Prof. Gaston Godin, Ph.D. Laval University, Quebec May 9, 2012

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 • 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… • Individuals... as well as... • Healthcare workers • Gap between evidence-based practices and the routine clinical practices of healthcare workers (HCW)

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

5. What about the quality of our interventions? • 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

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

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

8. Introduction (4) • Usefulness of psychosocial theories • Few studies reviewed existing literature • 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. Longitudinal studies (n = 16) Nurses (n = 7) Physicians (n = 6) Pharmacists (n = 2) Other HCW (n = 1) Cross-sectional studies (n = 72) Nurses (n = 29) Physicians (n = 29) Pharmacists (n = 4) Dentists (n = 2) Other HCW (n = 8) Studies included in the review (n =76)

11. Clinical-related behaviours • 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 • 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

13. Determinants of intention

14. Model efficacy for behaviour (n = 2 112; R2 = 0.31)

15. Model efficacy for intention (n = 14 986; R2 = 0.59)

16. Model efficacy for intention (continued)

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

18. Designing interventions • 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

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

20. Performance objectives and the determinants to be targeted

21. Type of intervention • Motivational vs. Volitional (post-motivational) • Level of intention at baseline of participants • Interventions are mainlyevaluatedusingmotivatedvolunteers

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

23. Behaviour No Yes Motivated to adopt Intervention to maintainadherence Yes No Volitional intervention Motivational intervention Settings Etc… Etc… Community Clinical Theory A or ? Theory B or ? Mode of delivery Gender Mass media Telephonecounselling Women Men Techniques A, B, C or ? Techniques B, D, E or ? Techniques F, G, H or ? Techniques G, H, I or ?

24. 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 • 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) • These techniques can be grouped according to the 12 theoretical domains of Michie et al. (2005)

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

28. Cognitive profiles of HCW Intention Low High Low Capabilities High

29. BCT for low intention & low capabilities A C B D

30. BCT for low intention & high capabilities A C B D

31. BCT for high intention & low capabilities A C B D

32. BCT for high intention & high capabilities A C B D • Ideal situation • Action planning

33. Example of action planning

34. BCT for breaking habit • Environmental restructuring • Strategies to modify the daily routine • 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, 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 • Also important to select behaviour change techniques appropriate for the cognitive profiles of HCW

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

40. Conclusion (3) • There is room for innovation in the techniques used to change behaviour • It is important to… • Understand before acting • Theoretical model • Plan interventions • Intervention mapping • 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 (3rd 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. Thank you ! QUESTIONS ?COMMENTS ? www.godin.fsi.ulaval.ca