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How can behaviour and social sciences help?
In this video, we introduce how a systematic behavioural change approach can be applied to Antimicrobial Stewardship.
Hello, my name is Fabiana Lorencatto. I’m a health psychologist and behavioural scientist. I currently work as the research lead at the Centre for Behaviour Change at the University College London, where we currently have a number of research studies underway related to antimicrobial stewardship. In this introductory module, I’m going to highlight why and how the behavioural and social sciences can contribute to the design of interventions to increase antimicrobial stewardship. The aim of this module is to set the scene for the remainder of the course. It’s, therefore, essentially the background introductory module.
I’m going to begin by briefly explaining why we should think about behaviour and behaviour change when it comes to designing interventions to change health care professional practise, sometimes referred to as health care quality improvement, or QI interventions. I’ll then go on to outline some of the limitations and common pitfalls in the typical way we often approach the design of quality improvement interventions before introducing the basic principles and steps of a behavioural science approach to designing interventions. We will impact these steps in much further detail in the subsequent modules. OK, let’s get started. So Behaviour change is an increasingly popular concept.
It’s one of those buzzwords, key terms, you’ve often probably heard of in relation to health care research and quality improvement practise. But I want to start off by thinking about why is it relevant to health care quality improvement, and why should we think about Behaviour change when it comes to designing interventions to change or improve health care? Evidence-based medicine has become the gold standard approach in health care. It’s an approach to optimising medical practise, which advocates that, to the greatest extent possible, we should base health care decisions and policies on evidence from well-designed and well-conducted research. Not just the beliefs of practitioners, experts, or administrators.
This approach is underpinned by the fundamental assumption that, if we increase health care professionals knowledge of what best practise and evidence is, for instance, by disseminating guidelines and policies summarising evidence based recommendations and standards of care– that this will result in patients getting evidence-based care. That is, there is a straight line, or bridge, between evidence and practise. However, I’m sure we all know from experience that the translation of evidence into practise is rarely a linear, or straightforward, process, and indeed, it often looks a little more like this– messy and complicated with lots of curved and broken lines. Indeed, health care professionals often know about the evidence or guidelines.
They know what best practise is, but the right thing to do may be difficult to implement in practise for all sorts of good reasons– resulting in evidence practise gaps. These failures to translate best practise evidence into routine clinical practise are sometimes referred to as implementation gaps. These implementation gaps are not a new or recent issue. There are decades, over 50 years worth, of health services and implementation research demonstrating the overuse, under use, and misuse of many types of health care processes– such as ordering of tests, diagnostics, prescribing of medications, communication or advice giving, providing referrals, et cetera.
These implementation gaps are not unique to any professional group or care setting and have been documented across clinical domains from acute to chronic care. For instance, there is evidence that between 30% and 40% of patients do not receive evidence-based healthcare. More worryingly, in some instances, patients even receive care that is unnecessary or even harmful. Combined, these implementation gaps mean that patients often miss opportunities to receive the best possible care and achieve the best possible clinical outcomes. Antimicrobial stewardship is no exception to this. For instance, although antibiotic overuse is widely acknowledged by health care professionals, antibiotics continue to be prescribed to patients who are unlikely to benefit.
For example, across health care settings, the proportion of antibiotic prescriptions that are either unnecessary or suboptimal in terms of choice of drug, dose, duration of therapy ranges from at least 20% in primary care to 30% to 40% in secondary care and up to 75% in care homes. These estimates highlight the difficulties experienced by prescribers who have to, first, determine the patient’s likelihood of bacterial infection before judging whether the public health need to restrict antibiotic use outweighs the risk to the patient of delaying or withholding antibiotic treatment. In recognition of these implementation gaps, health professionals, organisations, and systems have often invested substantial effort and resources into designing, and implementing, and testing quality improvement interventions to try to improve performance and outcomes.
For instance, antimicrobial stewardship programmes are a type of quality improvement intervention. The 2017 Cochrane Review of anti-microbial stewardship interventions for secondary care alone included over 200 interventions. That is a tremendous amount of resource, time and effort invested into designing and testing interventions in this area. Yet more often than not, when we look at reviews of how effective health care quality improvement interventions are, we almost always find the same thing. Overall, they work. They improve practise and clinical outcomes, but the effects of these interventions are often not large. They are modest at best, and more importantly, they can vary substantially.
Sometimes, the same type of intervention targeting the same Behaviour in the same setting works really well– other times, less well or even makes things worse. Peter will impact this further when discussing the findings from the Cochrane Review of secondary care interventions in a later module. However, this, in turn, begs the question as to why? Why are these interventions not working as optimally or consistently as they could be? Now there are a whole host of factors that could be contributing to this, but one key factor, that has been highlighted in implementation science literature, is that we are often not approaching the challenge of quality improvement in terms of Behaviour and Behaviour change.
