ASPECTOS COMERCIALES

The Behaviour Change Wheel (BCW) is a framework targeted at healthcare practice and public health. In the original paper, where the developers first present their framework, the BCW is described as the result of the systematic analysis of nineteen other frameworks, built intentionally to overcome their flaws and limitations (Michie et al., 2011b). The BCW includes its own model of behaviour, the COM-B model, which facilitates the correlation between behaviours and behaviour change strategies.

One of the gaps that the framework intends to address is the inappropriate

characterisation of previous methods with respect to how they establish links between the change mechanisms of the frameworks and the theory-based understanding of target behaviours (Michie et al., 2011b). The authors of the BCW have been developing an ‘evidence-base’ and ‘theory-base’ agenda regarding the development of behaviour change frameworks for a number of years (see, for instance, Abraham & Michie, 2008;

Michie et al., 2011; Michie et al. 2015), so their proposed framework also strives to reflect that broad focus. At the centre of the strategy is the inclusion of a dedicated model of behaviour, devised to inform the use of the framework (but not limited to it).

The resulting COM-B model aims to simplify understanding of the determinants of behaviour without incurring oversimplification, which highlights the authors’ concern with the applicability of their method – the use of the framework by practitioners.

34 The COM-B model (Figure 2.3) describes behaviour as the result of an interplay

between two or more of its components – C, capability; O, opportunity; M, motivation – which results in B, behaviour, that in turn, influences the other components

retroactively in cycles.

Fig. 2.3 The COM-B model of behaviour (Michie et al., 2011b)

The BCW attempts to bridge the know-do, or the theory-practice gap by providing mechanisms to connect the two worlds. It does this through the inclusion of

overarching policy categories and intervention functions within its structure. These are intended to account for preventing ‘policy makers and intervention designers from neglecting important options’ for addressing ‘the kinds of intervention that are likely to be appropriate for a given behavioural target in a given context and a given population’

(Michie et al., 2011b). The BCW is comprised of seven policy categories and nine intervention functions, as shown below in Figure 2.4, which also portrays the COM-B model as the hub of the wheel. According to the authors, these are non-overlapping categories that build from the analysis of previous works and relevant literature, and they should assist designers and practitioners in envisioning and planning effective interventions (Michie et al., 2011b).

35 Fig. 2.5 The Behaviour Change Wheel (Michie et al., 2011b)

Michie et al. (2014) describe, in the form of a guide, how the BCW can be used within intervention design. Application of the framework starts from an analysis of the sources of behaviour, using the COM-B model to identify which determinants are causing the prevalence or occurrence of the behaviour(s) to be changed. Once the behaviour(s) are understood in context, since ‘behaviours are a part of a system, they do not occur in isolation’ (Michie et al., 2014), one or more of the nine intervention functions can be chosen along with the best policy category(s) to deliver the

intervention. Each of these functions and policy categories are explained in Tables 2.4 and 2.5:

Table 2.4 The nine intervention functions of the Behaviour Change Wheel (adapted from Michie et al., 2011b)

Intervention functions Definitions

Education Increasing knowledge or understanding

Persuasion Using communication to induce positive or negative feelings or stimulate action

Incentivisation Creating expectation of reward

Coercion Creating expectation of punishment or cost

Training Imparting skills

Restriction Using rules to reduce the opportunity to engage in the target behaviour (or to increase the target behaviour by reducing the opportunity to engage in competing behaviours)

36 Environmental restructuring Changing the physical or social context

Modelling Providing an example for people to aspire to or to imitate Enablement Increasing means/reducing barriers to increase capability or

opportunity

Table 2.5 The seven policy categories of the Behaviour Change Wheel (adapted from Michie et al., 2011b)

Policy categories Definitions

Communication/marketing Using print, electronic telephonic or broadcast media

Guidelines Creating documents that recommend or mandate practice. This includes all changes to service provision

Fiscal measures Using the tax system to reduce or increase the financial cost Regulation Establishing rules or principles of behaviour or practice

Legislation Making or changing laws

Environmental/social planning Designing and/or controlling the physical or social environment Service provision Delivering a service

Intervention designers can utilise the Theoretical Domains Framework, (TDF)¹³ and a number of matrixes provided within the Guide as support to help establishing theory-based relationships between the components of the COM-B model that require attention and appropriate intervention functions and policy categories that can respond to the identified problems.

