How is the theoretical domains framework applied to developing health behaviour interventions? A systematic search and narrative synthesis

Strategies and resources used by public health units to encourage COVID-19 vaccination among priority groups: a behavioural science-informed review of three urban centres in Canada

BACKGROUND

Ensuring widespread COVID-19 vaccine uptake is a public health priority in Canada and globally, particularly within communities that exhibit lower uptake rates and are at a higher risk of infection. Public health units (PHUs) have leveraged many resources to promote the uptake of recommended COVID-19 vaccine doses. Understanding barriers and facilitators to vaccine uptake, and which strategies/resources have been used to address them to date, may help identify areas where further support could be provided. We sought to identify the strategies/resources used by PHUs to promote the uptake of the first and third doses of the COVID-19 vaccine among priority groups in their jurisdictions. We examined the alignment of these existing strategies/resources with behavioral science principles, to inform potential complementary strategies/resources.

METHODS

We reviewed the online and in-person strategies/resources used by three PHUs in Ontario, Canada to promote COVID-19 vaccine uptake among priority groups (Black and Eastern European populations, and/or neighbourhoods with low vaccine uptake or socioeconomic status). Strategies/resources were identified from PHU websites, social media, and PHU liaison. We used the Behaviour Change Techniques (BCT) Taxonomy - which describes 93 different ways of supporting behaviour change - to categorise the types of strategies/resources used, and the Theoretical Domains Framework - which synthesises 14 factors that can be barriers or facilitators to decisions and actions - to categorise the barriers and facilitators addressed by strategies/resources.

RESULTS

PHUs operationalised 21 out of 93 BCTs, ranging from 15 to 20 BCTs per PHU. The most frequently operationalised BCTs were found in strategies/resources that provided information about COVID-19 infection and vaccines, increased access to COVID-19 vaccination, and integrated social supports such as community ambassadors and engagement sessions with healthcare professionals. Identified BCTs aligned most frequently with addressing barriers and facilitators related to Knowledge, Environmental context and resources, and Beliefs about consequences domains.

CONCLUSION

PHUs have used several BCTs to address different barriers and facilitators to COVID-19 vaccine uptake for priority groups. Opportunities should be pursued to broaden the scope of BCTs used (e.g., operationalizing the pros and cons BCT) and barriers/facilitators addressed in strategies/resources for ongoing and future COVID-19 vaccine uptake efforts among general and prioritised populations.

Sarcopenia interventions in long-term care facilities targeting sedentary behaviour and physical inactivity: A systematic review

BACKGROUND

Sedentary behaviour and physical inactivity are independent risk factors for sarcopenia for long-term care facility residents. Understanding the components, mechanisms and context of interventions that target change in these risk factors can help optimize sarcopenia management approaches. This study aimed to identify, appraise and synthesize the interventions targeting sedentary behaviour and physical inactivity, construct a Theory of Change logic model, inform complex sarcopenia intervention development and identify areas for improvement.

METHODS

Eight electronic databases, including Embase and Web of Science, were searched for eligible interventional studies from inception until February 2024. Narrative synthesis was used. The Theory of Change was applied to develop a logic model presenting the synthesized results. A Cochrane risk of bias assessment tool was used for quality appraisal.

RESULTS

The study included 21 articles involving 1014 participants, with mean ages ranging from 72.5 to 90.4 years. The proportion of female participants ranged from 8.0% to 100.0%. The applied sarcopenia diagnosis criteria varied, including those of the Asian Working Group for Sarcopenia and the European Working Group on Sarcopenia in Older People. The overall risk of bias in the included studies was moderate. Interventions primarily targeted physical inactivity, with resistance training being the most common intervention type. The reporting of intervention adherence was insufficient (only 11 out of 21 included studies provided adherence reports), and adherence overall and by intervention type was not possible to discern due to inconsistent criteria for high adherence across these studies. Four categories of intervention input were identified: educational resources; exercise equipment and accessories; monitoring and tailoring tools; and motivational strategies. Intervention activities fell into five categories: determining the intervention plan; educating; tailoring; organizing, supervising, assisting and motivating; and monitoring. While sarcopenia-related indicators were commonly used as desired outcomes, intermediate outcomes (i.e., sedentary time and physical activity level) and other long-term outcomes (i.e., economic outcomes) were less considered. Contextual factors affecting intervention use included participant characteristics (i.e., medical condition and education level) and intervention provider characteristics (i.e., trustworthiness).

CONCLUSIONS

The findings led to the development of a novel logic model detailing essential components for interventions aimed at managing sarcopenia in long-term care facilities, with a focus on addressing sedentary behaviour and physical inactivity. Future sarcopenia interventions in long-term care facilities should fully attend to sedentary behaviour, enhance adherence to interventions through improved education, monitoring, tailoring and motivation and establish an agreed standard set of outcome measures.

Unveiling the landscape of antistigma interventions for individuals with substance use disorders: A scoping review

Background

Stigma against persons living with substance use disorders (PLSUD) fosters social and health inequities.

Aim

We aimed to map different populations targeted by antistigma interventions, analyze specific characteristics of these interventions, and identify and categorize the theoretical frameworks used in these interventions.

Methods

We examined randomized controlled trials and quasi or pre-experimental studies targeting stigma against PLSUD. Using two English databases, our analysis involved mapping study populations, antistigma interventions, and trial characteristics through a narrative synthesis. We adhered to the Workgroup for Intervention Development and Evaluation Research (WIDER) checklist for assessing reporting quality. The Theoretical Domain Framework (TDF) identified intervention domains and constructs of the interventions.

Results

Of 698 studies, 29 met eligibility, with three from low-middle-income countries: 12 studies addressed the public, 11 self, and 5 structural stigmas. Reduction in stigma or improvements in knowledge of and attitude toward PLSUD was observed in 23 studies. Eight used social contact-based interventions, and one used direct social contact. Other interventions were psychoeducation, collaborative community care and linkage to social services, acceptance and commitment therapy, and gatekeepers' training. Five focused on injection drug use stigma; others were not substance-specific. Most studies reported the characteristics of the recipients (n = 28), mode of delivery (n = 28), and delivery settings (n = 24). Adherence to delivery protocol was the least reported (n = 5). The number of theoretical domains varied: 18 studies had 1-5 domains, 3 studies had 10, and 8 studies had 6-9 domains.

Conclusion

Social contact-based interventions show promise for PLSUD; future research must improve the quality of reporting and design theory-informed interventions.

Healthcare Professionals' Responses to Complaints: A Qualitative Interview Study With Patients, Carers and Healthcare Professionals Using the Theoretical Domains Framework and COM-B Model

BACKGROUND

Patient complaints in healthcare settings can provide feedback for monitoring and improving healthcare services. Behavioural responses to complaints (e.g., talking or apologising to a patient) can influence the trajectory of a complaint for instance, whether a complaint is escalated or not. We aimed to explore healthcare professional (HCP) and service user (patient and carer) views on complaints' management and the perceived factors influencing responses to complaints within a healthcare setting by applying behavioural frameworks.

METHOD

A qualitative study was conducted using online or phone-based interviews with eleven HCPs and seven patients or carers. All participants (N = 18) had experience responding to or submitting a formal complaint in secondary and tertiary public healthcare settings in the United Kingdom. The interviews were structured using the Capability-Opportunity-Motivation-Behaviour (COM-B) Model. We analysed the transcripts using inductive thematic analysis. Then, themes were deductively mapped onto the COM-B Model and the more granular Theoretical Domains Framework (TDF).

RESULTS

Ten themes were generated from the analysis representing the influences on HCPs' responses to complaints from HCP and patient/carer perspectives. This included (with TDF/COM-B in brackets): 'Knowledge of complaint procedure' (Knowledge/Capability), 'Training and level of skill in complaints handling' (Skills/Capability), 'Regulation of emotions associated with complaints' (Behavioural regulation/Capability), 'Confidence in handling complaints' (Beliefs about capabilities/Motivation), 'Beliefs about the value of complaints' (Beliefs about consequences/Motivation) and 'Organisational culture regarding complaints' (Social influences/Opportunity). Staff highlighted strong support systems and open discussions as part of positive organisational cultures regarding complaints (Social influences/Opportunity), and a lack of certainty around when to treat issues raised by patients as a formal complaint or informal feedback (Knowledge/Capability).

CONCLUSION

Our study findings highlight the importance of strong support systems and organisational openness to patient feedback. These findings can be used to design targeted interventions to support more effective responses and enhance patient-centred approaches to complaints management in healthcare settings.

PATIENT AND PUBLIC CONTRIBUTION

Patient and public involvement (PPI) was integral in this research. The NIHR PRU in Behavioural and Social Sciences had a dedicated PPI strategy group consisting of six external representatives from the patient and public community (Newcastle University, 2024). These six PPI members actively participated in shaping the research by reviewing and providing feedback on all questionnaire items before the data collection. They were actively involved in supporting participant recruitment by advertising this study on their PPI platform, The VoiceR,1 and through their online social networks. During the analysis stages of the research, preliminary findings were discussed with the PPI group to support 'sense checking' and interpretation of the results.

Theoretically informed codesign of a tailored intervention to support pressure ulcer prevention behaviours by older people living in their own homes in the UK and their lay carers: an intervention codesign study (C-PrUP)

OBJECTIVE

To codesign a theoretically underpinned, healthcare practitioner-mediated, tailored intervention to support housebound older patients and their lay carers to adopt pressure ulcer prevention behaviours.

DESIGN

Theoretical domains framework informed codesign.

SETTING

One geographical area in the UK, spanning several community National Health Service Trusts.

PARTICIPANTS

Community-dwelling older patients at risk of pressure ulcer development and their lay carers (n=4) and health practitioners (n=6) providing related care.

RESULTS

Codesigners addressed five identified barriers to pressure ulcer prevention, knowledge and beliefs about consequences, social or professional role and influence, motivation and priorities, emotion and environment. Prioritised intervention components were (1) making every contact count, all health and social care workers to be conversant with basic prevention behaviours and to support and reiterate these at every visit (9.1/10), (2) signposting of existing support groups and sitting services (8.4/10), (3) accessible, timely, trustable and relatable written information including the role of patients, carers and staff in prevention and links to other resources (7.7/10) and (4) supporting close family involvement in some of the practical elements of care (5.6/10).

