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Applying BCTs in stewardship interventions

Applying Behaviour change taxonomy to antibiotic stewardship interventions
Hello. This is Dr. Eilidh Duncan, and I’m a research fellow and health psychologist based at the Health Services Research Unit at the University of Aberdeen. In this section, we will be looking at how to go about applying the behaviour change techniques taxonomy introduced in item 14 to antibiotic stewardship interventions. As mentioned, specifying antibiotic stewardship interventions in terms of BCTs has a number of advantages. Antibiotic stewardship interventions are typically complex and multifaceted. This makes it challenging to replicate in research and to implement in practise. Specifying the BCTs within a stewardship intervention makes it clear what has been included in an intervention, which increases the chance that an intervention can be replicated and implemented faithfully.
Using a common language to describe the active ingredients within stewardship interventions reduces the chances of the same label being applied to different techniques or different labels being applied to the same techniques, which results in confusion and prevents accumulation of knowledge. For our example of applying the BCT taxonomy to antibiotic stewardship, I am using a paper authored by Borde and colleagues, published in the Emergency Medical Journal in 2015. This paper describes an antibiotic stewardship programme implemented within an emergency medicine department in Germany. The published description of the intervention has been selected and shown word for word here. As you can see, it is a multifaceted intervention involving revising guidance, providing education, and producing protocols.
We are now going to break down the intervention using the behaviour change techniques taxonomy. The intervention within this paper includes provision of guidance verbally and through internal guidelines on what antibiotics to avoid and which ones to use, underlined in blue here. This type of stewardship component can be quoted as BCT 4.1, instruction on how to perform the behaviour. The definition of this BCT is advise or agree on how to perform the behaviour. One aspect of this stewardship programme involved replacing one type of antibiotic with another, as underlined in orange here. Within the taxonomy, this can be coded as 8.2 behaviour substitution, which is defined as “prompt substitution of unwanted behaviour with a wanted or neutral behaviour.”
Another aspect of the stewardship intervention reported in this paper was creating and distributing written pocket-sized guidelines and making the guidelines accessible on the hospital internet. This matches the BCT 12.5, adding objects to the environment in order to facilitate performance of the behaviour. The description of the stewardship intervention also includes this line. “Our initial idea was to test whether reduction by more than 20% of prescription of both cephalosporins and fluoroquinolones could be possible within 12 to 24 months without increasing overall use densities.” The BCT 1.3, goal setting outcome, is when a goal is set in terms of a positive outcome of wanted behaviour, in this case, the reduction in prescriptions of the target drugs without overall increasing use densities.
Published intervention descriptions within publications that have not used the BCT taxonomy for reporting may not always contain quite enough information to be sure that something meets the definition of a behaviour change technique. For example, here, there is mention of feedback. But we don’t have enough information available to know what kind of feedback this was. However, in this instance, we obtained further information from one of the authors of this paper to clarify, and we know that this stewardship programme included providing feedback on antibiotic use statistics. Therefore, this matches the BCT 2.2 feedback on behaviour, which is defined as “monitor and provide informative or evaluative feedback on performance of the behaviour in terms of form, frequency, duration, and intensity.”
The authors of the study also provided details to clarify that this involved reviewing progress within the clinical team and providing encouragement and congratulations. This fits with the BCTs 1.6, discrepancy between current behaviour and goal, and 10.4, social reward, “providing variable reward if and only if there has been effort and/or progress in performing the behaviour.” Similarly for the term “academic detailing,” the authors of the study provided details to clarify that this involved infectious disease physicians using case studies of patients the clinical team had managed to discuss actions they could take towards achieving the goal.
This fits with BCT 1.4, action planning, which is “the detailed planning of performance of a behaviour that must include planning of at least one of context, frequency, duration, and intensity.” You can see from just this one example of a stewardship intervention that there are many BCTs relevant to antibiotic stewardship that work in different ways to support behaviour change. Specifying stewardship interventions in terms of BCTs allows for better testing and replication of combinations of BCTs and supports implementation of an effective intervention through clearly defining the key active ingredients.

Watch this video by Eilidh Duncan who introduces how behaviour change techniques can apply to antibiotic stewardship interventions.

You will find a PDF containing the Behaviour Change Taxonomy table referred to in the video in the downloads section below.

PDF reference – Michie S, Richardson M, Johnston M, Abraham C, Francis J, Hardeman W, Eccles MP, Cane J, Wood CE. The behavior change technique taxonomy (v1) of 93 hierarchically clustered techniques: building an international consensus for the reporting of behavior change interventions. Annals of behavioral medicine. 2013 Mar 20;46(1):81-95.

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

  • How do you think BCTs might be useful for your interventions and practice?

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

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