Background
Methods
Sampling and recruitment
Semi-structured interviews
Data analysis
Identification of key theoretical domains
Triangulation
Identification and selection of BCTs
Results
Participants
General practicesa (n = 9) | Community pharmacies (n = 15) | |
---|---|---|
Participant gender | ||
Male | 10 | 7 |
Female | 5 | 8 |
Years of professional experience (range) | 3–27 | 3–32 |
Healthcare trust area | ||
1 | 4 | 4 |
2 | 1 | 2 |
3 | 3 | 3 |
4 | 3 | 2 |
5 | 4 | 4 |
Summary of findings from analysis at the level of theoretical domains
“…experience is the thing that teaches you the most because it’s the thing that you tend to remember…” PCT2“I think the confidence comes from experience.” GP2
“…ultimately the buck stops with me.” GP2“I know it’s easier to just go, ‘Oh should I just give it out or whatever’, but… you’re the one giving it out, I think you do have responsibility to, if you think something’s not appropriate, to double check.” PCT1
“…it's possible that things are overlooked in a busy day to day practice.” GP9“If somebody comes in about four other things, and you’ve got 10 minutes to see them in– it probably becomes, honestly probably becomes less of a priority… I think it’s not a fixed priority.” GP14“…there's no money involved in addressing polypharmacy, you know, you could be completely cynical and turn round and go, ‘This patient gets 12 items, I get paid 98p for each item I dispense. Why do I want to go out and tell this man he only needs seven of them?’” PCT2
“…pharmacists seem to be very well clued into it all already, you know, and I think they’re probably going to be main kind of stakeholders as well in reducing polypharmacy…” GP4“…it doesn’t necessarily have to be a doctor doing it, and em, I think sometimes the pharmacists look at things in a different way than we do… it’s a different kind of focus you have on things…” GP14“I think very often GPs eh or GP surgeries don’t often, value the intervention, interaction and, that is frustrating, continues to be frustrating, and I don’t see any improvement in it in the last 25 years of working. Don’t see any improvement in it at all, in fact I would say quite probably the reverse…” PCT10
“…there are few GPs who will challenge the recommendations of a specialist and if they say, ‘Add in this, add in that’, they will often get added.” GP11
“I mean another barrier I suppose is sometimes due to the receptionists in surgeries as well. Getting them to buy into the fact that clinical decisions should be taken between healthcare professionals, like pharmacists, nurses, doctors and not taken by receptionists which I find is happening a lot.” PCT15
“…the barriers that come up to us for polypharmacy is, em, a lot of it is created from our prescribing advisors, to try and get us to get patients off, you know, medications and switch to other appropriate medications.” GP2
“There might be evidence for each individual drug but, you know, I don’t think there’s– there’s no randomised controlled trials on, you know, what all those drugs in combination do and, you know, there aren’t going to be.” GP1“Guidelines tend to be very disease-specific but how do you do something? How do you prescribe for somebody who has comorbidities and the guideline would seem to be talking against each other, and so we need the– where is the evidence base for telling people to do then?” GP8
“…it’s a mountain of work and the reason why it’s not being done is because it’s not being resourced and there’s no money to do it.” GP11
“....quite often the computer's flagging up ones that there isn't really an interaction.” PCT5“…sometimes what’s in the BNF is not really enough. It does not match having a detailed past experience of prescribing something.” GP 1
Identification of key domains
Mapping of theoretical domains to BCTs
Domain | BCTs identified from Cane et al. 2015 [16] | Additional BCTs identified from mapping matrix [15] | Selected BCTs as proposed intervention components (including reasons to justify exclusion of other BCTs) |
---|---|---|---|
Skills | 1. Graded tasks 2. Behavioural rehearsal/practice 3. Habit reversal 4. Body changes 5. Habit formation | 6. Goal/target specified: behaviour or outcome 7. Monitoring 8. Self-monitoring 9. Rewards; incentives (inc Self-evaluation) 10. Graded task: start with easy tasks 11. Increasing skills: problem solving, decision making, goal setting 12. Rehearsal of relevant skills 13. Modelling/demonstration of behaviour by others 14. Homework 15. Perform behaviour in different settings | Modelling/demonstration of behaviour by others (BCT 13): HCPs would be provided with a demonstration of how to prescribe/dispense appropriate polypharmacy during a typical encounter/consultation with an older patient. |
Reasons for not selecting other BCTs | |||
BCTs 1, 2, 3, 5, 7, 8, 10, 12, 14: likely to require repeated administration and/or extended time periods to effect required changes in target behaviours. | |||