CONCLUSIONS

Our study sought to codesign a practitioner-mediated, tailored intervention to support housebound older patients and their lay carers to adopt pressure ulcer prevention behaviours. The process of barrier identification and selection of behaviour change techniques for intervention components was theoretically informed. However, further development will be needed to refine the prototype intervention to take into account the complexity of multiple health needs and priorities of patients. The principles of this study are likely to be transferable to similar national and international contexts.

A qualitative exploration of participants' perspectives and experiences of novel digital health infrastructure to enhance patient care in remote communities within the Home Health Project

The Home Health Project, set on Clare Island, five kilometres off the Irish Atlantic coast, is a pilot exploration of ways in which various forms of technology can be utilised to improve healthcare for individuals living in isolated communities. The integration of digital health technologies presents enormous potential to revolutionise the accessibility of healthcare systems for those living in remote communities, allowing patient care to function outside of traditional healthcare settings. This study aims to explore the personal experiences and perspectives of participants who are using digital technologies in the delivery of their healthcare as part of the Home Health Project. Individual semi-structured interviews were conducted with nine members of the Clare Island community participating in the Home Health Project. Interviews took place in-person, in June 2023. Interviews were audio-recorded and transcribed verbatim. The data were analysed inductively using reflexive thematic analysis. To identify determinants of engagement with the Home Health Project, the data was then deductively coded to the Theoretical Domains Framework (TDF) and organised into themes. Seven of the possible 14 TDF domains were supported by the interview data as influences on engagement with the Project: Knowledge, Beliefs about capabilities, Optimism, Intentions, Environmental context and resources, Social influences and Emotion. Overall, participants evaluated the Home Health Project as being of high quality which contributed to self-reported increases in health literacy, autonomy, and feeling well supported in having their health concerns addressed. There was some apprehension related to data protection, coupled with a desire for extended training to address aspects of digital illiteracy. Future iterations can capitalise on the findings of this study by refining the technologies to reflect tailored health information, personalised to the individual user.

Implementation and Impact of a Lifting Cushion for Care Home Residents Who Have Fallen

INTRODUCTION

Falls are a global public health problem and the second leading cause of death from unintentional injury. Globally, approximately 30%-50% of people living in nursing or residential care homes fall each year. Falls have an impact on quality of life and morbidity. Prevention of falls is gold standard care. When falls do occur, implementation of safe strategies to help the person rise is required. Structured risk assessment and the use of a 'lifting' cushion are one such strategy.

AIMS

To evaluate the impact of the lifting cushion on management of falls and assess barriers and facilitators to staff use of the lifting cushion in 18 care homes.

METHODS

Two-phase study involving (i) capturing quantitative pre- and post-cushion implementation data along with comparison of means testing and (ii) theoretically underpinned qualitative semi-structured interviews to explore barriers and facilitators to cushion implementation with inductive and deductive data analysis.

RESULTS

The cushion was used a total of 32 times out of 567 post-implementation recorded falls (6% of all falls). Barriers and facilitators to cushion use aligned to the Theoretical Domains Framework include knowledge, skills and confidence, emotion, beliefs about safety and decision processes, environmental context and resources and social influences.

CONCLUSION

The lifting cushion was poorly adopted. Identified barriers to adoption would not be addressed using routine train and cascade processes. We identified facilitators that could be enhanced to promote uptake. Theoretically underpinned implementation strategies, tailored to assess determinants, are known to be more effective; however, this approach has rarely been used in care homes. We have demonstrated a structured approach to implementation of cushion use; this may be transferable to other care home practices.

IMPLICATIONS FOR PRACTICE

Cae home leaders should be aware that giving information alone will not change practice. Implementation or improvement strategies will be more effective.

Theoretical Domains Framework: A Bibliometric and Visualization Analysis from 2005-2023

Background

The Theoretical Domains Framework (TDF) is among the most extensively utilised foundational frameworks in implementation science. It was developed from 33 psychological theories, with the latest version identifying 14 domains encompassing 84 theoretical constructs. These domains and constructs capture the complexity of factors that affect behaviours, making the framework a valuable tool for designing and implementing interventions within health and social care settings.

Objective

To summarise the development, hot topics, and future trends in TDF-related research and provide implementation practitioners with more information on the application of TDF.

Methods

We used TDF as the topic and searched the ISI Web of Science Core Collection, identifying 1382 relevant publications. We used analytical tools such as Excel, Tableau, VOSviewer, and Citespace to conduct a bibliometric analysis of the relevant publication.

Results

We identified the United Kingdom as the primary contributor, with University College London as the key institution. Susan Michie ranked highest in total citations. The analysis highlighted cancer and stroke as primary clinic medicine-related topics using TDF. Emerging themes encompass abuse, violence, maternal health, antenatal care, patient involvement, and trauma-informed care et al. "Nurse" and "qualitative research" emerged as recent and enduring hotspots, possibly indicating future research trends.

Conclusion

This article represents the first attempt to summarise the TDF using bibliometric analysis. We suggest this method can be used to analyse other theoretical frameworks in scientific implementation of its objectivity and quantifiability. Overall, the application scope of TDF is shifting from public health towards more specialised clinical directions, although its application in the field of public health is continuously expanding. In the future, the number of users of TDF is also expected to expand from implementation scientists to professional technical personnel.

Enhancing making every contact count (MECC) training and delivery for the third and social economy (TSE) sector: a strategic behavioural analysis

OBJECTIVE

To enhance Making Every Contact Count (MECC, an opportunistic approach to health promotion), training in the Third and Social Economy (TSE, all groups and organisations primarily working towards social justice, outside of the government or household) by examining the degree to which the behavioural content of MECC training tackled significant factors influencing MECC delivery.

METHODS AND MEASURES

A strategic behavioural analysis design. Semi-structured interviews with service providers (n = 15) and users (n = 5) were coded for barriers and facilitators of MECC delivery using the Theoretical Domains Framework (TDF). Existing MECC training was coded for behaviour change techniques (BCTs) and intervention functions (IFs). The degree to which BCTs and IFs addressed the key TDF domains of influences on MECC delivery in the TSE were examined using prespecified tools.

RESULTS

Seven key TDF domains of influences in MECC delivery were identified. Overall, only 9/31 linked BCTs were utilised within MECC training, with percentage utilisation of relevant BCTs for each domain ranging from 0% to 66.7%. Training adequately addressed 2/7 key domains.

CONCLUSION

The TSE and healthcare share many common key TDF domains, although there are differences in how each are relevant. Limitations and recommendations for MECC training are discussed.

What factors are associated with infant hearing aid use? A parent survey using the Theoretical Domains Framework

OBJECTIVE

Hearing aid use is lowest in 0-3-year-olds with hearing loss, placing spoken language development at risk. Existing interventions lack effectiveness and are typically not based on a theoretically driven, comprehensive understanding of the factors influencing infant hearing aid use. The present study is the first to address this gap in understanding.

DESIGN AND STUDY SAMPLE

A 55-item online survey based on the Theoretical Domains Framework (TDF) was completed by 56 parents of 0-3-year-old hearing aid users.

RESULTS

Participants reported a wide range of barriers across TDF domains, which were associated with parent-reported hearing aid use and more pronounced in parents of lower hearing aid users. The most strongly reported domains across participants were "emotion" (e.g. feelings of worry when using hearing aids), "beliefs about capabilities" (e.g. belief in ability to use hearing aids consistently), and "environmental context and resources" (e.g. child removing hearing aids).

CONCLUSIONS

Parents report a wider range of barriers to infant hearing aid use than existing investigations suggest and current interventions address. Interventions would benefit from: (i) targeting a wider range of TDF domains in their design; and (ii) implementing the present TDF survey to identify and target family-specific barriers to infant hearing aid use.

Barriers and facilitators to perioperative smoking cessation: A scoping review

OBJECTIVE

Smoking cessation interventions are underutilized in the surgical setting. We aimed to systematically identify the barriers and facilitators to smoking cessation in the surgical setting.

METHODS

Following the Joanna Briggs Institute (JBI) framework for scoping reviews, we searched 5 databases (MEDLINE, Embase, Cochrane CENTRAL, CINAHL, and PsycINFO) for quantitative or qualitative studies published in English (since 2000) evaluating barriers and facilitators to perioperative smoking cessation interventions. Data were analyzed using thematic analysis and mapped to the theoretical domains framework (TDF).

RESULTS

From 31 studies, we identified 23 unique barriers and 13 facilitators mapped to 11 of the 14 TDF domains. The barriers were within the domains of knowledge (e.g., inadequate knowledge of smoking cessation interventions) in 23 (74.2%) studies; environmental context and resources (e.g., lack of time to deliver smoking cessation interventions) in 19 (61.3%) studies; beliefs about capabilities (e.g., belief that patients are nervous about surgery/diagnosis) in 14 (45.2%) studies; and social/professional role and identity (e.g., surgeons do not believe it is their role to provide smoking cessation interventions) in 8 (25.8%) studies. Facilitators were mainly within the domains of environmental context and resources (e.g., provision of quit smoking advice as routine surgical care) in 15 (48.4%) studies, reinforcement (e.g., surgery itself as a motivator to kickstart quit attempts) in 8 (25.8%) studies, and skills (e.g., smoking cessation training and awareness of guidelines) in 5 (16.2%) studies.

CONCLUSION

The identified barriers and facilitators are actionable targets for future studies aimed at translating evidence informed smoking cessation interventions into practice in perioperative settings. More research is needed to evaluate how targeting these barriers and facilitators will impact smoking outcomes.

Kawasaki disease: patients' transition journey and recommendations for adult care

BACKGROUND

Children who develop coronary artery aneurysms after Kawasaki disease are at risk for cardiovascular morbidity, requiring health care transition and lifelong follow-up with an adult specialist. Follow-up losses after health care transition have been reported but without outcome and patient experience evaluation.

