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Background Designing implementation interventions to change the behaviour of healthcare providers and other professionals in the health system requires detailed specification of the behaviour(s) targeted for change to ensure alignment between intervention components and measured outcomes. Detailed behaviour specification can help to clarify evidence-practice gaps, clarify who needs to do what differently, identify modifiable barriers and enablers, design interventions to address these and ultimately provides an indicator of what to measure to evaluate an intervention’s effect on behaviour change. An existing behaviour specification framework proposes four domains (Target, Action, Context, Time; TACT), but insufficiently clarifies who is performing the behaviour (i.e. the Actor). Specifying the Actor is especially important in healthcare settings characterised by multiple behaviours performed by multiple different people. We propose and describe an extension and re-ordering of TACT to enhance its utility to implementation intervention designers, practitioners and trialists: the Action, Actor, Context, Target, Time (AACTT) framework. We aim to demonstrate its application across key steps of implementation research and to provide tools for its use in practice to clarify the behaviours of stakeholders across multiple levels of the healthcare system. Methods and results We used French et al.’s four-step implementation process model to describe the potential applications of the AACTT framework for (a) clarifying who needs to do what differently, (b) identifying barriers and enablers, (c) selecting fit-for-purpose intervention strategies and components and (d) evaluating implementation interventions. Conclusions Describing and detailing behaviour using the AACTT framework may help to enhance measurement of theoretical constructs, inform development of topic guides and questionnaires, enhance the design of implementation interventions and clarify outcome measurement for evaluating implementation interventions.

Background Decreasing ineffective or harmful healthcare practices (de-implementation) may require different approaches than those used to promote uptake of effective practices (implementation). Few psychological theories differentiate between processes involved in decreasing, versus increasing, behaviour. However, it is unknown whether implementation and de-implementation interventions already use different approaches. We used the behaviour change technique (BCT) taxonomy (version 1) (which includes 93 BCTs organised into 12 groupings) to investigate whether implementation and de-implementation interventions for clinician behaviour change use different BCTs. Methods Intervention descriptions in 181 articles from three systematic reviews in the Cochrane Library were coded for (a) implementation versus de-implementation and (b) intervention content (BCTs) using the BCT taxonomy (v1). BCT frequencies were calculated and compared using Pearson’s chi-squared ( χ 2 ), Yates’ continuity correction and Fisher’s exact test, where appropriate. Identified BCTs were ranked according to frequency and rankings for de-implementation versus implementation interventions were compared and described. Results Twenty-nine and 25 BCTs were identified in implementation and de-implementation interventions respectively. Feedback on behaviour was identified more frequently in implementation than de-implementation ( Χ 2 (2, n =178) = 15.693, p = .000057). Three BCTs were identified more frequently in de-implementation than implementation: Behaviour substitution ( Χ 2 (2, n =178) = 14.561, p = .0001; Yates’ continuity correction); Monitoring of behaviour by others without feedback ( Χ 2 (2, n =178) = 16.187, p = .000057; Yates’ continuity correction); and Restructuring social environment ( p = .000273; Fisher’s 2-sided exact test). Conclusions There were some significant differences between BCTs reported in implementation and de-implementation interventions suggesting that researchers may have implicit theories about different BCTs required for de-implementation and implementation. These findings do not imply that the BCTs identified as targeting implementation or de-implementation are effective, rather simply that they were more frequently used. These findings require replication for a wider range of clinical behaviours. The continued accumulation of additional knowledge and evidence into whether implementation and de-implementation is different will serve to better inform researchers and, subsequently, improve methods for intervention design.

Background Implementing evidence-based care requires healthcare practitioners to do less of some things (de-implementation) and more of others (implementation). Variations in effectiveness of behaviour change interventions may result from failure to consider a distinction between approaches by which behaviour increases and decreases in frequency. The distinction is not well represented in methods for designing interventions. This review aimed to identify whether there is a theoretical rationale to support this distinction. Methods Using Critical Interpretative Synthesis, this conceptual review included papers from a broad range of fields (biology, psychology, education, business) likely to report approaches for increasing or decreasing behaviour. Articles were identified from databases using search terms related to theory and behaviour change. Articles reporting changes in frequency of behaviour and explicit use of theory were included. Data extracted were direction of behaviour change, how theory was operationalised, and theory-based recommendations for behaviour change. Analyses of extracted data were conducted iteratively and involved inductive coding and critical exploration of ideas and purposive sampling of additional papers to explore theoretical concepts in greater detail. Results Critical analysis of 66 papers and their theoretical sources identified three key findings: (1) 9 of the 15 behavioural theories identified do not distinguish between implementation and de-implementation (5 theories were applied to only implementation or de-implementation, not both); (2) a common strategy for decreasing frequency was substituting one behaviour with another. No theoretical basis for this strategy was articulated, nor were methods proposed for selecting appropriate substitute behaviours; (3) Operant Learning Theory makes an explicit distinction between techniques for increasing and decreasing frequency. Discussion Behavioural theories provide little insight into the distinction between implementation and de-implementation. Operant Learning Theory identified different strategies for implementation and de-implementation, but these strategies may not be acceptable in health systems. Additionally, if behaviour substitution is an approach for de-implementation, further investigation may inform methods or rationale for selecting the substitute behaviour.