BCT 4: not applicable as a direct change to HCPs’ body structure/functioning is unlikely to have an impact on the target behaviours (i.e. prescribing/dispensing of appropriate polypharmacy). | |||
BCT 6: not possible to establish an acceptable goal/target in terms of the number of older patients that HCPs would perform target behaviours on because ideally the target behaviours should be performed on all older patients. | |||
BCT 9: not within scope of project to offer rewards/incentives and a general practice-based incentive scheme already exists in UK (i.e. the Quality and Oucomes Framework). | |||
BCT 11: intervention would likely need to be tailored to individual HCPs to account for baseline variation in skill levels. | |||
BCT 15: not applicable as the intervention will target HCPs in their normal place of work (i.e. general practice, community pharmacy) and the intervention will focus on the prescribing/dispensing of appropriate polypharmacy to community dwelling older patients as opposed to patients in other settings (e.g. nursing homes) whose clinical complexity and context is likely to be very different. | |||
Beliefs about capabilities | 1. Verbal persuasion to boost self-efficacy 2. Focus on past success | 3. Self-monitoring 4. Graded task: start with easy tasks 5. Increasing skills: problem solving, decision making, goal setting 6. Coping skills 7. Rehearsal of relevant skills 8. Social processes of encouragement, pressure, support 9. Modelling/demonstration of behaviour by others 10. Homework 11. Perform behaviour in different settings | Social processes of encouragement, pressure, support (BCT 8): mapped to ‘Social/professional role and identity’ and ‘Social influences' – see below. |
Modelling/demonstration of behaviour by others (BCT 9): outlined above – see ‘Skills’ domain. | |||
Reasons for not selecting other BCTs | |||
BCTs 3, 4, 10: likely to require repeated administration and/or extended time periods to effect required changes in target behaviours. | |||
BCT 1: intervention would likely need to be tailored to individual HCPs to account for baseline variation in self-efficacy levels. | |||
BCT 2: not suitable due to potential variation in experience amongst HCPs (i.e. if HCPs do not have previous experience of performing the target behaviours then this BCT will not apply to them). | |||
BCTs 5, 6, 7: intervention would likely need to be tailored to individual HCPs to account for baseline variation in skill levels. | |||
BCT 11: not applicable as the intervention will target HCPs in their normal place of work (i.e. general practice, community pharmacy) and the intervention will focus on the prescribing/dispensing of appropriate polypharmacy to community dwelling older patients as opposed to patients in other settings (e.g. nursing homes) whose clinical complexity and context is likely to be very different. | |||
Beliefs about consequences | 1. Emotional consequences 2. Salience of consequences 3. Covert sensitization 4. Anticipated regret 5. Social and environmental consequences 6. Comparative imagining of future outcomes 7. Vicarious reinforcement 8. Threat 9. Pros and cons 10. Covert conditioning | 11. Self-monitoring 12. Persuasive communication 13. Information regarding behaviour,outcome 14. Feedback | Information regarding behaviour, outcome/salience of consequences (BCTs 2 and 13 - equivalent): as part of the demonstration of how to prescribe/dispense appropriate polypharmacy during a typical encounter/consultation with an older patient, positive feedback would be included from the HCPs and patients to emphasise the positive consequences of performing the behaviour. |
Reasons for not selecting other BCTs | |||
BCTs 7, 10, 11, 14: likely to require repeated administration and/or extended time periods to effect required changes in target behaviours. | |||
BCT 1: emotional consequences of performing the target behaviours have not been established. | |||
BCTs 3, 4: not applicable as intervention is focussed on wanted behaviours as opposed to unwanted behaviours. | |||
BCT 5: not applicable as HCPs were already aware of the consequences of performing the target behaviours. | |||
BCT 6: intervention would likely need to be tailored to individual HCPs as the imagining and comparing of future outcomes of changed versus unchanged behaviour is likely to vary between individuals. | |||
BCT 8: not within scope of project to implement future punishment or removal of reward as a consequence of HCPs performing an unwanted behaviour. | |||
BCT 9: intervention would likely need to be tailored to individual HCPs because if advised to identify and compare pros and cons of performing the target behaviours, assessments are likely to vary between individuals. | |||
BCT 12: difficult to have a credible source present evidence-based arguments in favour of the target behaviours as few interventions to date have examined clinically relevant outcomes (e.g. hospital admissions, ADEs) and where these outcomes have been evaluated, the findings have been inconsistent. | |||
