The relationship between habit and healthcare professional behaviour in clinical practice: a systematic review and meta-analysis

Value of a quality label and European healthcare professionals' willingness to recommend health apps: An experimental vignette study

This study aimed to evaluate healthcare professionals' (HCPs') willingness to recommend health apps presented with versus without the CEN-ISO/TS 82304-2 health app quality label. The study was an experimental vignette study describing 12 short hypothetical scenarios, with Label (absent vs present) as a between and Type of App (prevention vs self-monitoring vs healthcare) and Patient Socioeconomic Status (low vs high) as within-subjects factors. The main outcome measure was HCPs' willingness to recommend apps. A total of 116 HCPs took part in the study. A significant main effect of the label was found. Further, HCPs were most willing to recommend self-management apps and more willing to recommend apps to high as opposed to low SES patients. However, the effect of the label did not differ between apps or according to patients' SES. Results confirm that the quality label has potential for increasing willingness to changing HCPs' recommendation behavior.

Determinants of and interventions for Proton Pump Inhibitor prescription behavior: A systematic scoping review

BACKGROUND

Proton Pump Inhibitors (PPI) are frequently prescribed. Long-term use is associated with side-effects and patients often lack a valid indication. Inappropriate PPI prescribing thus needs to be addressed. This review aims to scope 1) what determinants are studied as reasons for PPI prescribing, 2) what strategies are used for changing PPI (de)prescribing, and 3) whether important determinants are addressed in these interventions.

METHODS

We searched eight databases for papers on determinants of physician PPI prescribing. Studies were included if they were conducted in a Western country and focused on oral PPIs for an adult population. By following the Behaviour Change Wheel, we extracted information regarding PPI prescribing behavior, behavioral determinants and intervention strategies.

FINDINGS

We included 74 papers. Most focused on the determinants knowledge and beliefs about consequences. The latter was consistently related to PPI prescribing. Results for knowledge were mixed. Most interventions used education or enablement (e.g., algorithms, quality check improvements, involvement of pharmacists) as strategies. Enablement consistently improved PPI prescribing, while results for education were mixed.

INTERPRETATION

There is an overemphasis on reflective processes in studies on PPI prescribing. Future research should comprehensively identify behavioral determinants, focusing on reflective and impulsive processes, such that interventions can address the most important determinants.

Adherence to evidence-based guidelines for prevention of urinary retention in hip surgery patients: a multicentre observational study

Urinary retention is a healthcare complication putting patients at risk of unnecessary suffering and harm. Orthopaedic patients are known to face an increased such risk, calling for evidence-based preoperative assessment and corresponding measures to prevent bladder problems. The aim of this study was to evaluate healthcare professionals' adherence to risk assessment guidelines for urinary retention in hip surgery patients. This was an observational study from January 2021 to April 2021 with a descriptive and comparative design, triangulating three data sources: (I) Medical records for 1382 hip surgery patients across 17 hospitals in Sweden were reviewed for preoperative risk assessments for urinary retention and voiding-related variables at discharge; (II) The patients completed a survey regarding postoperative lower urinary tract symptoms, and; (III) data were extracted from a national quality registry regarding type of surgery, preoperative physical status, and perioperative urinary complications. Group differences were analysed with Chi-square/Fisher's exact test, t-test, Wilcoxon rank-sum test, or Mann-Whitney U-test. Logistic regression was used to analyse variables associated with completed risk assessments for urinary retention. Of all study participants, 23.4% (n = 323) had a preoperative documented risk assessment of urinary retention. Whether a risk assessment was performed was significantly associated with acute surgery [odds ratio (OR) 3.56, 95% confidence interval (CI) 2.48-5.12] and undergoing surgery at an academic hospital (OR 4.59, 95% CI 2.68-7.85). Acute patients were more often affected by urinary retention and had bladder issues and/or an indwelling catheter at discharge. More than every tenth patient (11. 9%, n = 53) completing the survey experienced intensified bladder problems after their hip surgery. The study shows a lack of adherence to risk assessment for urinary retention according to evidence-based guidelines, which negatively affects quality of care and patient safety.

Identifying the active ingredients of training interventions for healthcare professionals to promote and support increased levels of physical activity in adults with heart failure: a systematic review

Heart failure (HF) is characterised by breathlessness and fatigue that impacts negatively on patients' intentions to prioritise physical activity (PA). Healthcare professionals (HCPs) experience challenges when motivating patients to increase PA. It is essential to develop an understanding of how to support HCPs to deliver PA interventions. We aimed to identify active ingredients of HCP training interventions to enable delivery of PA interventions to HF patients. Nine databases were searched. Data were extracted on study characteristics, active ingredients, outcomes, and fidelity measures. Data were synthesised narratively, and a promise analysis was conducted on intervention features. Ten RCTs, which reported a training intervention for HCPs were included (N = 22 HCPs: N = 1,414 HF patients). Two studies reported the use of theory to develop HCP training. Seven behaviour change techniques (BCTs) were identified across the 10 training interventions. The most 'promising' BCTs were 'instruction on how to perform the behaviour' and 'problem solving'. Two studies reported that HCP training interventions had been formally evaluated. Fidelity domains including study design, monitoring and improving the delivery of treatment, intervention delivery, and provider training were infrequently reported. Future research should prioritise theory-informed development and robust evaluation of training interventions for HCPs to enable faithful and quality delivery of patient interventions.

The combined application of hand hygiene and non-sterile gloves by nurses in a tertiary hospital: a multi methods study

BACKGROUND

The application of hand hygiene (HH) and the use of non-sterile gloves (NSG) in daily care is highly intertwined. We aimed (1) to assess the combined application of HH and NSG among nurses and (2) to explore determinants that influence their ability to combine both measures in their care.

METHODS

In a multi-methods study, we combined direct observations of care episodes with semi-structured interviews with nurses in two affiliated university hospitals. Topics were based on Flottorp's checklist of determinants of practice.

RESULTS

In total, we observed 205 care episodes and interviewed 10 nurses. Observations revealed that the combination of NSG and HH was correctly applied in 19% of care episodes in which a single procedure was executed, and in 2% of care episodes in which multiple procedures were performed. From the interviews, we found determinants that influenced compliance, covered mainly by three out of seven of Flottorp's checklist domains. Nurses indicated that their knowledge of protocols was limited to HH and protocols were hardly ever actively consulted; visual reminders within their workplace were used as sources of information. Nurses' behavior was primarily influenced by their ability to operationalize this information and their ability to integrate both infection prevention measures into their care. The intention to apply and combine HH and NSG use was influenced by their risk assessment of cross-contamination, by the urge to self-protect and gut feeling. The feasibility to execute HH and NSG protocols is influenced by the urgency and the complexity of the care episode.

CONCLUSIONS

The combined correct application with HH and NSG measures by nurses is low. Nurses are instructed in a fragmented way while in the day to day care HH and NSG use are highly intertwined. Operationalization and simplification of infection prevention protocols, in which instructions on both infection prevention measures are fused, should be considered. Strategies to improve practice should consider the power of habit and nurses urge to self-protect.

