Background
Methods
A method for developing implementation interventions to change clinical behaviour
Step | Tasks |
---|---|
STEP 1: Who needs to do what, differently? | · Identify the evidence-practice gap · Specify the behaviour change needed to reduce the evidence-practice gap · Specify the health professional group whose behaviour needs changing |
STEP 2: Using a theoretical framework, which barriers and enablers need to be addressed? | · From the literature, and experience of the development team, select which theory(ies), or theoretical framework(s), are likely to inform the pathways of change · Use the chosen theory(ies), or framework, to identify the pathway(s) of change and the possible barriers and enablers to that pathway · Use qualitative and/or quantitative methods to identify barriers and enablers to behaviour change |
STEP 3: Which intervention components (behaviour change techniques and mode(s) of delivery) could overcome the modifiable barriers and enhance the enablers? | · Use the chosen theory, or framework, to identify potential behaviour change techniques to overcome the barriers and enhance the enablers · Identify evidence to inform the selection of potential behaviour change techniques and modes of delivery · Identify what is likely to be feasible, locally relevant, and acceptable and combine identified components into an acceptable intervention that can be delivered |
STEP 4: How can behaviour change be measured and understood? | · Identify mediators of change to investigate the proposed pathways of change · Select appropriate outcome measures · Determine feasibility of outcomes to be measured |
Results
Using a theoretical framework, which barriers and enablers need to be addressed? (Step 2) | Within which theoretical domains do the barriers and enablers operate? | Which intervention components (behaviour change techniques and mode(s) of delivery) could overcome the modifiable barriers and enhance the enablers? (Technique; mode; content*) (Step 3) |
---|---|---|
Low awareness of the meanings and actions associated with the guideline’s key messages; low awareness of LBP red flags and skills in how to identify them | Knowledge (GP) |
Technique: Information provision |
Mode: Facilitated workshop; GP opinion leader led; DVD | ||
Content:
· GP opinion leader/content expert [29] presents information about the guideline key messages. Algorithm provided for diagnosis of red flags. | ||
GPs’ perceptions of patients’ expectations and of patients’ beliefs about consequences | Knowledge (patient) |
Technique: Information provision (directed at patient) |
Mode: Patient handout [32] | ||
Content: Handout contains lay language about key messages from the guideline [33]; GPs encouraged to give patients with acute LBP the handouts to reinforce verbal advice | ||
Attitudes towards managing patients without x-ray, based on perceived consequences of the behaviour, e.g. fear of missing underlying pathology and belief that patient will feel reassured with an x-ray | 1. Beliefs about consequences 2. Knowledge (GP) |
Techniques: Information provision; Persuasive communication |
Mode: Facilitated workshop; DVD | ||
Content:
· Highly respected senior clinician presents persuasive message about harms (harmful amounts of unnecessary radiation) and limited benefits (poor diagnostic utility) of x-ray for LBP · GPs provide examples of when important underlying pathology was missed due to absence of x-ray of LBP episode, giving opportunity for expert to discuss this case and demonstrate that x-ray wasn’t required. | ||
Beliefs about negative consequences and beliefs about positive consequences of practising in a manner consistent with the guideline’s key messages | Beliefs about consequences |
Techniques: Monitoring of consequences of own behaviour; Barrier identification; Persuasive communication |
Mode: Pre-workshop activity; facilitated workshop; DVD | ||
Content:
· GPs record number of times they ordered plain x-ray and it didn’t change patient management, i.e. x-ray unnecessary. Highly respected senior clinician presents persuasive message about consequences of behaving in a manner consistent with the key messages. | ||
Skills and beliefs about capabilities related to guideline key messages | 1. Skills 2. Knowledge (GP) 3. Beliefs about capabilities |
Techniques: Barrier identification; Model/demonstrate the behaviour; Rehearsal |
Mode: Facilitated workshop; DVD | ||
Content:
· Participants write down wording of their last or usual message to stay active and then discuss in small groups. In pairs, with one GP role playing a patient with pre-prepared patient vignette, GP to create a script and role play with feedback from facilitator. | ||
Perceived need to give the patient something to replace x-ray | Skills |
Techniques: Provide instruction and modelling to increase a competing behaviour |
Mode: Facilitated workshop; DVD | ||
Content: Instruct, model/role-play and create a script to facilitate the competing behaviour of prescribing an activity log for patients (rather than giving x-ray referral). | ||
Limited time to explain why patient does not need an x-ray and explain advice to stay active | Environmental context |
Techniques: Information provision; Model/demonstrate the behaviour by a peer expert |
Mode: Facilitated workshop; DVD | ||
Content: use of handouts (patient handout [32] and activity log) to save time in consultation, and demonstration by a peer expert of how to incorporate into standard consultation. | ||
Beliefs about the role of the GP when managing acute low back pain | Professional role and identity |
Techniques: Persuasive communication; Provide opportunities for social comparison |
Mode: Facilitated workshop; DVD | ||
Content:
· Highly respected senior clinician presents persuasive message about the role of the GP to minimise harm (from unnecessary irradiation from plain x-ray) and in encouraging patients to stay active. · Small group work discussion to allow opportunity for discussion of behaviours among peers. | ||
Skills and beliefs about capabilities related to negotiating with/reassuring patients that plain x-ray is unnecessary | 1. Skills 2. Beliefs about capabilities (in reassuring the patient that an x-ray isn’t helpful) |
Technique: Rehearsal (prompt practice) |
Mode: Facilitated workshop | ||
GPs forget to give advice to stay active in standard consultation | Memory |
Technique: Model/demonstrate the behaviour by a peer expert |
Mode: Facilitated workshop; DVD | ||
Content: Peer expert goes through 10 step management plan as a prompt for remembering CPG target behaviours | ||
GPs’ perception that other people/organisations expectx-rays e.g., third party payors, radiologists | Social influences |
Techniques: Information provision; Persuasive communication |
Mode: Facilitated workshop; DVD | ||
Content: Peer expert to discuss content of guideline and highlight organisations that endorse it. |
What to measure | Measures |
---|---|
Mediating mechanisms of behaviour change | · Constructs theorised to be mediators of behaviour change (measured by practitioner survey) |
Practitioner outcomes | · X-ray referral rates (measured by patient file audit) · Patient given advice to stay active (measured via patient survey) |
Patient health outcomes | · Low back pain outcome measures (pain and disability measured via patient interview) |