This paper describes the systematic, structured development of an intervention to improve medication management for multimorbid patients by GPs. The intervention is called MY COMRADE. It is, to our knowledge, the first intervention directed at the management of multimorbidity in primary care, developed by using the Behaviour Change Wheel to clearly implement the framework of the MRC guide on complex interventions.
MY COMRADE involves collaborative decision-making by two GPs who support each other in the review of medications prescribed to a complex multimorbid patient, guided by cues which relate to safe prescribing. The broad functions of the intervention (enablement, environmental restructuring and incentivisation) are theoretically based. These functions will be achieved using five specific behavioural change techniques: social support (practical), restructuring the social environment, use of prompts/cues, action planning and self-incentives. The technique of collegial social support is a crucial feature of our intervention, which we expect will greatly enable GPs’ capabilities in conducting active medication reviews. It may be particularly important in de-prescribing medications or prioritising patient-centred rather than disease-focused care in multimorbidity which are challenging aspects of medication management, not least because of the fear of litigation which this intervention may now help ameliorate.
Comparison with other work
Since its publication in 2011, the BCW has been used in the development of interventions targeting healthcare professionals in a variety of ways. For example, Alexander et al. used COM-B to understand barriers and enablers to preventative health examinations for young children in Australian general practice, with a view to designing an implementation intervention to increase the conduct of these examinations . They did not describe later steps of the BCW, such as choice of intervention functions, and did not describe in detail how their implementation intervention would look. In contrast, we used the BCW to highlight areas for improvement in professional practice and then develop an intervention targeted to these areas, rather than simply increasing the implementation of a pre-existing intervention.
Murphy et al. used COM-B to develop a capacity-building programme to enhance pharmacists’ roles in mental health care . This group felt that implementation processes must be prioritised during the early stages of intervention development, and they wove theories of behavioural change and implementation together in an iterative way. While we agree that implementation should be considered at all stages of development work, we did not find it necessary to use a specific implementation framework. The initial steps of the BCW revealed multiple areas for improvement in GPs’ professional practice. Once one had been chosen, the remaining steps of the BCW involved developing an implementation intervention to enhance the performance of this desired behaviour. Additionally, by incorporating the behaviour change technique of action planning, implementation was explicitly integrated into our intervention. Action planning requires an individual GP to plan the frequency, duration and intensity of the planned intervention activity . Thus, rather than a prescriptive implementation strategy, action planning will allow each GP to adapt the intervention for use within their own practice. The variation in implementation, as well as fidelity to other behavioural change techniques, will be evaluated in the next phase of this work and will help to inform the debate on optimal approaches to implementation planning in intervention development.
Strengths and weaknesses
We began this work with the broad aim of developing an intervention to improve medication management in multimorbidty, but we did not have a predefined idea of what the intervention would be at the outset. Adhering to the guidance of the MRC by using a theoretical approach, which was chosen a priori, lent direction, structure and transparency to this process in multiple ways.
First, the MRC states the need to identify the evidence base and supplement this with new evidence if necessary. In doing this, we generated much needed data on the management of medications in multimorbidity, increased our understanding of the problematic areas experienced by GPs and revealed how they currently respond to these difficulties. Second, we then used this empirical data to directly influence the development of the intervention. Following the steps of the BCW allowed us to develop a list of options for behavioural change and to clarify what we were, and what we were not, trying to achieve. Third, we benefitted from using the links between the BCW model and the taxonomy of behavioural change techniques. The taxonomy highlighted novel strategies for behavioural change, many of which we would heretofore not have considered. Although only five techniques are ultimately included in the description of the final intervention, many of the others influenced other aspects of intervention development and the implementation strategy.
Despite the highly systematic and structured approach of the BCW, there are challenges associated with its use and it is not a magic bullet for intervention development. For example, the researcher must make a series of subjective and pragmatic decisions throughout the process. These ‘real life’ decisions can seem at odds with the scientific approach. To counter this and to improve the transparency and generalizability of our methods, we recorded in detail the multiple options available to us at each step of the BCW and expanded on why options were or were not taken.
Furthermore, the multiple steps of intervention development involved a lengthy process: from the beginning of our systematic review to the final refinements of the intervention spanned almost 3 years. Such a prolonged course must be factored in by those pursuing and funding evidence-based intervention development. Other intervention developers have used a ‘top-down’ approach of applying classical behavioural theories such as social cognitive  or control theory  to inform their choice of intervention functions and behavioural change techniques. In contrast, we employed a ‘bottom-up’ approach to theory development in which the framework of the BCW guided our use of existing evidence and our own qualitative explorations. This led to an intervention which was logical and practical yet still theoretically based.
In addition to the COM-B, the BCW also includes an optional, more detailed framework for behavioural analysis known as the Theoretical Domains Framework . After completing our intervention development, we conducted a validation using the Theoretical Domains Framework (see Additional file 4) which reassuringly demonstrated similar associations between our qualitative data, and our chosen intervention functions and behavioural change techniques.
Implications for future research
We used the BCW as a lens for viewing GP behaviour, understanding what needed to shift and determining how this shift could be achieved. Our experience confirms the usefulness and generalizability of this approach. Multimorbidity presents many challenges to GPs, particularly relating to the conflicts between patient-centred and disease-focused care but the BCW approach was not hampered by these complexities. Based on our experience, the method is potentially applicable to intervention developers across disciplines as long as sufficient contextual and empirical data exists or can be generated.
Throughout this study, we adhered to the ‘less is more’ maxim of intervention design . We could have taken a more complex multi-faceted approach, such as incorporating other stakeholders, i.e. pharmacists or specialists. Instead, we adopted the recommendations from the systematic review by Smith et al. that changes targeting specific problems are more likely to be effective . Smaller changes can be achieved, sustained and built upon in future interventions, and substantial behavioural change is more likely to result from the aggregation of these smaller changes . We applied the same tenets to our assessment of outcomes—rather than initially looking at downstream effects such as changes in prescribing, we will concentrate first on proximal changes such as implementation of the intervention. Once we are assured that it is acceptable, feasible and leads to behavioural change, we can assess outcomes in prescribing safety and polypharmacy at a later stage.
To date, there is limited evidence available on which behavioural change techniques are most effective in specific settings. We expect that characterising the active components in the MY COMRADE intervention using the taxonomy of behavioural change techniques  will aid implementation and replication of the intervention. The clear specification of the intervention will also facilitate a thorough evaluation of the impact of the selected behavioural change techniques and will help to inform evidence-based strategies for intervention development in the future.
In this study, we did not undertake the sixth step of the BCW relating to policy options in detail. However, if the intervention is shown to be effective in our ongoing feasibility and pilot work, scaling-up of the intervention will require greater consideration of the external context of healthcare policy and widespread implementation.