OBJECTIVE

The Theoretical Domains Framework underpinned our aim to explore the required self-care behaviours and experiences of young adults' post-health care transition.

METHODS

A qualitative description approach was used for virtual, 1:1 interviews with 11 participants, recruited after health care transition from a regional cardiac centre in Ontario. Directed content analysis was employed.

RESULTS

Health, psychosocial, and lifestyle challenges were compounded by a sense of loss. Six themes emerged within the Theoretical Domains Framework categories. Participants offered novel health care transition programme recommendations.

CONCLUSIONS

The realities of health care transition involve multiple, overlapping stressors for young adults with Kawasaki disease and coronary artery aneurysms. Our findings will inform a renewed health care transition programme and will include outcome evaluation.

Exploring attitudinal barriers to participation in inpatient fall risk assessment using the Theoretical Domains Framework: A survey of providers

Background and Aims

Lack of provider (physicians and advanced practice providers) participation in fall risk assessment was theorized to be contributing to rising rates of falls with injury at our institution. This project sought to identify if attitudinal barriers to inpatient provider participation in fall risk assessment were similar to those identified in other clinical settings.

Methods

Barriers to provider participation in fall risk assessment were identified in the literature. These were mapped to the Theoretical Domains Framework (TDF) domains to assist with interpretation of the data. A 10-item survey using a 5-point Likert scale (strongly agree to strongly disagree) with two open-ended questions was developed using these barriers. The survey was distributed via email to all providers on the Medical Staff in July 2021.

Results

The response rate was 9.1% (188/2062). 72.6% (95% confidence interval [CI]: 65.6, 78.5) of providers at our institution did agree that fall risk assessment was within their role and 72% (95% CI: 66.1, 78.5) agreed that assessment can prevent falls. Nearly half felt that they lacked formal training in fall risk assessment (48.1% [95% CI: 41.1, 55.1]) and 52.2% (95% CI: 44.6, 58.6) agreed that other aspects of patient care took priority over falls assessment. These barriers correlated best with the TDF domains of Beliefs about Capabilities and Beliefs about Consequences.

Conclusions

Survey results indicate that interventions focused on increasing provider motivation and capability regarding fall risk assessment and helping providers prioritize fall risk assessment are potential targets for future quality improvement projects.

Barriers and facilitators to pressure ulcer prevention behaviours by older people living in their own homes and their lay carers: a qualitative study

OBJECTIVE

To identify barriers and facilitators to pressure ulcer prevention behaviours in community-dwelling older people and their lay carers.

DESIGN

Theoretically informed qualitative interviews with two-phase, deductive then inductive, thematic analysis.

SETTING

The study was conducted in one geographical region in the UK, spanning several community National Health Service Trusts.

PARTICIPANTS

Community-dwelling older patients at risk of pressure ulcer development (n=10) and their lay carers (n=10).

RESULTS

Six themes and subthemes were identified: (1) knowledge and beliefs about consequences (nature, source, timing and taboo); (2) social and professional role and influences (who does what, conflicting advice and disagreements); (3) motivation and priorities (competing self-care needs and carer physical ability); (4) memory; (5) emotion (carer exhaustion and isolation, carergiver role conflict and patient feelings) and (6) environment (human resource shortage and equipment).

CONCLUSIONS

There is minimal research in pressure ulcer prevention in community-dwelling older people. This study has robustly applied the theoretical domains framework to understanding barriers and facilitators to pressure ulcer prevention behaviours. Our findings will support co-design of strategies to promote preventative behaviours and are likely to be transferable to comparable healthcare systems nationally and internationally.

Barriers and Enablers to Using Intervention Reporting Guidelines in Sports and Exercise Medicine Trials: A Mixed-Methods Study

OBJECTIVE: To identify barriers and facilitators for using intervention reporting guidelines (CERT and TIDieR) from authors of randomized controlled trials in sports and exercise medicine journals. DESIGN: Mixed-methods cross-sectional online survey. METHODS: We recruited authors of randomized controlled trials published from June 2, 2018, to June 2, 2022, in the 10 leading sports and exercise medicine journals. We invited authors of eligible trials to complete an online survey that included multiple-choice and Likert-scale questions, as well as open-ended free-text questions on the barriers and facilitators to using intervention reporting guidelines. We used descriptive analysis to summarize the quantitative data and a hybrid deductive-inductive thematic analysis to identify barriers and facilitators from the qualitative data. We conducted a subgroup analysis to explore differences in barriers and facilitators between early-mid career researchers and senior researchers. RESULTS: Eighty-four participants from 21 countries completed the survey (44 early-mid-career researchers, 40 senior researchers). We identified 8 themes relating to using intervention reporting guidelines. Themes classified as barriers related to publication constraints (word count limits), low awareness of intervention reporting guidelines, unclear benefits of the guidelines, and the increased burden imposed upon the researcher. Themes classified as facilitators related to journal requirements for guidelines use, the desire to accurately describe interventions, recommendations from other researchers, and reporting guideline use indicating "quality" of work. CONCLUSION: Barriers to using intervention reporting guidelines are largely modifiable and could be addressed by journals mandating their use, and educational initiatives. J Orthop Sports Phys Ther 2024;54(2):1-11. Epub 16 November 2023. doi:10.2519/jospt.2023.12110.

Digitisation and health: Second nationwide survey of internet users in Germany

Objective

Rapid digitisation of health occurred during the COVID-19 pandemic worldwide. In October 2020, we conducted a survey on digital health technology use in Germany. This study aimed to conduct a second survey to investigate in more detail the internet use in health context and digital technology use for health promotion and disease prevention in Germany.

Methods

A cross-sectional, nationwide telephone survey was conducted in November 2022. Anonymous data on internet and digital technology use, digital health literacy, and sociodemographic characteristics were analysed using descriptive statistics and binary logistic regressions.

Results

The 1020 participants were aged 18-92 years, 53% were male, 62% completed primary or secondary education, 71% resided in large cities, and 45% reported a country-average net household income. Overall, 61% reported internet use in health context via 1-4 devices. Among those, more than 50% used the internet and apps to obtain general health information and less than 50% used digital technologies for physical activity promotion or cancer prevention. Overall, 34% were confident in using the internet for health decisions and 71% preferred to receive health information non-digitally (e.g. on paper). Internet, app, and digital technology use were associated with higher digital health literacy and income, and residence in larger cities. Digital technologies were used for physical activity promotion by younger and for cancer prevention by older participants.

Conclusion

The internet and digital technologies were predominantly used to obtain health information, but less often for health promotion and disease prevention in 2022 in Germany. While health app and digital technology use for physical activity promotion increased, the confidence in using online information for health decisions decreased in 2022 relative to 2020. Factors that promote confidence in online health information and digital technology use for health promotion and disease prevention need to be investigated in future studies.

Designing an intervention to help the quitters quit: A qualitative, intervention co-design study

Objective

E-cigarettes are increasingly being provided by publicly funded stop smoking services. Our objectives were to understand the challenges and establish the means by which services could best support the use and subsequent discontinuation of e-cigarettes for this purpose.

Methods

Semi-structured interviews and co-design workshops with service users and providers of a stop smoking service.

Results

Thematic analysis was conducted. Interviews identified: 1. a reluctance to use e-cigarettes for cessation, 2. struggle to quit e-cigarettes (dependency, fear of relapse, compensatory "puffing") and 3. service development needs (consistency of approach). Co-design workshops suggested: 1. facilitation of e-cigarette use through understanding previous failed attempts, 2. offering a longer, two-staged approach to tobacco then e-cigarette cessation, careful timing of behavioural strategies and 3. enhanced communication between providers.

Conclusions

Our study suggests additional modifications to smoking cessation support measures when e-cigarettes are used for smoking cessation to address the challenges posed by public health guidance: "smokers should switch to vaping and vapers should stop smoking completely".

Innovation

Our study is the first to consider experiences of service users and providers about the challenges of using e-cigarettes for cessation; our co-design group of providers informed nine strategies needed to support this approach in practice.

Investigating physicians' views on non-formulary prescribing: a qualitative study using the theoretical domains framework

BACKGROUND

Well-designed and well-maintained drug formularies serve as a reliable resource to guide prescribing decisions; they are associated with improved medicine safety and increased efficiency, while also serving as a cost-effective tool to help manage and predict medicine expenditure. Multiple studies have investigated the inappropriate prescribing of non-formulary drugs (NFDs) with statistics indicating that up to 70% of NFD usage being inappropriate or not following the ascribed NFD policies.

AIM

To explore physicians' views and influences on their prescribing of non-formulary drugs.

METHOD

Data collection and analysis were underpinned using the Theoretical Domains Framework (TDF). Thirteen semi-structured interviews were conducted within Hamad Medical Corporation, the main provider of secondary and tertiary healthcare in Qatar, with physicians who had submitted a NFD request in the preceding 12 months.

RESULTS

Three overarching themes were identified: providing evidence-based care for individual patients; influences of others; and formulary management issues. Subthemes were mapped to specific TDF domains: environmental context and resources; social influences; professional role and identity; beliefs about consequences; goals; intentions.

CONCLUSION

The behavioral influences identified in this study can be mapped to behavior change strategies facilitating the development of an intervention to promote appropriate prescribing of NFDs with implications for medicine safety and healthcare efficiency.

Evaluating the effectiveness of mindfulness alone compared to exercise and mindfulness on fatigue in women with gynaecology cancer (GEMS): Protocol for a randomised feasibility trial

BACKGROUND

In 2020 Globocan reported nearly 1.4 million new cases of gynaecology cancer worldwide. Cancer related fatigue has been identified as a symptom that can be present for gynaecology cancer patients many years after treatment. The current evidence around the management of this symptom suggests that exercise has the most positive outcome. However, some ambiguity remains around the evidence and whether it can address all areas of fatigue effectively. More recently, other interventions such as mindfulness have begun to show a favourable response to the management of symptoms for cancer patients. To date there has been little research that explores the feasibility of using both these interventions together in a gynaecology cancer population. This study aims to explore the feasibility of delivering an intervention that involves mindfulness and mindfulness and exercise and will explore the effect of this on fatigue, sleep, mood and quality of life.

