Identifying behavior change techniques for inclusion in a complex intervention targeting antipsychotic prescribing to nursing home residents with dementia

Development of a Behavior-Change Intervention toward Benzodiazepine Deprescribing in Older Adults Living in Nursing Homes

OBJECTIVE

We aimed to develop a context-specific intervention toward benzodiazepine deprescribing in nursing homes (NHs), with insights from behavior-change theories and involvement of stakeholders.

DESIGN

Selection of behavior change techniques (BCTs), through online survey and group discussion, followed by operationalization of these BCTs into intervention components.

SETTING AND PARTICIPANTS

The intervention was developed for Belgian NHs, involving various stakeholders: health care professionals (HCPs), NH administrators, and policy makers.

METHODS

Using the Theory and Techniques Tool, we preselected the BCTs linked to one of the 9 Theoretical Domain Framework domains identified as being the main barriers for benzodiazepine deprescribing in Belgian NHs. These were then presented to stakeholders. Based on the APEASE (Acceptability, Practicability, Effectiveness, Affordability, Side-effects, and Ethics) criteria, participants ranked BCTs through an online survey, and then performed final selection during a group discussion. Selected BCTs were operationalized into intervention components, with specific contents and methods of delivery validated by stakeholders.

RESULTS

Thirty-seven potential BCTs were identified. Eighteen stakeholders participated in the survey, and 7 in the group discussion. This led to the final inclusion of 9 BCTs: instruction on how to perform the behavior, information about health consequences, pros and cons, problem solving, goal setting (behavior), social comparison, restructuring physical environment, restructuring social environment, and graded tasks. These BCTs were operationalized into a 6-component intervention: process and goal setting, HCP education, physical environment adaptations, audit and feedback, NH residents' and relatives' increased awareness, and multidisciplinary work.

CONCLUSION AND IMPLICATIONS

Use of a theory-based approach toward intervention development has the potential to improve the probability of its feasibility and effectiveness in tackling barriers to benzodiazepine deprescribing. By doing so, we have developed a multifaceted approach with actions taken at the patient, HCP, and NH levels. Our novel 6-component intervention will be evaluated in a pilot cluster-randomized controlled trial to assess its feasibility.

Multidisciplinary DEprescribing review for Frail oldER adults in long-term care (DEFERAL): Implementation strategy design using behaviour science tools and stakeholder engagement

INTRODUCTION

Deprescribing is a strategy for reducing the use of potentially inappropriate medications for older adults. Limited evidence exists on the development of strategies to support healthcare professionals (HCPs) deprescribing for frail older adults in long-term care (LTC).

OBJECTIVE

To design an implementation strategy, informed by theory, behavioural science and consensus from HCPs, which facilitates deprescribing in LTC.

METHODS

This study was consisted of 3 phases. First, factors influencing deprescribing in LTC were mapped to behaviour change techniques (BCTs) using the Behaviour Change Wheel and two published BCT taxonomies. Second, a Delphi survey of purposively sampled HCPs (general practitioners, pharmacists, nurses, geriatricians and psychiatrists) was conducted to select feasible BCTs to support deprescribing. The Delphi consisted of two rounds. Using Delphi results and literature on BCTs used in effective deprescribing interventions, BCTs which could form an implementation strategy were shortlisted by the research team based on acceptability, practicability and effectiveness. Finally, a roundtable discussion was held with a purposeful, convenience sample of LTC general practitioners, pharmacists and nurses to prioritise factors influencing deprescribing and tailor the proposed strategies for LTC.

RESULTS

Factors influencing deprescribing in LTC were mapped to 34 BCTs. The Delphi survey was completed by 16 participants. Participants reached consensus that 26 BCTs were feasible. Following the research team assessment, 21 BCTs were included in the roundtable. The roundtable discussion identified lack of resources as the primary barrier to address. The agreed implementation strategy incorporated 11 BCTs and consisted of an education-enhanced 3-monthly multidisciplinary team deprescribing review, led by a nurse, conducted at the LTC site.

CONCLUSION

The deprescribing strategy incorporates HCPs' experiential understanding of the nuances of LTC and thus addresses systemic barriers to deprescribing in this context. The strategy designed addresses five determinants of behaviour to best support HCPs engaging with deprescribing.

Applying the Behaviour Change Wheel to support deprescribing in long-term care: Qualitative interviews with stakeholder participants

Background

Implementation and behavioural science are increasingly being used to support development and translation of evidence-based interventions into practice. We used the Behaviour Change Wheel (BCW) approach in two stakeholder forums to identify target behaviours and supporting actions to inform the development of a framework to support deprescribing in long-term care homes. During our planning for these forums, we found many applications of the BCW approach used in healthcare. However, we found no accounts of stakeholders' experiences when the BCW approach was used with large groups of people who were mostly unfamiliar with behavioural science.

Objective

The goal of this research was to gain insight into the use of the BCW approach in the context of developing a framework to support deprescribing in long-term care.