Environmental context and resources | 1. Restructuring the physical environment 2. Discriminative (learned) cue 3. Prompts/cues 4. Restructuring the social environment 5. Avoidance/changing exposure to cues for the behaviour | 6. Environmental changes (e.g. objects to facilitate behaviour) | Prompts/cues (BCT 3): HCPs will be asked to arrange for support staff (e.g. receptionists, pharmacy technicians) to prompt them to check that older patients who meet specific criteria are prescribed/dispensed appropriate polypharmacy when patients present in the practice/pharmacy. |
Reasons for not selecting other BCTs | |||
BCT 1: not within scope of project to restructure HCPs’ physical work environment. | |||
BCTs 2: not within scope of project to offer reward (e.g. monetary fee) for performing target behaviour). | |||
BCT 4: not within scope of project to restructure HCPs’ social environment. | |||
BCT 5: not applicable as intervention is seeking to promote performance of target behaviours by HCPs as opposed to avoiding/reducing exposure to cues for the target behaviours. | |||
BCT 6: not within scope of project to restructure HCPs’ physical work environment. | |||
Memory, attention and decision processes | None | 1. Self-monitoring 2. Planning, implementation 3. Prompts, triggers, cues | Planning, implementation (BCT 2; equivalent to Action planning): HCPs would be asked to write an explicit plan of when and how they would ensure that patients meeting inclusion criteria are prescribed/dispensed appropriate polypharmacy. |
Prompts, triggers, cues (BCT 3): outlined under ‘Environmental context and resources’ domain. | |||
Reasons for not selecting other BCTs | |||
BCT 1: likely to require repeated administration and/or extended time periods to effect required changes in target behaviours. | |||
Social influences | 1. Social comparison 2. Social support or encouragement (general) 3. Information about others' approval 4. Social support (emotional) 5. Social support (practical) 6. Vicarious reinforcement 7. Restructuring the social environment 8. Modelling or demonstrating the behaviour 9. Identification of self as role model 10. Social reward | 11. Social processes of encouragement, pressure, support 12. Modelling/demonstration of behaviour by others | Social processes of encouragement, pressure, support/ Social support or encouragement (BCT 2, 11 - equivalent): Pharmacists would receive a list of pre-approved patients from the GP practice which would encourage/support them in engaging with patients to ensure that they are dispensed appropriate polypharmacy. |
Modelling /demonstration of behaviour by others/ Modelling or demonstrating the behaviour (BCT 8, 12 - equivalent): outlined above – see ‘Skills’ domain. | |||
Reasons for not selecting other BCTs | |||
BCTs 6, 9, 10: likely to require repeated administration and/or extended time periods to effect required changes in target behaviours. | |||
BCT 1: difficult to draw meaningful comparisons between HCPs’ performance of target behaviours. | |||
BCT 3: difficult to establish older patients’ views on HCPs performing target behaviours due to clinical heterogeneity amongst older patients who are receiving polypharmacy in terms of clinical conditions and medication types. | |||
BCTs 4, 5: encapsulated by BCT 2. | |||
BCT 7: not within scope of project to restructure HCPs’ social environment. | |||
Behavioural regulation | 1. Self-monitoring of behaviour | 2. Goal/target specified: behaviouror outcome 3. Contract 4. Planning, implementation 5. Prompts, triggers, cues 6. Use of imagery | Planning, implementation (BCT 4; equivalent to Action planning): see under ‘Memory, attention and decision processes’ domain above. |
Prompts, triggers, cues (BCT 5): see under ‘Environmental context and resources’ domain above. | |||
Reasons for not selecting other BCTs | |||
BCT 1: likely to require repeated administration and/or extended time periods to effect required changes in target behaviours. | |||
BCT 2: not possible to establish an acceptable goal/target in terms of the number of older patients that HCPs would perform target behaviours on because, ideally, the target behaviours should be performed on all older patients. | |||
BCT 3: not within scope of current project to impose additional contractual obligations on HCPs. | |||
BCT 6: used in the context of implementing other BCTs through the use of planned images (visual, motor, sensory); not applicable in the context of this research project. | |||
Social/professional role and identity | None | 1. Social processes of encouragement, pressure, support | Social processes of encouragement, pressure, support (BCT 1): see under ‘Social influences’ domain above. |
Nature of the behaviours | No BCTs were mapped to this domain because it was not included in the original BCT mapping matrix [15]. It was intended that this domain would be targeted indirectly using the selected BCTs that were mapped to the other seven key domains. |