METHODS/DESIGN

This randomised control trial will assess the interventions outcomes using a pre and post design and will also include a qualitative process evaluation. Participants will be randomised into one of 2 groups. One group will undertake mindfulness only and the other group will complete exercise and mindfulness. Both groups will use a mobile application to complete these interventions over 8 weeks. The mobile app will be tailored to reflect the group the participants have drawn during randomisation. Self-reported questionnaire data will be assessed at baseline prior to commencing intervention and at post intervention. Feasibility will be assessed through recruitment, adherence, retention and attrition. Acceptability and participant perspective of participation (process evaluation), will be explored using focus groups.

DISCUSSION

This trial will hope to evidence and demonstrate that combination of two interventions such as mindfulness and exercise will further improve outcomes of fatigue and wellbeing in gynaecology cancer. The results of this study will be used to assess (i) the feasibility to deliver this type of intervention to this population of cancer patients using a digital platform; (ii) assist this group of women diagnosed with cancer to manage fatigue and other symptoms of sleep, mood and impact their quality of life.

TRIAL REGISTRATION

NCT05561413.

The barriers and facilitators for the implementation of clinical practice guidelines in healthcare: an umbrella review of qualitative and quantitative literature

OBJECTIVES

To identify barriers and facilitators of clinical practice guidelines (CPGs) implementation, and map those factors to the theoretical domains framework (TDF) and behavior change wheel (BCW).

METHODS

We conducted an umbrella review of systematic reviews. PubMed, Embase, and the Cochrane Library were searched. Two investigators independently screened the studies, extracted the data, and assessed the methodological quality. The identified barriers and facilitators of CPG implementation were categorized and mapped to the TDF domains and BCW components.

RESULTS

Thirty-seven studies were included, and 193 barriers and 140 facilitators were identified. Intrinsic aspects (35 barriers and 28 facilitators) mainly included the CPGs' impracticality, complexity, and inaccessibility. Extrinsic aspects (158 barriers and 113 facilitators) mainly included lack of resources, training, funding, or awareness of CPG content in barriers; audits and feedback; strong leadership and management support; and educating and training about CPGs in facilitators. Environmental context and resources (n = 97, 19.48%) were the most reported barriers in TDF domains. Physical opportunity and social opportunity were the most frequently mentioned models in BCW.

CONCLUSION

Multiple barriers and facilitators for healthcare CPG implementation are identified, with further links to TDF and BCW. Future knowledge translation strategies should be developed accordingly in specified health care settings.

Interventions to support patients with sharing genetic test results with at-risk relatives: a synthesis without meta-analysis (SWiM)

Whilst the finding of heritable susceptibility to disease was once relatively rare, mainstreaming of genetic testing has resulted in a steady increase. Patients are often encouraged to share their genetic test results with relevant relatives, but relatives may not receive this information, leaving them without knowledge of their own risk. Therefore, strategies to help communicate such information are important. This review aimed to explore the efficacy of existing interventions to improve the sharing of genetic test results. A synthesis without meta-analysis design was used. A systematic search of Medline, CINAHL, PsychINFO, and AMED was conducted, and five studies were identified worldwide. Data were extracted for each study regarding study aim, participant characteristics, condition, intervention details, comparison, study duration, outcome measures, theory and behaviour change techniques used. Limited efficacy and application of theory was found. Knowledge, motivation and self-efficacy were not increased in any intervention. No gender differences in communication behaviour were encountered in interventions that recruited men and women. Two studies reported an evaluation of acceptability, which showed that the interventions were well received by patients and health professionals. No study reported the involvement of the target population in any phase of intervention development. Given the lack of health psychology-informed interventions in this area of clinical genetics, we recommend genetic health professionals, health psychologists and patients collaborate on all stages of future interventions that involve the cascading of genetic health information within families. We also provide guidance regarding use of theory and intervention elements for future intervention development.

Challenges in the care of patients with RET-altered thyroid cancer: a multicountry mixed-methods study

BACKGROUND

The discovery of driver oncogenes for thyroid carcinomas and the identification of genomically targeted therapies to inhibit those oncogenes have altered the treatment algorithm in thyroid cancer (TC), while germline testing for RET mutations has become indicated for patients with a family history of RET gene mutations or hereditary medullary TC (MTC). In the context of an increasing number of selective RET inhibitors approved for use, this paper aims to describe challenges and barriers affecting providers' ability to deliver optimal care for patients with RET-altered TC across the patient healthcare journey.

METHODS

A mixed-method educational and behavioral needs assessment was conducted in Germany (GER), Japan (JPN), the United Kingdom (UK), and the United States (US) prior to RET-selective inhibitor approval. Participants included medical oncologists (MO), endocrinologists (EN) and clinical pathologists (CP) caring for patients affected with TC. Data collection tools were implemented in three languages (English, German, Japanese). Qualitative data were coded and thematically analyzed in NVivo. Quantitative data were analyzed via frequency and crosstabulations in SPSS. The findings presented here were part of a broader study that also investigated lung cancer challenges and included pulmonologists.

RESULTS

A total of 44 interviews and 378 surveys were completed. Suboptimal knowledge and skills were self-identified among providers, affecting (1) assessment of genetic risk factors (56%, 159/285 of MOs and ENs), (2) selection of appropriate genetic biomarkers (59%, 53/90 of CPs), (3) treatment plan initiation (65%, 173/275 of MOs and ENs), (4) management of side effects associated with multitargeted tyrosine kinase inhibitors (78%, 116/149 of MOs and ENs), and (5) transfer of patients into palliative care services (58%, 160/274 of MOs and ENs). Interviews underscored the presence of systemic barriers affecting the use of RET molecular tests and selective inhibitors, in addition to suboptimal knowledge and skills necessary to manage the safety and efficacy of targeted therapies.

CONCLUSION

This study describes concrete educational needs for providers involved in the care of patients with RET-altered thyroid carcinomas. Findings can be used to inform the design of evidence-based education and performance improvement interventions in the field and support integration into practice of newly approved RET-selective inhibitors.

Using behavioral theory to adapt advance care planning for homeless-experienced older adults in permanent supportive housing

BACKGROUND

Older adults experiencing chronic homelessness (i.e., prolonged homelessness and a disabling condition) have low rates of advance care planning (ACP) despite high rates of morbidity and mortality. Rehousing of homeless-experienced individuals into permanent supportive housing (PSH) may present an opportunity to introduce ACP; but this is unknown. Therefore, we explored staff and resident perceptions of conducting ACP in PSH.

METHODS

We conducted semi-structured interviews with PSH staff (n = 13) and tenants (PSH residents) (n = 26) in San Francisco. We used the capability (C), opportunity (O), motivation (M), behavior (COM-B) framework within the Behavior Change Wheel model and the Theoretical Domains Framework (TDF) to inform interviews, categorize themes, and guide qualitative thematic analysis.

RESULTS

The mean age of PSH residents was 67 (SD = 6.1) years and 52% were women. Of staff, 69% were women. Important COM-B barriers included ACP complexity (C), complicated relationship dynamics (O), resource limitations (O), pessimism (M), variable staff confidence (M), and competing priorities (M). Facilitators included easy-to-use documents/videos, including the PREPARE for Your Care program (C), stability with housing (O), exposure to health crises (O), potential for strong relationships (O), and belief that ACP is impactful (M). Recommendations included adapting materials to the PSH setting, providing staff trainings/scripts, and using optional one-on-one or group sessions.

CONCLUSIONS

We identified behavioral determinants related to ACP for formerly chronically homeless older adults in PSH. Future interventions should include using easy-to-use ACP materials and developing resources to educate PSH residents, train staff, and model ACP in groups or one-on-one sessions.

Understanding the barriers and facilitators of COVID-19 risk mitigation strategy adoption and COVID-19 vaccination in refugee settlements in Uganda: a qualitative study

BACKGROUND

Perspectives on COVID-19 risk and the willingness and ability of persons living in refugee settlements to adopt COVID-19 prevention strategies have not been rigorously evaluated. The realities of living conditions in Ugandan refugee settlements may limit the extent to which refugees can uptake strategies to mitigate COVID-19 risk.

METHODS

In-depth qualitative interviews were conducted between April 2021 and April 2022 to assess COVID-19 knowledge, risk perception, prevention strategy adoption including COVID-19 vaccination, and COVID-19 impact on living conditions in refugee settlements in Uganda. Interview participants included 28 purposively selected refugees who called into "Dial-COVID", a free telephone COVID-19 information collection and dissemination platform that was advertised in refugee settlements by community health workers. Interviews were analyzed using a combination of deductive and inductive content analysis. Emerging themes were mapped onto the Theoretical Domains Framework to identify domains influencing prevention behavior. Results were synthesized to provide intervention and policy recommendations for risk mitigation in refugee settlements for COVID-19 and future infectious disease outbreaks.

RESULTS

The COVID-19 pandemic detrimentally impacted economic and food security as well as social interactions in refugee settlements. Youth were considered especially impacted, and participants reported incidents of child marriage and teenage pregnancy following school closures. Participants displayed general knowledge of COVID-19 and expressed willingness to protect themselves and others from contracting COVID-19. Risk mitigation strategy uptake including COVID-19 vaccination was influenced by COVID-19 knowledge, emotions surrounding COVID-19, the environmental context and resources, personal goals, beliefs about the consequences of (non)adoption, social influences, and behavior reinforcement. Resource constraints, housing conditions, and competing survival needs challenged the adoption of prevention strategies and compliance decreased over time.

CONCLUSIONS

Contextual challenges impact the feasibility of COVID-19 risk mitigation strategy uptake in refugee settlements. Pre-existing hardships in this setting were amplified by the COVID-19 pandemic and related lockdowns. Targeted dispelling of myths, alignment of information across communication mediums, supporting survival needs and leveraging of respected role models are strategies that may hold potential to mitigate risk of infectious diseases in this setting.

REGISTRATION DETAILS

World Pandemic Research Network - 490,652.

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.

