Behavioural approaches to knowledge translation

Jeremy Grimshaw MD, PhDClinical Epidemiology Program, OHRI

Department of Medicine, University of OttawaCanada Research Chair in Health Knowledge Transfer and Uptake

Personal background

• Trained as family doctor in UK• PhD in health services research• Developed implementation research program in

UK• Moved to Canada in 2002

Personal background

• Focus has been on:• professional and organizational behavior

change.• improving technical aspects of care ie how do

we ensure patients get the right (evidence based) treatments at the right time.

• populations of physicians and health care organizations.

Background

Why do we need to think about knowledge translation? • Consistent evidence of failure to translate research

findings into clinical practice• 30-40% patients do not get treatments of proven

effectiveness• 20–25% patients get care that is not needed or

potentially harmfulSchuster, McGlynn, Brook (1998). Milbank Memorial Quarterly

Grol R (2001). Med Care

• Structural (e.g. financial disincentives)

• Organisational (e.g. inappropriate skill mix, lack of facilities or equipment)

• Peer group (e.g. local standards of care not in line with desired practice)

• Professional (e.g. knowledge, attitudes, skills)

• Limitations of human information processing

• Immediate clinical environment

Potential barriers to knowledge translation

Knowledge to action cycle

Knowledge to Action loopFrom: Graham ID et al. Lost in Knowledge Translation: Time for a Map? Journal of Continuing Education in the Health Professions, 2006

Approaches to knowledge translation

ISLAGIATT principle

Martin P Eccles

‘It Seemed Like A Good Idea At The Time’

Behavioural perspective on Knowledge Translation

• KT depends on behaviour• Citizens, health professionals, managers, policy

makers, commissioners• To improve KT need to change behaviour• To change behaviour, helps to understand how behaviour

changes• Alternative is “trial and error”

• Substantial body of empirical and theoretical insights from behavioural and organisational sciences

Identifying behaviours of interest

• What is the behavior (or series of linked behaviors) that you are trying to change?

• Who performs the behavior(s)? (potential adopter)• When and where does the potential adopter perform the

behavior?• Are there obvious practical barriers to performing the

behavior?• Is the behavior usually performed in stressful

circumstances? (potential for acts of omission)

Assessing barriers to KT

• Formal assessment of context, likely barriers to KT

• Mixed methods• Literature review• Informal consultation• Focus groups• Surveys

• Needs interdisciplinary perspective

Assessing barriers to KT

Why use theory?• Interventions are likely to be more effective if they target

determinants of behaviour• Theoretical frameworks facilitate accumulation and

integration of evidence• across context, population and behaviour• of effects and of causal mechanisms

• Allows refinement and development of theory and, hence, more effective interventions

Assessing barriers to KT

Assessing barriers to KT

Determinants of behaviour• Knowledge• Skills• Social/professional role and identity • Beliefs about capabilities• Beliefs about consequences• Motivation and goals• Memory, attention and decision processes• Environmental context and resources • Social influences• Emotion• Behavioural regulation• Nature of the behaviours

Michie (2005) Quality and Safety in Health Care

Assessing barriers to KT

Assessing barriers to KT

IMPLEMENT• Focus groups, theoretical approach• Ongoing cluster RCT to develop and evaluate

intervention to improve GP management of low back pain ( diagnostic imaging, exercise)

• Conducted focus group with 42 general practitioners

• Focus group analysis based upon the “BPS domains”

Knowledge

Professional role and identity

Beliefs about capabilities

Beliefs about consequences

Motivation and goals

Environmentalcontext andresources

Social influences

Emotion

Behaviouralregulation

Nature of the behaviours

Memory and decision

processes

Skills

Michie (2005). Journal of Quality and Safety in Health Care.

Assessing barriers to KT

Designing KT interventions

• Methods of designing programs• Empirical • Intervention mapping

• Commonsense• Theory informed

Designing KT interventions

Designing interventions

Designing KT interventions

• Choice of dissemination and implementation should be based upon:• ‘Diagnostic’ assessment of barriers• Understanding of mechanism of action of

interventions• Empirical evidence about effects of interventions• Available resources• Practicalities, logistics etc

Designing KT interventions

Behaviour Change Techniques

Modes of Delivery

Theory / Mediators

Designing KT interventions

Modes of delivery • Educational materials• Educational meetings• Educational outreach• Audit and feedback• Opinion leaders• Mass media• Reminders • Tailored interventions• Multifaceted• Organisational

Designing KT interventions

Behaviour change techniques• Provide information about

behavior- health link. • Provide information on

consequences • Provide information about others’

approval • Prompt intention formation• Prompt barrier identification • Provide general encouragement

• Set graded tasks • Provide instruction • Model/ demonstrate the behavior • Prompt specific goal setting • Prompt review of behavioral goals

• Prompt self-monitoring of behavior

• Provide feedback on performance • Provide contingent rewards • Teach to use prompts/ cues • Agree behavioral contract • Prompt practice • Use follow up prompts • Provide opportunities for • Social comparison • Plan social support/ social change• Prompt identification as role model• Prompt self talk• Relapse prevention• Stress management • Motivational interviewing• Time management

