1. Clinical-related behaviours of healthcare workers: Determinants of adoption and planning interventions Prof. Gaston Godin, Ph.D. Laval University, Quebec May 9, 2012

2. Introduction Regardless of the context, we all want to see our interventions as efficient and successful Regardless of the context, we all want to see our interventions as efficient and successful Unfortunately, too often this is not the case Unfortunately, too often this is not the case

3. Introduction In the domain of health, the same situation prevails and it is not easy to modify behaviours of… In the domain of health, the same situation prevails and it is not easy to modify behaviours of… –Individuals... as well as... –Healthcare workers Gap between evidence-based practices and the routine clinical practices of healthcare workers (HCW) Gap between evidence-based practices and the routine clinical practices of healthcare workers (HCW)

4. Potential explanations Factors influencing clinical practice Factors influencing clinical practice –Motivational predisposition to change –Economic factors –Political aspects –Organisational context Partial understanding of those factors Partial understanding of those factors

5. What about the quality of our interventions? Interventions can be developed according to... Interventions can be developed according to... –Our feeling and beliefs –The advise of others and experience –Planned models With and without reference to behavioural theory With and without reference to behavioural theory

6. Conceptual framework of intervention mapping (Bartholomew et al., 2011) 1. Needs assessment Assess health problem, population, determinants and context 2. Objectives State expected changes Specify performance and change objectives 3. Theory and practice Identify theoretical bases Select program method & practical applications 4. Program Develop program Produce material Identify partners 6. Evaluation Describe program outcomes and research questions Specify evaluation design 5. Implementation Identify implementation and adoption conditions

7. Degree of planning of interventions on HIV (Godin et al., 2007)

8. Introduction (4) Usefulness of psychosocial theories Usefulness of psychosocial theories –Few studies reviewed existing literature Mechanisms of adoption of behaviour Mechanisms of adoption of behaviour –Understand and predict intention and behaviours of HCW –Ultimately, change their behaviours

9. Clinical-related behaviours of healthcare workers: Determinants of adoption Godin, G., Bélanger-Gravel, A., Eccles, M., Grimshaw, J. (2008). Healthcare professionals’ intentions and behaviours: A systematic review of studies based on social cognitive theories. Implementation Science. 3: 36.

10. Studies included in the review (n =76) Longitudinal studies (n = 16) Longitudinal studies (n = 16) –Nurses (n = 7) –Physicians (n = 6) –Pharmacists (n = 2) –Other HCW (n = 1) Cross-sectional studies (n = 72) Cross-sectional studies (n = 72) –Nurses (n = 29) –Physicians (n = 29) –Pharmacists (n = 4) –Dentists (n = 2) –Other HCW (n = 8)

11. Clinical-related behaviours Nurses Nurses –Clinical practice (e.g., professional support for labour, pain management, providing care to patients, etc.) –Compliance with guidelines (e.g., hand hygiene and wearing gloves) –Documentation Physicians Physicians –Clinical practice (e.g., prescribing, performing an examination, referring patients to specialists, etc.) –Compliance with guidelines (e.g., hand hygiene and wearing gloves) –Counselling

12. Determinants of behaviour Variables Number of times Assessed p <.05 (%) Beliefs about capabilities 8 5 (62.5) Intention12 6 (50.0) Beliefs about consequences 9 4 (44.4) Social influences 6 2 (33.3) Past behaviour 5 1 (20.0) Knowledge2 1 (N/A) Other beliefs 4 0 (N/A) Personal characteristics 1 1 (N/A) Environmental factors 1 1 (N/A)

13. Determinants of intention Variables Number of times Assessed p <.05 (%) Beliefs about capabilities 65 51 (78.5) Beliefs about consequences 79 58 (73.4) Moral norm 14 10 (71.4) Social influences 75 47 (62.3) Role & identity 14 8 (57.1) Past behaviour 31 14 (45.2) Other beliefs 17 4 (4.3) Personal characteristics 29 11 (37.9) Environmental factors 4 1 (25.0)

