,570 So we had you can see we had like lots of members of the team run from the press, the yard. 259 00:30:08,570 --> 00:30:15,980 He was on stage. So he was he would get wheeled out sometimes by the BBC when they could convince him to do it. 260 00:30:15,980 --> 00:30:25,460 And we had a Daily Mail article which really took off. 261 00:30:25,460 --> 00:30:32,540 And that was incredibly popular. We had it was mentioned on in the BMJ. 262 00:30:32,540 --> 00:30:41,540 It was mentioned on social media. You could share it was on the radio, it was on it from the UK, stay at home guidance. 263 00:30:41,540 --> 00:30:48,500 We were helping the message out. And the really great thing is we can and and it worked. 264 00:30:48,500 --> 00:31:01,620 I mean, to some extent, over and another. So we had around 600000 youth since then by careful with my language there because we don't know whether. 265 00:31:01,620 --> 00:31:08,220 We don't know whether one person you can more than one. 266 00:31:08,220 --> 00:31:16,740 I mean, I'm fairly confident from our fees are fairly comparable feedback that they didn't people didn't tend to, you know, 267 00:31:16,740 --> 00:31:25,060 find it hard and come back to it again and again, most of them in the UK, but it will be translated into louder, different languages. 268 00:31:25,060 --> 00:31:31,910 We a great project with like fluent speakers who are willing to help out to do that and we have used all over the world. 269 00:31:31,910 --> 00:31:42,090 Normally people take ten minutes on it and a new lighting up, and these are, to be perfectly honest, some of the best experiences inventions. 270 00:31:42,090 --> 00:31:47,850 These are like great sporting events and like this, 271 00:31:47,850 --> 00:31:56,470 nobody in often uses like one minute because people look on it and just think that something that cost the best part of this stuff. 272 00:31:56,470 --> 00:32:02,700 So we're really happy with these numbers. And this is this is what that pretty cool. 273 00:32:02,700 --> 00:32:10,110 As you can see, we get we get hit of like what where you can see like when I write the stuff, 274 00:32:10,110 --> 00:32:16,980 these are legitimate talking on the internet or on the radio and see that there was an interview in the Guardian and stuff at the time, 275 00:32:16,980 --> 00:32:27,510 but washing your hands. And then as time went on, when the power went out of town, when the press conference announced the funding fight, 276 00:32:27,510 --> 00:32:31,470 when that BMJ article came out about the importance of viral load, 277 00:32:31,470 --> 00:32:38,080 that was the biggest spike when the press release came out in the Daily Mail, which, by the way, they called it German defence. 278 00:32:38,080 --> 00:32:41,740 And people were getting really cool. 279 00:32:41,740 --> 00:32:49,380 And then and actually, that was really interesting because it spoke to the Daily Mail article with they just, well, the press guys picked out. 280 00:32:49,380 --> 00:32:54,630 They thought this was an interesting thing. What's the catch here? And they picked that. 281 00:32:54,630 --> 00:33:05,970 Part of the recommendations that we had was that the initial evidence suggested that the virus would die on a set after 72 hours. 282 00:33:05,970 --> 00:33:14,640 So in the intervention, we said, no, we try not to tell people to leave your pizza for 72 hours when it's delivered, 283 00:33:14,640 --> 00:33:20,400 but we try and say the don't leave something. And now all the evidence is ventilation. 284 00:33:20,400 --> 00:33:25,140 But this is right at the start where there wasn't that evidence in this the surface. 285 00:33:25,140 --> 00:33:31,700 And you know, trying these longer is better than not at all. 286 00:33:31,700 --> 00:33:35,620 You can leave it for a day. That's great. Yeah, it's always fantastic. 287 00:33:35,620 --> 00:33:42,700 Got no chance. But you know, 30 minutes is better than zero. 288 00:33:42,700 --> 00:33:52,740 They write that message the huge fury to the Daily Mail, because people like people immediately said, Well, I'm going to eat my takeaway. 289 00:33:52,740 --> 00:33:59,400 But actually, what it did do is get loads of people using it, and once they used it, they realised that wasn't the key message we were saying. 