Designing KT interventions

Technique for behaviour change

Social/ Professional role & identity

Knowledge Skills Beliefs about capabilities

Beliefs about consequences

Motivation and goals

Memory, attention, decision processes

Environmental context and resources

Social influences

Emotion Action planning

Goal/target specified:

1 2 1 3 2 3 1 3 1 3 3 3 3 1 1 1 1 1 1 3 2 3 3

Monitoring 1 2 3 3 3 1 2 2 1 2 2 1 2 2 1 2 2 2 1 2 2 1 1 2

Self-monitoring 2 3 3 3 3 2 3 3 2 2 2 1 3 2 1 2 2 3 2 1 3

Contract 2 1 1 1 1 1 2 3 1 2 2 3 2 2 2 2

Rewards; 1 2 1 1 3 3 3 2 1 2 1 2 2 3 3 3 1 1 2 1 1 2 1 2 1 2 1 1

Graded task, 1 1 3 3 2 2 2 3 2 2 3 2 2 1 2 1 1 1 1 2 1*

Increasing skills: 1 2 3 3 3 3 2 2 3 2 1 2 3 2 1 2 1 2 3 1

Stress management

1 1 2 1 1 1 1 1 2 1 1 2 1 1 3 3 2 1 1

Coping skills 1 2/3 3 1 2 2 2 1 1 1 1 1 1 3 2 2 1/2

Rehearsal of relevant skills

1 3 3 3 3 2 3 2 2 1 2 1 3 2 3 1 1

agree use; agree don’t use; disagreement; indefinite

Designing KT programs– IMPLEMENT example

• What we are trying to change? • Knowledge of what red flags are and skills in how to

identify them and diagnose acute low back pain• Why are we trying to change it?

• Construct: Knowledge (GP)• How are we going to change it?

• Technique: Information provision• Context: educational meeting; advertising campaign• Content: Behavioural task with feedback; eg in pairs

run through the process; quiz?; practise use of an algorithm

Designing KT programs– IMPLEMENT example

• What we are trying to change? • Skills and beliefs about capabilities related to giving advice to

stay active (inc what advice to give) • Why are we trying to change it?

• Construct: Skills, Knowledge (GP), Beliefs about capabilities • How are we going to change it?

• Technique: behavioural rehearsal; role play; scripting • Context: educational meeting; advertising campaign• Content: Participants write down wording of their last or usual

message to stay active and then discuss in groups of 2-4 and create a script they feel comfortable with. Then role play with feedback. Educators model if necessary. Idea is that GPs should feel comfortable with wording of their own script, compared with a generic script, so that it is in their own language and consistent with the way they speak, behave, etc

Designing KT programs– IMPLEMENT example Intervention

Method of delivery• Two small group educational meetings• Homework• Educational materials

Session One. Confidence in Diagnosis

Section Title Behaviour change techniques delivered Content

Welcome and Introductions

- Information provision Group introductions; Agenda and content for session

Small group work No.1: Discussion of pre-session reflective activity about x-ray

- Prompt barrier identification- Persuasive communication- Provide information on consequences- Provide opportunities for social

comparison

- Discussion in small groups (3-4) and fed back to larger group about implementing the key message about x-ray use

- Facilitator recorded barriers and enablers and revisited throughout session

Guideline recommendations

- Information provision - Persuasive communication

- Didactic presentation from facilitator with group discussion

- Introduction to acute non-specific LBP; Guideline development and stakeholders; Overview of guideline key messages

Small group No.2: Making recommendations behaviourally specific

- Prompt barrier identification - Participants reworded x-ray key message from guideline - by who, applying to who, what, where, when

Revisit small group discussions No.1 and No.2

- Persuasive communication - All group discussion. Facilitator challenged negative beliefs using persuasive communication and reinforce relevance of key message to GPs and LBP patients

Plain film x-ray for acute LBP

- Provide information on consequences- Persuasive communication

- Didactic presentation from radiologist, outlining potential harms and non-utility of x-ray for LBP

Red flag screening - Model/demonstrate the behaviour - Peer expert took clinical history of simulated patient demonstrating red flag screening and resisting pressure from patient to order an x-ray

Small group No.3:Red flag screening

practical

- Prompt practice (rehearsal)- Provide information on consequences- Persuasive communication

- Participants took clinical history of trained simulated patients who are demanding a x-ray

- Group discussion including feedback from simulated patients

Summary - Prompt barrier identification- Persuasive communication- Provide opportunities for social

comparison

- Group discussion - reflect on barriers on whiteboard- Questions; outstanding issues

Session 1

Summary

• Professional behaviour is a key proximal determinant of knowledge translation

• Using a behavioural perspective to KT highlights substantial empirical and theoretical insights (and practical tools) from behavioural and organisational disciplines

• Use of behavioural and organisational theory to assess barriers to KT and design KT interventions potentially increases transparency around hypothesised mechanism of action and logic model of interventions

Contact details

• Jeremy Grimshaw - jgrimshaw@ohri.ca• EPOC – epoc@uottawa.ca• Rx for Change database of appraised reviews of

professional behaviour change - www.rxforchange.ca

• KT Canada - http://ktclearinghouse.ca/ktcanada