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  • 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,


    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,DIUK:2006-24,DIUK:en

  • 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


    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, transparent and 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.

    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


    Cleaning surfaces

    Appropriate prescribing of treatments for infections

  • Antibiotic prescribing Identifying and

    diagnosing suspected infections


    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)


  • 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


    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 behaviour Intentions, Goals, Perceived relevance, identity, Beliefs about consequences, Self-confidence, Rewards, incentives, sanctions, Emotions

    Physical AND Social environmental factors that enables or inhibits the behaviour Access, layout, resources, prompts, cues Social influences (pressure, support)

  • Theoretical Domains Framework

    1. Knowledge 2. Skills 3. Memory, Attention, Decision

    Making 4. Behavioural regulation

    5. Social Influences 6. Environmental context and resources

    7. Emotions 8. Social professional role and identity 9. Goals 10. Beliefs about consequences 11. Reinforcement 12. Beliefs about capabilities 13. Intentions 14. Optimism

    Michie et al. 2005 BMJ Qual & Safety Cane 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/ e