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Barriers and Facilitators – part 1

In this presentation, Dr Magdalena Rzewuska introduces you to the identification of barriers & facilitators. There is also a small activity.
I’m Dr. Magdalena Rzewuska. Dr. Eilidh Duncan and I are research fellows at the Health Services Research Unit at the University of Aberdeen. Our colleague, Dr. Fabiana Lorencatto, is a research fellow at the University College London. We are psychologists with recognised special interests in investigating behaviour aspects of health care with the view of redesigning health services to optimise care provision. In this presentation that consists of two parts, we introduce you to the identification of barriers and facilitators to implementation of antimicrobial stewardship programmes using a behavioural approach. This was the focus of activities undertaken by our transnational multidisciplinary working group combined in 2016 in response to a call from the joint programme initiative on antimicrobial resistance.
Current strategies to tackle antimicrobial resistance, including not only antibiotic stewardship, but also infection control or increasing adherence to evidence-based guidelines, all require change in behaviour. Traditionally, a fast track approach has been used in which a seemingly good idea for a behaviour change intervention would be tested.
An alternative approach is a behavioural approach that can guide decision-making and facilitate a step by step transparent systematic approach to design behavioural change interventions.
Evidence from the Cochrane Review on interventions to improve hospital antibiotic prescribing was summarised earlier in this course. At this point, a behaviour theory, namely, the Capacity Opportunity Motivation Behaviour, in short, COM-B, model, and its author Susan McKee’s role in the review team, were introduced. The COM-B model of Behaviour explains some of the variation in the effectiveness of ASP interventions. However, few interventions actually used a Behaviour approach to their design.
It is likely that there are further opportunities to enhance the effectiveness of ASPs, for example, by understanding contextual influences on Behaviour. This diagram represents the complex organisation and clinical– complex organisation and clinical systems in which ASP-related Behaviour operate. The ASP and microbiology laboratory staff worked with clinical teams to optimise antimicrobial prescribing for the patients. Collaboration will be facilitated if prescribers and microbiologists still believe that the ASP is effective. However, collaboration also requires support of the hospital system level and would be undermined by a hospital administration that believes that the ASP is not a priority and does not allocate adequate resources for implementation.
Support from hospital administration would be influenced by the health care system and the socio-political environment in which they operate. ASP includes a diverse range of strategies and actions that are determined by the organisation and the clinical systems in which the ASP operates. Therefore, translating antibiotic prescribing recommendations into health professionals’ daily practice remains problematic. This is because changing ingrained Behaviour patterns is challenging, in general, and even so more when it is context dependent. Understanding the nature of ASP-related Behaviour and the context in which it occurs involved identifying influences and Behaviour referred to as barriers and facilitators. The barriers are related to nonperforming Behaviour and facilitators are enablers of Behaviour performance.
Identifying barriers and facilitators is facilitated through applying theories of Behaviour change. We can then develop strategies to minimise barriers and enhance facilitators to support Behaviour change. One Behaviour framework to design and evaluate Behaviour change intervention, such as ASPs, is by using the Behaviour change wheel synthesis of 19 frameworks of Behaviour change developed to aid intervention design, to improve the process of intervention evaluation, both to optimise and refine intervention, and theory development. Susan McKee and colleagues have published a guide that describes a step by step method to using the Behaviour change wheel. You would start with defining the problem you are trying to solve in behavioural terms, deciding what Behaviour you are trying to change and why, i.e.
mapping out a system of behaviours and specifying who needs to do what differently, where, when as discussed in the introduction to the TACTA video. Having done that, you would then identify what needs to change. By this we mean what needs to change in the person and/or environment in order to achieve the desired change in Behaviour. This is facilitated through the application of Behaviour theory. Given clinical practice is a form of human Behaviour, however, there is a large number of Behaviour theories and many overlapping constructs are out there, and there is a lack of a systematic method for selecting and applying such theories. Hence, efforts such as the COM-B model to synthesise those into a minimal set of constructs.
The more accurate this analysis of the target Behaviour, the more likely it is that the intervention will change the Behaviour in the desired direction. And the Behaviour change will– intervention development stages involve identifying relevant types of intervention strategies and specifying Behaviour change techniques. The COM-B is an integrative model that presents the basic preconditions for Behaviour to occur. Hence, it is the starting point used by the Behaviour change wheel for understanding Behaviour in the context in which it occurs. The central tenet of the model is that capability, opportunity, and motivation are equally important for any Behaviour to occur.
For a given Behaviour in a given context the COM-B model provides a way of understanding of what drives current Behaviour, that’s why Behaviour is as it is, and what would need to change to bring about desired Behaviour. For example, for a particular target Behaviour the only barrier might be capability or opportunity. Why if another change– why if another changed, it changes to capability, the motivation and opportunity might be required to increase or decrease the target Behaviour. We can use the COM-B for Behaviour diagnosis of the Behaviour of interest.
That is, to identify what drives the Behaviour of interest. And this can be done by collecting data or asking questions to investigate the role of capability, opportunity, motivation play in facilitating or hindering Behaviour of interest. This can be done using a range of methods, including more open qualitative methods, such as interviews and focus groups, which are often used in Behaviour and social sciences.
Interviews and focus groups are frequently used by social scientists for in-depth studies. Questionnaires are useful large samples. Structured observations based on the COM-B are useful case studies involving interactions, for example, description of an aspect of routine care delivery. However, if there are insufficient resources for in-depth investigation, the Behaviour that diagnosis data can be valid through structured discussions with representatives from key stakeholder groups. Available guidance to assist in the application of the COM-B, such as the behavioural change guide, allows for COM-B Behaviour diagnosis to be done by anybody in the implementation community.
They have also been published numerous examples of this application. This approach is increasingly applied in a ASP, and here are some further examples of some papers that describe using Behaviour diagnosis of behaviours related to antibiotic stewardship in case anyone wants to read further. Let’s look more closely at specific components of the COM-B. Capability refers to psychological and physical abilities to perform Behaviour, including knowledge and skills.
Motivation involves all the processes that boost and direct Behaviour, including reflective processes, such as goals, plans, beliefs, and automatic processes, such as emotions, habits, and impulses.
And opportunity involves all factors that are external to an individual that might influence engagement with an activity, including the physical environment, for example, material resources, staffing, business, and social influences, for example, superiors and peers in that environment. This slide shows six questions that were used by Steinmo, et. al., to identify and investigate barriers to the implementation of the Sepsis Six that were identified through focus groups and interviews with staff at a London hospital. For those unfamiliar with the Sepsis Six, it’s a bundle of medical guidelines describing the use of tests and medical therapies, including antibiotics, designed to reduce mortality in patients with sepsis.
Please take a few minutes now to match each of these six questions with one of the six subcomponents, and please see the Part 2 of this video for answers and continuation of this topic.