Barriers and facilitators to reducing low-value care for the management of low back pain in Iran: a qualitative multi-professional study

INTRODUCTION

Low back pain (LBP) is a prevalent musculoskeletal disorder with a wide range of etiologies, ranging from self-limiting conditions to life-threatening diseases. Various modalities are available for the diagnosis and management of patients with LBP. However, many of these health services, known as low-value care (LVC), are unnecessary and impose undue financial costs on patients and health systems. The present study aimed to explore the perceptions of service providers regarding the facilitators and barriers to reducing LVC in the management of LBP in Iran.

METHODS

This qualitative descriptive study interviewed a total of 20 participants, including neurosurgeons, physiatrists, orthopedists, and physiotherapists, who were selected through purposive and snowball sampling strategies. The collected data were analyzed using the thematic content analysis approach.

RESULTS

Thirty-nine sub-themes, with 183 citations, were identified as barriers, and 31 sub-themes, with 120 citations, were defined as facilitators. Facilitators and barriers to reducing LVC for LBP, according to the interviewees, were categorized into five themes, including: (1) individual provider characteristics; (2) individual patient characteristics; (3) social context; (4) organizational context; and (5) economic and political context. The ten most commonly cited barriers included unrealistic tariffs, provider-induced demand, patient distrust, insufficient time allocation, a lack of insurance coverage, a lack of a comprehensive referral system, a lack of teamwork, cultural challenges, a lack of awareness, and defensive medicine. Barriers such as adherence to clinical guidelines, improving the referral system, improving the cultural status of patients, and facilitators such as strengthening teamwork, developing an appropriate provider-patient relationship, improving the cultural status of the public, motivating the patients, considering an individualized approach, establishing a desirable payment mechanism, and raising the medical tariffs were most repeatedly stated by participants.

CONCLUSION

This study has pointed out a great number of barriers and facilitators that shape the provision of LVC in the management of LBP in Iran. Therefore, it is essential for relevant stakeholders to consider these findings in order to de-implement LVC interventions in the process of LBP management.

Effect of an electronic medical record nudge to improve quality improvement program tracking of neuraxial catheter replacements in obstetric patients

BACKGROUND

Monitoring complications associated with medical procedures requires reliable and accurate record keeping. Nudge reminders executed by way of electronic medical record (EMR) alerts influence clinician behaviour. We hypothesised that the introduction of an EMR nudge would improve documentation of replaced neuraxial blocks by obstetric anaesthesiologists at our institution.

METHODS

We developed an EMR nudge that would alert the physician to a replaced neuraxial block if two or more neuraxial procedure notes in a single patient encounter were detected. The nudge encouraged physicians to document neuraxial block replacements in our institution's quality improvement database. We assessed the rate of physician adherence to replaced neuraxial block charting prior to the introduction of the nudge (January 2019-September 2019) and after the implementation (October 2019-December 2020).

RESULTS

494 encounters during the chart review period, January 2019-December 2020, required a neuraxial block replacement, representing an actual neuraxial replacement rate of 6.3% prior to the introduction of the nudge in October 2019. This rate was largely unchanged (6.2%) after the introduction of the nudge (0.1% difference, 95% CI: -0.0119 to 0.0099). Prior to the introduction of the nudge, the proportion of correctly charted failed/replaced blocks in our quality improvement database was 80.0%, and after nudge introduction, the rate was 96.2% (p value <0.00001, OR=6.32, 95% CI: 3.15 to 12.66). A p-chart of the monthly adherence rate demonstrated sustained improvement over time.

CONCLUSIONS

EMR nudge technology significantly improved adherence with quality metric monitoring of neuraxial catheter replacement in obstetric patients. The results imply that data collection for quality metric databases of neuraxial block failures and replacements that rely on clinician memory without a nudge are likely under-reporting neuraxial block failures and replacements. This study supports widespread implementation of nudges in EMRs to improve quality metric reporting.

The Dutch Solid Start program: describing the implementation and experiences of the program's first thousand days

BACKGROUND

In 2018, the Dutch government initiated the Solid Start program to provide each child the best start in life. The program focuses on the crucial first thousand days of life, which span from preconception to a child's second birthday, and has a specific focus towards (future) parents and young children in vulnerable situations. A key program element is improving collaboration between the medical and social sector by creating Solid Start coalitions. This study aimed to describe the implementation of the Dutch Solid Start program, in order to learn for future practice and policy. Specifically, this paper describes to what extent Solid Start is implemented within municipalities and outlines stakeholders' experiences with the implementation of Solid Start and the associated cross-sectoral collaboration.

METHODS

Quantitative and qualitative data were collected from 2019 until 2021. Questionnaires were sent to all 352 Dutch municipalities and analyzed using descriptive statistics. Qualitative data were obtained through focus group discussions(n = 6) and semi-structured interviews(n = 19) with representatives of care and support organizations, knowledge institutes and professional associations, Solid Start project leaders, advisors, municipal officials, researchers, clients and experts-by-experience. Qualitative data were analyzed using the Rainbow Model of Integrated Care.

RESULTS

Findings indicated progress in the development of Solid Start coalitions(n = 40 in 2019, n = 140 in 2021), and an increase in cross-sectoral collaboration. According to the stakeholders, initiating Solid Start increased the sense of urgency concerning the importance of the first thousand days and stimulated professionals from various backgrounds to get to know each other, resulting in more collaborative agreements on cross-sectoral care provision. Important elements mentioned for effective collaboration within coalitions were an active coordinator as driving force, and a shared societal goal. However, stakeholders experienced that Solid Start is not yet fully incorporated into all professionals' everyday practice. Most common barriers for collaboration related to systemic integration at macro-level, including limited resources and collaboration-inhibiting regulations. Stakeholders emphasized the importance of ensuring Solid Start and mentioned various needs, including sustainable funding, supportive regulations, responsiveness to stakeholders' needs, ongoing knowledge development, and client involvement.

CONCLUSION

Solid Start, as a national program with strong local focus, has led to various incremental changes that supported cross-sectoral collaboration to improve care during the first thousand days, without major transformations of systemic structures. However, to ensure the program's sustainability, needs such as sustainable funding should be addressed.

Factors influencing adherence to clinical practice guidelines in patients with suspected chronic coronary syndrome: a qualitative interview study in the ambulatory care sector in Germany

BACKGROUND

Chronic coronary syndrome (CCS) is a potentially progressive clinical presentation of coronary artery disease (CAD). Clinical practice guidelines (CPGs) are available for prevention, diagnosis, and treatment. Embedded in the "ENLIGHT-KHK" healthcare project, a qualitative study was conducted to identify factors that influence guideline adherence from the perspective of general practitioners (GPs) and cardiologists (CA) in the ambulatory care sector in Germany.

METHODS

GPs and CAs were surveyed via telephone using an interview guide. The respondents were first asked about their individual approach to caring for patients with suspected CCS. Subsequently, the accordance of their approach with guideline recommendations was addressed. Finally, potential measures for assisting with guideline adherence were discussed. The semi-structured interviews were transcribed verbatim and analysed using a qualitative content analysis in accordance with Kuckartz and Rädiker. Factors influencing adherence to CPGs were categorised by assessing whether they (i) inhibited or facilitated guideline adherence, (ii) played a role in patients at risk of CCS or with suspected or known CCS, (iii) were mentioned in implicit or explicit thematic reference to CPGs, and (iv) were declared a practical problem.

RESULTS

Based on interviews with ten GPs and five CAs, 35 potential influencing factors were identified. These emerged at four levels: patients, healthcare providers, CPGs, and the healthcare system. The most commonly cited barrier to guideline adherence among the respondents was structural aspects at the system level, including reachability of providers and services, waiting times, reimbursement through statutory health insurance (SHI) providers, and contract offers. There was a strong emphasis on interdependencies between factors acting at different levels. For instance, poor reachability of providers and services at the system level may result in inexpedience of guideline recommendations at the CPG level. Likewise, poor reachability of providers and services at the system level may be aggravated or alleviated by factors such as diagnostic preferences at the patient level or collaborations at the provider level.

CONCLUSIONS

To assist with adherence to CPGs regarding CCS, promoting measures may be needed that account for interdependencies between barriers and facilitators at various healthcare levels. Respective measures should consider medically justified deviations from guideline recommendations in individual cases.

TRIAL REGISTRATION

German Clinical Trials Register: DRKS00015638; Universal Trial Number (UTN): U1111-1227-8055.

Exploring the evidence base for Communities of Practice in health research and translation: a scoping review

BACKGROUND

The translation of research into healthcare practice relies on effective communication between disciplines, however strategies to address the gap between information sharing and knowledge transfer are still under exploration. Communities of Practice (CoP) are informal networks of stakeholders with shared knowledge or endeavour and present an opportunity to address this gap beyond disciplinary boundaries. However, the evidence-base supporting their development, implementation and efficacy in health is not well described. This review explores the evidence underpinning the use of CoP in health research and translation.

METHODS

A scoping review was undertaken using Arksey and O'Malley's methodological framework. A comprehensive search of health databases and grey literature was performed using keywords and controlled vocabulary. Studies were not restricted by date or research method.

RESULTS

A total of 1355 potentially relevant articles were identified through the global search strategy. Following screening, six articles were retained for analysis. Included studies were published between 2002 and 2013 in the United Kingdom (n = 3), Canada (n = 2) and Italy (n = 1). Three papers reported primary research; one used a quantitative methodology, one a qualitative, and one a descriptive evaluation approach. The three remaining papers explored seminal and evolving theories of CoP in the context of knowledge transfer and translation to the health sector.

CONCLUSIONS

A paucity of evidence exists regarding the development and efficacy of CoP in health research and translation. Further empirical research is required to determine if communities of practice can enhance the translation of research into clinical practice.

Clinical practice guidelines for the prevention of childhood obesity: A systematic review of quality and content

Obesity in childhood is a significant global issue, and prevention is key to reducing prevalence. Healthcare providers can play an important role in the prevention of obesity. The aim of this systematic review was to identify and evaluate clinical practice guidelines (CPGs) for preventing childhood obesity with a focus on the role of medical doctors. Peer-reviewed literature and gray literature sources were searched for CPGs published from 2010 to 2021. Eleven CPGs were identified. Quality was evaluated using the Appraisal of Guidelines for Research and Evaluation Collaboration (AGREE II) instrument; seven CPGs were higher quality and four lower quality. Recommendations within the CPGs covered three main areas: growth monitoring, maintaining a healthy weight, and managing overweight. The importance of involving the whole family and healthy lifestyle behaviors was emphasized. The majority of the CPGs rated poorly in guideline applicability highlighting the need for practical implementation tools. Although our review identified a number of CPGs relevant to the prevention of obesity for doctors working with children and their families, more research is needed to produce high-quality meaningful and applicable CPGs to maximize uptake, implementation, and ultimately, benefit to children and their families.

A relational approach to improving interprofessional teamwork in post-partum haemorrhage (PPH)

Background

Post-partum haemorrhage (PPH) is an obstetric emergency that requires effective teamwork under complex conditions. We explored healthcare team performance for women who suffered a PPH, focusing on relationships and culture as critical influences on teamwork behaviours and outcomes.

Methods

In collaboration with clinical teams, we implemented structural, process and relational interventions to improve teamwork in PPH cases. We were guided by the conceptual framework of Relational Coordination and used a mixed methods approach to data collection and analysis. We employed translational simulation as a central, but not singular, technique for enabling exploration and improvement. Key themes were identified from surveys, focus groups, simulation sessions, interviews, and personal communications over a 12-month period.

Results

Four overarching themes were identified: 1) Teamwork, clear roles and identified leadership are critical. 2) Relational factors powerfully underpin teamwork behaviours—shared goals, shared knowledge, and mutual respect. 3) Conflict and poor relationships can and should be actively explored and addressed to improve performance. 4) Simulation supports improved team performance through multifaceted mechanisms.

One year after the project commenced, significant progress had been made in relationships and systems. Clinical outcomes have improved; despite unprecedented increase in labour ward activity, there has not been any increase in large PPHs.

Conclusions

Teamwork, relationships, and the context of care can be actively shaped in partnership with clinicians to support high performance in maternity care. We present our multifaceted approach as a guide for leaders and clinicians in maternity teams, and as an exemplar for others enacting quality improvement in healthcare.

Healthcare professional behaviour: health impact, prevalence of evidence-based behaviours, correlates and interventions

Healthcare professional (HCP) behaviours are actions performed by individuals and teams for varying and often complex patient needs. However, gaps exist between evidence-informed care behaviours and the care provided. Implementation science seeks to develop generalizable principles and approaches to investigate and address care gaps, supporting HCP behaviour change while building a cumulative science. We highlight theory-informed approaches for defining HCP behaviour and investigating the prevalence of evidence-based care and known correlates and interventions to change professional practice. Behavioural sciences can be applied to develop implementation strategies to support HCP behaviour change and provide valid, reliable tools to evaluate these strategies. There are thousands of different behaviours performed by different HCPs across many contexts, requiring different implementation approaches. HCP behaviours can include activities related to promoting health and preventing illness, assessing and diagnosing illnesses, providing treatments, managing health conditions, managing the healthcare system and building therapeutic alliances. The key challenge is optimising behaviour change interventions that address barriers to and enablers of recommended practice. HCP behaviours may be determined by, but not limited to, Knowledge, Social influences, Intention, Emotions and Goals. Understanding HCP behaviour change is a critical to ensuring advances in health psychology are applied to maximize population health.

Changing healthcare professionals' non-reflective processes to improve the quality of care

RATIONALE

Translating research evidence into clinical practice to improve care involves healthcare professionals adopting new behaviours and changing or stopping their existing behaviours. However, changing healthcare professional behaviour can be difficult, particularly when it involves changing repetitive, ingrained ways of providing care. There is an increasing focus on understanding healthcare professional behaviour in terms of non-reflective processes, such as habits and routines, in addition to the more often studied deliberative processes. Theories of habit and routine provide two complementary lenses for understanding healthcare professional behaviour, although to date, each perspective has only been applied in isolation.

OBJECTIVES

To combine theories of habit and routine to generate a broader understanding of healthcare professional behaviour and how it might be changed.