With the Guide, the authors also include eight worksheets that can be used to help designing the intervention in a stepwise fashion, with recommendations directed at how to accomplish all the intervention phases, while maintaining theoretical rigor and making sure choices are made according to the use of the proposed tools and methods.

The rationale, structure, methodology and accompanying materials of the BCW

13 The Theoretical Domains Framework is a support tool developed to help providing clear, categorised descriptions of behavioural concepts and constructs (such as knowledge, habits, motivation, beliefs etc.), commonly used in intervention design and implementation, by professionals from varied disciplines (Michie et al., 2014; Michie et al., 2015; Tombor & Michie, 2017).

37 framework were further developed as a set of tools to effectively guide the design and implementation of behaviour change interventions by people with or without a background in behavioural science (Atkins & Michie, 2015), and as such should be analysed, among other things, according to how easy and effective their use is in real-world practice. Although this study has identified a number of relevant publications that report the application of either the COM-B model, the TDF, the BCW or variations of their combined use in different healthcare settings, fewer publications describe in detail the systematic use of the framework in its entirety, along with the eight

worksheets and the step-by-step methodology proposed by the authors (for example Sinnott et al., 2015). This may be indicative that the integral use of the tools and methods is complex, cumbersome or simply disconnected from the reality of actual every-day practice. Issues regarding the use of this framework to date will be further analysed in the following section.

The Application of the Behaviour Change Wheel

A review of relevant literature regarding the application of the BCW¹⁴ indicates that the majority of studies describe a process of intervention development using the BCW tools – with some mention also made to the use of the TDF in the analysis of qualitative data to understand behavioural issues and as support for the selection of appropriate intervention functions and policy categories (such as Barker et al., 2016; Elrouby and Tully, 2016; Steinmo et al., 2016; Webb et al., 2016, Ross et al., 2015; Fleming et al., 2014). Fewer studies discuss the actual implementation, and the resulting impacts of the designed interventions as there is an acknowledged difference in the level of complexity between designing and implementing interventions (for example Curtis et al., 2017; Sinnott et al. 2015; Tavender et al., 2015).

The reviewed publications do not document complete adoption of all the tools that accompany the framework, and particularly disregard the use of the eight worksheets included in the Guide. The function of the worksheets is to assist a systematic, stepwise process of intervention planning, designing and implementation, and at the same time they can work as a checklist for practitioners (Michie et al., 2014).Although the

worksheets may not be essential for effective application of the BCW, their documented use would provide an accountable way of assessing the extent to which the framework was, or was not, employed according to its original intended use. Whether the reported

14 A table summarising the selected studies is included as an appendix to this thesis.

38 studies have followed the programme as prescribed by the developers of the

framework remains a question without a definite answer. Nonetheless, the selected studies usually include an overview description of the stages defined by the BCW, which provides a diverse landscape of perspectives concerning the philosophical underpinnings and practical aspects of using the framework and its tools in real-life contexts, according to the perspectives of different practitioners and academics.

The participants and areas of application of the reviewed studies are, also, very diverse encompassing research that focus on the behaviours of healthcare staff with various backgrounds, specialisations and levels of seniority. The studies cover a wide variety of healthcare areas and contexts such as offices, NHS departments, households, hospitals, and multiple settings.

