1. Behavior Change & Implementation Science: Translating research into practice
HMS Academy
Fellowship in Medical Education Research
June 2, 2016
Amy Sullivan & Amy Cohen

2. Beyond the carrot and the stick
Learning objectives:
Describe widely-used theories of behavior change
Compare and contrast approaches for physician and patient behavior change
Learn how to use the WOOP approach to change
Describe how to design & assess an intervention by identifying short- and long- term outcomes as well as moderators and mediators (mechanisms) of change.

3. IDENTIFY NEEDS, SPECIFY OUTCOMES AND TARGET POPULATION: Specify both short-term and long-term outcomes
Take away point: Use Type 2 thinking when designing and evaluating research!
DESIGN INTERVENTION: Use behavior change theory to identify & target specific intervention components
IMPLEMENT INTERVENTION: Use findings from implementation science to determine best practices in delivery of intervention
Cite scoping review article on percent of interventions using theory
ASSESS INTERVENTION: Assess both the targeted behavior change components (mediators, moderators, short-term and long-term outcomes) and assess the implementation by measuring how the intervention was delivered, by whom, and in what context (fidelity, cost, reach, barriers, facilitators).

4. Theories of change
Developed in psychological traditions of behaviorism and social learning
Applied and further developed in public health and economic research, policy, and practice 
GREAT RESOURCE!

5. Theories of change Theory of Planned Behavior (TBP)
Implementation intentions
Social learning theory
Self-determination theory
Transtheoretical model
…and many more!

6. Key characteristics Theories cover multiple levels:
Intrapersonal (motivation, affect regulation, self-monitoring, self-efficacy, beliefs, knowledge, attitudes)
Interpersonal (social norms, role modeling)
Environmental (context and resources)

7. Some examples

8. TPB, Icek Ajzen, PhD

9. From:
Clin Nurse Spec ; 23(3): 161–172. doi: /NUR.0b013e3181a42373.

10. How do I decide which theories to use?
Prior research
Careful deliberation on match between theory and specific behavior(s)
Scoping review—theoretical domains framework, NOH grid-enabled measures

11. A methodological aside
What is a Scoping Review?
Marcel Dijkers, PhD, FACRM

12. C. Perceived
behavioral control
Aim 3: Increase in A & B in hospital unit
Intervention: Didactic training increases A.
Moderating variables:
PT/CG demographics
PT/CG depression/anxiety
PT/CG spirituality
B. Subjective
norms
E. Behavior change:
Increased frequency and enhanced quality of CL communication with PT/CG
D. Intentions
(Mediating variable)
A, B, & C
A. Attitudes
Aim 1: Proximal outcomes
Figure 1 Conceptual framework. The Theory of Planned Behavior informs the selection of factors targeted in this intervention. Theoretical components and associated aims are shown. The intervention is hypothesized to impact Items A-D. We expect that the behavioral outcomes will also have a reciprocal effect on Items A-E (e.g., improved communication practices will increase knowledge); however, for simplicity these relationships are not shown on the model.
Definitions (PT=patient, CG-caregiver, CL=clinician):
Attitudes: CL perception that EOL communication is very important to PT/CG care and to clinician satisfaction with care
Subjective norms: CL perception that discussion of EOL issues is expected and routinely practiced in the unit.
Perceived behavioral control: CL belief in ability to communicate effectively and skillfully with PT/CG.
Intentions: CL intention to communicate with PT/CG about possibility of dying and goals of care
Intervention: Team discussion increases B & D.
Intervention: Role play and didactic increases C
Improved patient/family care:
Earlier referral to hospice/palliative care
Greater concordance w/PT wishes for care
Better CG preparation for PT death
Aim 2: Distal outcomes

13. change implementation
From Sullivan et al, Impact of Resident Training on Communication with Families in the ICU. Annals American Thoracic Society 2016

14. Implementation: the key to translating behavioral theory into practice
Behavior change theories provide the what
Implementation science can inform the how

15. Implementation
Overlaps with behavior change in some regards but focuses on strategies, with an emphasis on active versus passive approaches:
Motivational interviewing
Audit and feedback
Credible source/champion
Nudging
Training/deliberate practice
Rewards
Guidelines
Environmental supports or deterrents
WOOP

16. Some useful resources:

17. Some useful resources, cont:

18. How do I assess interventions?
Measure short- and long-term outcomes (can use Kirkpatrick’s levels as guideline or other meaningful outcome)
Test effects of moderators and mediators
If appropriate, may want to assess impact on clinician behavior and patient outcome
Measure implementation elements: what worked, what did not, to what extent was there an “instructor effect,” what were barriers and facilitators, reach, sustainability
Use mixed methods!

19. A very good paper to guide the development of a mixed methods study (posted on our website):

20. WOOP

21. How might these theories apply to your research?