Indeed, the aforementioned areas for which implementation gaps have been documented such as test ordering, prescribing of medications, referrals, communication, et cetera are all actions and, therefore, are all types of human Behaviour. If we recognise that clinical practise is a form of human Behaviour, then implementing evidence into practise or bringing about changes and improvements in clinical practise will require Behaviour change. There is a common misconception that Behaviour change is just about individuals, whereas quality improvement requires change across organisational levels. However, organisations are made up of individuals, and organisations will, therefore, change when people or individuals within these organisations change.
As such, improving the quality of health care depends on changing Behaviour of many different types of people and roles at different levels within organisational systems and networks, from different healthcare professional groups to support staff, commissioners, managers, policymakers, and also patients themselves. However, when it comes to traditional approaches to quality improvement, interventions are often designed in, what has been termed by Professor Martin Eccles, as the ISLAGIATT approach to intervention design. That is, it seemed like a good idea at the time. By that, I mean we often spot a problem or an implementation gap, and we rush to a solution or intervention to try and fix it. Sometimes, we are just under pressure to just do something.
Often, the choice of intervention strategy or approach does not have a specific rationale or justification. Instead, the choice of intervention is based on gut instincts, best guesses, or hunches as what needs to change and what will work to bring about that change. We are all human, right? We all do Behaviour, so Behaviour is common sense. More often than not, this assumption is that if we just educate and tell people what to do, this will help bring about change.
Although education and knowledge play absolutely vital roles in quality improvement, we now have a growing body of evidence that shows that factors influencing clinical practise behaviours are far more wide ranging than knowledge gaps alone and include other motivational, sociocultural, and environmental factors. Therefore, education on its own is unlikely to be the only or best strategy for achieving successful change. Similarly, another common pitfall is basing the choice of intervention on the fact that it worked elsewhere. Although, there are valuable lessons to be learned from implementation successes in other clinical areas and domains, as we will discuss over this course, Behaviour is highly context specific.
We cannot assume an intervention that has worked elsewhere will translate with equal success to the clinical Behaviour area or even your local hospital setting in which you are trying to achieve change. Now sometimes ISLAGIATT works. There is an arguably a value to be placed on familiarity and experience with the problem you are trying to change, which sometimes does lead to the intervention, which was chosen on a gut instinct or hunch, to working very well. However, more often than not, ISLAGIATT does not work, resulting in a waste of quality improvement resources and efforts. Furthermore, not having a why– that is, an explicit justification for the choice of intervention– means we don’t really know what’s in the intervention.
We don’t know why or how it works. What we have is a black box, which makes it very difficult to understand how the intervention worked and, therefore, explain implementation successes or failures. It also makes it very hard to learn from these implementation successes and failures in order to replicate interventions or scale them up if they have been shown to be successful. ISLAGIATT, or the lack of systematic intervention design, is a systemic issue across many areas of quality improvement. But again, antimicrobial stewardship does not appear to be an exception. There have been a number of reviews looking at how antimicrobial stewardship programmes have been traditionally designed.
These identify a number of limitations, including, first, there is often a lack of an explicit rationale or justification for the choice of the content and design of an antimicrobial stewardship programme or intervention. That is typical ISLAGIATT approach. Second, few interventions take into account the wide range of behavioural and social influences on antimicrobial use when deciding on what the intervention should include. Third, and lastly, interventions are seldom designed based on behavioural theory or incorporate Behaviour change techniques, so there is definitely room for improvement in how we approach the design of antimicrobial stewardship programmes and quality improvement interventions, more generally. So how can we do better?
I’m now going to introduce some of the basic principles in how we, in the behavioural and social sciences, approach the design of Behaviour change interventions. The analogy we often use to introduce this approach is that of simply going to see your doctor or General Practitioner, GP. Let’s say you have a physical symptom or illness that you’re concerned with. You decide to go see your doctor or GP for advice and possibly treatment. You would expect or hope that your GP would first examine you to identify your symptoms. Use this to make a formal diagnosis of what these symptoms are.
And then use that to match the choice of treatment to your symptoms in order to ensure you are getting the right type of treatment that is most likely to be appropriate and effective for treating your specific symptoms. There is no ISLAGIATT here. There’s no rushing to prescribe a treatment based on a hunch or gut instinct as to what’s wrong with you, although I’m sure this does happen sometimes in practise. Rather, there is a systematic linkage of diagnosis to treatment. In our discipline, we would argue that we should approach the design of behavioural interventions in the same way.
When selecting the type of intervention, that we’re going to use, we should first conduct a behavioural diagnosis to identify what factors are influencing or driving the Behaviour of interest– that is, the barriers and enablers to Behaviour change. We can, then, use this evidence to inform, or match, or tailor the choice of Behaviour change strategy we are going to use. This is the key principle in a behavioural science approach and one that we will unpack in detail over the subsequent modules. Indeed, the key conclusion and recommendations from a number of reviews and commentaries on antimicrobial stewardship have also argued that taking such a behaviorally informed interdisciplinary approach is needed in order to advance practise and research in antimicrobial stewardship.
Designing interventions based on a theoretical understanding of Behaviour is also considered best practise. This figure is the Medical Research Council guidance for designing and evaluating complex interventions, and Behaviour change interventions are certainly complex. This framework is widely recognised as best practise internationally. It advocates commencing with a systematic intervention development phase, drawing on theory and evidence as to what is driving the Behaviour of interest, and using this as a basis for developing the intervention. Whilst this framework advocates for this approach however, it does not go into specific detail as to how to achieve this and how to actually take a theory-driven systematic approach to intervention design. This is where the behavioural and social sciences come in and can facilitate or contribute.
They can help put the flesh on the bones of the Medical Research Council guidance. The behavioural and social sciences are a collection of disciplines dedicated to scientifically studying human Behaviour and include disciplines such as psychology, sociology, geography, economics, and many more. In terms of what these disciplines can offer, it is important to start with the health warning, or recognition, that there are no magic bullets when it comes to Behaviour change. No single discipline has the answer or universal truth as to what will work to change Behaviour in all instances. There are so many different types of behaviours, and what drives these different behaviours across different settings and contexts is likely to vary significantly.
So it is impossible to propose a one-size-fits-all approach to Behaviour change and nor would these disciplines wish to do that. Rather, what these disciplines can offer are a number of theories, frameworks, and methodological approaches for exploring why Behaviour is as it is and how we can use this understanding to identify ways to most effectively change it. Such frameworks and methods and the potential ways in which the behavioural and social sciences can contribute to antimicrobial stewardship are discussed in further detail with supporting examples in this paper written by Peter, myself, and colleagues. We would highly recommend you read this as an introduction to this course.
The remainder of this course will be structured around unpacking three key steps in a behavioural science approach to designing Behaviour change interventions. These are– first, precisely identifying and defining what exactly it is that you are trying to change in terms of who, what, where, and when. Second, conducting a Behavioural diagnosis of the Behaviour of interest in context– this will enable us to understand why Behaviour is as it is and what would it take to bring about change. That is, the barriers and enablers that need to be targeted by the intervention– third, using this Behavioural diagnosis to select or match your choice of intervention strategy to your behavioural diagnosis or your identified barriers and enablers.
This will help maximise the likelihood that the type of intervention you selected will be appropriate and effective in bringing about change. Along the way, we will unpack each of these steps in detail and introduce a number of principles, theories, models, frameworks, and methods from the behavioural and social sciences that can be used at each stage of this process. These tools form part of the Behaviour Change Wheel approach to intervention design, which is one increasingly popular behavioural science framework for designing Behaviour change interventions, which stems from a synthesis of other available frameworks and theories in the literature– so it intends to be comprehensive and accessible.
These frameworks are interlinked to facilitate a systematic, step-by-step, transparent, and hopefully more effective approach to intervention design.
I hope this talk has provided you with some background context for what you will learn in the next modules. In each module, we will demonstrate how these tools have been applied to antimicrobial stewardship and outline different ways in which this tool box can be used flexibly to adjust differing quality improvement needs, from designing new interventions from scratch to refining and optimising existing interventions, exploring what is in existing interventions, and improving reporting and descriptions of interventions. Thank you for listening.
In this video, we introduce how a systematic behavioural change approach can be applied to antimicrobial stewardship.
Antimicrobial intake is dependent on behavioural practices. Obstacles in appropriate antimicrobial stewardship are mainly due to inaccurate prescribing, not assessing test procedures and effectiveness, incomplete intake of medication, lack of surveillance and follow-ups – ultimately, these are behaviours which must be changed.
Please find a downloadable PDF of the PowerPoint slides below.
After watching the video, please read the following questions and share your comments below:
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What practices in your daily life contribute to challenges in antimicrobial stewardship?
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What changes can you make to rectify them? What challenges will you face in doing so?
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Are there any frameworks or methods that can be changed by local clinical practices to implement good quality antimicrobial stewardship?
This article is from the online course:
Utilising Social Science and Behaviour Change in Antimicrobial Stewardship Programmes: Improving Healthcare
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Utilising Social Science and Behaviour Change in Antimicrobial Stewardship Programmes: Improving Healthcare
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