Background Promoting the uptake of vaccination for infectious diseases such as COVID-19 remains a global challenge, necessitating collaborative efforts between public health units (PHUs) and communities. Applied behavioural science can play a crucial role in supporting PHUs’ response by providing insights into human behaviour and informing tailored strategies to enhance vaccination uptake. Community engagement can help broaden the reach of behavioural science research by involving a more diverse range of populations and ensuring that strategies better represent the needs of specific communities. We developed and applied an approach to conducting community-based behavioural science research with ethnically and socioeconomically diverse populations to guide PHUs in tailoring their strategies to promote COVID-19 vaccination. This paper presents the community engagement methodology and the lessons learned in applying the methodology. Methods The community engagement methodology was developed based on integrated knowledge translation (iKT) and community-based participatory research (CBPR) principles. The study involved collaboration with PHUs and local communities in Ontario, Canada to identify priority groups for COVID-19 vaccination, understand factors influencing vaccine uptake and co-design strategies tailored to each community to promote vaccination. Community engagement was conducted across three large urban regions with individuals from Eastern European communities, African, Black, and Caribbean communities and low socioeconomic neighbourhoods. Results We developed and applied a seven-step methodology for conducting community-based behavioural science research: (1) aligning goals with system-level partners; (2) engaging with PHUs to understand priorities; (3) understanding community strengths and dynamics; (4) building relationships with each community; (5) establishing partnerships (community advisory groups); (6) involving community members in the research process; and (7) feeding back and interpreting research findings. Research partnerships were successfully established with members of prioritized communities, enabling recruitment of participants for theory-informed behavioural science interviews, interpretation of findings, and co-design of targeted recommendations for each PHU to improve COVID-19 vaccination uptake. Lessons learned include the importance of cultural sensitivity and awareness of sociopolitical context in tailoring community engagement, being agile to address the diverse and evolving priorities of PHUs, and building trust to achieve effective community engagement. Conclusion Effective community engagement in behavioural science research can lead to more inclusive and representative research. The community engagement approach developed and applied in this study acknowledges the diversity of communities, recognizes the central role of PHUs, and can help in addressing complex public health challenges.

Vaccination in pregnancy (VIP) protects pregnant individuals and their newborns; yet, uptake remains suboptimal. Pregnant individuals face unique decision-making challenges, and communication with their health care provider (HCP) is crucial for uptake. While there is extensive data on barriers to VIP, interventions applying evidence-based behavior change strategies and co-designed with end users are scarce. Our prior work indicated that a new Canadian intervention was needed. This study aimed to co-design a multicomponent intervention to support informed decision-making and vaccine communication in pregnancy. Our multimethod study followed the Double Diamond phases (ie, Discover, Define, Develop, and Deliver) and partnered with a diverse patient advisory council and a multidisciplinary team of HCPs. During the Discover and Define phases, our previous work, we explored gaps and barriers to VIP in Canada and defined the behavior change strategies to address those needs. During the Develop phase, we co-designed and conducted iterative prototyping of four intervention components: (1) a pregnancy-specific communication approach, (2) a skills course for HCPs, (3) a practice change plan, and (4) a website with evidence-based resources for patients and HCPs. We used online and in-person participatory co-design sessions and peer-to-peer, patient-oriented online focus groups and semistructured in-depth interviews. During the Deliver phase, we refined the intervention components through functionality and usability testing. The Vaccines in Pregnancy Canada (VIP Canada) intervention consists of four integrated components: (1) DECIDE (Determine, Elicit, Consent, Interactive discussion, Deliver, and Empower): a patient-centered, pregnancy-specific communication approach for providers to deliver a clear vaccine recommendation while respecting autonomy. (2) Skills course for HCPs: 4 self-paced, online modules to learn the rationale for VIP and the DECIDE communication approach and 2 group sessions. Providers found the skills course clear, practical, and applicable across diverse clinical roles and settings. Feedback led to enhancements, including improved audio-visual synchronization, consistent closed captioning, and the addition of downloadable reference materials to support learning. (3) Practice change plan: an action plan HCPs make to integrate vaccine communication into their practice. (4) VIP Canada website: an evidence-based website with resources to support informed vaccine decision-making for patients and providers. Patient feedback informed iterative refinements to the layout and content of the website to enhance navigation, readability, and representation of diverse identities. Functionality and usability testing demonstrated that patients found the VIP Canada website visually appealing, easy to navigate, and supportive of informed decision-making. The VIP Canada is a promising intervention co-designed to drive behavior change by addressing key barriers to vaccine communication and informed decision-making around our patient partners' and HCPs' perspectives and lived experiences to bridge theoretical frameworks with real-world relevance. Next steps include a feasibility study for further refinement and a subsequent effectiveness study.

