'Demystifying Knowledge Transfer- an introduction to Implementation Science Master Class (Newcastle 28 May 2014)

Collaborating for Better Care
Partnership
Master Class: ‘Demystifying Knowledge Transfer’:
Implementing Evidence Based Guidance
An introduction to Implementation Science
28th May 2014
International Centre for Life
@AHSN_NENC
@JPresseau

Welcome and Introduction
Professor Paula Whitty
Director of NEQOS & Acting NENC AHSN
Knowledge & Information Programme lead

Programme
10.10 Session 1: Implementing evidence based guidance
11.00 Session 2: Case studies (working in pairs-followed by group feedback)
11.30 Coffee & biscuits
11.45 Session 3a: Behavioural approaches to implementing evidence based guidance
Identifying barriers and modifiable determinants
12.15 Sessions 3b: Identifying barriers and modifiable determinants of implementation
Neighbour discussion (15 mins) plus some feedback time (15 mins).
Jeremy/Justin barrier assessment in case studies
13.15 Lunch
14.00 Session 4: Behavioural approaches to implementing evidence based guidance
Designing implementation programmes (Justin and Jeremy)
Case studies
Neighbour discussion (15 mins) plus some feedback time (15 mins)
15.15 Coffee
15.30 Session 5: Implementation design in case studies (Justin and Jeremy)
16.00 Summary, conclusions and group discussion - Jeremy
16.20 Concluding remarks - Paula/Jackie
16.30 Close

Session 1: Implementing
Evidence Based Guidance
Prof Jeremy Grimshaw
Dr Justin Presseau

Session 1
Core concepts
Knowledge creation funnel

Background
‘All breakthrough, no follow through’
Woolf (2006) Washington Post op ed
Much of the US $100 billion/year worldwide
investment in biomedical and health research is
wasted because of dissemination and
implementation failures

Background
Institute of Medicine; Clinical Research Roundtable,
Sung et al. JAMA 289:1278,2003

Background
Why do we need to think about implementation?
• Consistent evidence of failure to translate
research findings into clinical practice
– 30-40% patients do not get treatments of proven
effectiveness
– 20–25% patients get care that is not needed or
potentially harmful
Schuster, McGlynn, Brook (1998). Milbank Memorial Quarterly
Grol R (2001). Med Care
• Suggests that implementation of evidence based care is
fundamental challenge for healthcare systems to optimise
care, outcomes and costs

How do healthcare
organisations currently address
quality challenges?

Internal solutions
ISLAGIATT
principle
Martin P Eccles
‘It Seemed
Like A Good
Idea At The
Time’

Designing interventions
If you have a
hammer,
everything
looks like nail

Throw everything at the problem!
1628466356N =
Absolute effect size
Number of interventions in treatment group
>44321
80%
60%
40%
20%
0%
-20%
-40%
-60%
-80%
Grimshaw et al
(2004) Health
Technology
Assessment

To date, many organisational responses to poor
implementation have failed to achieve optimal
care despite considerable investments
Most approaches to changing clinical practice are
more often based on beliefs than on scientific
evidence
‘Evidence based medicine should be complemented
by evidence based implementation’
Grol (1997). British Medical Journal

Could we do better?
Undoubtedly

Implementing evidence based
practices
• Implementation is about ensuring that
stakeholders are aware of and use research
evidence to inform their decision making and
actions to improve processes and outcomes of
care

practices
• Successful implementation depends upon:
– Internal knowledge (eg performance data, tacit knowledge
of how organisation (and individuals) work)
– External knowledge (eg clinical and implementation
science)
– Behaviour and organisational change expertise

practices
Quality by any means
necessary suggests
need to use all tools
and levers at your
disposal

Implementation Science
• Implementation is a human enterprise that can
be studied to understand and improve
implementation approaches
• Implementation science is the scientific study of
the determinants, processes and outcomes of
implementation.
• Goal is to develop a generalisable empirical and
theoretical basis to optimise implementation
activities

applied health research
capacity building
co-optation - cooperation - competing
diffusion*
dissemination*
getting knowledge into practice
impact
Implementation*
knowledge communication
knowledge cycle
knowledge exchange
knowledge management
knowledge translation
knowledge mobilization
knowledge transfer
linkage and exchange
popularization of research,
research into practice
research mediation
research transfer
research translation
science communication
teaching
“third mission”
translational research
transmission
utilization
*cited most frequently

Implementation science
• Implementation science is a research relatively new field in
health research
• Inherently interdisciplinary
• Wide range of disciplines need to be engaged
– Clinical
– Health services research
– Social sciences
– Design and engineering
– Informatics
– Methodologists
• Broad range of forms of enquiry needed

Implementation science
• Knowledge synthesis (what care should we be providing, what do we
know about the effectiveness of different implementation approaches);
• Research into the evolution of and critical discourse around research
evidence;
• Research into knowledge retrieval, evaluation and knowledge
management infrastructure
• Identification of implementation failures;
• Development of methods to assess barriers and facilitators to
implementation;
• Development of the methods for optimising implementation programs;
• Evaluations of the effectiveness and efficiency of implementation
programs;
• Sustainability and scalability of implementation programs;
• Development of implementation science theory; and
• Development of implementation science research methods.

