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

How can a behavioral economics lens contribute to implementation science?

BACKGROUND

Implementation science in health is an interdisciplinary field with an emphasis on supporting behavior change required when clinicians and other actors implement evidence-based practices within organizational constraints. Behavioral economics has emerged in parallel and works towards developing realistic models of how humans behave and categorizes a wide range of features of choices that can influence behavior. We argue that implementation science can be enhanced by the incorporation of approaches from behavioral economics. Main body First, we provide a general overview of implementation science and ways in which implementation science has been limited to date. Second, we review principles of behavioral economics and describe how concepts from BE have been successfully applied to healthcare including nudges deployed in the electronic health record. For example, de-implementation of low-value prescribing has been supported by changing the default in the electronic health record. We then describe what a behavioral economics lens offers to existing implementation science theories, models and frameworks, including rich and realistic models of human behavior, additional research methods such as pre-mortems and behavioral design, and low-cost and scalable implementation strategies. We argue that insights from behavioral economics can guide the design of implementation strategies and the interpretation of implementation studies. Key objections to incorporating behavioral economics are addressed, including concerns about sustainment and at what level the strategies work.

CONCLUSION

Scholars should consider augmenting implementation science theories, models, and frameworks with relevant insights from behavioral economics. By drawing on these additional insights, implementation scientists have the potential to boost efforts to expand the provision and availability of high quality care.

Implementation science challenges: hearing care professionals identify barriers to clinical research

OBJECTIVES

Conducting research in clinical settings is challenging. The aim of this study was to increase our understanding of hearing care professionals' perceptions of barriers to participating in such research.

DESIGN

A modified group concept mapping approach was used to gain anonymous responses from 124 hearing care professionals to the statement: "One reason why it is hard to conduct intervention research studies in my centre/practice is….". Participants were asked for reasons other than 'time' as this is universally reported as a barrier to clinical research.

RESULTS

A total of 107 distinct reasons were provided by participants and these were sorted into 5 clusters: "Competing demands/pressures" (18 statements), "Not a priority for management/organisation" (14 statements), "Lack of opportunity/support" (19 statements), "Clinician's knowledge, confidence, and beliefs" (24 statements), and "Recruitment/adherence to protocols is challenging" (32 statements). Identified barriers were generally similar to those reported in other healthcare settings, with unique barriers being those associated with a fear of scrutiny and lack of trust in the "academic elite".

CONCLUSION

Findings highlight the importance of researchers, clinicians, and clinic managers working together at all stages of the research process in order for clinical research to be successful.

IMP2ART: development of a multi-level programme theory integrating the COM-B model and the iPARIHS framework, to enhance implementation of supported self-management of asthma in primary care

BACKGROUND

Supported asthma self-management, incorporating an asthma action plan and annual clinical review, has been recommended by UK/global guidelines for over three decades. However, implementation remains poor, as only around a third of individuals receive basic asthma care, according to the UKs leading respiratory charity Asthma and Lung UK. A systematic review of implementation studies recommended that a whole systems approach targeting patients, healthcare professional education, and organisations is needed to improve implementation of supported asthma self-management in primary care. The IMPlementing IMProved Asthma self-management as RouTine (IMP2ART) is a national Hybrid-II implementation cluster randomised controlled trial that aims to evaluate such an approach. This paper describes the development of the implementation strategy for IMP2ART with particular focus on the integration of multiple level theories.

METHODS

The Medical Research Council design and evaluation of complex interventions framework and the Person-Based Approach to intervention development were used as guidance for stages of strategy development. Specifically, we (i) set up a multidisciplinary team (including practicing and academic clinicians, health psychologists, public health and patient colleagues), (ii) reviewed and integrated evidence and theory, (iii) developed guiding principles, (iv) developed prototype materials, and (v) conducted a pre-pilot study before final refinement.