No study was found concerning the use of the BCW in the context of UTI diagnosis and management of older adults in the emergency department – the specific application area empirically investigated in this thesis. However, Curtis et al. (2017) have

employed the BCW in a process of revising and improving a clinical protocol for chest injury management in the ED. These authors used the TDF categories to analyse the results of a questionnaire conducted with diverse healthcare professionals, to then compare those categorised results against eligible intervention functions and policy categories included in the BCW. The framework was used as a reference to identify barriers and facilitators to the understanding and use of the existing protocol, as well as to inform areas or topics which were addressed in the successful re-launch of a

redesigned protocol, increasing port-intervention uptake to 91% (Curtis et al., 2017).

Steinmo et al. (2016) explored the benefits of using the TDF, the BCTs and the

APEASE¹⁵ criteria to improve an ongoing effort of implementing the SEPSIS bundle¹⁶ in a hospital in the UK. The study, aimed at investigating compatibility of the BCW tools with the PDSA cycle¹⁷, found that the behaviour change tools facilitated modifications to the ongoing interventions, particularly, by identifying new behavioural issues (via using the TDF to analyse interviews with staff) as well as by selecting BCTs and two additional interventions to complement the implementation of the SEPSIS bundle across different areas of the hospital, including the ED.

15 APEASE = Affordability, Practicability, Effectiveness and Cost-Effectiveness, Acceptability, Side-Effects/Safety, Equity (Michie et al., 2014).

16 The SEPSIS bundle or SEPSIS SIX is a set of tasks to be implemented by practitioners in the front line within one hour of admission to help diminishing the relative risk of death of patients. It includes oxygen, cultures, antibiotics, fluids, lactate measurement and urine output monitoring.

17 Plan, Do, Study, Act improvement cycle.

39 Though not describing the use of intervention functions and policy categories,

Tavender et al. (2015) used the TDF to help determine behavioural barriers and enablers related to the correct, routine use of guidelines for treating mild traumatic brains injuries in the Emergency Department. These authors also co-related the

identified behavioural categories with appropriate behaviour change techniques which were delivered, using Cochrane validated modes of delivery¹⁸, as a support strategy to

‘inform intervention development in managing mild traumatic brain injury in the ED’

(Tavender et al., 2015).

Contributions and Gaps of the Behaviour Change Wheel

It seems clear that the BCW has significantly advanced the way in which theories and mechanisms of change are connected, based on evidence of the effectiveness of

methods and rigorous analysis of existing frameworks. This is mainly accomplished by an original strategy employed by the developers of the framework – the inclusion of a concise and encompassing model of behaviour, the COM-B, also developed by the same authors. The COM-B constitutes the single most applied and celebrated tool related to the BCW in the analysed literature.

Furthermore, the BCW may seem more prescriptive and programmatic then most frameworks because it includes a number of tools and matrices that aim to simplify its use by practitioners without much expertise from the behavioural sciences. The TDF and the Behaviour Change Technique Taxonomy version 1 (BCTTv1) (Michie et al., 2015) allow for practitioners to make direct, and allegedly unambiguous, associations of behavioural cause and desired effects that lead to a quicker decision-making process.

It does so by establishing associative relationships between the components of behaviour identified to be problematic (utilising the COM-B model) and the possible intervention functions and policy categories (using matrices that build from the TDF).

That analysis finally leads to the adoption of one or more behaviour change techniques (consulting the BCTTv1¹⁹) determined to be effective for the identified behavioural issues.

18 Modes of delivery included (Tavender et al., 2015): (i) local stakeholder meetings, (ii) identification of local opinion leader teams, (iii) a train-the-trainer workshop for appointed local opinion leaders, (iv) local training workshops for delivery by trained local opinion leaders and (v) provision of tools and materials to prompt recommended behaviours.

19 The Behaviour Change Techniques Taxonomy version 1 (BCTTv1) is a collection of change techniques hierarchically categorised according to the domains identified in the Theoretical Domains Framework see footnote 7 above). The taxonomy’s intention is to support practitioners in the selection of behaviour

40 This programmatic characteristic, associated with the growing ‘scientification’ of the broad field of behaviour change, has led to an over-systematisation of theory and practice that is currently under criticism, because it eliminates variability in the ways that behaviour change knowledge and action are approached and discussed (Ogden, 2016). It also has been pointed that the volume of options that open from the process of relating intervention functions, policy categories and BCTs can be burdensome, make decision-making more difficult and the intervention design process lengthier (Webb et al., 2016).