290 00:33:59,400 --> 00:34:05,400 It's kind of an important lesson on working effectively with press releases. 291 00:34:05,400 --> 00:34:10,860 And then there were BBC interview that going towards a huge spike before the press conference with that question. 292 00:34:10,860 --> 00:34:21,570 Yeah. You know, you have someone to do that or do well because we're doing so many different methods. 293 00:34:21,570 --> 00:34:26,640 No, and part of the I mean, part of the issue was this was before we did this project. 294 00:34:26,640 --> 00:34:35,700 There's no real guidance on how to disseminate something like this. So it was I mean, it became the primary job of me, 295 00:34:35,700 --> 00:34:43,290 Lisa and the team really to try and disseminate it for as many channels as possible and outside of a trial, 296 00:34:43,290 --> 00:34:51,790 because a trial, you have a tremendous amount of resources. You have people employed to chase people up and complex and stuff like that. 297 00:34:51,790 --> 00:34:57,120 You know, we didn't have anywhere near that amount of funding, and it was really about finding out different things to know. 298 00:34:57,120 --> 00:35:07,740 It was kind of me. Hit me and try to dominate something we did in the pandemic, something I know, like a lot of people, 299 00:35:07,740 --> 00:35:13,590 just stopped watching the news because they didn't want to hear about it every day. Like I muted a load of times on my third. 300 00:35:13,590 --> 00:35:17,880 Yeah, I didn't want it all in my face. I wonder if that made it even harder. 301 00:35:17,880 --> 00:35:25,350 Well, maybe I know, but I'm about to talk about another method which might be at his side and that that might be true. 302 00:35:25,350 --> 00:35:29,910 I guess we never know it, but we did have another method in a bit. 303 00:35:29,910 --> 00:35:34,860 We talked about that. Yes, this is one of the cool things as well. 304 00:35:34,860 --> 00:35:44,910 I will whip through this. What we do get we in digital trends so we can kind of gather all the data that's going on so we can see like people fill 305 00:35:44,910 --> 00:35:51,930 out this quiz and we can say we had a thing to do this before and we can see what current levels of behaviour are. 306 00:35:51,930 --> 00:35:56,500 Of course, it is in a highly motivated subgroup. I mean, that's the thing about these interventions. 307 00:35:56,500 --> 00:36:03,570 If you don't tell them that people who are already doing it, but we can see like how much people. 308 00:36:03,570 --> 00:36:12,520 So this is analysis done last August, and you can see basically into these bars. 309 00:36:12,520 --> 00:36:14,190 You get one two three four five. 310 00:36:14,190 --> 00:36:21,290 And it's how many people say the further to the left that the population is weighted, the less people are doing the behaviour. 311 00:36:21,290 --> 00:36:27,120 You can see very few people wearing face coverings at home, virtually none, which you would expect, right? 312 00:36:27,120 --> 00:36:32,400 Because it's quite an intrusive target. Few people put packages inside. 313 00:36:32,400 --> 00:36:36,450 Quite enough people are saying disinfecting, not that many people social distancing. 314 00:36:36,450 --> 00:36:45,980 And this is probably lower than you would expect during a pandemic because it's not saying, you know, do you socially distance from your loved? 315 00:36:45,980 --> 00:36:51,630 It's kind of you if you're vulnerable. And we look at this and we could look at this within different groups, 316 00:36:51,630 --> 00:36:58,080 which pathway would go down if people selected that I'm living with someone who is vulnerable and living with them? 317 00:36:58,080 --> 00:37:02,920 We had a pathway. I'm living with someone who's showing symptoms. I am showing symptoms. 318 00:37:02,920 --> 00:37:04,590 And you could still be your average. 319 00:37:04,590 --> 00:37:11,280 So you can still see this by a lot of these people being high risk or vulnerable or showing symptoms that people still aren't doing. 320 00:37:11,280 --> 00:37:15,700 A lot of these behaviours, as you can see. 321 00:37:15,700 --> 00:37:22,410 So we could look and we could find that people with a high risk household member were more likely to do the behaviours. 322 00:37:22,410 --> 00:37:26,850 People who had someone showing symptoms would be more likely to self isolate. 