Knowledge to action cycle
Knowledge to
action cycle
Graham et al (2006).
Lost in Knowledge
Translation. Time for
a Map? Journal of
Continuing Education
for Health
Professionals

Potential barriers to evidence based practice –
knowledge management
• Over 20,000 health journals published per year
– Average time professionals have available to read = <1 hour/week
• Published research of variable quality and relevance
– Research users (consumers, health care professionals, policy makers,
researchers) often poorly trained in critical appraisal skills
• Individual studies rarely by themselves provide sufficient
evidence for policy or practice changes
– Individual studies are often misleading

Don’t believe the hype: early highly
positive results often contradicted

• Analyzed 115 articles published in 1990-2003
in the 3 major general medical journals (NEJM,
JAMA, Lancet) and specialty journals that had
received over 1000 citations each by August
2004
• 49 reported evaluations of health care
interventions; 45 claimed that the
interventions were effective.
• By 2004 5/6 non randomised studies and 9/39
randomised trials were already contradicted
or found to be exaggerated
Don’t believe the hype: early highly
positive results often contradicted
Ioannidis JP. JAMA 2005

• AHSC release average of 49 press releases annually
• 44% promoted animal or laboratory research
– 74% of these explicitly claimed relevance to human health.
• 47.5% were about primary human research
– 23% omitted study size
– 34% failed to quantify results
– 17% promoted studies with the strongest designs (randomized trials or
meta-analyses)
– 40% reported results of weak designs (uncontrolled studies, small
samples (30 participants), surrogate primary outcomes, or unpublished
data) but 58% lacked relevant caution
Don’t generate the hype

Systematic reviews are a generic methodology
used to synthesise evidence from a broad range
of research methods addressing different
questions

The steps involved in undertaking a systematic review include
– stating the objectives of the research
– defining eligibility criteria for studies to be included
– identifying (all) potentially eligible studies
– applying eligibility criteria
– assembling the most complete dataset feasible
– analysing this dataset, using statistical synthesis and
sensitivity analyses, if appropriate and possible
– preparing a structured report of the research.

Systematic reviews are a generic methodology used
to synthesise evidence from a broad range of
research methods addressing different questions
– Effectiveness of health care interventions
– Diagnostic and screening tests
– Determinants of health
– Aetiological epidemiological studies
– Genetic epidemiological studies
– Health system issues (eg quality of discharge coding)
– Qualitative methods – consumers’ experiences of
health care

Clarke MJ, Hopewell S, Juszczak E, Eisinga A, Kjeldstrøm M. Compression
stockings for preventing deep vein thrombosis in airline passengers. Cochrane
Database of Systematic Reviews 2006, Issue 2. Art. No.: CD004002.

Cochrane Effective Practice and
Organisation of Care (EPOC) Group
• Cochrane Effective Practice and Organisation of
Care (EPOC) group undertakes systematic reviews
of interventions to improve health care systems
and health care delivery including:
– Professional interventions (e.g. continuing
medical education, audit and feedback)
– Financial interventions (e.g. professional
incentives)
– Organisational interventions (e.g. the expanded
role of pharmacists)
– Regulatory interventions

EPOC Progress to date
• 96 reviews, 1 overview, 36 protocols
• Professional interventions
– Audit and feedback: effects on professional practice and health care
outcomes
– The effects of on-screen, point of care computer reminders on
processes and outcomes of care
• Organisational interventions
– The effectiveness of strategies to change organisational culture to
improve healthcare performance
– Lay health workers in primary and community health care for
maternal and child health and the management of infectious diseases

EPOC Progress to date
• Financial interventions
– The impact of user fees on access to health services in low- and
middle-income countries
– Capitation, salary, fee-for-service and mixed systems of payment:
effects on the behaviour of primary care physicians
• Regulatory interventions
– Effects of changes in the pre-licensure education of health workers on
health-worker supply
– Pharmaceutical policies: effects of cap and co-payment on rational
drug use

Intervention # of trials Median absolute
effect
Interquartile
range
Audit and feedback
(Ivers 2011)
140 +4.3% +0.5% - +16%
Educational meetings
(Forsetlund 2009)
81 +6% +3 – +15%
Financial incentives
(Scott 2011)
3 NA NA
Hand hygiene
(Gould 2010)
1 NA NA

Factors influencing effectiveness of
audit and feedback
Ivers N et al. Audit and feedback: effects on
professional practice and health care outcomes.
Cochrane Library 2012
– Larger effects were seen if:
• baseline compliance was low.
• the source was a supervisor or colleague
• it was provided more than once
• it was delivered in both verbal and written formats
• it included both explicit targets and an action plan

Summary
• The results of individual studies need to be interpreted alongside the
totality of evidence (ie systematic reviews)
• Emphasis on KT of individual studies may distract the stakeholder
group (increasing the noise to signal)
– ‘Don’t believe the hype’
– ‘Don’t generate the hype’
• Substantial evidence of effectiveness of implementation interventions
• Average effects modest but considerable variation of observed effects
suggesting that intervention design features and contextual factors
likely effect modifiers
• Key (research and service) challenge is how to optimise interventions
and tailor intervention to context

Knowledge infrastructure
• Knowledge management is fundamental
challenge for health care organisations wishing to
use evidence
• There is a need to develop knowledge
infrastructure (services and processes)
– Knowledge intelligence services
– Rapid synthesis services
– Requirements for statement about evidence
considered in high level policy documents (eg senior
management team submissions)
– ….

Is research working for you?
http://www.cfhi-
fcass.ca/PublicationsAnd
Resources/ResourcesAnd
Tools/SelfAssessmentTool
.aspx

Is research working for you?
1. Acquire
1.1 Are we able to acquire research?
1.2 Are we looking for research in the right places?
2. Assess
2.1 Can we tell if the research is valid and of high quality?
2.2 Can we tell if the research is relevant and applicable?
3. Adapt
3.1 Can we summarize results in a user-friendly way
4. Apply
4.1 Do we lead by example and show that we value research use?
4.2 Do our decision making processes have a place for research?

Knowledge to action cycle
Knowledge to
Action loop
From: Graham ID et al. Lost in
Knowledge Translation: Time
for a Map? Journal of
Continuing Education in the
Health Professions, 2006

Adapting knowledge to local context
• May require additional data collection to
assess applicability of knowledge to local
context
• May require modification of recommended
actions based upon applicability, resources
and contextual issues

Summary
• Implementation is about ensuring that stakeholders
are aware of and use research evidence to inform
their decision making and actions to improve
processes and outcomes of care
• Implementation science is the scientific study of the
determinants, processes and outcomes of
implementation.

Summary
• Successful implementation depends upon:
– Internal knowledge (eg performance data, tacit knowledge
of how organisation (and individuals) work)
– External knowledge (eg clinical and implementation
science)
– Behaviour and organisational change expertise
• Adopting a systematic (theoretically informed) approach will
likely enhance likelihood of successful implementation
• The knowledge to action cycle is a useful planning framework.