RESULTS

The implementation strategy included resources for patients, team-based and individual healthcare professional education, practice audit and feedback, and an asthma review template, as well as a facilitator role accessible to primary care practices for 12 months. The synthesis of the integrated Promoting Action on Research Implementation in Health Services (iPARIHS) and Capability, Opportunity, Motivation and Behaviour (COM-B) frameworks led to an evolved framework bringing together important implementation and behaviour change elements which will be used as a basis for the study process evaluation.

CONCLUSIONS

A description of rigorous implementation strategy development for the IMP2ART study is provided along with newly theorised integration of implementation and behaviour change science which may be of benefit to others targeting implementation in primary care.

TRIAL REGISTRATION

ISRCTN15448074. Registered on 2nd December 2019.

A qualitative process evaluation using the behaviour change wheel approach: Did a whole genome sequence report form (SRF) used to reduce nosocomial SARS-CoV-2 within UK hospitals operate as anticipated?

PURPOSE

The aim of this study was to conduct a process evaluation of a whole-genome sequence report form (SRF) used to reduce nosocomial SARS-CoV-2 through changing infection prevention and control (IPC) behaviours within the COVID-19 pandemic.

METHODS

We used a three-staged design. Firstly, we described and theorized the purported content of the SRF using the behaviour change wheel (BCW). Secondly, we used inductive thematic analysis of one-to-one interviews (n = 39) to explore contextual accounts of using the SRF. Thirdly, further deductive analysis gauged support for the intervention working as earlier anticipated.

RESULTS

It was possible to theorize the SRF using the BCW approach and visualize it within a simple logic model. Inductive thematic analyses identified the SRF's acceptability, ease of use and perceived effectiveness. However, major challenges to embedding it in routine practice during the unfolding COVID-19 crisis were reported. Notwithstanding this insight, deductive analysis showed support for the putative intervention functions 'Education', 'Persuasion' and 'Enablement'; behaviour change techniques '1.2 Problem solving', '2.6 Biofeedback', '2.7 Feedback on outcomes of behaviour' and '7.1 Prompts and cues'; and theoretical domains framework domains 'Knowledge' and 'Behavioural regulation'.

CONCLUSIONS

Our process evaluation of the SRF, using the BCW approach to describe and theorize its content, provided granular support for the SRF working to change IPC behaviours as anticipated. However, our complementary inductive thematic analysis highlighted the importance of the local context in constraining its routine use. For SRFs to reach their full potential in reducing nosocomial infections, further implementation research is needed.

Behaviour change, the itchy spot of healthcare quality improvement: How can psychology theory and skills help to scratch the itch?

Despite the clear utility and transferability, National Health Service (NHS) quality improvement initiatives have yet to benefit fully from what is already known within health psychology. Thus far, evidence from established, seminal behaviour change theory and practice have been ignored in favour of newly developed models and frameworks. Further, whilst there is a growing interest in what is commonly referred to as 'human factors' of change and improvement, there is scant transferability of known psychologically informed implementation skills into routine NHS Improvement practice. The science and practice of healthcare improvement is growing, and the behaviour change aspect is critical to sustainable outcomes. Therefore, this paper offers practical guidance on how seminal psychological behaviour change theory and motivational interviewing (a person-centred skills-based approach specifically developed to support people through change) can be combined to better address individual and organisational change within a healthcare improvement context.

Use of the Behaviour Change Wheel to design an intervention to improve the provision of mental wellbeing support within the audiology setting

OBJECTIVE

This study describes the development of an intervention to increase the frequency of audiologists' asking about and providing information regarding mental wellbeing within adult audiology services.

DESIGN

The Behaviour Change Wheel (BCW), an eight-step systematic process, was followed to develop the intervention. Reports describing the first four steps are published elsewhere. This report describes the final four steps and details the intervention developed.

RESULTS

A multifaceted intervention was developed to change audiologists' behaviours relating to providing mental wellbeing support to adults with hearing loss. Specifically, three behaviours were targeted: (1) asking clients about their mental wellbeing, (2) providing general information on the mental wellbeing impacts of hearing loss, and (3) providing personalised information on managing the mental wellbeing impacts of hearing loss. A variety of intervention functions and behaviour change techniques were incorporated into the intervention, including instruction and demonstration, information about others approval, adding objects to the environment, use of prompts/cues, and endorsement from credible sources.