Barriers and facilitators for providing self-care advice in community pharmacies: a qualitative study

BACKGROUND

Community pharmacies are easily accessible for self-care advice. Guidelines for providing self-care advice were introduced in several countries, including the Netherlands in the 1990s. Previous studies have indicated room for improvement in self-care advice in daily pharmacy practice.

AIM

To identify barriers and facilitators for providing self-care advice.

METHOD

Semi-structured interviews were conducted face-to-face or online with pharmacists and pharmacy assistants using a topic guide based on the Theoretical Domains Framework. The interviews were audio-recorded and transcribed verbatim. The transcripts were deductively analysed to identify barriers and facilitators for self-care counselling. COREQ guidelines were followed.

RESULTS

In total, 13 pharmacists and 12 pharmacy assistants were interviewed to reach data saturation. In general, most themes addressed by pharmacists and pharmacy assistants belonged to similar domains. The following domains were frequently mentioned: environmental context and resources (e.g. priority for prescription drugs, privacy, collaboration with general practitioners, access to patients' records), intentions (providing reliable advice), skills (communication, decision-making), knowledge (ready guideline knowledge), beliefs about consequences (patient safety), social influences (patient awareness of pharmacist role), reinforcement (lack of reimbursement for relatively time-consuming advice).

CONCLUSION

This study identifies barriers and facilitators for evidence-based self-care advice. Pharmacists should first support pharmacy assistants by helping them keep their knowledge and skills up to date and creating suitable pharmacy preconditions to facilitate improvements in self-care counselling. Second, collaboration with general practitioners regarding minor ailments should be improved.

Describing capability, opportunity, and motivation for food safety practices among actors in the Cambodian informal vegetable market

Introduction

Several Cambodian initiatives seek to improve nutritional outcomes via increased production and consumption of nutrient-dense foods, including vegetables. However, food safety gaps in informal markets, where most vegetables are purchased, allow for the transmission of foodborne pathogens and threaten the positive nutritional outcomes associated with vegetable consumption.

Methods

This study describes a tool used to measure perceptions of Cambodians involved with informal vegetable markets regarding their capabilities, opportunities, and motivations to implement food safety practices. The quantitative tool could also be used to assess capability, opportunity, and motivation to adopt a behavior in a wide range of development contexts. To these ends, a questionnaire assessing these perceptions was developed using the Capability, Opportunity, Motivation-Behavior (COM-B) model of behavior and the Theoretical Domains Framework (TDF).

Results

The questionnaire was piloted with vegetable vendors in Phnom Penh (N = 55), revised, and subsequently implemented in the provinces of Battambang and Siem Reap with vegetable producers, distributors, and vendors (N = 181). Confirmatory factor analysis resulted in a nine-factor model corresponding to TDF constructs with a comparative fit index of 0.91, a Tucker-Lewis index of 0.89, and a root mean square error of ~0.05. Further analysis indicated that vegetable vendors and distributors typically had significantly higher (p < 0.05) levels of perceived motivation and capability to implement the target food safety practice (washing surfaces that come in contact with vegetables with soap and water every day) compared to their perceived opportunity to do so. Among farmers, however, levels of perceived motivation were significantly higher (p < 0.05) than levels of perceived opportunity and capability. In addition, vendors in Battambang had significantly higher (p < 0.05) levels of perceived capability, opportunity, and motivation to implement the target food safety practice in comparison to farmers in either province. Vendors in Battambang had significantly higher (p < 0.05) levels of perceived opportunity and motivation than vendors in Siem Reap.

Conclusions

These data suggest that efforts to bolster vegetable vendors' and distributors' perceived opportunity and vegetable farmers' perceived opportunity and capability to implement food safety practices could increase the likelihood of adoption of the target food safety practice.

Midwives and service users' perspectives on implementing a dialogue about alcohol use in antenatal care: A qualitative study

AIM

There are barriers to midwives engaging in conversations about alcohol with pregnant women. Our aim was to capture the views of midwives and service users to co-create strategies to address these barriers.

DESIGN

Qualitative description.

METHODS

Structured Zoom-based focus group interviews of midwives and service users where we presented known barriers and sought solutions to midwives discussing alcohol use in antenatal settings. Data collection took place between July and August 2021.

RESULTS

Fourteen midwives and six service users attended five focus groups. Barriers considered were as follows: (i) lack of awareness of guidelines, (ii) poor skills in difficult conversations, (iii) lack of confidence, (iv) lack of belief in existing evidence, (v) women would not listen to their advice, and (vi) alcohol conversations were not considered part of their role. Five strategies to address barriers to midwives discussing alcohol with pregnant women were identified. These were as follows: Training that included mothers of children with Foetal Alcohol Spectrum Disorder, champion midwives, a service user questionnaire about alcohol for completion before the consultation, questions about alcohol added to the maternity data capture template and a structured appraisal to provide a means of audit and feedback on their alcohol dialogue with women.

CONCLUSIONS

Co-creation involving providers and users of maternity services yielded theoretically underpinned pragmatic strategies to support midwives to ask advise assist about alcohol during antenatal care. Future research will test if the strategies can be delivered in antenatal care settings, and if they are acceptable to service providers and service users.

IMPACT

If these strategies are effective in addressing barriers to midwives discussing alcohol with pregnant women, this could support women to abstain from alcohol during pregnancy, thus reducing alcohol-related maternal and infant harm.

PATIENT AND PUBLIC CONTRIBUTION

Service users were involved in the design and execution of the study, considering data, supporting intervention design and delivery and dissemination.

Acceptability and feasibility of a planned preconception weight loss intervention in women with long-acting reversible contraception: the Plan-it mixed-methods study

BACKGROUND

Women with overweight (a body mass index of ≥ 25 kg/m2) or obesity (a body mass index of ≥ 30 kg/m2) are at greater risk of experiencing complications during pregnancy and labour than women with a healthy weight. Women who remove their long-acting reversible contraception (i.e. coils or implants) are one of the few groups of people who contact services as part of their preparation for conception, creating an opportunity to offer a weight loss intervention.

OBJECTIVES

The objectives were to understand if routine NHS data captured the pathway from long-acting reversible contraception removal to pregnancy and included body mass index; to identify the suitable components of a preconception weight loss intervention; and to engage with key stakeholders to determine the acceptability and feasibility of asking women with overweight/obesity to delay the removal of their long-acting reversible contraception in order to take part in a preconception weight loss intervention.

DESIGN

This was a preparatory mixed-methods study, assessing the acceptability and feasibility of a potential intervention, using routine NHS data and purposefully collected qualitative data.

PARTICIPANTS

The NHS routine data included all women with a long-acting reversible contraception code. There were three groups of participants in the surveys and interviews: health-care practitioners who remove long-acting reversible contraception; weight management consultants; and women of reproductive age with experience of overweight/obesity and of using long-acting reversible contraception.

SETTING

UK-based health-care practitioners recruited at professional meetings; and weight management consultants and contraceptive users recruited via social media.

DATA SOURCES

Anonymised routine data from UK sexual health clinics and the Clinical Practice Research Datalink, including the Pregnancy Register; and online surveys and qualitative interviews with stakeholders.

RESULTS

The records of 2,632,871 women aged 16-48 years showed that 318,040 had at least one long-acting reversible contraception event, with 62% of records including a body mass index. Given the identified limitations of the routine NHS data sets, it would not be feasible to reliably identify women with overweight/obesity who request a long-acting reversible contraception removal with an intention to become pregnant. Online surveys were completed by 100 health-care practitioners, four weight management consultants and 243 contraceptive users. Ten health-care practitioners and 20 long-acting reversible contraception users completed qualitative interviews. A realist-informed approach generated a hypothesised programme theory. The combination of weight discussions and the delay of long-acting reversible contraception removal was unacceptable as an intervention to contraceptive users for ethical and practical reasons. However, a preconception health intervention incorporating weight loss could be acceptable, and one potential programme is outlined.

LIMITATIONS

There was very limited engagement with weight management consultants, and the sample of participating stakeholders may not be representative.

CONCLUSIONS

An intervention that asks women to delay long-acting reversible contraception removal to participate in a preconception weight loss intervention would be neither feasible nor acceptable. A preconception health programme, including weight management, would be welcomed but requires risk communication training of health-care practitioners.

FUTURE WORK

Work to improve routine data sets, increase awareness of the importance of preconception health and overcome health-care practitioner barriers to discussing weight as part of preconception care is a priority.

TRIAL REGISTRATION

This trial is registered as ISRCTN14733020.

FUNDING

This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 27, No. 1.

Understanding Hand Hygiene Behavior in a Public Hospital in Benin Using the Theoretical Domain Frameworks: The First Step for Designing Appropriate Interventions

Background: Hand Hygiene (HH) is widely recognized to be one of the most successful and cost-effective measures for reducing the incidence of healthcare-associated infections (HAIs). The hand hygiene behavior of hospital healthcare workers (HCWs) is not well-documented in Benin. Therefore, Theoretical Domains Framework (TDF) was used to identify the behavioral determinants that may impact HCWs’ hand-hygiene compliance in a public hospital. Methods: A qualitative design comprising face-to-face semi-structured interviews with nine HCWs. The interviews included questions on transmission of infections, hand-hygiene practices, problems with their implementation; and ways to improve hand hygiene compliance. Two pharmacists independently coded interviews into behavioral domains using the TDF and then subdivided them into several themes. Interview transcripts were analyzed following 3-steps approach: coding, generation of specific beliefs, and identification of relevant domains. Results: Almost all interviewees have cited the environmental context and resources (such as lack of water) as a barrier to HH practice. They also believed that role models had a significant impact on the good practices of others HCWs. Fortunately, they were confident of their capabilities to perform appropriate HH behaviors. The majority (7/9) reported having the necessary knowledge and skills and believed they could carry out appropriate HH behavior. In all cases, the participants were motivated to carry out HH behavior, and it was recognized that HH remains the cornerstone to reduce health care associated infections. Conclusion: This study identified several behavioral constructs aligned with the TDF that can be targeted and help for the development of new hand-hygiene interventions. These may increase the likelihood of a successful intervention, thereby improving HH compliance and patient safety, especially in hospitals.