Background Routine pre-operative tests for anesthesia management are often ordered by both anesthesiologists and surgeons for healthy patients undergoing low-risk surgery. The Theoretical Domains Framework (TDF) was developed to investigate determinants of behaviour and identify potential behaviour change interventions. In this study, the TDF is used to explore anaesthesiologists’ and surgeons’ perceptions of ordering routine tests for healthy patients undergoing low-risk surgery. Methods Sixteen clinicians (eleven anesthesiologists and five surgeons) throughout Ontario were recruited. An interview guide based on the TDF was developed to identify beliefs about pre-operative testing practices. Content analysis of physicians’ statements into the relevant theoretical domains was performed. Specific beliefs were identified by grouping similar utterances of the interview participants. Relevant domains were identified by noting the frequencies of the beliefs reported, presence of conflicting beliefs, and perceived influence on the performance of the behaviour under investigation. Results Seven of the twelve domains were identified as likely relevant to changing clinicians’ behaviour about pre-operative test ordering for anesthesia management. Key beliefs were identified within these domains including: conflicting comments about who was responsible for the test-ordering (Social/professional role and identity); inability to cancel tests ordered by fellow physicians (Beliefs about capabilities and social influences); and the problem with tests being completed before the anesthesiologists see the patient (Beliefs about capabilities and Environmental context and resources). Often, tests were ordered by an anesthesiologist based on who may be the attending anesthesiologist on the day of surgery while surgeons ordered tests they thought anesthesiologists may need (Social influences). There were also conflicting comments about the potential consequences associated with reducing testing, from negative (delay or cancel patients’ surgeries), to indifference (little or no change in patient outcomes), to positive (save money, avoid unnecessary investigations) (Beliefs about consequences). Further, while most agreed that they are motivated to reduce ordering unnecessary tests (Motivation and goals), there was still a report of a gap between their motivation and practice (Behavioural regulation). Conclusion We identified key factors that anesthesiologists and surgeons believe influence whether they order pre-operative tests routinely for anesthesia management for a healthy adults undergoing low-risk surgery. These beliefs identify potential individual, team, and organisation targets for behaviour change interventions to reduce unnecessary routine test ordering.

Background Ensuring widespread COVID-19 vaccine uptake is a public health priority in Canada and globally, particularly within communities that exhibit lower uptake rates and are at a higher risk of infection. Public health units (PHUs) have leveraged many resources to promote the uptake of recommended COVID-19 vaccine doses. Understanding barriers and facilitators to vaccine uptake, and which strategies/resources have been used to address them to date, may help identify areas where further support could be provided. We sought to identify the strategies/resources used by PHUs to promote the uptake of the first and third doses of the COVID-19 vaccine among priority groups in their jurisdictions. We examined the alignment of these existing strategies/resources with behavioral science principles, to inform potential complementary strategies/resources. Methods We reviewed the online and in-person strategies/resources used by three PHUs in Ontario, Canada to promote COVID-19 vaccine uptake among priority groups (Black and Eastern European populations, and/or neighbourhoods with low vaccine uptake or socioeconomic status). Strategies/resources were identified from PHU websites, social media, and PHU liaison. We used the Behaviour Change Techniques (BCT) Taxonomy – which describes 93 different ways of supporting behaviour change – to categorise the types of strategies/resources used, and the Theoretical Domains Framework – which synthesises 14 factors that can be barriers or facilitators to decisions and actions – to categorise the barriers and facilitators addressed by strategies/resources. Results PHUs operationalised 21 out of 93 BCTs, ranging from 15 to 20 BCTs per PHU. The most frequently operationalised BCTs were found in strategies/resources that provided information about COVID-19 infection and vaccines, increased access to COVID-19 vaccination, and integrated social supports such as community ambassadors and engagement sessions with healthcare professionals. Identified BCTs aligned most frequently with addressing barriers and facilitators related to Knowledge, Environmental context and resources, and Beliefs about consequences domains. Conclusion PHUs have used several BCTs to address different barriers and facilitators to COVID-19 vaccine uptake for priority groups. Opportunities should be pursued to broaden the scope of BCTs used (e.g., operationalizing the pros and cons BCT) and barriers/facilitators addressed in strategies/resources for ongoing and future COVID-19 vaccine uptake efforts among general and prioritised populations.