CONCLUSION

This study is the first to use the Behaviour Change Wheel to develop an intervention targeting mental wellbeing support behaviours in audiologists and confirms the usability and usefulness of the approach in a complex area of clinical care. The systematic development of the Ask, Inform, Manage, Encourage, Refer (AIMER) intervention will facilitate a thorough evaluation of its effectiveness in the next phase of this work.

Individual and Contextual Factors Associated with Classroom Teachers' Intentions to Implement Classroom Physical Activity

Classroom-based physical activity (CPA) is an evidence-based practice that improves student physical activity outcomes, but national data suggest implementation is insufficient in US classrooms. The purpose of this study was to examine individual and contextual factors associated with elementary school teachers' intentions to implement CPA. We collected input survey data from 181 classroom teachers (10 schools; 98.4% participation among eligible teachers) across three separate cohorts to examine associations between individual and contextual constructs and future CPA implementation intentions. Data were analyzed using multilevel logistic regression. Individual-level characteristics of perceived autonomy for using CPA, perceived relative advantage/compatibility of CPA, and general openness to educational innovations were positively associated with intentions to implement CPA (p < 0.05). Teacher perceptions of contextual factors such as administrator support for CPA were also associated with implementation intentions. This study adds to prior evidence about the importance of theoretically determined constructs for understanding behavioral intentions among front-line implementers such as classroom teachers. Additional research is needed to evaluate interventions designed to change malleable factors, including teachers' perceptions, as well as changing school environments so that teachers perceive more autonomy to use CPA and have the training and resources that build skills for implementation.

Ivers N. Surfacing the causal assumptions and active ingredients of healthcare quality improvement interventions: An application to primary care opioid prescribing

Background

Efforts to maximize the impact of healthcare improvement interventions are hampered when intervention components are not well defined or described, precluding the ability to understand how and why interventions are expected to work.

Method

We partnered with two organizations delivering province-wide quality improvement interventions to establish how they envisaged their interventions lead to change (their underlying causal assumptions) and to identify active ingredients (behavior change techniques [BCTs]). The interventions assessed were an audit and feedback report and an academic detailing program. Both focused on supporting safer opioid prescribing in primary care in Ontario, Canada. Data collection involved semi-structured interviews with intervention developers (n = 8) and a content analysis of intervention documents. Analyses unpacked and articulated how the interventions were intended to achieve change and how this was operationalized.

Results

Developers anticipated that the feedback report would provide physicians with a clear understanding of their own prescribing patterns in comparison to others. In the feedback report, we found an emphasis on BCTs consistent with that assumption (feedback on behavior; social comparison). The detailing was designed to provide tailored support to enable physicians to overcome barriers to change and to gradually enact specific practice changes for patients based on improved communication. In the detailing materials, we found an emphasis on instructions on how to perform the behavior, for a range of behaviors (e.g., tapering opioids, treating opioid use disorder). The materials were supplemented by detailer-enacted BCTs (e.g., social support [practical]; goal setting [behavior]; review behavioral goal[s]).

Conclusions

The interventions included a small range of BCTs addressing various clinical behaviors. This work provides a methodological example of how to apply a behavioral lens to surface the active ingredients, target clinical behaviors, and causal assumptions of existing large-scale improvement interventions that could be applied in other contexts to optimize effectiveness and facilitate scale and spread.

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.

Data Velocity in HIV-Related Implementation Research: Estimating Time From Funding to Publication

BACKGROUND

Given available effective biomedical and behavioral prevention and treatment interventions, HIV-related implementation research (IR) is expanding. The rapid generation and dissemination of IR to inform guidelines and practice has the potential to optimize the impact of the Ending the Epidemic Initiative and the HIV pandemic response more broadly.