Theoretically derived interventions aimed at improving appropriate polypharmacy in primary care: A systematic review

Background

Polypharmacy (the use of multiple medications) is common in older patients and achieving a balance between appropriate and inappropriate polypharmacy is a challenge routinely faced by prescribers. It is recommended to incorporate the use of theory when developing complex interventions, but it is not known if theoretically derived interventions aimed at improving appropriate polypharmacy are effective.

Objective

This systematic review aimed to establish the overall effectiveness of theoretically derived interventions on improving appropriate polypharmacy and to investigate the degree to which theory informed intervention design.

Methods

Seven electronic databases were searched from inception to August 2021 including hand-searching of reference lists. Interventions developed using a theory, involving the use of a validated tool to assess prescribing, delivered in primary care to participants with a mean age of ≥65 years and prescribed ≥four medications, were included. Data was extracted independently by two reviewers. The Theory Coding Scheme (TCS) was applied to evaluate the use of theory; Risk of Bias (RoB) was assessed using the Cochrane RoB 2.0 tool.

Results

Two studies, one feasibility study and one randomised controlled trial (RCT) were included, and therefore overall effectiveness of the theoretically derived intervention could not be assessed. Theory used in development included the Theoretical Domains Framework and Reason's system-based risk management theory. The RCT was rated to have a high RoB. Based on the TCS, neither study used theory completely.

Conclusion

The effectiveness of theoretically derived interventions to improve appropriate polypharmacy in primary care could not be determined due to the small number of studies and their heterogeneity. Further incorporation of theory into intervention development is required to understand the effectiveness of this approach.Prospero registration: CRD42020157175.

Barriers and enablers to the effective implementation of robotic assisted surgery

Background

Implementation of Robotic Assisted Surgery (RAS) is complex as it requires adjustments to associated physical infrastructure, but also changes to processes and behaviours. With the global objective of optimising and improving RAS implementation, this study aimed to: 1) Explore the barriers and enablers to RAS service adoption, incorporating an assessment of behavioural influences; 2) Provide an optimised plan for effective RAS implementation, with the incorporation of theory-informed implementation strategies that have been adapted to address the barriers/enablers that affect RAS service adoption.

Methods

Semi-structured interviews were conducted with RAS personnel and stakeholders, including: surgeons, theatre staff, managers, industry representatives, and policy-makers/commissioners. The Theoretical Domains Framework (TDF) and the Consolidated Framework for Implementation Research (CFIR) was used to identify barriers and enablers that represent individual behaviours, capabilities, attitudes, beliefs, and external organisational factors that influence the implementation of RAS.

Results

Findings suggest that implementation planning has three separate phases–pre-, early, and late implementation. For pre-implementation, barriers and enablers identified included the cost of RAS equipment and issues of economic viability, weak outcome evidence for RAS, a preponderance of an eminence driven model, the clinician/manager relationship, and views around the uptake and expansion of RAS in the future. Early implementation findings revealed role changes for theatre personnel and an enhanced team approach, reliance on industry for training provision, and changes in skill sets and attentional processes. Late implementation factors included equipment maintenance costs, technological limitations, changes to cognition during RAS routine use, and benefits to institutions/healthcare professionals (such as ergonomic improvement).

Conclusion

Together, findings suggest the factors that affect RAS implementation are multi-faceted and change across the life-cycle of intervention adoption. Theory-informed strategies are suggested which can optimise implementation of RAS. Optimisation strategies need planning from the outset.

Stakeholders' perception on the implementation of Developmental Progress Assessment: using the Theoretical Domains Framework to document behavioral determinants

BACKGROUND

The widespread implementation of longitudinal assessment (LA) to document trainees' progression to independent practice rests more on speculative rather than evidence-based benefits. We aimed to document stakeholders' knowledge of- and attitudes towards LA, and identify how the supports and barriers can help or hinder the uptake and sustainable use of LA.

METHODS

We interviewed representatives from four stakeholder groups involved in LA. The interview protocols were based on the Theoretical Domains Framework (TDF), which contains a total of 14 behaviour change determinants. Two team members coded the interviews deductively to the TDF, with a third resolving differences in coding. The qualitative data analysis was completed with iterative consultations and discussions with team members until consensus was achieved. Saliency analysis was used to identify dominant domains.

RESULTS

Forty-one individuals participated in the study. Three dominant domains were identified. Participants perceive that LA has more positive than negative consequences and requires substantial ressources. All the elements and characteristics of LA are present in our data, with differences between stakeholders.

CONCLUSION

Going forward, we could develop and implement tailored and theory driven interventions to promote a shared understanding of LA, and maintain potential positive outcomes while reducing negative ones. Furthermore, ressources to support LA implementation need to be addressed to facilitate its uptake.

Barriers and facilitators on the implementation of physical activity in Primary Health Care: A systematic review

Barriers and facilitators influence the implementation of physical activity (PA) in Primary Health Care (PHC). This study aimed to analyze the scientific evidence on barriers and facilitators perceived by stakeholders on the implementation of PA in PHC.The search databases consisted of Web of Science, Medline, Scopus, and Lilacs. Two independent researchers reviewed the eligibility criteria and extracted and coded the information according to the Theoretical Domains Framework (TDF). The Consolidated Criteria for Reporting Qualitative Research was used to report the quality of the included studies. We analyzed 8.471 studies but included only 16. The studies identified 54 different reports on barriers and 48 on facilitators. Reports were often identified in the "environmental context and resources" domain, with 27 reports on barriers and 27 on facilitators. We found 25 reports of barriers and 16 of facilitators in the TDF domains that demonstrate professional profile characteristics. The low expectations in the professional profile for the implementation can influence the context and the organizational climate to identify more barriers than facilitators.

Behavioural optimisation to address trial conduct challenges: case study in the UK-REBOA trial

BACKGROUND

Clinical trials comprise multiple processes at various stages of the trial lifecycle. These processes often involve complex behaviours such as recruiting vulnerable patient populations and clinicians having to deliver complex trial interventions successfully. Few studies have utilised a behavioural framework to assess challenges and develop strategies for effective trial recruitment and delivery of trial interventions. This study reports the application of an innovative methodological approach to understand core trial processes, namely recruitment and intervention delivery, using a behavioural science approach to develop strategies designed to mitigate trial process problems.

METHODS

The UK-REBOA trial aims to evaluate the clinical and cost-effectiveness of resuscitative endovascular balloon occlusion of the aorta (a novel intervention) in injured patients with exsanguinating haemorrhage. A behavioural investigation ('diagnosis') was conducted using theory-informed (Theoretical Domains Framework, TDF) semi-structured interviews with site staff from the UK-REBOA trial to examine trial processes which could be improved in relation to trial recruitment and delivery of the intervention. Interviews were analysed using the TDF to identify influences on behaviour, which were then mapped to techniques for behaviour change and developed into potential solutions.

RESULTS

The behavioural diagnosis of the challenges experienced during trial processes highlighted factors relevant to a range of TDF domains: Skills, Environmental context and resources, Beliefs about capabilities, Beliefs about consequences, Social influences, and Memory, attention, and decision-making processes. Within the solution development phase, we identified 24 suitable behaviour change techniques that were developed into proposed solutions to target reported process problems with the aim of changing behaviour to improve recruitment and/or intervention delivery. Proposed solutions included targeted changes to trial training content, suggestions to restructure the environment (e.g. reinforced the purpose of the trial with information about the social and environmental consequences) and other strategies to reduce barriers to recruitment and intervention delivery.

CONCLUSIONS

This study demonstrates the feasibility of applying a behavioural approach to investigate ('diagnose') behavioural trial process problems and subsequently develop and implement targeted solutions ('treatment') in an active trauma trial. Understanding the factors that affected behaviour, attitudes and beliefs in this trauma trial allowed us to implement theoretically informed, evidence-based solutions designed to enhance trial practices.

TRIAL REGISTRATION

ISRCTN 16,184,981.

Translating qualitative data into intervention content using the Theoretical Domains Framework and stakeholder co-design: a worked example from a study of cervical screening attendance in older women

BACKGROUND

Previous screening interventions have demonstrated a series of features related to social determinants which have increased uptake in targeted populations, including the assessment of health beliefs and barriers to screening attendance as part of intervention development. Many studies cite the use of theory to identify methods of behaviour change, but fail to describe in detail how theoretical constructs are transformed into intervention content. The aim of this study was to use data from a qualitative exploration of cervical screening in women over 50 in the UK as the basis of intervention co-design with stakeholders using behavioural change frameworks. We describe the identification of behavioural mechanisms from qualitative data, and how these were used to develop content for a service-user leaflet and a video animation for practitioner training. The interventions aimed to encourage sustained commitment to cervical screening among women over 50, and to increase sensitivity to age-related problems in screening among primary care practitioners.

METHODS

Secondary coding of a qualitative data set to extract barriers and facilitators of cervical screening attendance. Barrier and facilitator statements were categorised using the Theoretical Domains Framework (TDF) to identify relevant behaviour change techniques (BCTs). Key TDF domains and associated BCTs were presented in stakeholder focus groups to guide the design of intervention content and mode of delivery.

RESULTS

Behavioural determinants relating to attendance clustered under three domains: beliefs about consequences, emotion and social influences, which mapped to three BCTs respectively: (1) persuasive communication/information provision; (2) stress management; (3) role modelling and encouragement. Service-user stakeholders translated these into three pragmatic intervention components: (i) addressing unanswered questions, (ii) problem-solving practitioner challenges and (iii) peer group communication. Based on (ii), practitioner stakeholders developed a call to action in three areas - clinical networking, history-taking, and flexibility in screening processes. APEASE informed modes of delivery (a service-user leaflet and a cartoon animation for practitioners).

CONCLUSION

The application of the TDF to qualitative data can provide an auditable protocol for the translation of qualitative data into intervention content.