METHODS

Sixteen experts met for a two-day multidisciplinary workshop on how to advance implementation science by developing greater understanding of non-reflective processes.

RESULTS

From a psychological perspective 'habit' is understood as a process that maintains ingrained behaviour through a learned link between contextual cues and behaviours that have become associated with those cues. Theories of habit are useful for understanding the individual's role in developing and maintaining specific ways of working. Theories of routine add to this perspective by describing how clinical practices are formed, adapted, reinforced and discontinued in and through interactions with colleagues, systems and organisational procedures. We suggest a selection of theory-based strategies to advance understanding of healthcare professionals' habits and routines and how to change them.

CONCLUSION

Combining theories of habit and routines has the potential to advance implementation science by providing a fuller understanding of the range of factors, operating at multiple levels of analysis, which can impact on the behaviours of healthcare professionals, and so quality of care provision.

Healthcare professionals' perspective on delivering personalised and holistic care: using the Theoretical Domains Framework

Background

Interventions to improve personalised and holistic care delivery by healthcare professionals are more likely to be effective if they target the factors influencing specific behaviours. This study reports on the development and testing of a questionnaire to identify perspectives of healthcare professionals’ personalised and holistic care behaviours based on the Theoretical Domains Framework.

Methods

The study was conducted in public health services in Victoria, Australia. The questionnaire was developed and pilot-tested with behaviour change researchers and healthcare professionals. Doctors, nurses and midwives were recruited via notices and email invitations from Safer Care Victoria's website and mailing lists of healthcare professionals and invited to completed the questionnaire online (hosted on Qualtrics). Health services administrators and allied health professionals were excluded from the study. Confirmatory factor analysis was undertaken to generate the model of best fit and group differences were tested using univariate tests.

Results

One hundred and four healthcare professionals from public health services in Victoria, Australia, completed the 39-item questionnaire focusing on specific personalised and holistic care behaviours. The final model consisted of 13 factors and 39 items, and CFA produced an acceptable fit, as well as adequate levels of discriminant validity and internal consistency (α = 0.60 to 0.84). Seven domains, “social influence”, “motivation & goals”, “environmental context and resources’, “skills”, ‘beliefs about consequences”, “behaviour regulation” and “nature of behaviour” were identified. Significant differences in the factors influencing these behaviours were found in groups with different years of experience and role seniority. These findings suggest that future interventions need to be targeted to specific groups.

Conclusion

This study identified the specific behaviours and the factors associated with performance of personalised and holistic care among healthcare professionals. The findings suggest several interventions and policy functions may be taken to improve personalised and holistic care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07630-1.

Assessing Knowledge, Beliefs, and Behaviors around Antibiotic Usage and Antibiotic Resistance among UK Veterinary Students: A Multi-Site, Cross-Sectional Survey

Antimicrobial resistance (AMR) is a profound threat to human and animal health. Antimicrobial prescribing behaviours are influenced by psychological factors such as knowledge, beliefs, and emotions. As future antimicrobial prescribers, it is important to understand beliefs about AMR and stewardship among veterinary (vet) students. This cross-sectional online survey assessed vet students’ self-reported behavior, knowledge, and beliefs in specific relation to antibiotic resistance (ABR) and antibiotic usage. Participants were early years (first- and second-year; n = 460) and later-years (third- and fourth-year; n = 113) undergraduate vet students from three UK universities. Self-reported antibiotic-related behaviors were responsible among most students. Knowledge about ABR and stewardship was moderate among early years students and good among later years students. Vet students typically believed that vets had less responsibility for both causing and preventing ABR than other groups (animal owners, human medics, and the public). This study offers evidence that vet students (along with other groups) tend to lay greater responsibility for ABR/AMR outside of their own profession, which may impact their future prescribing behaviors. It is vital that AMR and antimicrobial stewardship are embedded across veterinary curricula, and that the One Health nature of the challenge posed by AMR is emphasized to encourage shared responsibility across all stakeholder groups, thereby helping to reduce ‘other-blaming’ for AMR.

Implementing the use of objective medication adherence data in routine clinical practice via the digital CFHealthHub platform: situation analysis and strategy development using the theoretical domains framework

Background

Preventative inhaled treatments preserve lung function and reduce exacerbations in cystic fibrosis (CF). Self-reported adherence to these treatments is over-estimated. An online platform (CFHealthHub) has been developed with patients and clinicians to display real-time objective adherence data from dose-counting nebulisers, so that clinical teams can offer informed treatment support.

Methods

In this paper, we identify pre-implementation barriers to healthcare practitioners performing two key behaviours: accessing objective adherence data through the website CFHealthHub and discussing medication adherence with patients. We aimed to understand barriers during the pre-implementation phase, so that appropriate strategy could be developed for the scale up of implementing objective adherence data in 19 CF centres.

Thirteen semi-structured interviews were conducted with healthcare practitioners working in three UK CF centres. Qualitative data were coded using the theoretical domains framework (TDF), which describes 14 validated domains to implementation behaviour change.

Results

Analysis indicated that an implementation strategy should address all 14 domains of the TDF to successfully support implementation. Participants did not report routines or habits for using objective adherence data in clinical care. Examples of salient barriers included skills, beliefs in consequences, and social influence and professional roles. The results also affirmed a requirement to address organisational barriers. Relevant behaviour change techniques were selected to develop implementation strategy modules using the behaviour change wheel approach to intervention development.

Conclusions

This paper demonstrates the value of applying the TDF at pre-implementation, to understand context and to support the development of a situationally relevant implementation strategy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-022-00263-9.

Understanding low-value care and associated de-implementation processes: a qualitative study of Choosing Wisely Interventions across Canadian hospitals

BACKGROUND

Choosing Wisely (CW) is an international movement comprised of campaigns in more than 20 countries to reduce low-value care (LVC). De-implementation, the reduction or removal of a healthcare practice that offers little to no benefit or causes harm, is an emerging field of research. Little is known about the factors which (i) sustain LVC; and (ii) the magnitude of the problem of LVC. In addition, little is known about the processes of de-implementation, and if and how these processes differ from implementation endeavours. The objective of this study was to explicate the myriad factors which impact the processes and outcomes of de-implementation initiatives that are designed to address national Choosing Wisely campaign recommendations.

METHODS

Semi-structured interviews were conducted with individuals implementing Choosing Wisely Canada recommendations in healthcare settings in four provinces. The interview guide was developed using concepts from the literature and the Implementation Process Model (IPM) as a framework. All interviews were conducted virtually, recorded, and transcribed verbatim. Data were analysed using thematic analysis.

FINDINGS

Seventeen Choosing Wisely team members were interviewed. Participants identified numerous provider factors, most notably habit, which sustain LVC. Contrary to reporting in recent studies, the majority of LVC in the sample was not 'patient facing'; therefore, patients were not a significant driver for the LVC, nor a barrier to reducing it. Participants detailed aspects of the magnitude of the problems of LVC, providing insight into the complexities and nuances of harm, resources and prevalence. Harm from potential or common infections, reactions, or overtreatment was viewed as the most significant types of harm. Unique factors influencing the processes of de-implementation reported were: influence of Choosing Wisely campaigns, availability of data, lack of targets and hard-coded interventions.