How would you tackle this?
• Two scenarios: choose one scenario, then
work in pairs at your tables
– Hand hygiene
– Diabetes care
• Spend 15 minutes in pairs
• Feedback to your table for 5 minutes
• General thoughts from tables 10 minutes

Scenario 1
Hand hygiene in hospital
staff
• Healthcare-associated infections are
among top 10 causes of hospital
deaths worldwide
• Hand hygiene (washing or
disinfecting hands) is most effective
and cost-effective prevention
method
• Adherence to hand hygiene
recommendations consistently
below 50%
Scenario 2
Diabetes care in primary care
2011-2012 National diabetes audit showed:
- 66% of patients meet guideline-recommended
treatment targets HbA1c (<=58mmol/mol)
- 47% had blood pressure < 140/80mmHg
- 41% reaching cholesterol target of <4mmol/L
- 22% meeting all three targets
- Care process completion has plateaued
2011 National study of 99 practices showed:
• 73% of patients received general education
• 51% with BMI>30 received weight advice
• 68% received self-management advice
• 59% prescribed for HbA1c when above target
• 40% prescribed when BP above target
How would you improve the
implementation of hand hygiene
practices in hospital?
How would you improve the quality of
diabetes care in primary care?
Spend 15 minutes in pairs
Feedback to your table for 5 minutes
General thoughts from tables 10 minutes

Feedback
How would you improve the
implementation of hand hygiene
practices in hospital?
How would you improve the quality of
diabetes care in primary care?

Session 3a: Behavioural
approaches to implementing
evidence based guidance
Dr Justin Presseau

Barriers to implementation
• Structural (e.g. financial disincentives)
• Organisational (e.g. inappropriate skill mix, lack of
facilities or equipment)
• Peer group (e.g. local standards of care not in line
with desired practice)
• Individual (e.g. knowledge, attitudes, skills)
• Professional - patient interaction (e.g. problems
with information processing)

A behaviour change approach to
implementation science
• Behaviour change approaches apply to any
level: from individuals to groups to
organisations
– Diagnosis:
• Who needs to do what, differently?
• What is preventing them from doing so
– Intervention:
• Help them change what they do to promote
implementation

Identifying behaviours of interest
• What is the behavior (or series of linked
behaviors) that you are trying to change?
• Who performs the behavior(s)? (potential
adopter)
• When and where does the potential adopter
perform the behavior?
• Are there obvious practical barriers to performing
the behavior?
• Is the behavior usually performed in stressful
circumstances? (potential for acts of omission)

Identifying whose behaviour(s)
need to change
• Often useful to specify target behaviours in terms of:
– Actor performing the behaviour
– Action being performed
– Target at which the action is directed
– Context in which action is performed
– Time during which the action is performed.
• Provides clarity regarding what to change

Why use theory?
• An organized, heuristic, coherent, and systematic
articulation of a set of statements related to significant
questions that are communicated in a meaningful whole for
the purpose of providing a generalisable form of
understanding.
Meleis AI: Theoretical nursing. Development and progress
• It describes observations, summarizes current evidence,
proposes explanations, and yields testable hypotheses.
• It represents aspects of reality that are discovered or
invented for describing, explaining, predicting and
controlling a phenomenon
The Improved Clinical Effectiveness through Behavioural Research Group(ICEBeRG). (2006) Imp Sci
Assessing barriers to
implementation

Why use theory?
• Interventions are likely to be more effective if
they target determinants of behaviour
• Theoretical frameworks facilitate accumulation
and integration of evidence
– across context, population and behaviour
– of effects and of causal mechanisms
• Allows refinement and development of theory
and, hence, more effective interventions
implementation

What levels of theory?
• Ferlie and Shortell suggest four levels of interventions to
improve the quality of health care:
– the individual health professional;
– health care groups or teams;
– organisations providing health care (e.g., NHS trusts);
– the larger health care system or environment in which
individual organisations are embedded.
• Different types of theory will be relevant to interventions
at different levels
Ferlie, Shortell (2001). Milbank Quarterly
implementation

Making sense of theory
• Multiple theories and frameworks of
individual and organizational behaviour
change, often with conceptually overlapping
constructs
• Two recent attempts to make theory more
accessible
– Theoretical domains framework
– Behaviour change wheel

Theoretical domains framework
• Conceptual mapping of 128 explanatory
constructs drawing on 33 psychological
theories
• Identified 14 domains covering main known
factors influencing behaviour and behaviour
change

Theoretical domains framework
• Knowledge
– Aware of guidelines and evidence?
• Skills
– Sufficient training in techniques required?
• Social/professional role and identity
– Is the action part of what the actor sees as
‘typical’ of their profession?
• Beliefs about capabilities
– Confident in capacity to do the behaviour?
What makes it easier or difficult?
• Optimism
– Is the actor generally optimistic that doing
the behaviour will make a difference in the
grand scheme of things?
• Beliefs about consequences
– What the the benefits and negative aspects
of doing the behaviour?
• Reinforcement
– Does the behaviour lead to any personal or
external reward when it is performed?
• Intentions
– How motivated is the actor to do this?
• Goals
– How much of a priority is this action
compared to other competing demands?
• Memory, attention and decision
processes
– Does the actor ever forget? Are there
reminders in place?
• Environmental context and resources
– Are there sufficient resources to do the
behaviour? If not, what is missing?
• Social influences
– Who influences the decision to perform the
behaviour?
• Emotion
– Is performing the behaviour stressful?
• Behavioural regulation
– What does the actor personally do to ensure
that they perform the behaviour?
Cane et al 2012 (Impl.Sci.)