Prioritizing the target audience for a hearing awareness campaign in Australia using the TARPARE model

Hearing loss affects one in six Australians, and it is estimated that around one-third of all hearing loss is preventable. Over the past decade, there have been repeated calls for the development of a national campaign in Australia, aimed at raising the public's awareness of hearing health. We identified six target groups either at risk of developing hearing loss, vulnerable to poor outcomes as a result of untreated hearing loss, or lacking awareness of hearing health services, and applied the TARPARE model as a way of gathering insight into how a national hearing campaign might prioritize these different population segments. An online survey of prominent Australian academics, health practitioners and advocacy professionals with expertise in hearing health and/or public health promotion was created, through which their views on each of six potential target groups that had been identified as likely recipients of a potential hearing health campaign was sought. Young children and caregivers received the highest score based on survey responses and TARPARE criteria. A qualitative analysis of open-ended survey responses from the survey respondents revealed three key themes to consider as part of a potential campaign: Accessibility and availability of hearing services, Deciding on a preventative or treatment-focused approach, and The difficulty of changing behavior.

Understanding potential barriers and enablers to a perioperative early phase cell therapy trial

BACKGROUND AIMS

Early-phase cell therapy clinical trials depend on patient and physician involvement, yet barriers can impede their participation.

METHODS

To optimize engagement for a planned cell therapy trial to prevent perioperative cardiac complications, the authors conducted semi-structured interviews with at-risk patients and physicians who could potentially be involved in the study. The authors used the theoretical domains framework to systematically identify potential barriers and enablers.

RESULTS

Forty-one interviews were conducted to reach data saturation, and four overall potential barriers to participation (themes) were identified. Theme 1 emphasizes that patients and physicians need accessible information to better understand the benefits and risks of the novel therapy and trial procedures and to address misconceptions. Theme 2 underscores the need for clarity on whether the trial's primary purpose is safety or efficacy, as this may influence patient and physician decisions. Theme 3 recognizes the resource and logistic realities for patients (e.g., convenient follow-up appointments) and physicians (e.g., personnel to assist in trial procedures, competing priorities). Theme 4 describes the importance of social influences (e.g., physicians and family, peers/colleagues) that may affect decisions to participate and the importance of patient preferences (e.g., availability of physicians to discuss the trial, including caregivers in discussions).

CONCLUSIONS

Prospectively addressing these issues may help optimize feasibility prior to conducting an expensive, resource-intensive trial.

Behavior Change Interventions for Health Promotion in Physical Therapist Research and Practice: An Integrative Approach

There is an increasing focus on health promotion in physical therapist research and practice. A clinical model (Health-Focused Physical Therapy Model) was developed for identifying major steps in the delivery of health promotion focusing on adoption of healthy lifestyle behaviors. One of the primary steps within this model is the design and delivery of behavior change interventions. Such interventions involve coordinated sets of activities that target change in a specific pattern of unhealthy behavior (eg, physical inactivity, smoking). This Perspective contends that the science and practice of behavior change interventions can be significantly advanced in the field of physical therapy (implementation science) through the integration of behavior change frameworks and techniques within the context of an experimental medicine approach for health behavior change. This perspective presents the integration of the Theoretical Domains Framework, the Behavior Change Wheel, including the Capability Opportunity Motivation-Behavior core system, and the Behavior Change Technique Taxonomy as a comprehensive approach for designing and delivering behavior change interventions in physical therapy. An experimental medicine approach is described, outlining a 4-step process in the design, delivery, and evaluation of behavior change interventions that can be applied to health promotion in physical therapist research and practice. The proposed integrative approach can advance public health and health promotion through healthy lifestyle behavior change in the field of physical therapy.

Leveraging Implementation Science to Achieve Empirical Outcomes

Organizations are often challenged to demonstrate the evidence of empirical outcomes required for Magnet® application and designation. Theoretically, the application of evidence-based guidelines to the clinical setting leads to empirical outcomes. However, successful integration of guidelines into practice remains problematic. This article explains how organizations can leverage implementation science to promote the effective uptake of best practice standards to achieve the outcomes necessary to improve care and demonstrate Magnet standards.

Investigating primary healthcare practitioners' barriers and enablers to referral of patients with COPD to pulmonary rehabilitation: a mixed-methods study using the Theoretical Domains Framework

OBJECTIVES

Pulmonary rehabilitation (PR) is a highly effective, recommended intervention for patients with chronic obstructive pulmonary disease (COPD). Using behavioural theory within mixed-methods research to understand why referral remains low enables the development of targeted interventions in order to improve future PR referral.

DESIGN

A multiphase sequential mixed-methods study.

SETTING

United Kingdom (UK).

PARTICIPANTS

252 multiprofessional primary healthcare practitioners (PHCPs).

MEASURES

Phase 1: semistructured interviews. Phase 2: a 54-item paper and online questionnaire, based on the Theoretical Domains Framework (TDF). Content and descriptive analysis utilised. Data mixed at two points: instrument design and interpretation.

RESULTS

19 PHCPs took part in interviews and 233 responded to the survey. Integrated results revealed that PHCPs with a post qualifying respiratory qualification (154/241; 63.9%) referred more frequently (91/154; 59.1%) than those without (28/87; 32.2%). There were more barriers than enablers for referral in all 13 TDF domains. Key barriers included: infrequent engagement from PR provider to referrer, concern around patient's physical ability and access to PR (particularly for those in work), assumed poor patient motivation, no clear practice referrer and few referral opportunities. These mapped to domains: belief about capabilities, social influences, environment, optimism, skills and social and professional role. Enablers to referral were observed in knowledge, social influences memory and environment domains. Many PHCPs believed in the physical and psychological value of PR. Helpful enablers were out-of-practice support from respiratory interested colleagues, dedicated referral time (annual review) and on-screen referral prompts.

CONCLUSIONS

Referral to PR is complex. Barriers outweighed enablers. Aligning these findings to behaviour change techniques will identify interventions to overcome barriers and strengthen enablers, thereby increasing referral of patients with COPD to PR.

Community pharmacists' views on providing a reproductive health service to women receiving opioid substitution treatment: A qualitative study using the TDF and COM-B

Background

The absence of menstruation is common in women who use drugs. This can give a belief that conception is unlikely. When stabilised on Opioid Substitution Treatment (OST), fertility often returns, initially without realisation as ovulation precedes menstruation. This leaves women vulnerable to unplanned pregnancies. Community pharmacists (CPs) are frequently in contact with this patient group through the Supervised Consumption of OST service. This provides a timely opportunity to provide reproductive health (RH) advice. The aim of this study was to investigate pharmacists' views on providing a RH service to women receiving OST.

Methods

Twenty semi-structured interviews based on the Capability-Opportunity-Motivation to Behaviour (COM-B) model and the Theoretical Domains Framework (TDF) were conducted between 2016 and 2017. Data analysis involved deductive coding using the TDF domains. The TDF domains were mapped onto the elements of the COM-B and used in the second step to create the framework and chart the data. The third step involved re-reading and clustering the codes, and inductive themes were generated to explain the data in depth.

Results

Nine of the 14 TDF domains, mapped into five elements of the COM-B, were identified. Five inductive themes were generated: 1) The pharmacists' experience and knowledge of reproductive health (RH) needs of women receiving OST, 2) The pharmacists' approach to providing advice, 3) The pharmacists' perception of the relationship with women receiving OST, 4) Social influences, and 5) Environmental factors. Community pharmacists feared causing offense to women receiving OST and described requiring cues as to when the service was needed. Pharmacists' highlighted a power imbalance in the relationship with women receiving OST. This could influence how receptive this patient group would be to pharmacy RH interventions.

Conclusions

CPs' concerns of providing RH service could hinder a proactive service provision. Supporting good rapport and providing a structured consultation would increase the accessibility of such a service.

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Reproductive health advice is triggered by social or physical cues from women.

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Provision of this advice is subject to the reflective thinking of the provider.

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A power imbalance characterizes supervised opioid substitution treatment.

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Good rapport and a structured consultation were seen to increase the accessibility.

Barriers and Enablers to Objective Testing for Asthma and COPD in Primary Care: A Systematic Review Using the Theoretical Domains Framework

BACKGROUND

Although guidelines have long recommended objective pulmonary function testing to diagnose asthma and chronic obstructive lung disease (COPD), many primary care patients receive a clinical diagnosis of asthma or COPD without objective testing. This often leads to unnecessary treatment with associated incremental costs and side-effects, and delays actual diagnosis.

RESEARCH QUESTION

What are the barriers and enablers to lung function testing for asthma and/or COPD in primary care?

STUDY DESIGN AND METHODS

We searched the literature for qualitative and quantitative studies reporting barriers and/or enablers to in-office or out-of-office lung function testing for diagnosing asthma and/or COPD, in primary care. Two reviewers independently screened abstracts and full texts; assessed methodological quality using the Mixed Methods Appraisal Tool; and extracted data from included studies. Identified barriers and enablers were categorized using the Theoretical Domains Framework (TDF), applying a pre-established coding manual.

RESULTS

We identified 7988 unique articles, reviewed 336 full-text articles, and included 18 studies in this systematic review. Of these 18, 12 were quantitative, 3 were qualitative, and 3 used mixed methods. All 18 addressed in-office testing and 11 also addressed out-of-office testing. Barriers and enablers overlapped for asthma and COPD, and in- and out-of-office settings. We identified more reported barriers (e.g. lack of knowledge of the usefulness of spirometry) than enablers (e.g. skills for performing reliable spirometry). Barriers mapped to 9 (of a possible 14) TDF domains (for both in- and out-of-office settings). Enablers mapped to three domains for in-office testing and five domains for out-of-office testing.

INTERPRETATION

Barriers to objective testing for airways disease in primary care are complex and span many theoretical domains. Correspondingly, a successful intervention must leverage multiple behaviour change techniques. A theory-based, multifaceted intervention to address underuse of diagnostic testing for asthma or COPD should now be developed and tested.

Using the Behaviour Change Wheel to design an intervention for partner abusive men in drug and alcohol treatment

Background

We aimed to establish what core elements were required in a group therapy programme for men who disclose perpetrating intimate partner abuse in a substance use setting and develop, and test the feasibility of delivering an intervention in this setting.