After you have watched this video presentation you will be able to take part in a short activity.

In this presentation, Dr Magdalena Rzewuska introduces you to the identification of barriers and facilitators to implementation of antimicrobial stewardship programmes, using a behavioural approach.

This was the focus of activities undertaken by Dr Magdalena Rzewuska and Dr Eilidh Duncan, research fellows at the Health Services Research Unit (University of Aberdeen), along with Dr Fabiana Lorencatto – a research fellow at the University College London. Together they are psychologists, with recognised special interest in investigating behavioural aspects of healthcare, with the view of re-designing health services to optimise care provision.

Please find a downloadable PDF of the PowerPoint slides below.


  1. To what extent does working as a team facilitate or hinder implementation of the Sepsis Six?
  2. Do you think that emotional states get in the way of implementation?
  3. Is remembering the steps of the Sepsis Six ever an issue?
  4. Do you have access to the necessary resources needed to implement the Sepsis Six?
  5. Are there any additional skills you and your colleagues could acquire that would make your practice more likely to go according to protocol?
  6. Do you think implementing Sepsis Six is a priority?

Match the six questions with the six COM-B sub-components:

A. Psychological Capability

B. Physical Capability

C. Reflective Motivation

D. Automatic Motivation

E. Physical Opportunity

F. Social Opportunity

Please share your answers in the comments below. The next step will provide an answer guide.

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

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