Methods

This descriptive qualitative study employed one-on-one semi-structured interviews with Ontario long-term care stakeholders who had participated in one or both of two in-person forums that we hosted. Interviews were transcribed verbatim and an inductive content-analysis approach was used to code data and determine themes.

Results

Fifteen interviews were conducted. Four themes were identified. First, the BCW was new and made sense, but people found it hard to identify target behaviours before planning solutions. Second, participants varied in their opinions as to whether the 'right' people were participating. Third, participants found that the forum activities, worksheets and facilitators helped people use the approach. Fourth, stakeholder perspectives about potential implementation challenges and strategies to maximize success were identified.

Conclusions

Overall, participants were positive about the use of the BCW approach, however, its usefulness could be optimized by enhancing explanations, facilitation and logistics to ensure an initial focus on targeting behaviours. Making stakeholder perspectives transparent and ensuring mechanisms are present to ensure all views are sought and considered are also important to optimizing participant experience.

Rationalising Antipsychotic Prescribing in Dementia (RAPID) complex intervention: A mixed-methods feasibility intervention study

BACKGROUND

To help address the issue of inappropriate antipsychotic prescribing to nursing home residents with dementia, the 'Rationalising Antipsychotic Prescribing in Dementia' (RAPID) complex intervention was developed, comprising staff education and training, academic detailing and a novel resident assessment tool.

OBJECTIVES

The primary objective was to assess the feasibility and acceptability of the RAPID complex intervention in a nursing home setting. The secondary objective was to describe associated trends in psychotropic prescribing, falls, and behavioural symptoms.

METHODS

A mixed-methods feasibility intervention study in one large nursing home in Ireland was undertaken between 07/2017 and 01/2018. Focus groups and semi-structured interviews were conducted with nursing home staff and GPs at the end of the 3-month follow up period to assess participants' experience of the intervention. Quantitative measurements included pre- and post-course evaluation and psychotropic prescribing rates.

RESULTS

Sixteen nursing home staff members attended the two education and training days (21% attendance rate), and four GPs participated in the academic detailing sessions (100% attendance rate). Participants of the focus groups and interviews (n = 18) found the education and training beneficial for their work and expressed a desire to continue educating new staff after the study's completion. However, there was limited usage of the resident assessment tool. Participants also offered recommendations to enhance the intervention.The proportion of dementia residents prescribed at least one regular antipsychotic was stable over the 3-months pre-intervention at 45% (n = 18), and at baseline at 44% (n = 19) but decreased slightly to 36% (n = 14) at 3-months post-intervention. At the same time the absolute number of 'PRN' psychotropics administered monthly to dementia residents decreased substantially from 90 at baseline to 69 at 3-months post-intervention.

CONCLUSION

The RAPID complex intervention was broadly feasible to conduct and may be acceptable to stakeholders. However, before it can be evaluated in larger scale studies, certain protocol modifications and further exploratory work are required to improve implementation.

Behavioral Change Factors and Retention in Web-Based Interventions for Informal Caregivers of People Living With Dementia: Scoping Review

BACKGROUND

Web-based interventions aimed at supporting informal caregivers of people living with dementia have the potential to improve caregivers' well-being and psychological health. However, few interventions are widely implemented for this population, and none of the prior reviews have systematically examined the use of behavior change techniques (BCTs), theories, and agents in web-based interventions for informal caregivers of people living with dementia. To better understand this implementation gap, we reviewed the literature to map behavioral factors (BCTs, theories, and agents) deployed in the studies. Furthermore, because there is an emerging consensus that retention could be shaped by participant characteristics and behavioral factors, we explored relationships between these features and retention rates across studies.

OBJECTIVE

We pursued 3 objectives: to map behavioral factors involved in the web-based interventions for informal caregivers of people living with dementia; to examine the relationship between behavioral change elements and retention in the studies; and to examine the relationship between participant characteristics (gender, age, and spouse or adult children caregiver proportion) and study retention.

METHODS

We conducted a literature review using the following keywords and their corresponding Medical Subject Headings terms: dementia, caregivers, and web-based intervention. The time limits were January 1998 to March 2022. Using the BCTv1 taxonomy, which specifies active behavioral components in interventions, 2 coders collected, summarized, and analyzed the frequency distributions of BCTs. Similarly, they abstracted and analyzed participant characteristics, behavior change theories, behavior change agents, and retention rates in the studies.

RESULTS

The average age was 61.5 (SD 7.4) years, and the average proportion of spousal informal caregivers, adult children informal caregivers, and retention rates were 51.2% (SD 24.8%), 44.8% (SD 22%), and 70.4% (SD 17%), respectively. Only 53% (17/32) of the studies used behavior change theories, but 81% (26/32) included behavior change agents. The most common BCTv1 clusters were shaping knowledge and social support. The median number of BCTv1 clusters was 5 (IQR 3). We observed a negative correlation between the proportion of spousal informal caregivers and the retention rate (r=-0.45; P=.02) and between the number of BCTv1 clusters and retention rates (r=-0.47; P=.01). We also found that the proportion of adult children informal caregivers in the study was significantly and positively correlated with the retention rate (r=0.5; P=.03). No other participant characteristics or behavioral factors were associated with retention rates.