CONCLUSIONS

This study explicates factors ranging from those which impact the maintenance of LVC to factors that impact the success of de-implementation interventions intended to reduce them. The findings draw attention to the significance of unintentional factors, highlight the importance of understanding the impact of harm and resources to reduce LVC and illuminate the overstated impact of patients in de-implementation literature. These findings illustrate the complexities of de-implementation.

‘What Makes It Nice Is Also What Makes It Difficult’

In health care the appropriation of new technology to assist and improve the diagnosis, treatment, and care of patients can be challenging. Based on observations and interviews with nurses and midwives during the early implementation process of a new interactive and technologically improved patient room, this article examines how health care professionals make sense of their work in the new patient room as it becomes enacted in their everyday work practice. We find that the technologically improved room is met with some resistance by the nurses and midwives. We argue that by exploring appropriation of technology as a social process of sense-making (Weick 1995), it can be revealed how meanings assigned to the new room influences actions and interactions with it.

Antibiotic prescribing for respiratory tract infection: exploring drivers of cognitive effort and factors associated with inappropriate prescribing

BACKGROUND

Antibiotics are over-prescribed for upper respiratory tract infection (URTI). It is unclear how factors known to influence prescribing decisions operate 'in the moment': dual process theories, which propose two systems of thought ('automatic' and 'analytical'), may inform this.

OBJECTIVE(S)

Investigate cognitive processes underlying antibiotic prescribing for URTI and the factors associated with inappropriate prescribing.

METHODS

We conducted a mixed methods study. Primary care physicians in Scotland (n = 158) made prescribing decisions for patient scenarios describing sore throat or otitis media delivered online. Decision difficulty and decision time were recorded. Decisions were categorized as appropriate or inappropriate based on clinical guidelines. Regression analyses explored relationships between scenario and physician characteristics and decision difficulty, time and appropriateness. A subgroup (n = 5) verbalized their thoughts (think aloud) whilst making decisions for a subset of scenarios. Interviews were analysed inductively.

RESULTS

Illness duration of 4+ days was associated with greater difficulty. Inappropriate prescribing was associated with clinical factors suggesting viral cause and with patient preference against antibiotics. In interviews, physicians made appropriate decisions quickly for easier cases, with little deliberation, reflecting automatic-type processes. For more difficult cases, physicians deliberated over information in some instances, but not in others, with inappropriate prescribing occurring in both instances. Some interpretations of illness duration and unilateral ear examination findings (for otitis media) were associated with inappropriate prescribing.

CONCLUSION

Both automatic and analytical processes may lead to inappropriate prescribing. Interventions to support appropriate prescribing may benefit from targeting interpretation of illness duration and otitis media ear exam findings and facilitating appropriate use of both modes of thinking.

Hand hygiene during facility-based childbirth in Cambodia: a theory-driven, mixed-methods observational study

Background

Despite current efforts to improve hand hygiene in health care facilities, compliance among birth attendants remains low. Current improvement strategies are inadequate, largely focusing on a limited set of known behavioural determinants or addressing hand hygiene as part of a generalized set of hygiene behaviours. To inform the design of a facility –based hand hygiene behaviour change intervention in Kampong Chhnang, Cambodia, a theory-driven formative research study was conducted to investigate the context specific behaviours and determinants of handwashing during labour and delivery among birth attendants.

Methods

This formative mixed-methods research followed a sequential explanatory design and was conducted across eight healthcare facilities. The hand hygiene practices of all birth attendants present during the labour and delivery of 45 women were directly observed and compliance with hand hygiene protocols assessed in analysis. Semi-structured, interactive interviews were subsequently conducted with 20 key healthcare workers to explore the corresponding cognitive, emotional, and environmental drivers of hand hygiene behaviours.

Results

Birth attendants’ compliance with hand hygiene protocol was 18% prior to performing labour, delivery and newborn aftercare procedures. Hand hygiene compliance did not differ by facility type or attendants’ qualification, but differed by shift with adequate hand hygiene less likely to be observed during the night shift (p = 0.03). The midwives’ hand hygiene practices were influenced by cognitive, psychological, environmental and contextual factors including habits, gloving norms, time, workload, inadequate knowledge and infection risk perception.

Conclusion

The resulting insights from formative research suggest a multi-component improvement intervention that addresses the different key behaviour determinants to be designed for the labour and delivery room. A combination of disruption of the physical environment via nudges and cues, participatory education to the midwives and the promotion of new norms using social influence and affiliation may increase the birth attendants’ hand hygiene compliance in our study settings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03901-7.

Examining the Effect of Context, Beliefs, and Values on UK Farm Veterinarians' Antimicrobial Prescribing: A Randomized Experimental Vignette and Cross-Sectional Survey

Antimicrobial resistance (AMR) is a pressing threat to public and animal health. There is evidence that antimicrobial prescribing and stewardship behaviors by veterinarians (vets) are influenced by non-clinical factors, such as psychological, social, and environmental factors. This study explored the role of context, beliefs, and values on vets' antimicrobial prescribing decisions. UK-based practicing farm vets (n = 97) were recruited to an online study. Using an experimental vignette methodology, vets were randomly assigned across four conditions, to examine the effects of different contexts (pressure on farm economics, the farmer, or the vet-farmer relationship, compared to a control condition) on vets' likelihood of prescribing antibiotics. Vets' beliefs about different groups' responsibility for causing and preventing AMR and vets' values were also measured. Key findings were that context alone, values, and beliefs about groups' responsibilities for causing AMR were not predictive of vets' likelihood of prescribing antibiotics. However, vets' beliefs about groups' responsibilities for preventing AMR were predictive of an increased likelihood of prescribing antibiotics, when vets were exposed to the experimental condition of the vignette in which the vet-farmer relationship was under pressure. Farm vets also believed that different groups have different levels of responsibility for causing and preventing AMR. Results should be interpreted cautiously, given the smaller than planned for sample size, and the possibility for both false negatives and false positives. Further research is needed to explore how these findings could inform antimicrobial stewardship interventions in veterinary medicine.

Enhancing the translation of health behaviour change research into practice: a selective conceptual review of the synergy between implementation science and health psychology

Health psychology is at the forefront of developing and disseminating evidence, theories, and methods that have improved the understanding of health behaviour change. However, current dissemination approaches may be insufficient for promoting broader application and impact of this evidence to benefit the health of patients and the public. Nevertheless, behaviour change theory/methods typically directed towards health behaviours are now used in implementation science to understand and support behaviour change in individuals at different health system levels whose own behaviour impacts delivering evidence-based health behaviour change interventions. Despite contributing to implementation science, health psychology is perhaps doing less to draw from it. A redoubled focus on implementation science in health psychology could provide novel prospects for enhancing the impact of health behaviour change evidence. We report a Health Psychology Review-specific review-of-reviews of trials of health behaviour change interventions published from inception to April 2020. We identified 34 reviews and assessed whether implementation readiness of behaviour change interventions was discussed. We then narratively review how implementation science has integrated theory/methods from health psychology and related discipline. Finally, we demonstrate how greater synergy between implementation science and health psychology could promote greater follow-through on advances made in the science of health behaviour change.

