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Table 2 Description of the steps used to choose the behaviour change techniques for the IMPLEMENT intervention

From: Developing theory-informed behaviour change interventions to implement evidence into practice: a systematic approach using the Theoretical Domains Framework

Using a theoretical framework, which barriers and enablers need to be addressed? (Step 2)

Within which theoretical domains do the barriers and enablers operate?

Which intervention components (behaviour change techniques and mode(s) of delivery) could overcome the modifiable barriers and enhance the enablers? (Technique; mode; content*) (Step 3)

Low awareness of the meanings and actions associated with the guideline’s key messages; low awareness of LBP red flags and skills in how to identify them

Knowledge (GP)

Technique: Information provision

 

Mode: Facilitated workshop; GP opinion leader led; DVD

 

Content:

· GP opinion leader/content expert [29] presents information about the guideline key messages. Algorithm provided for diagnosis of red flags.

Small group activity: participants reword key messages from the guideline to create behaviourally worded specific key messages (who, what, where, when) [30, 31].

GPs’ perceptions of patients’ expectations and of patients’ beliefs about consequences

Knowledge (patient)

Technique: Information provision (directed at patient)

 

Mode: Patient handout [32]

 

Content: Handout contains lay language about key messages from the guideline [33]; GPs encouraged to give patients with acute LBP the handouts to reinforce verbal advice

Attitudes towards managing patients without x-ray, based on perceived consequences of the behaviour, e.g. fear of missing underlying pathology and belief that patient will feel reassured with an x-ray

1. Beliefs about consequences

2. Knowledge (GP)

Techniques: Information provision; Persuasive communication

Mode: Facilitated workshop; DVD

Content:

· Highly respected senior clinician presents persuasive message about harms (harmful amounts of unnecessary radiation) and limited benefits (poor diagnostic utility) of x-ray for LBP

· GPs provide examples of when important underlying pathology was missed due to absence of x-ray of LBP episode, giving opportunity for expert to discuss this case and demonstrate that x-ray wasn’t required.

Beliefs about negative consequences and beliefs about positive consequences of practising in a manner consistent with the guideline’s key messages

Beliefs about consequences

Techniques: Monitoring of consequences of own behaviour; Barrier identification; Persuasive communication

 

Mode: Pre-workshop activity; facilitated workshop; DVD

 

Content:

· GPs record number of times they ordered plain x-ray and it didn’t change patient management, i.e. x-ray unnecessary.

Highly respected senior clinician presents persuasive message about consequences of behaving in a manner consistent with the key messages.

Skills and beliefs about capabilities related to guideline key messages

1. Skills

2. Knowledge (GP)

3. Beliefs about capabilities

Techniques: Barrier identification; Model/demonstrate the behaviour; Rehearsal

Mode: Facilitated workshop; DVD

Content:

· Participants write down wording of their last or usual message to stay active and then discuss in small groups.

In pairs, with one GP role playing a patient with pre-prepared patient vignette, GP to create a script and role play with feedback from facilitator.

Perceived need to give the patient something to replace x-ray

Skills

Techniques: Provide instruction and modelling to increase a competing behaviour

 

Mode: Facilitated workshop; DVD

 

Content: Instruct, model/role-play and create a script to facilitate the competing behaviour of prescribing an activity log for patients (rather than giving x-ray referral).

Limited time to explain why patient does not need an x-ray and explain advice to stay active

Environmental context

Techniques: Information provision; Model/demonstrate the behaviour by a peer expert

Mode: Facilitated workshop; DVD

Content: use of handouts (patient handout [32] and activity log) to save time in consultation, and demonstration by a peer expert of how to incorporate into standard consultation.

Beliefs about the role of the GP when managing acute low back pain

Professional role and identity

Techniques: Persuasive communication; Provide opportunities for social comparison

Mode: Facilitated workshop; DVD

Content:

· Highly respected senior clinician presents persuasive message about the role of the GP to minimise harm (from unnecessary irradiation from plain x-ray) and in encouraging patients to stay active.

· Small group work discussion to allow opportunity for discussion of behaviours among peers.

Skills and beliefs about capabilities related to negotiating with/reassuring patients that plain x-ray is unnecessary

1. Skills

2. Beliefs about capabilities (in reassuring the patient that an x-ray isn’t helpful)

Technique: Rehearsal (prompt practice)

Mode: Facilitated workshop

Content: Small group activity: participants to take clinical history with a trained simulated patient to identify red flags. Simulated patients trained to expect and apply pressure for GP to order an x-ray. Discuss after task with feedback from facilitators [3436].

GPs forget to give advice to stay active in standard consultation

Memory

Technique: Model/demonstrate the behaviour by a peer expert

 

Mode: Facilitated workshop; DVD

 

Content: Peer expert goes through 10 step management plan as a prompt for remembering CPG target behaviours

GPs’ perception that other people/organisations expectx-rays e.g., third party payors, radiologists

Social influences

Techniques: Information provision; Persuasive communication

Mode: Facilitated workshop; DVD

  

Content: Peer expert to discuss content of guideline and highlight organisations that endorse it.

  1. * Technique: which behaviour change technique was chosen. Mode: how the technique was delivered. Content: what was delivered.