In addition, in its process of becoming more evidence-based and theory-based, the BCW framework has abandoned or, at the very least, largely dismissed the ways in which different stakeholders – that are affected by or that will implement the changes – participate in the development of the intervention. That becomes clear in the analysis presented above in Table 2.2, where it is shown that the original document, which first introduced the framework, displays one of the lowest incidences of terms traditionally associated with the engagement of people in participatory processes; a tendency also observed in subsequent publications such as the complete Guide for the use of the framework (see Michie et al., 2014). These publications, and the framework in itself, do not deny participation; they simply do not approach it as explicitly and appropriately as this research proposes as being ideal. Although, exceptions were found in publications that reported some level of exploration concerning the use of collaborative processes throughout the data collection and intervention design (Ross et al., 2015; Sinnott et al.

2015; and Webb et al., 2016), no publication reviewed established connections between stakeholder participation and ethical implications within behaviour change initiatives.

Bringing stakeholder participation into the very structure of the BCW framework, or to the forefront of its application process, therefore appears as a persisting missed opportunity to which participatory design could add substantial value.

Rationale for Choosing the Behaviour Change Wheel

Despite some identified shortcomings – many of which are shared with other frameworks and approaches – the BCW was chosen as the behavioural approach to guide the exploration of this thesis’ empirical studies. The reasons for this are manifold,

change techniques that are appropriate in provoking change according to the determinants and

manifestations of the behaviours that are intended to be changed (see Michie & Johnston, 2012; Michie et al. 2015).

41 including broad aspects related to theory, as well as pragmatic aspects concerning methodology.

The BCW is healthcare-specific – unlike other frameworks, including most of the design for behaviour change ones. As described in Chapter 01, many quality improvement approaches in use within healthcare are adaptations of models designed for entirely different applications. Since the BCW was designed to be applied predominantly within the healthcare realm – and it has been developed by researchers working with/for/in the NHS – its rationale takes into consideration the particularities of this complex and distinct context.

Relative to other frameworks (health-specific or not), the BCW is fairly recent, which allows interesting opportunities to analyse and experiment. Considering more

established, traditional approaches – like the Theory of Reasoned Action (1967) or the Transtheoretical Model (1983), which have been extensively investigated – the BCW (2011) is comparatively underexplored by designers. Therefore, given its healthcare focus, it appears worthwhile to investigate how its practical application would fit within a design-led approach to change in the context of healthcare service improvement.

At the core of selecting the BCW are a set of methodological reasons that make it a suitable choice for the purposes of this research. First, although health-focused, the BCW is not limited to certain domains, subject areas or subsets of healthcare; it is broad enough (i.e. non-specific to smoke cessation or HIV management, for example) to allow effective application within a variety of issues concerning healthcare systems and practice. Secondly, as discussed before, the BCW has its own model of behaviour (COM-B) which facilitates application by multiple stakeholders, regardless of how versed they are with behavioural theory and intervention design. And thirdly, the BCW process is organised into logical, stepwise stages with clear suggestions of methods and tools.

This aspect is of particular interest to this research since understanding the BCW intervention process as something similar to the design process²⁰ would likely facilitate the integration of both approaches.

Lastly, elements of the BCW approach had been utilised by collaborating researchers who conducted a qualitative study within the environment where this thesis’ fieldwork was to take place. Their study was used as an initial basis for the development of some

20 A comparison between the BCW and the design process is presented in detail in section 4.2 of Chapter 04, and the whole of section 6.1 of Chapter 06.

42 of the first activities within this research. Thus, adopting the BCW could facilitate navigation and use of data previously collected and analysed in this related study²¹.