From the TDF to COM-B
Michie, van Stralen,
West (2011) Impl.Sci.
Ability
• Physical
• Psychological
Environmental factors
• Physical
• Social
Conscious and
automatic decision
processes

Physical: physical skills
Psychological: Knowledge,
cognitive and interpersonal skills,
memory/ attention/ decisions
processes, behavioural
regulation
Reflective: intention, goals,
social/professional role and
identity, beliefs about
capabilities, beliefs about
consequences, optimism
Automatic: reinforcement,
emotions
Physical: Environmental context
and resources
Social: Social influences
Linking the TDF to the COM-B Model
Michie, Atkins, West (2014)

Should we use the TDF or COM-B?
• COM-B highlights higher-level factors
• TDF provides a fine-grained analysis that can
be aggregated to the COM-B level

Summary so far
Whatever the level of granularity of the assessment,
theory provides a way to assess barriers to
implementation that provides…
– Common language for building cumulative knowledge-
base to learn from past successes (and failures)
– Move beyond trial and error and ISLAGIATT
– Provides a basis for designing targeted interventions
optimised to address identified barriers to improve
care

Sessions 3b: Identifying barriers
and modifiable determinants of
implementation
Professor Jeremy Grimshaw
Dr Justin Presseau
• Neighbour discussion (15 min) Feedback time (15 min)
• Barrier assessment in case studies

Small group exercise
• Diagnosing the implementation problem
1. Whose behaviour needs to change?
2. Which behaviour(s)/actions do they need to
change?
3. What are the barriers stopping them?
• Using COM-B or TDF as your framework for assessing
barriers

Scenario 1
Hand hygiene in
hospital staff
Scenario 2
Diabetes care in
primary care
In pairs, discuss the following
1. What is the specific behaviour in terms of:
ACTION: the specific behaviour(s)
ACTOR(s): the person(s) whose behaviour needs to change
TARGET: details of the recipient of the action
CONTEXT: where is the action performed?
TIME: When is the action performed
2. Using the TDF or COM-B, identify which barriers may stopping them
With your neighbour: Choose a scenario:
OR

Small group exercise
• Feedback
• What are advantages and disadvantages of
using the theoretical domains framework

Case study – physician hand hygiene

Theoretical domains framework –
physician hand hygiene example
Determinants of behaviour
• Knowledge
• Skills
• Social/professional role and identity
• Beliefs about capabilities
• Optimism
• Beliefs about consequences
• Reinforcement
• Intentions
• Goals
• Memory, attention and decision processes
• Environmental context and resources
• Social influences
• Emotion
• Behavioural regulation
Cane et al (2012)

Knowledge
• I am (not) aware of hand hygiene guidelines
and have (not) heard of the 4 moments of
hand hygiene
• I am (not) aware of evidence linking hand
hygiene to health care associated infections
• Education about hand hygiene ensures that I
practice it consistently

Beliefs about consequences
• Practicing hand hygiene reduces the
transmission of infection
• While improper hand hygiene can contribute
to infection, it is not the only factor that can
do so
• Practicing hand hygiene gives patients
confidence in their physician

Beliefs about Capabilities
• Hand hygiene is easy to practice
• I am not confident that I am following hand
hygiene guidelines when practicing hand
hygiene

Social influence
• Patients expectations do (not) influence me to
perform hand hygiene
• If I see someone practicing hand hygiene, it
influences me to do the same
• Team culture influences others hand hygiene
practice

Goals
• Hand hygiene is always a necessity
• Hand hygiene is not my highest priority in
patient emergency situations
• Hand hygiene is one of many priorities that I
have to balance every day

Skills
• I do (not) consider hand hygiene a skill
• I have (not) had training in hand hygiene
practice
• With repetition, hand hygiene practice
becomes automatic

Memory, attention, decision processes
• Hand hygiene is (not) an automatic process for me
• When not touching the patient or patient environment,
hand hygiene is unnecessary
• Reminders are useful for my hand hygiene practice
• Easily visible hand hygiene stations make it easier to
remember hand hygiene

Social professional role and identity
• Hand hygiene is a standard part of my patient
consultations
• My hand hygiene is in line with my peers
• Physician hand hygiene compliance is
suboptimal
• It is my job to be a hand hygiene role model to
the members of my team

Environment
• Easy access to hand hygiene stations makes it
easier to practice hand hygiene
• The location of hand hygiene stations is
important in facilitating hand hygiene practice
• Practicing hand hygiene takes time
• When I am busy, I am less likely to comply with
hand hygiene guidelines

Environment - Nonparticipant Observation
• Observations made while on a Surgery and
Medicine Unit confirmed what was said in the
physician interviews:
– Alcohol dispensers are sometimes empty
– Alcohol dispensers blend in with the wall
– Beside alcohol bottle baskets are empty

Case study:
the iQuaD example
• Three dominant theories and approaches in implementation
science:
– “If you build it they will come”: the structural approach to
behaviour change
– “There is no ‘I’ in team”: change involves exchanges and
shared processes between individuals working in teams
within organisations
– “Between the ears” : individuals’ perceptions, cognitions
beliefs, schemas, cognitive associations about their behaviour
• Rarely ever considered alongside each other. Need for empirical
comparison of theory for utility in implementation science

The improving Quality in Diabetes care (iQuaD) study1,2
Aim: investigate how effectively and consistently factors from predominant
organisational and behaviour theories predict
- multiple evidence-based clinical behaviors promoted in guidelines
- same sample of clinicians, primary care diabetes management in the UK
Design: Predictive. Questionnaires sent at baseline and 12 months later to GPs and
nurses in 99 practices across the UK
National study of primary care in the UK
1 Eccles et al (2011, Impl Sci); 2 Presseau et al (in press, Journal of Behavioral Medicine)

National study
• Outcomes:
– Clinician-level: clinicians’ self-reported behaviour at 12 months follow-up
– Practice level: patient report of care received and patient medical records
• Recruitment and response rates1
– 12 months follow-up
• 427 (289 GPs, 138 nurses) returned questionnaire (51% response rate).
• Mean of 41 patients/practice responded to questionnaire
• Main Findings
• Gaps in quality of care across the behaviours1
• Theory-based factors that predicted high quality care2
1 Eccles et al (2011, Impl Sci); 2 Presseau et al (in press, Journal of Behavioral Medicine)

