Applying behavioural science theories and frameworks in ... · Applying behavioural science...
Transcript of Applying behavioural science theories and frameworks in ... · Applying behavioural science...
Applying behavioural science theories and frameworks in implementation science
Dr. Fabiana Lorencatto
Research Lead, UCL Centre for Behaviour Change, UK
4th BeSP Sypmosium
March 2020
@UCLBehaveChange@fabilorencatto
This talk
• Why behaviour change in implementation?
• Limitations typical approaches to implementation interventions
• Applying behavioural science• Frameworks and theories for systematic intervention design• Behaviour Change Wheel Approach
• Examples from healthcare context
Why behaviour change?
Implementation is challenging….
New intervention, practice, tool,
technology
Tell people about it
(e.g. guidelines, dissemination)
Uptake and implementation
The problem – evidence practice gaps:
• Despite training and guidelines, many do not always act in line with evidence-based recommendations
• Research• Netherlands: 30-40% of patients did not receive ‘evidence-based’ health care Grol et
al, 2001
• US: 20-25% received care that was unnecessary or even harmful Schuster et al, 2005
Implementation as behaviour change• Guidelines do not implement themselves!
• Implementation almost always requires someone to do act or do something differently
• E.g.
• These actions are all forms of human behaviour
Implementation as behaviour change • Implementation depends on changing behaviour of many different
types of people and roles at different levels in organisations, networks and systems
• Professionals, • support staff, • commissioners,• managers, • policy makers, • patients, etc.
Implementation interventions • ‘specific methods or techniques used to enhance the adoption, implementation, and
sustainability of a clinical program or practice’ (Proctor et al. 2013)
Many have achieved modest and
variable success
• Why?
• Often not approaching
implementation interventions
in terms of behaviour
change…
EPOC taxonomy
ISLAGIATT principle
It Seemed Like A Good Idea At
The Time
Prof. Martin Eccles, implementation researcher, UK
‘Hunches…Common sense’
lack rationale…
‘just educate’ ‘it worked elsewhere’‘guidelines’
Traditional approaches to designing interventions:
Sometimes ISLAGIATT works…more often it doesn’t….
Behavioural science• Disciplines dedicated to scientifically studying human behaviour:
• Offer theories, frameworks, methods for understanding what drives behaviour and how to use this to most effectively change it
Warning: no magic bullets or
universal truths
• Interrelated theories, frameworks and evidence-based principles
• Theoretical basis for linking barriers/facilitators to intervention strategies
• Guide decision making and facilitate systematic, step-by step, transparentand more effective approach to intervention design
• Policy makers, practitioners, researchers from different disciplines and levels of experience
Michie S, Van Stralen MM, West R. The behaviour change wheel: a new method for characterising
and designing behaviour change interventions. Implementation science. 2011 Dec;6(1):42.
Michie S, Atkins L, West R. The behaviour change wheel. A guide to designing
interventions. 1st ed. Great Britain: Silverback Publishing. 2014.
https://www.ucl.ac.uk/behaviour-change/files/bcw-summary.pdf
Behaviour Change Wheel approach
The Behaviour Change Wheel approach: key steps
What behaviour are you trying to change?
What will it take to bring about the desired change?
What types of broad intervention approaches
might be relevant?
What specifically components should my
intervention involve?
• Define ‘problem’ in behavioural terms• Map out system of behaviours• Who, needs to do what, when, where?
• ‘Behavioural Diagnosis’• Understand behaviour in context• Identify barriers/enablers to change
• Consider range of intervention strategies• Match choice to behavioural diagnosis
Step 1: Defining the problem in behavioural terms
• Tendency to think in terms of outcomes
• ‘reduce infection rates’ or ‘improve infection control’ ≠ a behaviour
• Product of numerous discrete behaviours
Hand-washing
Effective use of protective
clothing
Cleaning surfaces
Appropriate prescribing of treatments for infections
Antibiotic prescribingIdentifying and
diagnosing suspected infections
Communicating/
documenting/ escalating
Prescribing antibiotic + decision around dose, route, administration
Timely review of
antibiotic prescription
Stop/ de-escalate
Performed by:
• Multiple actors (care assistants, nurses, doctors, patients, family members)
• At different time points in care pathway
• In different settings
• Vary by type of patient and/or type of infection
Why does this matter?