323 00:37:26,850 --> 00:37:38,030 Generally, things like that. So we did find people who thought that they might have symptoms were actually less likely to clean 324 00:37:38,030 --> 00:37:42,800 and disinfect than people who thought that someone they were living with might have symptoms, 325 00:37:42,800 --> 00:37:53,510 which is interesting. So it kind of shows maybe you're putting the burden on the person who is well to clean up so they don't get it. 326 00:37:53,510 --> 00:37:58,580 And interestingly, all of these behaviours, these like classic behaviours and we've now, 327 00:37:58,580 --> 00:38:03,350 by the way, this data analysis came before ventilation, so we now added ventilation. 328 00:38:03,350 --> 00:38:06,560 I believe we've taken out putting passengers back into the side and adding ventilation. 329 00:38:06,560 --> 00:38:11,900 Opening windows were performed much less frequently than hand-washing. 330 00:38:11,900 --> 00:38:16,850 Hand-washing was because do you remember at the beginning, like last February and April, it really pushed. 331 00:38:16,850 --> 00:38:22,430 It was like washing your hands any second. So people really don't do that. 332 00:38:22,430 --> 00:38:28,220 And this is this is the best because it's all the one we don't have at the trial, follow up or anything like that. 333 00:38:28,220 --> 00:38:33,740 If we look at current behaviours from the plan, what might be next? 334 00:38:33,740 --> 00:38:46,280 You can see there's a decent effect, no small increases, but it's actually, interestingly, exactly the same data marker in the original trial. 335 00:38:46,280 --> 00:38:51,170 In less of an effect, which is really nice because even though we don't have that hard clinical data yet, 336 00:38:51,170 --> 00:38:57,020 we know we can think so best estimate that it might be doing something if you have like the infection. 337 00:38:57,020 --> 00:39:03,080 So if we remember that reduced risk of like 10 percent, 338 00:39:03,080 --> 00:39:09,650 there's no real reason to think well of scepticism and rightly sceptical about the fact that this is 339 00:39:09,650 --> 00:39:15,200 the best marker that possibly we might expect a similar risk reduction effect of this infection. 340 00:39:15,200 --> 00:39:27,820 In fact, we might even great it because the the virus is much more prevalent because the infection behaviours that you were targeting ventilation. 341 00:39:27,820 --> 00:39:34,600 In case you didn't think are more likely to be more effective than just we can all say that, 342 00:39:34,600 --> 00:39:38,380 I mean, I'm not going to to it because it takes a long time to it. 343 00:39:38,380 --> 00:39:44,740 But what was cool was we could have a seven day rolling average of these back so you can get over any distance and you can find it. 344 00:39:44,740 --> 00:39:53,210 By the way, even if you don't have a trial, you can start modelling what is going on with you. 345 00:39:53,210 --> 00:40:00,230 And we were able to use that data to decipher the uptake data, things like that, to inform state papers. 346 00:40:00,230 --> 00:40:05,850 And it currently is. It's the only way that encroachment, yes, we have. 347 00:40:05,850 --> 00:40:08,280 Current infection behaviour we didn't really like, 348 00:40:08,280 --> 00:40:20,480 it does still seem to be a slightly overlooked aspect of infection control and actually they the infections quite bit. 349 00:40:20,480 --> 00:40:26,070 And my dry throat. So yeah, this is going to have a dissemination rate. 350 00:40:26,070 --> 00:40:38,850 What we don't know. And so we need to have ad hoc talking to the press, talking to Janet at Twitter, social media, Facebook, stuff like that. 351 00:40:38,850 --> 00:40:49,120 The OTP practise with the email out and one of our team emailed out and we could see a little spike of like 500 800 uses that day. 352 00:40:49,120 --> 00:40:56,050 We know these patients do. We think that's a cool and what we end up doing with designing a trial with a human at risk? 353 00:40:56,050 --> 00:41:04,710 Do we need health protection? Research Unit got marked there as an public health COVID 19 study. 