Prescribing ...
1. ...additional antihypertensive drugs for people with type
2 diabetes whose blood pressure (BP) is above a target of
140 mm Hg for Systolic BP or 80 mm Hg for Diastolic
2. ...additional therapy for the management of glycaemic
control (HbA1c) for the management of HbA1c in people
whose HbA1c is higher than 8.0%, despite maximum
dosage of 2 oral hypoglycaemic drugs.
Providing advice about...
1. ... weight management to people with type 2 diabetes
whose BMI is above a target of 30kg/m2, even following
previous management.
2. ... self-management to people with type 2 diabetes.
3. ...general education about diabetes for people with type
2 diabetes.
Examining...
1. ...foot circulation & sensation in the feet of people with
type 2 diabetes.
Health professionals: 63%
Patient Records: 40%
People with diabetes: 51%
Eccles et al (2011, Impl Sci)
National study: gaps in quality of care

Staffing ratios
Meetings
Appointment length
Admin support
Recall system
Insulin initiation
Dedicated diabetes clinic
Structured education
Access to specialist care
List size
IMD
National study: testing structural correlates

Procedural Justice
Relational Justice
Implementation
Behaviour
Participative Safety
Support for Innovation Implementation
Behaviour
Vision
Task Orientation
Altruism, Courtesy,
Sportsmanship,
Conscientiousness, Civic
Virtue
Implementation
Behaviour
Organizational Citizenship Behaviours (Moorman, 1991)
Team Climate (Anderson & West, 1994)
Organizational Justice (Greenberg 1990)
Elovainio, Steen, Presseau, Francis et al. (2012) Family Practice.
R2
adj = 0.01 (0.00, 0.03)
R2
adj = 0.00 (0.00, 0.03)
Predicting 12m self-
report (median, range):
R2
adj = 0.00 (0.00, 0.00)
National study: testing team theories

Presseau, Johnston, Francis, Hrisos, Stamp, Steen, Hawthorne, Grimshaw, Elovainio, Hunter, Eccles (in press) Journal of Behavioral Medicine
Outcome
Expectations
Self-efficacy
Proximal
Goals
Implementation
Behaviour
Attitude
Subjective Norm
PBC
Intention Implementation
Behaviour
Anticipated Consequences
Evidence of habit
Implementation
Behaviour
Action Planning
Coping Planning
Implementation
Behaviour
Social Cognitive Theory
TPB
Learning
Theory
Planning
R2
adj = 0.15 (0.09, 0.50)
R2
adj = 0.14 (0.09, 0.48)
Predicting 12m self-
report (median, range):
R2
adj = 0.15 (0.09, 0.50)
R2
adj = 0.15 (0.07, 0.43)
National study: testing behaviour theories

• Constructs from Organizational Theories did not predict
implementation-related behaviours
• Constructs from Behaviour Theories consistently predicted
multiple behaviours and scores showed room for improvement:
– Social cognitive theory in particular, along with habit and
post-intentional factors
• Testing different theories in the same sample across multiple
behaviours provides empirical theory selection through internal
replication
– Can be used to design intervention to improve care by targeting
modifiable factors shown to consistently predict clinicians behaviour
National study: testing multiple theories

 Analytical
 Effortful
 Resource intensive
 Slow, Low capacity
 Conscious, deliberate2
 Perceptual and cued
 Minimal effort, resources
 Fast, High capacity
 Unconscious
 Automatic
 Default process
 Operates in parallel2
Clinician
Behaviour
Reflective
process1
Impulsive
process1
1Strack & Deutch, 2004; 2Evans 2008
• Dual process approach provides an opportunity to jointly
• Skilled decision-making involving behaviours with highly salient consequences
(reflective process)
• Automatic responses to environmental cues in stable contexts (impulsive process)
• Dual process models suggest that behaviour is determined by two interacting process1
Towards a dual process model of clinician behaviour

Motivational Phase Volitional Phase
Clinician
Behaviour
Intention
Action Planning
Coping Planning
Towards a dual process model of clinician behaviour
Automaticity
1Presseau, Johnston, Heponiemi, Elovainio, Francis, Eccles, et al (in press) Annals of Behavioral Medicine
Tested a dual process model predicting
• …six clinical behaviours in same sample
• Hypothesising differences relative importance of reflective and
impulsive system depending on the behaviour

• Motivational process remain a key direct and indirect
predictor of clinician behaviour
• Volitional process help to explain how intentions are
translated into behaviour for advising behaviours but not
examining behaviours (unclear for prescribing)
• Automatic processes are involved in prescribing, examining
and advising behaviours, though not without the input of the
reflective process
 both reflective and automatic processes involved in
predicting clinician behaviours
 both could be targeted to promote the implementation of
healthcare interventions
Summary so far

Michie, van Stralen,
West (2011) Impl.Sci.
• Physical
• Psychological
• Physical
• Social
• Conscious
• Automatic
Interpreting iQuaD findings
according to COM-B






Predictive

Session 4: Behavioural approaches to
implementing evidence based guidance
Designing implementation programmes
Dr Justin Presseau

• Choice of implementation intervention
should be based upon:
– ‘Diagnostic’ assessment of barriers
– Understanding of mechanism of action of
interventions
– Empirical evidence about effects of interventions
– Available resources
– Practicalities, logistics etc

Who needs to do
what differently?
Using a theoretical framework,
which barriers and enablers need
to be addressed?
Which intervention components
could overcome the modifiable
barriers and enhance the enablers?
How will we measure
behaviour change?

Who needs to do
what differently?
to be addressed?
How will we measure
behaviour change?