14. Model efficacy for behaviour (n = 2 112; R 2 = 0.31) HCW Type of behaviours Nb. HCW (studies) Weighted R 2 Nurses Clinical practice Compliance - guidelines Documentation 220 (3) 225 (2) 158 (2) 0.410.190.09 Total 603 (7) 0.24 Physicians Clinical practice Compliance - guidelines Counselling 387 (4) 33 (1) 765 (1) 0.110.0010.40 Total 1 185 (6) 0.28 Other Clinical practice Counselling 284 (1) 40 (1) 0.580.33 Total 324 (2) 0.55

15. Model efficacy for intention (n = 14 986; R 2 = 0.59) HCW Type of behaviours Nb. HCW (studies) Weighted R 2 Nurses Clinical practice Technologies acceptance Compliance - guidelines Documentation 4 443 (21) 151 (1) 1 181 (5) 108 (1) 0.680.770.620.46 Total 5 883 (28) 0.66 Physicians Clinical practice Technologies acceptance Compliance - guidelines CounsellingDocumentation 2 185 (11) 1 150 (4) 762 (4) 1 146 (3) 180 (2) 0.540.680.500.280.19 Total 5 423 (24) 0.51

16. Model efficacy for intention (continued) HCW Type of behaviours Nb. HCW (studies) Weighted R 2 Other Clinical practice Compliance - guidelines Counselling 2 042 (6) 527 (1) 1 111 (5) 0.530.730.62 Total 3 680 (12) 0.59

17. Prediction model for clinical- related behaviours of HCW Beliefs about consequences Moral norm Social influences Role & identity Beliefs about capabilities INTENTIONBEHAVIOUR Habit / past behaviour Characteristics of HCW

18. Designing interventions Prediction model presented can guide the development of interventions with a high potential for effectiveness Prediction model presented can guide the development of interventions with a high potential for effectiveness Should be done and planned appropriately and according to the behavioural determinants and cognitive profile of HCW Should be done and planned appropriately and according to the behavioural determinants and cognitive profile of HCW

19. Conceptual framework of intervention mapping (Bartholomew et al., 2011) 1. Needs assessment Assess health problem, population, determinants and context 2. Objectives State expected changes Specify performance and change objectives 3. Theory and practice Identify theoretical bases Select program method & practical applications 4. Program Develop program Produce material Identify partners 6. Evaluation Describe program outcomes and research questions Specify evaluation design 5. Implementation Identify implementation and adoption conditions

20. Performance Objective Determinants Behaviour-1 Behaviour-2 Behaviour-3 Performance objectives and the determinants to be targeted

21. Type of intervention Motivational vs. Volitional (post- motivational) Motivational vs. Volitional (post- motivational) –Level of intention at baseline of participants Interventions are mainly evaluated using motivated volunteers Interventions are mainly evaluated using motivated volunteers

22. Outcome expectancies Intention Maintenance Self-efficacy Recovery Self-efficacy Action planning Coping planning Action control Action Barriers and resources (e.g., social support) Disengagement Motivational phaseVolitional phase Task self-efficacy Risk perception Health action process approach

23. Behaviour NoYes Motivated to adopt YesNo Motivational interventionVolitional intervention Etc…Settings CommunityClinical Theory A or ?Theory B or ? Techniques A, B, C or ? Techniques B, D, E or ? Gender WomenMen Techniques F, G, H or ? Techniques G, H, I or ? Intervention to maintain adherence Mode of delivery Telephone counselling Mass media Etc…

24. Performance Objective Determinants Behaviour change techniques Behaviour-1 Behaviour-2 Behaviour-3 Performance objectives, determinants to be targeted and behavior change technique

25. Which behaviour change techniques can be used to target the determinants? BCT group (Michie et al.) developed taxonomies of behaviour change techniques for different behaviours BCT group (Michie et al.) developed taxonomies of behaviour change techniques for different behaviours –Physical activity and healthy eating –Smoking cessation –Reducing excessive alcohol consumption –Condom use

26. The taxonomy (Michie et al., 2011) Contains 40 behaviour change techniques (BCT) Contains 40 behaviour change techniques (BCT) These techniques can be grouped according to the 12 theoretical domains of Michie et al. (2005) These techniques can be grouped according to the 12 theoretical domains of Michie et al. (2005)