Using behavioral insights to design implementation strategies in public mental health settings: a qualitative study of clinical decision-making

BACKGROUND

Trauma-focused cognitive behavioral therapy (TF-CBT) is an evidence-based intervention for youth with posttraumatic stress disorder. An important component of TF-CBT is the trauma narrative (TN), a phase in the intervention in which youth are guided to process the memories, thoughts, and feelings associated with their traumatic experience(s). Previous work has shown that TF-CBT clinicians complete TNs with only half of their clients, yet little is known about what determines TF-CBT clinicians' use of TNs. The behavioral insights literature-an interdisciplinary field studying judgment and decision-making-offers theoretical and empirical tools to conceptualize what drives complex human behaviors and decisions. Drawing from the behavioral insights literature, the present study seeks to understand what determines clinician use of TNs and to generate strategies that target these determinants.

METHODS

Through semi-structured qualitative interviews, we sought the perspectives of trained TF-CBT clinicians working in public mental health settings across the city of Philadelphia (N = 17) to understand their decisions to use TNs with clients. We analyzed the qualitative data using a coding approach informed by the behavioral insights literature. We used an iterative process of structured hypothesis generation, aided by a behavioral insights guide, and rapid validation informed by behavioral insights to uncover the determinants of TN use. We then generated implementation strategies that targeted these determinants using the "Easy Attractive Social Timely" framework, a behavioral insights design approach.

RESULTS

We generated and validated three broad themes about what determines clinician implementation of TNs: decision complexity, clinician affective experience, and agency norms. We hypothesized behavioral insights that underlie these implementation determinants and designed a list of nine corresponding behavioral insights strategies that may facilitate TN implementation.

CONCLUSIONS

Our study investigated why an effective component of an evidence-based intervention is difficult to implement. We leveraged robust scientific theories and empirical regularities from the behavioral insights literature to understand clinician perspectives on TN implementation. These factors were theoretically linked to implementation strategies. Our work revealed the potential for using behavioral insights in the diagnosis of evidence-based intervention determinants and the design of implementation strategies.

Conceptualising Four Categories of Behaviours: Implications for Implementation Strategies to Achieve Behaviour Change

Background: Effectiveness of implementation strategies is influenced by the extent to which they are based on appropriate theories concerning the behaviours that the strategies intend to impact. Effectiveness may be limited simply because the strategies are based on theories that are limited in scope or are derived from partially inaccurate assumptions about the behaviours in question. It may therefore be important to combine insights from various theories to cover the range of influences on the behaviours that will be changed. Aim: This article aims to explore concepts, theories and empirical findings from different disciplines to categorise four types of behaviours and discuss the implications for implementation strategies attempting to change these behaviours. Influences on behaviours: Multilevel influences on behaviours are dichotomized into individual-level and collective-level influences, and behaviours that are guided by conscious cognitive processes are distinguished from those that rely on non-conscious processing. Combining the two dimensions (levels and cognitive modes) creates a 2 x 2 conceptual map consisting of four categories of behaviours. Explicitly conceptualising the levels and cognitive modes is crucial because different implementation strategies are required depending on the characteristics of the behaviours involved in the practise that needs to be changed. Conclusion: The 2 x 2 conceptual map can be used to consider and reflect on the nature of the behaviours that need to be changed, thus providing guidance on the type of theory, model or framework that might be most relevant for understanding and facilitating behaviour change.

Factors affecting the use of clinical practice guidelines by hospital physicians: the interplay of IT infrastructure and physician attitudes

Background

Compliance with clinical practice guidelines (CPGs) remains insufficient around the world, despite frequent updates and continuing efforts to disseminate and implement these guidelines through a variety of strategies. We describe the current status of young resident physician practices towards CPGs and investigate the multiple factors associated with the active use of CPGs, including the physician’s knowledge, attitudes, behaviours, CPG-related education received, and the hospital’s IT infrastructures. The aim is to identify a more effective point for intervention to promote CPG implementation.

Methods

We conducted a questionnaire survey among resident physicians working at 111 hospitals across Japan in 2015 and used results with hospital IT score data collected from a prior survey. Multivariable logistic regression analysis was performed to examine the determinants of frequent use of CPGs (defined at least once per week). The independent variables were selected based on physician demographics, clinical speciality and careers, daily knowledge and behaviour items, CPG-related education received, digital preference, and hospital IT score (high/medium/low), with and without interaction terms.

Results

Responses from 535 resident physicians, at 61 hospitals, were analysed. The median hospital IT score was 6 out of a possible 10 points. Physicians who had learned about CPGs tended to work at hospitals with medium to high IT scores, had easier access to paywalled medical databases, and had better knowledge of the guideline network ‘Minds’. In addition, these physicians tended to use CPGs electronically. A physician’s behaviour towards using CPGs for therapeutic decision-making was strongly associated with frequent use of CPGs (odds ratio [95% CI] 6.1 [3.6–10.4]), which indicated that a physician’s habit strongly promotes CPG use. Moreover, CPG-related education was associated with active use of CPGs (OR1.7 [1.1–2.5]). The interaction effects between individual digital preferences and higher hospital IT score were also observed for frequent CPG use (OR2.9 [0.9–8.8]).

Conclusions

A physician’s habitual behaviours, CPG-related education, and a combination of individual digital preference and superior hospital IT infrastructure are key to bridging the gap between the use and implementation of CPGs.

Supplementary information

Supplementary information accompanies this paper at 10.1186/s13012-020-01056-1.

Influenza vaccination: A qualitative study of practice level barriers from medical practitioners caring for children with special risk medical conditions

BACKGROUND

Understanding the influenza vaccination practices of general practitioners (GP) and paediatric hospital specialists caring for children with special risk medical conditions (SRMC) is imperative for designing interventions to improve uptake. This study aimed to identify the vaccination decision making, provider practices and perceived barriers and facilitators to recommending or delivering influenza vaccine for children with SRMCs at the tertiary and primary care levels.

METHODS

Nominated GPs and hospital specialists from a single tertiary hospital were interviewed to explore influenza vaccination practices and challenges for children with confirmed SRMCs. Interviews were digitally recorded, transcribed verbatim and thematic analysis was used to inductively code these data. Resulting themes were mapped across the COM-B ('capability', 'opportunity', 'motivation' and 'behaviour') theoretical framework to understanding barriers and potential interventions.

RESULTS

Twenty-six medical practitioners (21 GPs and 5 hospital specialists) completed semi-structured interviews. Barriers, and facilitators for influenza vaccine recommendation (the intended behaviour) were thematically grouped. Opportunity themes included structural barriers (e.g. limited use of systems and processes to support the identification of children with SRMCs); recommendation as standard practice; vaccination inconvenience; lack of communication and educational resources; social acceptance and normalisation; and media messaging. Capability themes included provider communication with parents; knowledge of influenza vaccine recommendations; and professional boundaries to implement the recommendation. Themes in the Motivation category included provider clinical prioritisation and responsibility towards providing a recommendation.