• What is the behavior (or series of linked behaviors)
that you are trying to change?
• Who performs the behavior(s)? (potential adopter)
• When and where does the potential adopter perform
the behavior?
• Are there obvious practical barriers to performing the
behavior?
• Is the behavior usually performed in stressful
circumstances? (potential for acts of omission)

Who needs to do
what differently?
to be addressed?
How will we measure
behaviour change?
• COM-B
• TDF
• Behaviour change
theory

We have found it useful to distinguish…
– What we are trying to change
– Why are we trying to change it? (constructs: barriers
and enablers)
– How are we going to change it, including
• Intervention functions and Behaviour change
techniques
• Context: the mode of delivery (eg group meeting,
DVD)
• Content: how the technique will be operationalised

Behaviour change wheel
Michie, van Stralen, West (2012)
Central: COM-B model of
behaviour
• Intervention functions
surround the COM-B
• Policy categories to
support change

Behaviour change wheel: intervention
functions
Increase knowledge and understanding
Use communication tools
to provoke positive or
negative emotions or
behaviour
Develop an
expectation that a
reward will be
provided for
performance
Develop an expectation
that performance will
result in cost or
punishment
Developing physical,
cognitive or social skills
Reduce performance opportunities
through rule-setting
Make a change to the
external social or physical
context
Exposure to someone
that one identifies with
to imitate
Facilitation beyond education,
training and environmental
restructuring

COM-B TDF Intervention functions
Physical capability Physical skills Training
Psychological capability Knowledge Education
Cognitive and
interpersonal skills
Training
Memory, attention and
decision processes
Training; Environmental
restructuring; Enablement
Behavioural regulation Education; Training;
Modelling; Enablement
Capability
Michie, Atkins, West (2014), p113-114
From TDF, to COM-B to Intervention Functions

Physical opportunity Environmental context and
resources
Training; Restriction;
Environmental
restructuring; Enablement
Social opportunity Social influences Restriction; Environmental
restructuring; Modelling;
Enablement
Opportunity

Reflective
motivation
Professional/social role
and identity
Education; Persuasion; Modelling
Beliefs about capabilities Education; Persuasion; Modelling; Enablement
Optimism Education; Persuasion; Modelling; Enablement
Beliefs about
consequences
Education; Persuasion; Modelling
Intentions Education; Persuasion; Incentivisation;
Coercion; Modelling
Goals Education; Persuasion; Incentivisation;
Coercion; Modelling; Enablement
Automatic
motivation
Reinforcement Training; Incentivisation; Coercion;
Environmental restructuring
Emotion Persuasion; Incentivisation; Coercion;
Modelling; Enablement
Motivation

Links between COM-B and intervention functions
in the Behaviour Change Wheel
COM-B
Intervention functions
Education
Persuasion
Incentivisation
Coercion
Training
Restriction
Environmentalrestructuring
Modelling
Enablement
Physical capability
Psychological capability
Physical opportunity
Social opportunity
Automatic motivation
Reflective motivation
Michie, Atkins, West (2014, p116)

Designing interventions – from functions to
behaviour change techniques
Need greater clarity re: specific content of interventions to change behaviour
- What does an ‘educational session’ involve? What does providing a new piece of guidance
involve? What does ‘we sent our GPs on a training day’ actually involve? What are the
active ingredients of change?
- If we want to replicate and generalise efforts in implementation science, we need a shared
understanding of the content of our interventions

Goals and Planning
Goal setting (behavior) OR Goal setting (outcome)
Problem solving
Action planning
Review behavior goal(s) OR Review outcome goal(s)
Discrepancy between current behavior and goal
Behavioral contract
Commitment
Feedback and monitoring
Monitoring of behaviour by others without feedback
Feedback on behaviour/outcomes of behaviour
Feedback on outcomes of behaviour
Self-monitoring of behaviour
Self-monitoring of outcomes of behaviour
Monitoring of outcome(s) of behaviour without feedback
Biofeedback
Social Support
Social support (unspecified)
Social support (practical)
Social support (emotional)
Shaping Knowledge
Instruction on how to perform the behaviour
Information about Antecedents
Re-attribution
Behavioural experiments
Natural Consequences
Info about health consequences
Info about emotional consequences
Info re social and environment consequences
Salience of consequences
Monitoring of emotional consequences
Anticipated regret
Comparison of behaviour
Demonstration of the behaviour
Social comparison
Information about others’ approval
Associations
Prompts/cues
Cue signalling reward
Reduce prompts/cues
Remove access to the reward
Remove aversive stimulus
Satiation
Exposure
Associative learning
Repetition and substitution
Behavioural practice/rehearsal
Behaviour substitution
Habit formation
Habit reversal
Overcorrection
Generalisation of target behaviour
Graded tasks
Comparison of outcomes
Credible source
Pros and cons
Comparative imagining of future outcomes
Reward and threat
Incentive (outcome
Material incentive (behaviour)
Social incentive
Non-specific incentive
Self-incentive
Self-reward
Reward (outcome)
Material reward (behaviour)
Non-specific reward
Social reward
Future punishment
Regulation
Conserving mental resources
Pharmacological support
Reduce negative emotions
Paradoxical instructions
Antecedents
Adding objects to the environment
Restructuring the physical environment
Restructuring the social environment
Avoidance/reducing exposure to cues for
behaviour
Distraction
Body changes
Identity
Identification of self as role model
Framing/reframing
Incompatible beliefs
Valued self-identify
Identity associated with changed behaviour
Scheduled consequences
Behaviour cost
Punishment
Remove reward
Reward approximation
Rewarding completion
Situation-specific reward
Reward incompatible behaviour
Reward alternative behaviour
Reduce reward frequency
Remove punishment
Self-belief
Verbal persuasion about capability
Mental rehearsal of successful perform
Focus on past success
Self-talk
Covert learning
Imaginary punishment
Imaginary reward
Vicarious consequences
V1 Behaviour change techniques taxonomy (Michie et al 2013)

Examples of techniques w/ definitions
• Graded tasks: “Set easy-to-perform tasks, making them increasingly
difficult, but achievable, until behaviour is performed”
– Capability (Psychological) in COM-B
– Beliefs about Capabilities in TDF
• Habit formation: “Prompt rehearsal and repetition of the behaviour in the
same context repeatedly so that the context elicits the behaviour”
– Motivation (automatic) in COM-B
– Behavioural Regulation and Reinforcement in TDF
• Feedback on behaviour: “Monitor and provide informative or evaluatve
feedback on performance of the behaviour (e.g. form, frequency, duration,
intensity)”
– Motivation (reflective) in COM-B
– Behaviour regulation in TDF
Not all techniques are useful, and many techniques are designed to address
specific types of barriers

