1. Theories of Behaviour Change
Designing a primary care intervention with the Behaviour Change Wheel: the case of maternal Indigenous smoking
GS Gould1, Y Bar-Zeev1, M Bovill1, L Atkins2, B Bonevski1
1School of Medicine and Public Health, University of Newcastle, CALLAGHAN, Australia
2Behaviour Change Centre, University College London, LONDON, United Kingdom
Introduction
Clinicians seldom perform all recommended components of smoking cessation care (SCC) for pregnant Indigenous Australians.
Smoking prevalence high at 47% among Indigenous Australian pregnant women.
Evidence-practice gaps were identified by:
a) Systematic literature reviews on provider attitudes and interventions for SCC in pregnancy
b) A national survey of 378 Australian clinicians
c) Stories of smoking and quitting from Aboriginal mothers
We aimed to develop an intervention to change provider behaviour and improve culturally competent SCC for pregnant Indigenous smokers, using the Theoretical Domains Framework (TDF)1 and the Behaviour Change Wheel (BCW)2 – Figure 1 .
Results
Main areas for performance improvement included: capability (psychological skills), motivation (optimism), and opportunity (resources/time) – see Table 1.
We aim to improve capability by training clinicians in NRT prescribing; structuring the consultation using a flipchart and prompts; and regulating behaviour through audit and feedback.
To improve optimism we present recent evidence about NRT, and positive testimonials from patients and clinicians.
Webinar brings the opportunity of training to services to accommodate time and location constraints. Resources are supplied such as a flipchart, desktop guide and training manual; free oral NRT; a patient information booklet including embedded videos (Figure 2), and referral pads.
Conclusion
The BCW and TDF can be used to inform the design of a tailored intervention, based on previous identified gaps.
Where to from here?
The intervention materials were pre-tested in three states via focus groups with health providers at Aboriginal Medical Services, and via an expert panel. The training and resources are being piloted in three states for feasibility, and will then be used nationally in a large cluster randomised control trial.
Methods
Indigenous Counselling and Nicotine (ICAN) QUIT in Pregnancy is a smoking cessation program based on a “Pragmatic Guide” to smoking cessation.3
The guide uses and ABCD approach: Ask/Assess; Brief advice; Cessation; Discuss Psychosocial context.
We summarised the key items that required remediating for health providers, by considering the COM-B model, the TDF and BCW. Interventions that were pragmatic and fulfilled the APPEASE criteria, were considered for inclusion.
A Stakeholder & Consumer Aboriginal Advisory Panel co-developed the intervention materials.
Theories of Behaviour Change
BCW is a parsimonious model developed out of a systematic analysis of behaviour intervention frameworks. It is used to link interventions to potential behavioural targets.
At its centre are three main ingredients necessary for volitional behavior to occur – capability, opportunity and motivation or COM-B.
TDF is a validated and integrative theoretical framework covering a range of domains relevant to behaviour change.
Figure 2: “We want a better future for our children and it all starts in the womb.”
From video of Aboriginal OBGYN Dr Marilyn Clarke
Figure 1: The Behaviour Change Wheel2
Table 1: Targeting Provider Behaviour
COM-B
TDF
Intervention
Psychological Capability
Cognitive & Interpersonal Skills
Webinar training on how to consult Indigenous pregnant smokers
Video case studies
Memory, attention & decision
Environmental restructuring
Flipchart
Patient resources
Pregnant smokers flagged on computer
Behaviour regulation
Audit & feedback about NRT prescribed
Reflective Motivation
Belief about capability
Belief about consequences
Persuasion
Building Self-Efficacy
Inform re standard practices
Guidelines
NNT only 16 for quitting
Smoking as an addiction
Enablement through resources
Optimism
Motivational videos & success stories
Turning “near misses” into success
Celebrating small wins
Response efficacy – its worthwhile!
Automatic Motivation
Reinforcement
Emotion
Persuasion sentimental/emotive videos
Physical Opportunity
Environmental context
Resources
Free NRT
Referral pads
Patient booklets
Social opportunity
Norms
Social influences
Whole of service training
Audit and feedback
References:
Cane J, et al. Validation of the theoretical domains framework for use in behaviour change and implementation research. Implement Sci. 2012;7:37.
Michie S, et al. The Behaviour Change Wheel - A guide to designing interventions. Silverback Publishing; 2014.
Gould et al. A Pragmatic Guide for Smoking Cessation Counselling and the Initiation of Nicotine Replacement Therapy for Pregnant Aboriginal and Torres Strait Islander Smokers. J Smok Cessat. 2015;10: