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Skip to 0 minutes and 6 seconds This article shows how application of behaviour change theory explain variation in the effectiveness of interventions in the Cochrane Review. It will introduce you to the behaviour change wheel, which will be covered in more detail later in the course. The objective of the Cochrane Review was to estimate the effectiveness and the safety of interventions to improve antibiotic prescribing to hospital inpatients, and investigate the effect of two intervention functions– restriction and enablement. Interventions are activities that are designed to change behaviours. Restriction and enablement are two of the nine interventions in the behaviour change wheel. The hub of the wheel identifies the sources of behaviour that could be fruitful targets for intervention. These are capability, opportunity, and motivation.

Skip to 0 minutes and 58 seconds The current version of the Cochrane Review is the second update of a review that was originally published in 2005. The protocol was informed by review of the interventions from the 89 studies in the previous update, which contained components that fulfil the definitions for five of the nine intervention functions in the behaviour change wheel. It’s important to note that most interventions included more than one intervention function. We expected that the interventions that included either enabling or restrictive elements would be more effective than those that did not. To be clear, some enabling or restrictive interventions also had educational persuasive elements and might also include environmental restructuring.

Skip to 1 minute and 43 seconds The Cochrane interventions with restrictive elements were all examples of using rules to reduce the opportunity to engage in the target behaviour through requiring expert approval or completion of compulsory order forms, or removal of target antibiotics from clinical areas, or use of automatic stop orders. Enablement is defined as increasing means or reducing barriers to increase capability or opportunity. Capability, opportunity, and motivation are the three components of the COMBI model of behaviour. We’ll discuss COMBI in detail later in the course. In the Cochrane Review, we use meta-regression to make two comparisons. First, interventions that had at least one restrictive element versus those that had none. And second, interventions that had at least one enabling element versus those that had none.

Skip to 2 minutes and 39 seconds The meta-regression used data from 29 randomised controlled trials and 91 ITS studies. 70% of the ITS studies were hospital-wide interventions, compared with 29% of the RCTs, the majority of which were located in single units within a hospital. The ITS studies, therefore, provide evidence of application of interventions in routine practice. The results provided high certainty evidence that interventions with at least one restrictive element were more effective than those that had none, and that those with at least one enabling element were more effective than those that had none. There were enough data to perform two additional analyses. First, we compared enabling interventions that included feedback with enabling interventions that did not use feedback, and found moderate evidence that feedback increased effectiveness.

Skip to 3 minutes and 32 seconds The evidence was downgraded because only 4 of the 23 randomised controlled trials in the analysis included feedback. Second, we compared restrictive interventions that included enabling components with restrictive interventions that did not, and found low certainty evidence that enablement increased the effectiveness of restriction. The evidence was downgraded to low certainty because there were no RCTs in the comparison. A previous Cochrane Review of 140 RCTs assessed the effects of audit and feedback on the practice of health care professionals in various clinical settings, including primary care. The review looked at the impact on patient outcomes and examined factors that may explain variation in the effectiveness of audit and feedback.

Skip to 4 minutes and 21 seconds Multiple variable meta-regression indicated that feedback may be more effective when first, the source is the supervisor or colleague; secondly, it is provided more than once; third, it is delivered in both verbal and written formats; and fourth, it includes both explicit targets and an action plan. We had intended to include explicit targets and action plans as effect modifiers in our meta-regression for the Cochrane Review interventions to improve antibiotic prescribing to hospital in-patients. We defined an explicit target as one that specified how good by when. For example, to achieve 95% compliance with a policy within three months of the start of the intervention.

Skip to 5 minutes and 6 seconds However, we found that how good by when targets weren’t specified for any of the 29 RCTs and were only specified in 9 of 91 ITS studies. We identified evidence of action planning in two, which is 50% of the RCTs, and 14– 56%– of 25 ITS studies with feedback. Overall, we were unable to analyse the effects of including both explicit targets and action plans in our data. In summary, we found high certainty evidence from 29 RCTs that interventions that included either restrictive or enabling elements were more effective than those that did not. And these results were confirmed in 91 ITS studies.

Skip to 5 minutes and 52 seconds In comparison with the RCTs, the ITS studies were more likely to be hospital-wide interventions and representative of real world anti-microbial stewardship practice. However, AMS teams need to apply evidence about behaviour change from other settings. The design of the 212 Cochrane Review of audit and feedback was informed by over 50 years of evidence about behaviour change techniques from psychology. This evidence showed that the effectiveness of feedback is likely to be enhanced by setting explicit targets and by using action planning when feedback shows that there is room for improvement. In this course, we’ll show you how you can apply behaviour change theory to facilitate systematic intervention design by addressing four questions. First, what behaviours are you trying to change?

Skip to 6 minutes and 41 seconds Second, what will it take to bring about the desired change? Third, what types of broad intervention approaches might be relevant? And fourth, what specifically should your intervention involve? At the end of the course, we’ll revisit the results the Cochrane Review of interventions to improve antibiotic prescribing to hospital in-patients. We will identify the behaviour change techniques that were used in the enabling interventions.

How did application of behaviour change theory explain variation in the effectiveness of interventions in the Cochrane review?

In this video presentation we introduce the Behaviour Change Wheel.

The objective of the Cochrane review was “To estimate the effectiveness and safety of interventions to improve antibiotic prescribing to hospital inpatients and investigate the effect of two intervention functions: restriction and enablement”.

In the Cochrane review we used Meta-regression to make two comparisons, which will be explored along with the full Meta-regression data in the PowerPoint slides.

In this course we will show how you can apply behaviour change theory to facilitate systematic intervention design by addressing four questions:

  1. What behaviours are you trying to change?
  2. What will it take to bring about the desired change?
  3. What types of broad intervention approaches might be relevant?
  4. What specifically should my intervention involve?

At the end of the course we will revisit the results of the Cochrane Review of Interventions to Improve Antibiotic Prescribing to Hospital Inpatients. We will identify the behaviour change techniques that were used in the enabling interventions.

For a brief summary on applying the Behaviour Change Wheel, please refer to the PDF under the downloads section.

Please find a downloadable PDF of the PowerPoint slides below.


After watching the video, please read the following question and share your comments below:

  • How do you think you could use the Behaviour Change Wheel in your practice?

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This video is from the free online course:

Utilising Social Science and Behaviour Change in Antimicrobial Stewardship Programmes: Improving Healthcare

BSAC