CONCLUSIONS

The main barriers to influenza recommendation raised by our study participants were structural. These included lack of processes to identify children with SRMCs, limited use of reminder systems and unclear delineation of role responsibility between hospital specialists and GPs. An important driver that emerged was GPs' responsibility for providing a recommendation. To increase influenza vaccine coverage for children with SRMCs, consideration should be given to addressing practice level structural barriers and improving collaboration.

Nudges to Support Health and Wellness for Individuals Served by Behavioral Health Programs

Individuals served by behavioral health programs experience risk factors that threaten health and longevity. Health behavior changes may be supported through environmental modifications known as nudges. The current review (a) examines the potential value of nudges for helping individuals receiving services from behavioral health programs, and (b) offers physical and social environment strategies to support positive health behaviors. The authors discuss literature related to nudges and environmental influences on health behaviors. The research related to nudges supports the potential value of this framework for nurses in behavioral health settings, who are in a strong position to help address health and wellness concerns disproportionately experienced by individuals in behavioral health programs. [Journal of Psychosocial Nursing and Mental Health Services, 59(1), 21-28.].

Patterns of behaviour in nursing staff actioning the afferent limb of the rapid response system (RRS): A focused ethnography

AIM

To improve understanding of afferent limb behaviour in acute hospital ward settings, to define and specify who needs to do what differently and to report what afferent limb behaviours should be targeted in a subsequent multi-phase, theory-based, intervention development process.

DESIGN

Focused ethnography was used including direct observation of nursing staff enacting afferent limb behaviours and review of vital signs charts.

METHODS

An observation guide focused observation on "key moments" of the afferent limb. Descriptions of observations from between 7 January 2019-18 December 2019 were recorded in a field journal alongside reflexive notes. Vital signs and early warning scores from charts were reviewed and recorded. Field notes were analysed using structured content analysis. Observed behaviour was compared with expected (policy-specified) behaviour.

RESULTS

Observation was conducted for 300 hr. Four hundred and ninety-nine items of data (e.g., an episode of observation or a set of vital signs) were collected. Two hundred and eighty-nine (58%) items of data were associated with expected (i.e. policy-specified) afferent limb behaviour; 210 (42%) items of data were associated with unexpected afferent limb behaviour (i.e. alternative behaviour or no behaviour). Ten specific behaviours were identified where the behaviour observed deviated (negatively) from policy or where no action was taken when it should have been. One further behaviour was seen to expedite the assessment of a deteriorating patient by an appropriate responder and was therefore considered a positive deviance.

CONCLUSION

Afferent limb failure has been described as a problem of inconsistent staff behaviour. Eleven potential target behaviours for change are reported and specified using a published framework.

IMPACT

Clear specification of target behaviour will allow further enquiry into the determinants of these behaviours and the development of a theory-based intervention that is more likely to result in behaviour change and can be tested empirically in future research.

Predicting implementation: comparing validated measures of intention and assessing the role of motivation when designing behavioral interventions

BACKGROUND

Behavioral intention (which captures one's level of motivation to perform a behavior) is considered a causal and proximal mechanism influencing the use of evidence-based practice (EBP). Implementation studies have measured intention differently, and it is unclear which is most predictive. Some use items referring to "evidence-based practice" in general, whereas others refer to a specific EBP. There are also unresolved debates about whether item stems should be worded "I intend to," "I will," or "How likely are you to" and if a single-item measure can suffice. Using each stem to refer to either a specific EBP or to "evidence-based practice," this study compares the ability of these commonly used measures to predict future EBP implementation. The predictive validity is important for causal model testing and the development of effective implementation strategies.

METHODS

A longitudinal study enrolled 70 teachers to track their use of two EBPs and compare the predictive validity of six different items measuring teachers' intention. The measures differ by whether an item refers to a specific EBP, or to "evidence-based practices" in general, and whether the stem is worded in one of the three ways: "I intend to," "I will," or "How likely are you to." For each item, linear regressions estimated the variance in future behavior explained. We also compared the predictive validity of a single item versus an aggregate of items by inter-correlating the items using different stems and estimating the explained variance in EBP implementation.

RESULTS

Depending on the EBP and how intention was measured, the explained variance in implementation ranged from 3.5 to 29.0%. Measures that referred to a specific EBP, rather than "evidence-based practices" in general, accounted for more variance in implementation (e.g., 29.0% vs. 8.6%, and 11.3% vs. 3.5%). The predictive validity varied depending on whether stems were worded "I intend to," "I will," or "How likely are you to."

CONCLUSIONS

The observed strength of the association between intentions and EBP use will depend on how intention is measured. The association was much stronger if an item referred to a specific EBP, rather than EBP in general. To predict implementation, the results support using an aggregate of two or three intention items that refer to the specific EBP. An even more pragmatic measure of intention consisting of a single item can also predict implementation. As discussed, the relationship will also vary depending on the EBP, which has direct implications for causal model testing and the design of implementation strategies.

Use of dementia care mapping in the care for older people with intellectual disabilities: A mixed-method study

Background

The ageing of people with intellectual disabilities, with associated morbidity like dementia, calls for new types of care. Person‐centred methods may support care staff in providing this, an example being Dementia Care Mapping (DCM). DCM has been shown to be feasible in ID‐care. We examined the experiences of ID‐professionals in using DCM.

Methods

We performed a mixed‐methods study, using quantitative data from care staff (N = 136) and qualitative data (focus‐groups, individual interviews) from care staff, group home managers and DCM‐in‐intellectual disabilities mappers (N = 53).

Results

DCM provided new insights into the behaviours of clients, enabled professional reflection and gave new knowledge and skills regarding dementia and person‐centred care. Appreciation of DCM further increased after the second cycle of application.

Conclusion

DCM is perceived as valuable in ID‐care. Further assessment is needed of its effectiveness in ID‐care with respect to quality of care, staff‐client interactions and job performance.

Nudge strategies to improve healthcare providers' implementation of evidence-based guidelines, policies and practices: a systematic review of trials included within Cochrane systematic reviews

BACKGROUND

Nudge interventions are those that seek to modify the social and physical environment to enhance capacity for subconscious behaviours that align with the intrinsic values of an individual, without actively restricting options. This study sought to describe the application and effects of nudge strategies on clinician implementation of health-related guidelines, policies and practices within studies included in relevant Cochrane systematic reviews.

METHODS

As there is varied terminology used to describe nudge, this study examined studies within relevant systematic reviews. A two-stage screening process was undertaken where, firstly, all systematic reviews published in the Cochrane Library between 2016 and 2018 were screened to identify reviews that included quantitative studies to improve implementation of guidelines among healthcare providers. Secondly, individual studies within relevant systematic reviews were included if they were (i) randomised controlled trials (RCTs), (ii) included a nudge strategy in at least one intervention arm, and (iii) explicitly aimed to improve clinician implementation behaviour. We categorised nudge strategies into priming, salience and affect, default, incentives, commitment and ego, and norms and messenger based on the Mindspace framework.

SYNTHESIS

The number and percentage of trials using each nudge strategy was calculated. Due to substantial heterogeneity, we did not undertake a meta-analysis. Instead, we calculated within-study point estimates and 95% confidence intervals, and used a vote-counting approach to explore effects.