• Influences will vary across different:• Behaviours, actors, settings, time, contexts
• Start by mapping out system• Do not need to intervene on full system! Focus on one aspect • Consider:
• Impact• Likelihood of change• Spillover
And therefore so might the type of intervention(s)
needed
Be specific: AACTT principle:• Asks: precisely who would do what, differently, to whom, when and where
that would lead to improved outcome?
Actor- who?
Action – needs to do what?
Context- where?
Timeframe- when?
Target- to whom?
Presseau J, McCleary N, Lorencatto F, Patey, A, Grimshaw J, & Francis JJ. (2019). Action, Actor, Context, Target, Time (AACTT): A framework for specifying behaviour. Implementation Sci
‘hand hygiene in hosptials’
Duncan et al. "A behavioural approach to specifying interventions: what insights can be gained for the reporting and implementation of interventions to reduce antibiotic use in hospitals?." Journal of Antimicrobial Chemotherapy (2020).
A (more!) behaviourally specific example:
Nurses (who) in intensive care (where)
should clean there hands with alcohol rub
(what) before and after (when) physical
contact with patients (whom) (Sun et al 2011)
Step 2. Understand the behaviour in context (‘Behavioural diagnosis’)
• Why are behaviours as they are?
• What would it take to implement?
• What would facilitate? What would hinder?
• Clinical practice is a form of human behaviour…
• Answering these Qs helped by a theory of
behaviour change
Prof. Susan Michie
Many theories applied to implementation!
Nilsen P. Making sense of implementation theories, models and frameworks. Implementation science. 2015
Dec;10(1):53.
Michie SF, West R, Campbell R, Brown J, Gainforth H. ABC of behaviour change theories. Silverback Publishing; 2014.
The COM-B system: Behaviour occurs as an interaction between three necessary conditions
Michie et al (2011) Implementation Science
Psychological AND Physical ability to enact the behavior Knowledge, Memory attention decision making, physical and social skills
Reflective AND Automatic mechanisms that activate or inhibit the behaviourIntentions, Goals, Perceived relevance, identity, Beliefs about consequences, Self-confidence, Rewards, incentives, sanctions, Emotions
Physical AND Social environmental factors that enables or inhibits the behaviourAccess, layout, resources, prompts, cuesSocial influences (pressure, support)
Theoretical Domains Framework
1. Knowledge2. Skills3. Memory, Attention, Decision
Making 4. Behavioural regulation
5. Social Influences6. Environmental context and resources
7. Emotions8. Social professional role and identity9. Goals10. Beliefs about consequences11. Reinforcement 12. Beliefs about capabilities13. Intentions14. Optimism
Michie et al. 2005 BMJ Qual & SafetyCane et al 2012 Implementation Sci
Am I aware of what I need to do (guidelines/evidence)?
Appropriate skills/training?How do I decide to do X?
Do you ever forget to do X?
Is doing X part of my clinical role? What will happen if I do X? What if I
don’t do X?Is it a priority?
How confident am I? How worried/ concerned?
Do I have sufficient resources (time/ staff/ equipment) to do X?
Is doing X influenced by my peers, managers, other professional
groups, patients, relatives?
Behavioural Diagnosis:
• Complex behavior
• Complex set of interacting influences…
• …beyond knowledge
• Need to consider broad range of intervention strategies…
• …beyond education!
• Match choice of strategy based on behaviouraldiagnosis
How do we move from diagnosis to intervention?
Facilitated by using a framework:• To outline/define variety of options and aid selection
• Several such frameworks to date…• Review of 19 frameworks related to health promotion, environment, culture change, social marketing
etc• Including EPOC taxonomy implementation strategies
• Overlapping, none comprehensive• None linked to model of behaviour change• Different assumptions/emphasis around what drives behaviour (attitudes, unconscious biases, social
environment)
Michie et al (2011) Implementation Science.
