Loughborough University
CARVALHO_Fernando_FINAL_PhD_thesis_May_2020.pdf (14.9 MB)

Participatory design for behaviour change: an integrative approach to improving healthcare practice focused on staff participation

Download (14.9 MB)
posted on 2020-06-01, 13:14 authored by Fernando Carvalho
This thesis explores the application of participatory design and behaviour change in the process of planning and developing quality and safety improvement interventions within the hospital environment. This focus is examined through the empirical investigation of a real-life improvement process, looking at the diagnosis and management of Urinary Tract Infection (UTI) in older adults within the busy environment of an Emergency Department.
A review of the literature helped identify that, whilst a behavioural approach to healthcare has been employed with some measured success at a public health level, its application at the healthcare service level has been less explored and studied. Furthermore, there has been an acknowledged necessity to better integrate stakeholder engagement in behaviour change interventions, but such integration is underplayed and underexplored by current frameworks.
A comprehensive participatory action research project – encompassing workshops, focus groups, interviews, meetings and digital communication led and facilitated by the researcher – was conducted with the engagement of over fifty staff, including nurses, doctors, managers, pharmacists and microbiologists working in various departments of a large NHS University Hospital in the East Midlands region of the UK. The improvement project followed the stepwise process of the Behaviour Change Wheel framework, while also observing the premises and principles of stakeholder participation, put forth by participatory design practice. The research resulted in an original integrative approach, which developed from the work involving researcher and stakeholders in a process of cyclical reflection-in-action. This iterative process facilitated the recognition of specific ways whereby staff wanted to and could be involved throughout the intervention; it also led to the adaptation of selected tools and the incorporation of new tools tailored to the expertise, preferences and priorities sought by the group of stakeholders.
Collectively, the study findings identified the need for a new behaviour change support framework for participatory use. Likewise, they also indicate that the degree of stakeholder engagement normally expected from a participatory design process is often not feasible – and sometimes, not wanted – within the hospital context. Healthcare professionals have time limitations that need to be respected and the rationale for participation should follow real, rather than ideal possibilities of engagement. The findings led to the identification of specific recommendations that should be considered when looking at the advantages and disadvantages, facilitators and barriers, motivations, and hierarchical issues of involving healthcare staff in participatory quality improvement projects.
Finally, this thesis proposes an original approach – the Participatory Design for Behaviour Change framework – which integrates behavioural theory, models and tools, with participatory principles and methods. The framework underwent various iterations, and a final validation with a group of qualified healthcare professionals who had not taken part in the original intervention process. Opportunities for further research are presented to evaluate the applicability and effectiveness of the proposed framework within similar healthcare contexts, especially in comparison with existing alternative approaches.


Brazil, Ministry of Science, Technology, Innovations and Communications, Conselho Nacional de Desenvolvimento Científico e Tecnológico (Science without Borders programme)



  • Design


Loughborough University

Rights holder

© Fernando Felicio dos Santos de Carvalho

Publication date



A doctoral thesis. Submitted in partial fulfilment of the requirements for the award of Doctor of Philosophy of Loughborough University.


  • en


Gyuchan Thomas Jun ; Val Mitchell

Qualification name

  • PhD

Qualification level

  • Doctoral

This submission includes a signed certificate in addition to the thesis file(s)

  • I have submitted a signed certificate