354 00:41:04,710 --> 00:41:12,420 Well, negotiations with the NIH are selected by Chris Whitty as this means that we've got to rapidly go through ethical approval, 355 00:41:12,420 --> 00:41:15,750 which is really handy because again, 356 00:41:15,750 --> 00:41:22,080 so we sort of managed to whip through a lot of stuff that might take you a year to do in order to get it up and running. 357 00:41:22,080 --> 00:41:29,190 And we're going to do with nearly finished a really big trial where we got to be got the email addresses of 358 00:41:29,190 --> 00:41:35,940 every single GP practise in England from NHS X randomise them to 50 percent of them were in the control group. 359 00:41:35,940 --> 00:41:44,010 And we can tell them we're in the German defence group and sent an email to every single one of them in the intervention group, 360 00:41:44,010 --> 00:41:50,830 saying his evidence for definitely have to take. 361 00:41:50,830 --> 00:41:58,720 And then we can look at sort of freely available routine practise data was quite freely available, 362 00:41:58,720 --> 00:42:05,170 but available routine practise data in the GP practises that you've done transverse the GP, 363 00:42:05,170 --> 00:42:13,870 practises that did it and see whether the infection rate in those GP practises were slightly lower. 364 00:42:13,870 --> 00:42:20,680 So I think actually, it's really exciting. It's a really exciting trial to be a part of. 365 00:42:20,680 --> 00:42:24,490 So we haven't got that completed the analysis yet. 366 00:42:24,490 --> 00:42:30,970 We have good data from it. But I think this is but you don't see each of these Charles normally involved, 367 00:42:30,970 --> 00:42:37,360 like individual patients and a GP practise by having the randomisation level at the practise. 368 00:42:37,360 --> 00:42:49,720 We certainly are able to a. Conduct a real world clinical trial and be implemented, 369 00:42:49,720 --> 00:42:56,540 disseminate it to patients via text to their phone from their health care professional, which is really exciting. 370 00:42:56,540 --> 00:43:08,110 Now the challenge with this was that like, I mean, how is that that generic GMP at any and even don't try to involve their GP? 371 00:43:08,110 --> 00:43:15,490 They're not brilliant at replying thinkers because I'm sure they get 100000 emails a day and something that says, 372 00:43:15,490 --> 00:43:22,060 hello, we're doing a research project. It's not very likely to get through to them. 373 00:43:22,060 --> 00:43:23,290 So it was really, really hard. 374 00:43:23,290 --> 00:43:36,310 And I think if we don't show any effect, it is 100 percent due to a lack of uptake because that email access didn't get through. 375 00:43:36,310 --> 00:43:43,900 We said in three cent GP practise three emails, each of those emails we piloted and we trialled and we walk, 376 00:43:43,900 --> 00:43:52,000 we talk them through with members of the practise and people who we try to find out in a given year we've got to would receive the email. 377 00:43:52,000 --> 00:43:55,540 Would it be a kind of receptionist? Would it be a health care system? 378 00:43:55,540 --> 00:44:01,420 Would it be a partner, anything like that? And we try to work out how to challenge it and how to get the most engagement with it. 379 00:44:01,420 --> 00:44:08,500 And then we would even suggest behavioural behaviour change text that they sent to a patient right now. 380 00:44:08,500 --> 00:44:13,840 But that may not seem to be really exciting. 381 00:44:13,840 --> 00:44:21,640 But I mean, one thing takeaway is that this was by far the best way of disseminating germ defence. 382 00:44:21,640 --> 00:44:26,380 When it did get to patients, it came from their health care professional. 383 00:44:26,380 --> 00:44:33,810 It had that credibility, and it also had all of the world number three. 384 00:44:33,810 --> 00:44:39,110 But I mean, we were kind of lucky to be able to do that. 385 00:44:39,110 --> 00:44:49,800 We had that team. But this is by no means a guaranteed solution, you can't have an intervention that shows effectiveness and then say, 386 00:44:49,800 --> 00:44:57,250 Well, I'll just run a national randomised controlled trial and disseminate it like incredibly hard. 387 00:44:57,250 --> 00:45:02,440 And this is for me, this is the one thing that is missing in a kind of pandemic response. 388 00:45:02,440 --> 00:45:14,140 A well in a public health response like this is I might have an intervention that works for anything beyond like a poster or a viral video. 