• So developed a synthesis of the 19 frameworks
Use rules to reduce the opportunity to engage in the behaviour (or to increase behaviour by reducing opportunity to engage in competing behaviours)
Increase knowledge or understanding
Use communication to induce positive or negative feelings to
stimulate action
Create an expectation of reward
Create an expectation of punishment or cost
Impart skills
Increase means or reduce barriers to increase
capability (beyond education or training) or opportunity
(beyond environmental restructuring)
Provide an example for people to aspire to or emulate
Change the physical or social context
But how will you ‘educate,’ ‘enable,’ ‘restrict,’ ‘model…’?• Intervention functions are made up of component Behaviour change techniques (BCTs)
• ‘active ingredients’ (e.g. goal setting, feedback, action planning)
BCT Taxonomy v1: 93 BCTs in 16 groupings (Michie et al. 2013)
Matching intervention strategy to diagnosisTo change …. Consider one or more of ….
Education – Training (i.e. build knowledge and
skills)
Persuasion - Incentivisation - Coercion -
Modelling (i.e. increase motivation to engage
in target behaviour; reduce motivation
competing behaviours)
Restriction- Environmental Restructuring –
Enablement (i.e. to increase opportunity target
beh/ reduce competing behaviours)
Selecting relevant functions: mapping tools
Intervention functions
Education Persuasion Incentivisation Coercion Training Restriction Environmental restructuring
Modelling Enablement
Physical capability
Psychological capability
Physical opportunity
Social opportunity
Automatic motivation
Reflective motivation
Based on expert consensus
Which BCTs? Mapping matrices
Michie et al. 2014
Narrowing down the list: APEASE criteria
Affordability Can it be delivered within an acceptable budget?
Practicability Can it be delivered as designed and to scale?
Effectiveness/
cost-effectivenessHow well does it work and is it worth the cost?
Acceptability Is it judged appropriate to relevant stakeholders (policy makers,
practitioners, the public) and engaging for potential users?
Side-effects/safety Does it have unwanted side-effects or unintended consequences?
Equity Will it reduce or increase disparities in health/wellbeing/standard of
living?
Michie et al. 2014
An example of intervention design using BCW
Multimorbidity = presence of 2+ conditions
Affects 60% patients primary care
Few interventions to improve medication management
1. Define the problem in behavioural terms
2. Select target behaviour
3. Specify the target behaviour
4. Identify what needs to change
Identify:
5. Intervention functions
6. Policy categories
Identify:
7. Behaviour change techniques
8. Mode of delivery
Stage 3: Identify content and implementation options
Stage 2: Identify intervention options
Stage 1: Understand the behaviour
What data did they draw on?
• Published literature
o Available evidence and reviews of medication management in multimorbidity
o Synthesised in a systematic review
• Primary research
o Interviews with 20 GPs on their approaches to prescribing
o Case focused
o Further define problem + selection target
Impact: likely large. Needs to happen first
for other behaviours to occur. Expressed in
all interviews.
Likelihood of change: High based on
interview findings. Easy to measure.
Spillover: High. Promote improvements in
other prescribing activities
Who? GPs
What? Active, purposeful medication review instead of passive ‘maintaining the status quo’
When? [unclear]
Where? In routine general practice
How often? Regular intervals (according to guidelines)
With whom? Patients with multimorbidity
1. Define the problem in behavioural terms
2. Select target behaviour
3. Specify the target behaviour
4. Identify what needs to change
Identify:
5. Intervention functions
6. Policy categories
Identify:
7. Behaviour change techniques
8. Mode of delivery
Stage 3: Identify content and implementation options
Stage 2: Identify intervention options
Stage 1: Understand the behaviour
How did they identify what needs to change?