METHODS

We leveraged a prior mapping review of NIH-funded awards in HIV and IR from January 2013 to March 2018 and identified all publications linked to those grants in NIH RePORTER through January 1, 2021 (n = 1509). Deduplication and screening of nonoriginal research reduced the count to 1032 articles, of which 952 were eligible and included in this review. Publication volume and timing were summarized; Kaplan-Meier plots estimated time to publication.

RESULTS

Among the 215 NIH-funded IR-related awards, 127 of 215 (59%) published original research directly related to the grant, averaging 2.0 articles (SD: 3.3) per award, largely in the early IR phases. Many articles (521 of 952, 55%) attributed to grants did not report grant-related data. Time from article submission to publication averaged 205 days (SD: 107). The median time-to-first publication from funding start was 4 years. Data dissemination velocity varied by award type, trending toward faster publication in recent years. Delays in data velocity included (1) time from funding to enrollment, (2) enrollment length, and (3) time from data collection completion to publication.

CONCLUSION

Research publication was high overall, and time-to-publication is accelerating; however, over 40% of grants have yet to publish findings from grant-related data. Addressing bottlenecks in the production and dissemination of HIV-related IR would reinforce its programmatic and policy relevance in the HIV response.

Re-visiting the relevance and importance of health psychology in South Africa

Health psychology as a discipline has existed for more than four decades and is primarily concerned with research, theory, and practice at the nexus of psychology and health. The discipline is well established across Europe, the United States, and Australia with health psychology societies, postgraduate programmes, conferences, and academic journals dedicated to the discipline in the majority of these countries. However, in South Africa, health psychology remains a broad umbrella term under which psychologists and other health care professionals conduct research. Health psychology is concerned with the biological, social, psychological, contextual, and structural drivers of health and illness, and relies on theory and empirically-driven research to identify and understand important links between health and behaviour. In South Africa, where a large proportion of the population faces multiple co-occurring disease epidemics, such as HIV/AIDS, TB, COVID-19, diabetes, and heart disease, there is a need for a uniting sub-discipline like health psychology to focus intervention efforts and to meet the sustainable development goals. The recent re-establishment of a special interest group in health psychology in the Psychological Society of South Africa (PsySSA) is an important first step. In this article, and as members of the newly re-established special interest group in health psychology, we call attention to the need to promote health psychology in South Africa. In this article, we describe the paradigmatic traditions and theoretical models that inform the discipline. We then argue why health psychology should be prioritised again and recommend future directions for health psychology in South Africa.

Exploring the readiness of senior doctors and nurses to assess and address patients' social needs in the hospital setting

BACKGROUND

Adverse social circumstances are a key factor in health outcomes. Hospitals are an opportune setting for assessing and addressing the unmet social needs of patients, however, the readiness of healthcare workers in hospitals to undertake such tasks requires further exploration in the Australian context. This study aimed to generate a theory of doctors' and nurses' readiness to assess and address patients' social needs in a hospital setting.

METHODS

A constructivist grounded theory methodology was applied, with purposive and theoretical sampling used to gather diverse perspectives of readiness during semi-structured interviews with twenty senior doctors and nurses from a variety of clinical specialties working in hospitals serving communities experiencing inequitable social and health outcomes. Line-by-line coding, memo writing, and diagramming were used in analysis to construct an interpretive theory of readiness. Application of constant comparison analytic processes were used to test the robustness of the theory.

RESULTS

The readiness of doctors and nurses varies across individuals and departments, and is founded upon a state of being comfortable and confident to assess social need as determined by a range of personal attributes (e.g. knowledge of social need; skills to assess social need); a state of being willing and prepared to assess and address social need facilitated by supportive environments (e.g. departmental culture); and enabling characteristics of the clinical encounter (e.g. time, rapport).

CONCLUSIONS

We found that the readiness of doctors and nurses is dynamic and impacted by a complex interplay of personal attributes along with contextual and situational factors. These findings indicate that any efforts to strengthen the readiness of doctors and nurses to assess and address social needs must target personal capabilities in addition to characteristics of the working environment.