From behaviour change techniques to
theory-informed barriers
• Behaviour change techniques can be mapped
onto the theory-based barriers and facilitators
from the models covered
– Behaviour change theories
– TDF
– COM-B
• Behaviour change wheel (intervention functions)

Supporting change through policy
Michie, van Stralen, West (2012)
Policy initiatives can
facilitate intervention
functions impact on
COM-B components

Policy categories
Intervention functions
Education
Persuasion
Incentivisation
Coercion
Training
Restriction
Environmentalrestructuring
Modelling
Enablement
Communication/marketing
Guidelines
Fiscal measures
Regulation
Legislation
Environmental and social planning
Service provision
Links between policy categories and intervention
functions in the Behaviour Change Wheel
Michie, Atkins, West (2014, p138)

Optimising interventions
Usability studies
• Develop prototype intervention
• Test prototype in 5 to 8 subjects to review content and
format using ‘think aloud’ methodology. These sessions
will be audio recorded and the results transcribed and
analysed.
• In general a modest number of subjects are required
for usability testing (e.g. 8-9 subjects), and often 4 to 5
are necessary to identify 80% of the usability problems.
• Cycles of design, development and testing will be
completed until no further major revisions are needed.

Case studies
• Neighbour discussion(15 min)
Feedback time (10 min)
• Implementation design in
case studies

Scenario 1
Hand hygiene in
hospital staff
Scenario 2
Diabetes care in
primary care
In pairs, discuss the following
Based on the barriers you identified using the TDF or COM-B, select…
1. Potential intervention functions to target those barriers
2. Potential policy categories that would support that intervention
function
With your neighbour: Choose the same scenario
OR

Session 5: Behavioural approaches to
implementing evidence based guidance
Implementation design in case studies
Dr Justin Presseau

Case study of physician hand hygiene

physician hand hygiene
Physician need to practice hand
hygiene routinely
Beliefs about consequences –
failure to practice hand hygiene
not necessarily associated with
adverse event
Persuasion/social influence –
information on hospital
associated infections and negative
associated consequences,
emphasis on hand hygiene as a
team level responsibility delivered
to team session by social
influential
Who needs to do
what differently?
to be addressed?
How will we measure
behaviour change?

Choice of implementation intervention should
be based upon:
– ‘Diagnostic’ assessment of barriers
– Understanding of mechanism of action of
interventions
– Empirical evidence about effects of interventions
– Available resources
– Practicalities, logistics etc

1. Initial sensitisation (residents)
Intervention content:
Refresher about:
– the 4 moments of hand hygiene (knowledge)
– what is the patient environment (knowledge)
– TOH hand hygiene compliance and infection rates (beliefs about
consequences, social influences (priority for chief resident and hospital))
Proposed delivery for Medicine:
– When: During Resident Orientation -1st day of block
– What: 1-2 slides on hand hygiene to be developed by team and given to
Chief Resident
– Who will deliver: Chief Resident at the beginning of the block

2. Reinforcement (residents, attending physicians)
Intervention Content:
Knowledge about:
– Infection rates, the 4 moments, the patient environment (exact content to
be developed and will be clinically relevant) (knowledge)
– Add Glo Germ demonstration in one of these sessions to illustrate technique
(booth after session for all to try if interested) (skills)
– When: During Antibiotic Stewardship Rounds – a weekly pause of rounds
that lasts a few minutes (already in practice) (social influence)
– What: A hand hygiene curriculum delivered weekly (~2min/session) X 4 (for
one block)
– Who will deliver: Local experts/opinion leaders

3. Address environmental barriers (unit staff)
Intervention Content:
– Ensure that hand hygiene resources are easily accessible and noticeable
(including systems to ensure hand hygiene resources are routinely
replaced)
– How: Will walk through the chosen unit(s)
– Who will deliver: Members of the study team
– Accountability – unit

-4
6
26 26
3
11
50
44
-10
0
10
20
30
40
50
60
Medicine
M1
Medicine
M4
Surgery
M1
Surgery
M4
Resident Audit Scores
% Change Between Pre and Post
Control Group
Intervention Group

Aim: Conduct a cluster-RCT to evaluate the effectiveness and costs of a
theory-based multiple behaviour change intervention targeting general
practitioners (GPs) and nurses, to support improvement in the provision of
high quality care for people with type 2 diabetes in the North East of England
AdvisingPrescribing Examining
Local
example:

Prescribing ...
1. ...additional antihypertensive drugs for people with type 2
diabetes whose blood pressure (BP) is above a target of 140
mm Hg for Systolic BP or 80 mm Hg for Diastolic
2. ...additional therapy for the management of glycaemic
control (HbA1c) for the management of HbA1c in people
whose HbA1c is higher than 8.0%, despite maximum
dosage of 2 oral hypoglycaemic drugs.
Providing advice about...
1. ... weight management to people with type 2 diabetes
whose BMI is above a target of 30kg/m2, even following
previous management.
2. ... self-management to people with type 2 diabetes.
3. ...general education about diabetes for people with type 2
diabetes.
Examining...
1. ...foot circulation & sensation in the feet of people with
type 2 diabetes.
Eccles et al (2011, Impl Sci)
Evidence from our previous national study:
gaps in quality of care

Design: Cluster randomised controlled trial (stratified by practice size)
- Theory-based process evaluation
- Interview based process evaluation
- Fidelity of delivery
- Cost analysis
Recipients: GPs, nurses, healthcare assistants delivering care to people with type 2
diabetes
Timeline:
– Intervention development from Sept 2012 to start of Sept 2013
– Pilot May/June 2013
– Recruitment began in March 2013
– Intervention delivery started mid September 2013
– Follow-up 12 months later
The IDEA trial