389 00:45:14,140 --> 00:45:26,020 How do I get that to people? We have this National Health Service like we have these communication systems, but there is no at the moment there isn't. 390 00:45:26,020 --> 00:45:35,950 It's incredibly hard. I mean, even like, you know, a clear pathway on who you meet with, who you talk to to actually disseminate something like this, 391 00:45:35,950 --> 00:45:41,740 like, I know you just have a bunch of lessons on mask wearing and discussions of mask wearing. 392 00:45:41,740 --> 00:45:47,200 How do you like that? That's a behaviour, really cute behaviour that's going to be clear, 393 00:45:47,200 --> 00:45:54,010 interventions that could be designed or have been designed on how to change people's behaviour around masks. 394 00:45:54,010 --> 00:46:02,710 But again, there's no clear pathway on accessing everyone in England on getting that through. 395 00:46:02,710 --> 00:46:06,970 And sometimes there, of course, is with the vaccines. 396 00:46:06,970 --> 00:46:17,050 Right? So but again, it's an kind of ad hoc thing that is done and loads of loads of stars have to align in order to do anything. 397 00:46:17,050 --> 00:46:21,730 And you've got this. Hopefully in the future, there will be a guaranteed way of life. 398 00:46:21,730 --> 00:46:26,950 Stop us in order to make me think so. 399 00:46:26,950 --> 00:46:29,200 Yes. To sum up, 400 00:46:29,200 --> 00:46:41,110 this adaptation of Denver defence enabled us to develop really effective methods to get buy into the stakeholders to optimise these interventions. 401 00:46:41,110 --> 00:46:46,610 Reducing these barriers to implementation of evidence based medicine is incredibly important. 402 00:46:46,610 --> 00:46:58,480 I, for me, the best line, the most important learning will be what are the barriers that we faced and how can we not know? 403 00:46:58,480 --> 00:47:06,790 How did we? But how can we hope to deal with them better in the future and not rely on, to some extent, being lucky, but anything? 404 00:47:06,790 --> 00:47:11,860 What I would say is ad hoc and an opportunity comes up. What can we do for someone? 405 00:47:11,860 --> 00:47:17,310 I mean, we we had to get it on the Shelf Duke website. 406 00:47:17,310 --> 00:47:23,890 It's currently on the guidance for multi-generational households and reducing infection if someone has it to get it on that website. 407 00:47:23,890 --> 00:47:29,890 It took almost the entire length of the project 18 months, despite the fact that we had, unlike almost everything else, 408 00:47:29,890 --> 00:47:38,080 we had an evidence base rate for this stuff and we had people from the quite senior people from Public Health England working individuals, 409 00:47:38,080 --> 00:47:46,750 and we still found it incredibly hard. And some of the learning we had sort of reflective discussion meeting actually last week, 410 00:47:46,750 --> 00:47:53,800 and both Richard and Tim on the team were like, we thought this would be a lot easier than it was. 411 00:47:53,800 --> 00:47:58,960 But this, even within Public Health England, there still wasn't a clear channel, 412 00:47:58,960 --> 00:48:05,350 and we don't even know who the gatekeepers are to try and march forward, and it is just incredibly interesting. 413 00:48:05,350 --> 00:48:12,040 And to that identifying and reducing barriers, hopefully all that will help them find the time. 414 00:48:12,040 --> 00:48:16,390 And I really think they're able to be an innovative type of these great adaptations, 415 00:48:16,390 --> 00:48:24,400 the constant updating how do we integrate people's views so effectively the changing context? 416 00:48:24,400 --> 00:48:33,250 I know the pandemic was really rapidly changing, but actually anything digital is constantly being. 417 00:48:33,250 --> 00:48:40,840 If you have any digital behaviour change components like the platform that firing people's habits, 418 00:48:40,840 --> 00:48:50,950 what apps they plug into constantly updating and how can you keep that is some of the methods being developed with what they do. 419 00:48:50,950 --> 00:48:53,260 So that's it for me. Thank you for listening. 420 00:48:53,260 --> 00:49:04,962 And yeah, like you said, there were loads of people involved in it, and this is exactly the audience that they.