Behavioural oncology research in Africa: Lessons from the last two decades and key considerations moving forward

OBJECTIVE

To analyse the state of behavioural oncology research in Africa and outline key considerations for future research.

METHODS

Five bibliographic databases were searched to identify original English-language articles published between January 2000 and August 2020. The Behavioural Epidemiology Framework was applied to studies with data/findings from Africa to delineate their current state. Research gaps/opportunities available for behavioural oncology research in Africa were further highlighted.

RESULTS

Two hundred eighty-seven original research with findings from Africa has been published over the last two decades, with the highest contribution arising from Nigeria, Kenya, Ethiopia and South Africa. Cervical and breast cancers were the most widely investigated. Prominently studied behaviours relate to cancer screening, health literacy, lifestyle, and vaccination. Behavioural oncology literature in Africa is generally in Phases I and III and lacks in measurement studies (<2%) and studies that seek to evaluate behaviour change/health promotion interventions (<6%) or translate them into practice (13.2%).

CONCLUSION

Embracing new and progressive approaches, including methodological/analytical paradigms and implementation science is imperative to advance the frontiers of behavioural oncology research in Africa. This calls for a responsive research approach that can mobilise multidisciplinary/multilevel coalitions, ensuring a research structure that effectively integrates behavioural research and cancer prevention/control in the region.

Attitude theory and measurement in implementation science: a secondary review of empirical studies and opportunities for advancement

BACKGROUND

Implementation science studies often express interest in "attitudes," a term borrowed from psychology. In psychology, attitude research has an established methodological and theoretical base, which we briefly summarize here. We then review implementation studies designed to measure attitudes and compare their definitions and methods with those from psychology.

METHODS

A recent review identified 46 studies empirically examining factors associated with implementation. For each of these studies, we evaluated whether authors included attitudes as a construct of interest, and if so, whether and how the construct was defined, measured, and analyzed.

RESULTS

Most of the articles (29/46 [63%]) mention attitudes as an implementation factor. Six articles include a definition of the construct. Nineteen studies were designed to measure attitudes but lacked clarity in describing how attitudes were measured. Those that explained their measurement approach used methods that differed from one another and from validated methods in social psychology. Few articles described associated analyses or provided results specific to attitudes. Despite the lack of specificity regarding relevant measurement, analysis, and results, the articles often included causal conclusions about the role of attitudes.

CONCLUSIONS

Attitudes may be an important construct to implementation scientists, but studies to date are ambiguous in their definitions of attitudes and inconsistent in the methods used to measure and analyze attitudes. We discuss how implementation studies can apply psychology's standardized definitions, validated measurement approaches, and causal models that include attitudes. This application of attitude theory and methods could offer implementation research valuable scientific opportunities.

Enhancing Behavior Change Skills in Health Extension Workers in Ethiopia: Evaluation of an Intervention to Improve Maternal and Infant Nutrition

Maternal and infant nutrition are problematic in areas of Ethiopia. Health extension workers (HEWs) work in Ethiopia's primary health care system, increasing potential health service coverage, particularly for women and children, providing an opportunity for health improvement. Their roles include improving maternal and infant nutrition, disease prevention, and health education. Supporting HEWs' practice with 'non-clinical' skills in behavior change and health communication can improve effectiveness. This intervention study adapted and delivered a UK-developed training intervention for Health Extension Workers (HEWs) working with the United Nations World Food Programme in Ethiopia. The intervention included communication and behavioral training adapted with local contextual information. Mixed methods evaluation focused on participants' reaction to training, knowledge, behavior change, and skills use. Overall, 98 HEWs were trained. The intervention was positively received by HEWs. Pre-post evaluations of communication and behavior change skills found a positive impact on HEW skills, knowledge, and motivation to use skills (all p < 0.001) to change women's nutritional behavior, also demonstrated in role-play scenarios. The study offered substantial learning about intervention delivery. Appropriate cultural adaptation and careful consideration of assessment of psychological constructs are crucial for future delivery.