IntroductionOverprescription of antibiotics poses a significant threat to healthcare globally as it contributes to the issue of antibiotic resistance. While antibiotics should be predominately prescribed for bacterial infections, they are often inappropriately given for uncomplicated upper respiratory tract infections (URTIs) and related conditions, such as the common cold. This study will involve a qualitative systematic review of physician-reported barriers to using evidence-based antibiotic prescription guidelines in primary care settings and synthesise the findings using a theoretical basis.Methods and analysisWe will conduct a systematic review of qualitative studies that assess physicians’ reported barriers to following evidence-based antibiotic prescription guidelines in primary care settings for URTIs. We plan to search the following databases with no date or language restrictions: MEDLINE, Web of Science, CINAHL, Embase, the Cochrane Library and PsycInfo. Qualitative studies that explore the barriers and enablers to following antibiotic prescription guidelines for URTIs for primary care physicians will be included. We will analyse our findings using the Theoretical Domains Framework (TDF), which is a theoretically designed resource based on numerous behaviour change theories grouped into 14 domains. Using the TDF approach, we will be able to identify the determinants of our behaviour of interest (ie, following antibiotic prescription guidelines for URTIs) and categorise them into the 14 TDF domains. This will provide the necessary information to develop future evidence-based interventions that will target the identified issues and apply the most effective behaviour change techniques to affect change. This protocol follows the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols guidelines.Ethics and disseminationEthical approval is not required. Findings will be published in a peer-reviewed journal and presented at conferences.

Introduction Engaging with patients about their lived experience of health and illness and their experience within the healthcare system can help inform the provision of care, health policies and health research. In the context of health research, however, operationalizing the levels of patient engagement is not straightforward. We suggest that a key challenge to the routine inclusion of patients as partners in health research is a lack of tangible guidance regarding how this can be accomplished. Methods In this article, we provide guidance on how to codesign and operationalize a concrete patient engagement plan for any health research project. Results We illustrate a seven‐step approach using the example of a national clinical trial in Canada and provide a patient engagement planning template for use in any health research project. Conclusion Such concrete guidance should improve the design and reporting of patient engagement in health research. Patient or Public Contribution The De‐Implementing Wisely Research group is informed by a national 9‐member patient partner council (PPC). The research team includes three lead patient partners who are coinvestigators on the grant that funds the program of research. Members of the council advise on all aspects of the study design and implementation. The ideas presented in this paper were informed by regular communication and planning with the PPC; specific contributions of lead patient partner authors are outlined as follows: Brian Johnston, Susan Goold and Vanessa Francis are patient partners with a wide breadth of experience in the healthcare system and health research projects. The guidance in this article draws on their lived and professional expertise. All patient partner authors contributed to the planning of the manuscript, participated in meetings to develop content and provided critical manuscript edits and comments on drafts.

Background Despite availability of effective screening and treatment for Hepatitis C (HCV), the uptake remains suboptimal. Immigrants from HCV endemic countries comprise 35% of cases in Canada. There is an average 10-year diagnosis delay, causing poor health outcomes and high healthcare system costs. Therefore, we aimed to understand immigrants’ perceptions and beliefs about HCV, as well as the barriers and enablers to HCV care among immigrants, with a focus on individuals from Egypt, given the country’s high endemic rates of HCV infection and the large Egyptian community in Canada. Methods We established a Community Advisory Group to provide advice at all stages. We used a qualitative-descriptive design guided by the Common-Sense Self-Regulation Model and Theoretical Domains Framework to perform semi-structured interviews with adult immigrants from Egypt (with or without HCV) in Ottawa, Canada. Sampling continued until thematic saturation was achieved. The interviews were double-coded and key findings were identified. Results We conducted interviews with 18 individuals (eight females, ten males), including 12 who had undergone HCV screening. Among them, seven had tested positive, and all had received treatment. While all participants were aware of HCV, misconceptions and a lack of knowledge regarding its symptoms, modes of transmission, and treatment options were prevalent. Many stated that they would not seek screening in the absence of significant symptoms. Perceived stigma associated with HCV and experiences of ethnocultural discrimination discouraged some individuals from seeking care. Additionally, challenges such as limited access to family doctors and long wait times were frequently cited as barriers. However, those who had received HCV treatment reported positive experiences and remained engaged in follow-up care. Conclusion There is an urgent need to improve access to care for immigrants from endemic countries to eliminate HCV in Canada. We took a systematic, theory-informed approach to understand lived experiences and views among Egyptian immigrants in Canada. We identified key factors contributing to the low uptake of HCV screening and treatment. These findings will inform a theory-based intervention to optimize HCV care in immigrant communities.