Recruit GPs, nurses, healthcare assistants
in 44 Practices
Baseline Questionnaire
Randomisation (stratified by practice size)
Intervention Practices (22) Control Practices (22)
Deliver Intervention
Interviews (4)
Follow-up questionnaire
Outcomes (12 months later)
- Random 100 patients per practice (anonymous postal questionnaire)
- Patient computer records
The IDEA trial: flow chart

Outcome
expectations
Self-efficacy
Proximal
Goals
Automaticity
Goal conflict
Goal Facilitation
Goal Priority
Action Planning
Coping Planning
- Based on findings from iQuaD1,2,3
- Social Cognitive Theory4 + volitional constructs5 + dual process model3,6
- Reciprocal determinism1 operationalised to involve environment factors:
- Automaticity (automatic response to cues)3
- Competing behaviours (conflict, facilitation and priority)4,5
Behaviour
Eccles et al (2011); 2,3 Presseau et al (in pressa; in pressb) 4 Bandura (1998); 5 Sniehotta (2009), 6 Strack & Deutsch (2004); 7,8 Presseau et al (2009,
2011);
Logic model

Intervention content
1 BCTs from Michie et al (2013). ABM
Target Construct Behaviour Change Techniques1
Self-efficacy - Demonstration of the behaviour
(beliefs about
capabilities)
- Social comparison
- Verbal persuasion of capability
- Behavioural practice/rehearsal
- Graded tasks
Outcome expectations - Information about health consequences
(beliefs about
consequences)
- Credible source
Proximal goals
(Reflective motivation)
- Goal setting (behaviour)
- Discrepancy between current behaviour and goal
- Commitment
Action planning - Action planning
Coping planning - Problem solving
- Adding objects to the environment
Habit/Automaticity - Behavioural practice/rehearsal
(Automatic motivation) - Habit formation
- Action planning and problem solving

• Self-administered pre-
intervention questionnaire
• Pre-reading, website and PDF-
based
• Group-based workshop to each
practice
– PowerPoint slides
– Participant Workbooks
– Small group tasks
– Video case studies
• DVD of materials during
evaluation
• Self-administered post-
intervention questionnaire
• DVD of materials after
evaluation
Intervention Control
✓ ✓
✓
✓
✓
✓
✓
✓
Format

clinical expert
behaviour change expert
Intervention providers

44 GP practices in the North-east of England
Setting

 Audio recorded sessions
- Transcribed/coded for delivery of BCTs, by whom
 Facilitator debrief questionnaires
- Independently completed; reported delivery of BCTs;
coverage across 6 behaviours; intensity
 Participant feedback
- Write plans on feedback forms
Training sessions based on BCTs
1) Facilitator handbook
2) Within facilitator team: observe, coping planning
3) Within research team: practice/rehearsal
4) Feedback on to facilitator team after delivery
1 Bellg et al 2002
Fidelity of delivery

– Intervention may or may not be effective
– Process evaluation to understand mechanism of change
– Theory-based process evaluation1,2:
• Pre/post theory-based questionnaires
• Test for change in targeted constructs between intervention
and control
1,2 Grimshaw et al (2007; submitted) Implementation Science;
Outcome
expectations
Self-efficacy
Proximal
Goals
Automaticity
Goal conflict
Goal Facilitation
Goal Priority
Action Planning
Coping Planning
Behaviour
Process evaluation (quantitative)

• Four practices randomly selected for follow-up
interviews
– TDF based barriers and facilitators to engaging in
the intervention sessions
– Participants: clinicians participating in the
intervention, practice manager
Process evaluation (qualitative)

• Cost of delivering the intervention
• Staff training (facilitators)
• Primary care costs
• Increases in standard materials used (e.g., leaflets)
• Time use in consultation
• Average cost per patient to the NHS for
medication prescribed
• Costs of service usage by people with Type 2
diabetes
Cost analysis

Summary
• Designing interventions involves assessing
barriers to change and identifying
interventions that potentially address these
• Behavioural theories may be helpful to inform
barrier assessment and intervention choice
• Intervention mapping is a technique for
systematically considering barriers and
potential interventions

Developing the field of
• Implementation science is a relatively new field - few
health researchers have been engaged in the field for
more than 10 years
• Substantive level of research activity
– Cochrane Effective Practice and Organisation of Care
(EPOC) group register includes over 6,000 RCTs and quasi
experiments of interventions to improve health care
delivery and health care services
• Increasing funding and reporting opportunities for
knowledge translation research
• Move towards research programs and laboratories

Implementation Research Laboratories
• Research teams integrated into healthcare systems
undertaking program(s) of research directly relevant to
healthcare systems’ priorities
• Reduces problems relating to convening de novo research
teams, seeking project by project funding, negotiating
access with healthcare systems, conducting study, writing
up (usually out of funding period)
• Opportunities for formal and informal linkages of mutual
advantage to research team and healthcare system
• More explicitly recognise relatives roles and responsibilities
of research team and healthcare system

Developing the field of implementation
science

www.implementationscience.com

Summary
• Implementation science is a relatively new field
of health services research
• Rapid progress has been made but substantial
challenges remain
• Opportunities to foster linkages between
implementation service departments and
implementation researchers to form
implementation science laboratories and address
I2 challenge

Discussion
• Based on the workshop today, what are your
current views on:
– Value of behavioural approaches to implementing
evidence based guidance?
– What would be needed to adopt these
approaches in practice?
– Are there any additional approaches that might
complement behavioural approaches?

Closing remarks
Professor Paula Whitty
Director of NEQOS & Acting NENC AHSN Knowledge &
Information Programme lead
Dr. Jackie Gray
Medical Epidemiologist, NEQOS

Get involved in the Work
Programme
• Sign up at the registration desk (in main foyer)
or
• Email Dr Jackie Gray jackie.gray5@nhs.net

Keep up to date with developments:
• Sign up for the e- bulletin at the registration desk (if you haven’t
already)
Resources will be available on:
You Tube - video will be uploaded (link included in next e- bulletin)
Slide Share - slide deck will be uploaded (link included in next e-bulletin)
AHSN web site www.ahsn-nenc.org.uk
NEQOS web site www.neqos.nhs.uk/
Twitter - @AHSN_NENC

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