Methods

We describe the theoretical development and feasibility testing of an integrated substance use and intimate partner abuse intervention (‘ADVANCE’) for delivery in substance use services. We employed a comprehensive eight-stage process to guide this development applying the ‘COM-B’ (‘capability’, ‘opportunity’, ‘motivation’ and ‘behaviour’) model for intervention design which specifies the following: (1) define the problem, (2) select the target behaviour, (3) specify the target behaviour, (4) identify what needs to change, (5) identify intervention functions, (6) identify policy categories, (7) select behaviour change techniques, and (8) design a mode of delivery. The development was informed by primary research conducted by the authors, consulting with organisation steering groups and by those with personal experiences. The identified targets for intervention and mode and method of delivery were then refined over 4 intervention development meetings, using the nominal group technique with the ADVANCE experts, then further refined following consultation with service user groups and wider expert groups via a learning alliance meetings.

Results

Our final intervention, the ADVANCE intervention consisted of a group intervention comprising of up to four pre-group individual interviews, followed by 12 × 2-h group sessions supported by integrated safety work for victim/survivors, and risk and safety support and integrity support for the professionals. The main targets for change were personal goal planning, self-regulation, and attitudes and beliefs supporting intimate partner abuse. The intervention was regarded as very acceptable to both staff and clients in substance use services, with group attendees reported positive behaviour changes and development of new skills.

Conclusion

We have demonstrated the ability to employ a structured eight-step process to develop an integrated intervention to address substance use-related intimate partner abuse that is acceptable to staff and clients in substance use services. This led to a feasibility study (ISRCTN 79435190) involving 104 men and 30 staff at three different locations across the UK was conducted to assess the feasibility and acceptability of the intervention and to refine the content and approach to delivery (BMC Public Health, 21: 980, 2021).

Using the Consolidated Framework for Implementation Research to design and implement a perinatal education program in a large maternity hospital

BACKGROUND

Implementation science aims to embed evidence-based practice as 'usual care' using theoretical underpinnings to guide these processes. Conceptualising the complementary purpose and application of theoretical approaches through all stages of an implementation project is not well understood and is not routinely reported in implementation research, despite call for this. This paper presents the synthesis and a collective approach to application of a co-design model, a model for understanding need, theories of behaviour change with frameworks and tools to guide implementation and evaluation brought together with the Consolidated Framework for Implementation Research (CFIR).

METHOD

Using a determinant framework such as the CFIR provides a lens for understanding, influencing, and explaining the complex and multidimensional variables at play within a health service that contribute to planning for and delivering effective patient care. Complementary theories, models, frameworks, and tools support the research process by providing a theoretical and practical structure to understanding the local context and guiding successful local implementation.

RESULTS

This paper provides a rationale for conceptualising the multidimensional approach for implementation using the worked example of a pregnancy, birth, postnatal and early parenting education intervention for expectant and new parents at a large maternity hospital.

CONCLUSION

This multidimensional theoretical approach provides useful, practical guidance to health service researchers and clinicians to develop project specific rationale for their theoretical approach to implementation projects.

Learning From Consultations Conducted by Community Pharmacists in Northern Ireland for Nonprescription Sildenafil: A Qualitative Study Using the Theoretical Domains Framework

INTRODUCTION

Nonprescription sildenafil was introduced to the United Kingdom in 2018 as the first pharmacy service concerning sexual function, an important but often ignored factor for quality of life.

AIM

This study aimed to evaluate pharmacists' views on providing nonprescription sildenafil, their perceptions of the barriers and facilitators to provide this service and strategies to overcome potential barriers, using a theory-based approach.

METHODS

Community pharmacists were purposefully sampled in Northern Ireland, followed by snowball sampling. Face-to-face interviews were conducted between October 2019 and January 2020. The semi-structured interviews used a piloted topic guide based on the 14-domain Theoretical Domains Framework (TDF). All interviews were audio-recorded, transcribed verbatim and anonymized. Transcripts were analyzed deductively in NVivo 13, utilizing the TDF domains as coding categories. Within each domain, content analysis was utilized to identify barriers and facilitators.

MAIN OUTCOME MEASURE

Barriers and facilitators within the TDF domains for pharmacists to provide nonprescription sildenafil.

RESULTS

Ten pharmacists were interviewed to reach data saturation. Eight pharmacists had experience with dispensing nonprescription sildenafil. They valued nonprescription sildenafil as an additional service ("Social/professional role and identity"). Training, concise product guidelines, and private consultation areas were important facilitators ("Environmental context and resources"). The service required trusting clients ("Optimism"), with concerns about abuse and men not visiting their GP. From experience gained, pharmacists became more confident dealing with difficult situations such as patients being vague about their medical history or alcoholism or mental problems as causes for erectile disfunction (ED) ("Skills" and "Beliefs about capabilities"). Pharmacists considered lifestyle and medication causes of ED important but preferred to focus on safe supply. In general, pharmacists were satisfied with the perceived professional recognition, using their clinical knowledge or helping patients resume sexual relationships ("Beliefs about consequences").

CONCLUSION

Pharmacists welcomed nonprescription sildenafil to enhance their role as easily accessible healthcare providers for patients. Gordijn R, Teichert M, Nicolai MPJ, et al. Learning From Consultations Conducted by Community Pharmacists in Northern Ireland for Nonprescription Sildenafil: A Qualitative Study Using the Theoretical Domains Framework. Sex Med 2021;9:100440.

Advancing understanding of influences on cervical screening (non)-participation among younger and older women: A qualitative study using the theoretical domains framework and the COM-B model

BACKGROUND

Effective screening can prevent cervical cancer, but many women choose not to attend their screening tests.

OBJECTIVE

This study aimed to investigate behavioural influences on cervical screening participation using the Theoretical Domains Framework (TDF) and COM-B models of behaviour change.

DESIGN

A qualitative study and semistructured phone interviews were conducted with women invited for routine screening tests within the national cervical screening programme in Ireland.

SETTING AND PARTICIPANTS

Forty-eight women aged 25-65 years were recruited from the national screening register.

RESULTS

Seven core themes were identified that mapped to three COM-B components and 11 TDF domains: (1) knowledge of cervical cancer and screening, (2) coping with smear tests, (3) competing motivational processes-automatic and reflective, (4) cognitive resources, (5) role of social support, (6) environmental influences and (7) perceputal and practical influences. A range of knowledge about screening, perceived risk of cervical cancer and human papillomavirus infection was evident. Factors that influenced screening behaviours may be hierarchical-some were assigned greater importance than others. Positive screening behaviours were linked to autonomous motivation. Deficits in physical and psychological capability (inadequate coping skills) were barriers to screening, while physical and social opportunity (e.g. healthcare professional 'champions') could facilitate participation. Older women raised age-related issues (e.g. screening no longer necessary) and had more negative attitudes to screening, while younger women identified practical barriers.

CONCLUSIONS

This study provides insight into screening participation and will aid development of theoretically informed interventions to increase uptake.

PATIENT OR PUBLIC CONTRIBUTION

Women invited for screening tests through the national screening programme were interviewed. A Public & Patient Involvement (PPI) Panel, established to provide input into all CERVIVA research projects, advised the research team on recruitment materials and were given the opportunity to review and comment on the interview topic guide. This panel is made up of six women with various cervical screening histories and experiences.

What the guide does not tell you: reflections on and lessons learned from applying the COM-B behavior model for designing real life interventions

Substantial inconsistency exists in the effectiveness of existing interventions to improve heart failure (HF) self-care, which can be partially explained by the fact that self-management interventions often lack theoretical models that underpin intervention development. The COM-B behavior model is a comprehensive theoretical framework that can be used to develop effective, theory-based interventions. The aim of this article is to highlight the challenges and practical solutions when applying the COM-B model to HF self-care, in order to provide useful support for researchers intending to use the model for designing behavior change interventions. "The Behaviour Change Wheel" handbook provides a step-by-step guide to understand and change behavior. When following the guide, some practical and methodological challenges were encountered. Lessons learnt to overcome these challenges are reported. Although the handbook is a comprehensive guide for designing behavior change interventions, a number of challenges arose. For example, the descriptions provided in the guide were not always sufficient to make solid judgments on how to categorize determinants; narrowing down intervention possibilities to a manageable number and prioritizing potential behavior change techniques over others involved a certain amount of subjectivity in an otherwise highly systematic and structured approach. For the encountered challenges, solutions are provided to illustrate how the model was applied practically to design theory-based behavior change interventions. This article provides a useful reference for researchers' use of the COM-B behavior model, as it outlines challenges that may occur and potential solutions to overcome them.

Implementation of evidence-based PCOS lifestyle management guidelines: Perceived barriers and facilitators by consumers using the Theoretical Domains Framework and COM-B Model

BACKGROUND

The 2018 Evidence-Based Polycystic Ovary Syndrome (PCOS) Clinical Guidelines recommend lifestyle management as first-line treatment for PCOS, yet implementation of PCOS lifestyle programs into practice is not well understood.

OBJECTIVE

To complete systematic intervention mapping by identifying the facilitators and barriers to lifestyle management in women with PCOS using the theoretical domains framework (TDF) and the Capacity, Opportunity, Motivation and Behaviour model (COM-B).

PATIENT INVOLVEMENT

Women (N = 20) in Australian with PCOS were interviewed.

METHODS

Telephone semi-structured interviews.

RESULTS

Nine themes mapped onto seven TDF domains and the COM-B. Capability: psychological co-morbidities, knowledge and awareness of lifestyle change and ability to identify and resolve barriers. Opportunity: presence of other medical conditions, access to practical resources and availability of social support.

MOTIVATION

outcomes expectancies of lifestyle behaviour, personal values, enjoyment and readiness to change and the impact of stress on lifestyle choices.

DISCUSSION

This is the first study to explore barriers and facilitators to lifestyle change from the perspectives of women with PCOS using the TDF and COM-B. Addressing these themes will facilitate patient-centred care and long-term behaviour change.

PRACTICAL IMPLICATIONS

May increase the efficacy and effectiveness of PCOS lifestyle programs and reduce the risk of PCOS-associated disease in this population.