RESULTS

Seven reviews including 42 trials reporting on 57 outcomes were included. The most common nudge strategy was priming (69%), then norms and messenger (40%). Of the 57 outcomes, 86% had an effect on clinician behaviour in the hypothesised direction, and 53% of those were statistically significant. For continuous outcomes, the median effect size was 0.39 (0.22, 0.45), while for dichotomous outcomes the median Odds Ratio was 1.62 (1.13, 2.76).

CONCLUSIONS

This review of 42 RCTs included in Cochrane systematic reviews found that the impact of nudge strategies on clinician behaviour was at least comparable to other interventions targeting implementation of evidence-based guidelines. While uncertainty remains, the review provides justification for ongoing investigation of the evaluation and application of nudge interventions to support provider behaviour change.

TRIAL REGISTRATION

This review was not prospectively registered.

Action, actor, context, target, time (AACTT): a framework for specifying behaviour

BACKGROUND

Designing implementation interventions to change the behaviour of healthcare providers and other professionals in the health system requires detailed specification of the behaviour(s) targeted for change to ensure alignment between intervention components and measured outcomes. Detailed behaviour specification can help to clarify evidence-practice gaps, clarify who needs to do what differently, identify modifiable barriers and enablers, design interventions to address these and ultimately provides an indicator of what to measure to evaluate an intervention's effect on behaviour change. An existing behaviour specification framework proposes four domains (Target, Action, Context, Time; TACT), but insufficiently clarifies who is performing the behaviour (i.e. the Actor). Specifying the Actor is especially important in healthcare settings characterised by multiple behaviours performed by multiple different people. We propose and describe an extension and re-ordering of TACT to enhance its utility to implementation intervention designers, practitioners and trialists: the Action, Actor, Context, Target, Time (AACTT) framework. We aim to demonstrate its application across key steps of implementation research and to provide tools for its use in practice to clarify the behaviours of stakeholders across multiple levels of the healthcare system.

METHODS AND RESULTS

We used French et al.'s four-step implementation process model to describe the potential applications of the AACTT framework for (a) clarifying who needs to do what differently, (b) identifying barriers and enablers, (c) selecting fit-for-purpose intervention strategies and components and (d) evaluating implementation interventions.

CONCLUSIONS

Describing and detailing behaviour using the AACTT framework may help to enhance measurement of theoretical constructs, inform development of topic guides and questionnaires, enhance the design of implementation interventions and clarify outcome measurement for evaluating implementation interventions.

Connecting patients, practitioners, and regulators in supporting positive experiences and processes of shared decision making: A progress report

This paper describes a novel approach to explore how regulators, working with patients and practitioners, may contribute to supporting person-centred care and processes of shared decision making in implementing professional standards and reducing harms. Osteopathic patients report high levels of patient care. However, areas of consultations less likely to be rated as high included "fully understanding your concerns," "helping you to take control," and "making a plan of action with you," suggestive of a paternalistic approach to care and a barrier to the effective implementation of standards. This programme explored how to support patients and practitioners to make more explicit what is important to support consultations with better communication in accordance with standards. A series of workshops took place involving approximately 80 participants, which explored and identified practitioner and patient values; these were themed to develop a common framework and tested using case studies. Aspects of what enables or presents a barrier to a positive consultation were further explored with real patient narratives, and a range of resources were subsequently developed, which may support patients and practitioners to make explicit what is important to them in a consultation. A series of approaches and tools were then developed for piloting including patient curriculum vitae; patient goal planner; patient animation to support preparation for an appointment; infographic: a patient poster or leaflet; practitioner reflective tool; and an audio recording to increase awareness and understanding of values-based practice. In conclusion, a range of approaches may help to support patients and practitioners to make explicit what is important to them in a consultation. The next phase of our programme will use a range of methods including cluster sampling, pre-testing and post-testing with the Consultation and Relational Empathy (CARE) measure tool, and interviews and focus groups with users and practitioners to demonstrate impact.

On the Role of Habit in Self-Reported and Observed Hand Hygiene Behavior

BACKGROUND

The present contribution tests the main ideas that (a) hand hygiene behavior is associated with habit, and (b) this association is robust when deliberative constructs (i.e. knowledge and intention) are controlled for, indicating an automatic component in hand hygiene behavior.

METHODS

Two correlational studies using different operationalisations of hand hygiene behavior are reported. In Study 1, hand hygiene was assessed in the context of food preparation; data were measured using the Day Reconstruction Method in a sample of the general population. Study 2 considered hand hygiene compliance of healthcare workers applying video observation by body cameras and additionally self-reported behavior. In both studies, habit was assessed using the Self-Report Behavioral Automaticity Index.

RESULTS

Both studies found the expected positive association between habit and hand hygiene (0.271 < r < 0.570). Habit was further analyzed in combination with knowledge and intention (Study 2), and emerged as a significant predictor of observed hand hygiene, while knowledge and intention were marginally significant. No significant interactions were found.

CONCLUSIONS

The present work provides evidence that hand hygiene behavior is reliably related to habit. The findings speak to the notion that addressing the automatic route to hand hygiene behavior when designing interventions can be fruitful.

Exploring the role of competing demands and routines during the implementation of a self-management tool for type 2 diabetes: a theory-based qualitative interview study

BACKGROUND

The implementation of new medical interventions into routine care involves healthcare professionals adopting new clinical behaviours and changing existing ones. Whilst theory-based approaches can help understand healthcare professionals' behaviours, such approaches often focus on a single behaviour and conceptualise its performance in terms of an underlying reflective process. Such approaches fail to consider the impact of non-reflective influences (e.g. habit and automaticity) and how the myriad of competing demands for their time may influence uptake. The current study aimed to apply a dual process theoretical approach to account for reflective and automatic determinants of healthcare professional behaviour while integrating a multiple behaviour approach to understanding the implementation and use of a new self-management tool by healthcare professionals in the context of diabetes care.

METHODS

Following Diabetes UK's national release of the 'Information Prescription' (DUK IP; a self-management tool targeting the management of cholesterol, blood pressure and HbA1c) in January 2015, we conducted semi-structured interviews with 13 healthcare professionals (general practitioners and nurses) who had started to use the DUK IP during consultations to provide self-management advice to people with type 2 diabetes. A theory-based topic guide included pre-specified constructs from a previously developed logic model. We elicited healthcare professionals' views on reflective processes (outcome expectations, self-efficacy, intention, action and coping planning), automatic processes (habit), and multiple behaviour processes (goal priority, goal conflict and goal facilitation). All interviews were audio recorded and transcribed verbatim and all transcripts were independently double coded and analysed using content analysis.

RESULTS

The majority of healthcare professionals interviewed reported strong intentions to use the DUK IP and having formed a habit of using them after a minimum of one month continuous use. Pop-up cues in the electronic patient records were perceived to facilitate the use of the tool. Factors that conflicted with the use of the DUK IP included existing pathways of providing self-management advice.

CONCLUSION

Data suggests that constructs from dual process and multiple behaviour approaches are useful to provide supplemental understanding of the implementation of new self-management tools such as the DUK IP and may help to advance behavioural approaches to implementation science.