CONCLUSIONS

We found that almost half of the studies were not informed by behavior change theories. In addition, spousal involvement and a higher number of BCTs were each associated with lower retention rates, while the involvement of adult children caregivers in the study was associated with higher retention. In planning future studies, researchers should consider matching participant characteristics with their intended intervention as the alignment might improve their retention rates.

Enhancing the Behaviour Change Wheel with synthesis, stakeholder involvement and decision-making: a case example using the 'Enhancing the Quality of Psychological Interventions Delivered by Telephone' (EQUITy) research programme

Background

Using frameworks such as the Behaviour Change Wheel to develop behaviour change interventions can be challenging because judgement is needed at various points in the process and it is not always clear how uncertainties can be resolved. We propose a transparent and systematic three-phase process to transition from a research evidence base to a behaviour change intervention. The three phases entail evidence synthesis, stakeholder involvement and decision-making. We present the systematic development of an intervention to enhance the quality of psychological treatment delivered by telephone, as a worked example of this process.

Method

In phase 1 (evidence synthesis), we propose that the capabilities (C), opportunities (O) and motivations (M) model of behaviour change (COM-B) can be used to support the synthesis of a varied corpus of empirical evidence and to identify domains to be included in a proposed behaviour change intervention. In phase 2 (stakeholder involvement), we propose that formal consensus procedures (e.g. the RAND Health/University of California-Los Angeles Appropriateness Methodology) can be used to facilitate discussions of proposed domains with stakeholder groups. In phase 3 (decision-making), we propose that behavioural scientists identify (with public/patient input) intervention functions and behaviour change techniques using the acceptability, practicability, effectiveness/cost-effectiveness, affordability, safety/side-effects and equity (APEASE) criteria.

Results

The COM-B model was a useful tool that allowed a multidisciplinary research team, many of whom had no prior knowledge of behavioural science, to synthesise effectively a varied corpus of evidence (phase 1: evidence synthesis). The RAND Health/University of California-Los Angeles Appropriateness Methodology provided a transparent means of involving stakeholders (patients, practitioners and key informants in the present example), a structured way in which they could identify which of 93 domains identified in phase 1 were essential for inclusion in the intervention (phase 2: stakeholder involvement). Phase 3 (decision-making) was able to draw on existing Behaviour Change Wheel resources to revisit phases 1 and 2 and facilitate agreement among behavioural scientists on the final intervention modules. Behaviour changes were required at service, practitioner, patient and community levels.

Conclusion

Frameworks offer a foundation for intervention development but require additional elucidation at each stage of the process. The decisions adopted in this study are designed to provide an example on how to resolve challenges while designing a behaviour change intervention. We propose a three-phase process, which represents a transparent and systematic framework for developing behaviour change interventions in any setting.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13012-021-01122-2.

Developing a complex intervention targeting antipsychotic prescribing to nursing home residents with dementia

Background: Antipsychotics are commonly prescribed to people living with dementia in nursing home settings, despite strong guideline recommendations against their use except in limited circumstances. We aimed to transparently describe the development process for a complex intervention targeting appropriate requesting and prescribing of antipsychotics to nursing home residents with dementia in Ireland, by nurses and general practitioners (GPs) respectively.

Methods: We report the development process for the ‘Rationalising Antipsychotic Prescribing in Dementia’ (RAPID) complex intervention, in accordance with the ‘Guidance for reporting intervention development studies in health research’ (GUIDED) checklist.  The UK Medical Research Council framework for developing and evaluating complex interventions guided our overall approach, incorporating evidence and theory into the intervention development process. To unpack the intervention development process in greater detail, we followed the Behaviour Change Wheel approach. Guided by our stakeholders, we conducted three sequential studies (systematic review and qualitative evidence synthesis, primary qualitative study and expert consensus study), to inform the intervention development.

Results: The RAPID complex intervention was developed in collaboration with a broad range of stakeholders, including people living with dementia and family carers, between 2015 and 2017. The finalised RAPID complex intervention was comprised of the following three components; 1) Education and training sessions with nursing home staff; 2) Academic detailing with GPs; 3) Introduction of an assessment tool to the nursing home.

Conclusions: This paper describes the steps used by the researchers to develop a complex intervention targeting antipsychotic prescribing to nursing home residents with dementia in Ireland, according to the GUIDED checklist. We found that the GUIDED checklist provided a useful way of reporting all elements in a cohesive manner and complemented the other tools and frameworks used. Transparency in the intervention development processes can help in the translation of evidence into practice.