• Used the COM-B model to identify GPs’ Capabilities, Opportunities and Motivations for engaging, or not
engaging, in active medication review
o Synthesised barriers and facilitators from the literature and their interviews with GPs
1. Define the problem in behavioural terms
2. Select target behaviour
3. Specify the target behaviour
4. Identify what needs to change
Identify:
5. Intervention functions
6. Policy categories
Identify:
7. Behaviour change techniques
8. Mode of delivery
Stage 3: Identify content and implementation options
Stage 2: Identify intervention options
Stage 1: Understand the behaviour
• Uncertain which medications were the most effective in the
presence of other conditions (psychological capability)
• GPs’ sense of isolation in the management of multimorbid patients(social opportunity)
• Lack of time to review medication during the consultation (physical opportunity)
• Automatically print off prescriptions, reviewing is not routine. Habit of ‘not rocking the boat’ (automatic motivation)
• Perception there are more important things to do in a consultation than review medications (reflective motivation)
1. Define the problem in behavioural terms
2. Select target behaviour
3. Specify the target behaviour
4. Identify what needs to change
Identify:
5. Intervention functions
6. Policy categories
Identify:
7. Behaviour change techniques
8. Mode of delivery
Stage 3: Identify content and implementation options
Stage 2: Identify intervention options
Stage 1: Understand the behaviour
How did they select which intervention functions?
1. Used the COM-B / intervention function matrix to identify potential
intervention functions– All intervention functions were potentially relevant
2. Used the APEASE criteria to select the most appropriate
intervention functions
1. Define the problem in behavioural terms
2. Select target behaviour
3. Specify the target behaviour
4. Identify what needs to change
Identify:
5. Intervention functions
6. Policy categories
Identify:
7. Behaviour change techniques
8. Mode of delivery
Stage 3: Identify content and implementation options
Stage 2: Identify intervention options
Stage 1: Understand the behaviour
How did they select which behaviour change techniques?
1. Drew up a long list from BCTTv1 of the most frequently used BCTs linked to enablement, incentives
and environmental restructuring. This resulted in 32 BCTs.
2. Expert panel rated each according to the APEASE criteria + in light of behavioural diagnosis
findings.
3. Selected 5 BCTs to include in intervention + panel agreed how to operationalize BCTS
End to end development reported in the paper
COM-B component
Barrier Intervention function/ technique
Example
CAPABILITY ‘uncertainty about what medications were most effective in the presence of other conditions’
‘professional isolation’
• F: Enablement• BCT: Social support (practical)• Action planning
Two GPs support each other to review medication (Social support practical)
GPs choose a day/time/office that suits them best and decide how many patient cases to review in one sitting (Action planning)
OPPORTUNITY ‘insufficient consultation time to review medications’
• F: Environmental restructuring• BCTs: Restructuring social
environment• prompts/cues
Agree on a policy of protected time to review medication (~1 hr p/week)
Use a standardised checklist of questions to cue the review
MOTIVATION ‘more important things to do’
• F: Incentives • BCT: self-incentives
GPs award themselves continuing professional development points: one point for each cumulative hour
Systematic, transparent, step-wise-approach for choice of intervention strategy
Australia• Management for Borderline
Gestational Diabetes Mellitus• Reduce hip/knee surgery in
osteoarthritis
Ghana• Reduce risk of infection in
changing toilet cartridges in slums
India• Smartphone app to reduce
cardiovascular disease risk
International Red Cross• Train volunteers
Kenya• Improve paediatric health care
Kosovo• Improve maternal health
guideline implementationNetherlands• An organisational
intervention tool
Papua New Guinea
• Change Betel nut chewing behaviour
Thailand• Preventing melioidosis
USA• Improving colorectal cancer
screening • Providing long-acting
reversible contraception to adolescents
• Improve parenting practices for children with challenging behaviour
International applications of the BCW
Summary and recommendations Implementation in healthcare requires behaviour change- but this is rarely considered when designing implementation interventions
Where possible, avoid ‘rushing’ to intervention and ISLIGIATT
Behavioural science has tools and theoretical frameworks to facilitate
Be specific about what (and who/where/when/whom) you wish to change.
Ask why would people change? What is driving behaviour?
Look beyond education: consider full range of intervention strategies and match to behavioural diagnosis
Be transparent and systematic: to maximise cumulative learning and aid implementation
Thank you for listening!
@UCLBehaveChange
@Fabilorencatto
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