27. Theoretical domains (Michie et al., 2005) 1. Knowledge 2. Skills 3. Social/professional role & identity 4. Beliefs about capabilities (self-efficacy, PBC) 5. Beliefs about consequences (attitude) 6. Motivation & goals (intention) 7. Memory, attention & decision processes 8. Environmental context & resources 9. Social influences (subjective norm, social support) 10. Emotion (anticipated regret, fear) 11. Behavioural regulation (action planning, coping planning) 12. Nature of behaviours (past behaviour)

28. AC BD Intention LowHigh Capabilities Low High Cognitive profiles of HCW

29. BCT for low intention & low capabilities AC BD Theoretical domains Techniques Motivation & goals (intention) Motivational interviewing Beliefs about consequences Provide information on consequences of behaviour Social influences Provide normative information about others’ behaviour Role & identity Prompt identification as role model / position advocate Beliefs about capabilities Set graded tasks

30. BCT for low intention & high capabilities AC BD Theoretical domains Techniques Motivation & goals (intention) Motivational interviewing / Goal setting (e.g., I will wash my hands before examining a patient) Beliefs about consequences Provide information on consequences of behaviour Social influences Provide normative information about others’ approval Role & identity Prompt identification as role model / position advocate

31. BCT for high intention & low capabilities AC BD Theoretical domains Techniques Beliefs about capabilities Barrier identification / problem solving Beliefs about capabilities Set graded tasks Beliefs about capabilities Provide feedback on performance Beliefs about capabilities Model / demonstrate the behaviour

32. BCT for high intention & high capabilities Ideal situation Ideal situation Action planning Action planning AC BD

33. Example of action planning

34. BCT for breaking habit Environmental restructuring Environmental restructuring Strategies to modify the daily routine Strategies to modify the daily routine Behavioural regulation techniques Behavioural regulation techniques –Coping planning

35. Example of coping planning

36. Conclusion

37. Conclusion Beliefs about capabilities and intention are the two main determinants of clinical-related behaviours of HCW Beliefs about capabilities and intention are the two main determinants of clinical-related behaviours of HCW Beliefs about capabilities, beliefs about consequences, moral norm, social influences and role & identity are the main determinants of intention Beliefs about capabilities, beliefs about consequences, moral norm, social influences and role & identity are the main determinants of intention

38. Conclusion (2) Identifying the determinants of behaviour and intention allows the development of interventions tailored to the cognitive profiles of HCW Identifying the determinants of behaviour and intention allows the development of interventions tailored to the cognitive profiles of HCW Also important to select behaviour change techniques appropriate for the cognitive profiles of HCW Also important to select behaviour change techniques appropriate for the cognitive profiles of HCW

39. Steps to evaluate the usefulness of theory for intervention Evaluate 1.Measurement of contructs 2.Mediation and moderation analyses Understand 1.Selection of the theory 2.Identification of determinants Plan 1.Selection of behavior change techniques (BCT) 2.Methodological considerations

40. Conclusion (3) There is room for innovation in the techniques used to change behaviour There is room for innovation in the techniques used to change behaviour It is important to… It is important to… –Understand before acting Theoretical model Theoretical model –Plan interventions Intervention mapping Intervention mapping Behaviour change techniques Behaviour change techniques

41. Clinical-related behaviours of healthcare workers: Planning interventions Bartholomew, L. K., Parcel, G. S., Kok, G., Gottlieb, N. H. & Fernandez, M. E. (2011). Planning health promotion programs: An intervention mapping approach (3 rd edition). San Francisco: Jossey-Bass. Godin, G., Gagnon, H., Alary, M., Lewy, J. J. & Otis, J. (2007). The degree of planning: An indicator of potential success of health education programs. Promotion & Education. 14, 138-142. Michie, S., Ashford, S., Sniehotta, F., Dombrowski, U., Bishop, A. & French, D. P. (2011). A refined taxonomy of behaviour change techniques to help people change their physical activity and healthy eating behaviours: The CALO-RE taxonomy. Psychology & Health, 26(11), 1479-1498. Michie, S., Johnston, M., Abraham, C., Lawton, R., Parker, A., Walker, A. (2005). Making psychological theory useful for implementing evidence-based practice: A consensus approach. Quality & Safety in Health Care. 14, 26-33.

42. QUESTIONS ? COMMENTS ? www.godin.fsi.ulaval.ca Thank you !