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Role of Theory and Implementation Science

Watch the short video by Dr Sion Scott who explains the role of theory and implementation science.
Welcome to this short screencast on the role  of theory and developing health interventions. 
Now as researchers and practitioners, we are  constantly looking to generate new evidence that   shows that there is a better way of treating our  patients so that could be developing a new drug,   or it could be developing a new service. Either way when the research evidence tells us  that there is a better way of doing something   there is an expectation  from funders, from patients,   and from us as practitioners, that, that  evidence base is adopted into practice. However, we know that, that is not necessarily  the case, and in fact in up to 40 percent of   cases we know that patients do not receive care  according to the present scientific evidence.
i.e in 40 percent of cases, there are patients  receiving care where we know that out there,   there is evidence for doing something  in a different and a better way. And that’s a huge loss on the  investment in terms of finance   and research at time, patience,  and rolling into trials etcetera. That is a huge loss on that investment. And there is really something  that we need to do about that.  So what we end up getting is  this evidence being generated   and it not diffusing into practice, and we  often refer to this as a translational gap. A gap between the evidence base  and what we know should happen,   and practice by the care that patients receive.
And so you can kind of think of  this a little bit like a black box. This is not a passive process. It is not diffusion, you have to do work in  order to get evidence taken up into practice. And the role of theory, which is what this  screencast and much of this week is about,   is in trying to understand this process. And so you can think of theory a bit as a lens by  which to help us understand the process by which   evidence is taken up into practice,  and by understanding that evidence   by understanding that process we hope to develop  strategies to take evidence up into practice.  Now this often requires people  to change their behaviour.
It requires practitioners to  change their behaviour, but also   patients and wider policy makers as well. Behaviour change is really complex, and using  theory is not necessarily a magic bullet,   but it is a strategy that is heavily  endorsed now, to understand this process,   and the first thing to really do is to  understand the barriers - the things that   stop this new bit of evidence from being  used, and the enablers or the strategies   that might facilitate this new  evidence from being used in practice. First thing to do is understand  those relative to the new behaviour.
Now the way theory comes into  this, is we can use theory to   synthesise those barriers and enable  us into the mechanism by which   behaviour change occurs and we’ll talk a  bit more about that later in the screencast. Once you’ve got that mechanism synthesised,  you then want to go and look at strategies   or in the behavioural science world we  call these behaviour change techniques   that are unique to that mechanism that  you can include in your intervention to   bring about change and behaviour bring  - about adoption of that new evidence. And the final thing is to  then combine those techniques   into a intervention or a  behaviour change intervention.
So just to illustrate this you’ve understood  your mechanism, you’ve used theory,   you’ve developed your intervention, and then we  look to have once this intervention is implemented   that evidence based up uptake into practice  by way of your behaviour change intervention. So this all seems fairly straightforward. Where people often struggle,  is right at the beginning. And trying to understand - well  which theories should I pick? There are hundreds of theories out there  from the field of health psychology,   sociology, organisational sciences. So which theory do you pick? There are lots out there, many of them  overlap, but some of them don’t necessarily   cover all bases, and so how do you pick  the most appropriate theory for you?
Well really you need something that is going to  account for all determinants of human behaviour. All the things that are associated  with changes in human behaviour,   and broadly speaking there are kind of  three things that determine human behaviour. There is the capability. So you have to be able to do the behaviour. You have to have the opportunity to do that  behaviour, and you’ve got to want to do it. You’ve got to be motivated to do it, and  so when you’re thinking of applying theory   you really need something that  is going to help you understand   the barriers and enablers from  all of these perspectives.
And the Theoretical Domains  Framework was a framework   of theories and constructs developed by Susan  Mickey and her group at University College London. The Theoretical Domains Framework has 14  individual domains that you can think of   as determinants of human behaviour, and they sit  quite nicely in those three kind of overarching   things that you need to be in place for you  to have in place in order to change behaviour. So just to illustrate an example, if I was  developing an intervention to encourage people   to cycle more, and I was trying to understand  the barriers and enablers, and synthesise those   into a mechanism, I would go to them and ask  them what can we do to help you to cycle more?
And they would say “well first of all  we would need to know how to cycle,   we’d need the skills, and that’s something that  we don’t know at the moment and so we would,   we would want some support to do that”. So you think, right okay. So skills is something I need to address. The other thing, is we would actually need  a bike that we don’t have at the moment,   and we would need a safe environment to ride that. So you’d know that actually  environmental context and resources   is also something that you need some help with.
And they might also say “well we’re also  not really confident in our belief that we   can ride a bike safely” so, so something  there around beliefs about capability. And finally, we need to be convinced that going  to be positive consequences and the absence of   negative consequences to doing this. So, I need to know that I’m not going to,  or need to believe that I’m not going to   fall off my bike and injure myself, and  actually there are going to be health benefits. So those would be the sort of things  that you’d be thinking about as you’re   understanding your mechanism of behaviour change.
Now the next thing to do of course is to think  about how you go to change that behaviour. And in the field of behavioural science,   to change behaviour we look to  identify behaviour change techniques. Now these are intervention components that  bring about a change in behaviour, and there’s   a definition there of behaviour change techniques  from the Encyclopaedia of Behavioural Medicine. But in a nutshell, behaviour change techniques  should be things that you can observe, they   should be replicable, they should be irreducible,  ie they can’t be split up into anything smaller. They are a component of the intervention  that is designed to change behaviour,   and by definition they are the active ingredients   within an intervention that bring  about that behaviour change.
And Susan Mickey a couple of years after initially  developing the TDF, did some work to link the 14   domains of the Theoretical Domains Framework  to theory-based behaviour change techniques. So they have created this link  between understanding behaviour,   and synthesising that mechanism,   and selecting corresponding behaviour change  techniques or strategies to change behaviour. And so just to give you an example in this paper   for the knowledge domain of the  Theoretical Domains Framework,   there are four linked behaviour change techniques  that you could select from to change behaviour. And over the course of the next week, you  will have a go at understanding behaviour   and synthesising the mechanism to  identify your relevant TDF domains.
And then using this table  developed by Susan Mickey   to identify relevant strategies for changing  behaviour for an intervention of your choice.
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Developing and Testing Complex Healthcare Interventions

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