Table 2 Mapping of behaviour change techniques (BCTs) to key domains for inclusion in an intervention to improve appropriate polypharmacy in older people

Skills

1. Graded tasks

2. Behavioural rehearsal/practice

3. Habit reversal

4. Body changes

5. Habit formation

6. Goal/target specified: behaviour or outcome

7. Monitoring

8. Self-monitoring

9. Rewards; incentives (inc Self-evaluation)

10. Graded task: start with easy tasks

11. Increasing skills: problem solving, decision making, goal setting

12. Rehearsal of relevant skills

13. Modelling/demonstration of behaviour by others

14. Homework

15. Perform behaviour in different settings

Modelling/demonstration of behaviour by others (BCT 13): HCPs would be provided with a demonstration of how to prescribe/dispense appropriate polypharmacy during a typical encounter/consultation with an older patient.

Reasons for not selecting other BCTs

 BCTs 1, 2, 3, 5, 7, 8, 10, 12, 14: likely to require repeated administration and/or extended time periods to effect required changes in target behaviours.

 BCT 4: not applicable as a direct change to HCPs’ body structure/functioning is unlikely to have an impact on the target behaviours (i.e. prescribing/dispensing of appropriate polypharmacy).

 BCT 6: not possible to establish an acceptable goal/target in terms of the number of older patients that HCPs would perform target behaviours on because ideally the target behaviours should be performed on all older patients.

 BCT 9: not within scope of project to offer rewards/incentives and a general practice-based incentive scheme already exists in UK (i.e. the Quality and Oucomes Framework).

 BCT 11: intervention would likely need to be tailored to individual HCPs to account for baseline variation in skill levels.

 BCT 15: not applicable as the intervention will target HCPs in their normal place of work (i.e. general practice, community pharmacy) and the intervention will focus on the prescribing/dispensing of appropriate polypharmacy to community dwelling older patients as opposed to patients in other settings (e.g. nursing homes) whose clinical complexity and context is likely to be very different.

Beliefs about capabilities

1. Verbal persuasion to boost self-efficacy

2. Focus on past success

3. Self-monitoring

4. Graded task: start with easy tasks

5. Increasing skills: problem solving, decision making, goal setting

6. Coping skills

7. Rehearsal of relevant skills

8. Social processes of encouragement, pressure, support

9. Modelling/demonstration of behaviour by others

10. Homework

11. Perform behaviour in different settings

Social processes of encouragement, pressure, support (BCT 8): mapped to ‘Social/professional role and identity’ and ‘Social influences' – see below.

Modelling/demonstration of behaviour by others (BCT 9): outlined above – see ‘Skills’ domain.

Reasons for not selecting other BCTs

 BCTs 3, 4, 10: likely to require repeated administration and/or extended time periods to effect required changes in target behaviours.

 BCT 1: intervention would likely need to be tailored to individual HCPs to account for baseline variation in self-efficacy levels.

 BCT 2: not suitable due to potential variation in experience amongst HCPs (i.e. if HCPs do not have previous experience of performing the target behaviours then this BCT will not apply to them).

 BCTs 5, 6, 7: intervention would likely need to be tailored to individual HCPs to account for baseline variation in skill levels.

 BCT 11: not applicable as the intervention will target HCPs in their normal place of work (i.e. general practice, community pharmacy) and the intervention will focus on the prescribing/dispensing of appropriate polypharmacy to community dwelling older patients as opposed to patients in other settings (e.g. nursing homes) whose clinical complexity and context is likely to be very different.

Beliefs about consequences

1. Emotional consequences

2. Salience of consequences

3. Covert sensitization

4. Anticipated regret

5. Social and environmental consequences

6. Comparative imagining of future outcomes

7. Vicarious reinforcement

8. Threat

9. Pros and cons

10. Covert conditioning

11. Self-monitoring

12. Persuasive communication

13. Information regarding behaviour,outcome

14. Feedback

Information regarding behaviour, outcome/salience of consequences (BCTs 2 and 13 - equivalent): as part of the demonstration of how to prescribe/dispense appropriate polypharmacy during a typical encounter/consultation with an older patient, positive feedback would be included from the HCPs and patients to emphasise the positive consequences of performing the behaviour.

Reasons for not selecting other BCTs

 BCTs 7, 10, 11, 14: likely to require repeated administration and/or extended time periods to effect required changes in target behaviours.

 BCT 1: emotional consequences of performing the target behaviours have not been established.

 BCTs 3, 4: not applicable as intervention is focussed on wanted behaviours as opposed to unwanted behaviours.

 BCT 5: not applicable as HCPs were already aware of the consequences of performing the target behaviours.

 BCT 6: intervention would likely need to be tailored to individual HCPs as the imagining and comparing of future outcomes of changed versus unchanged behaviour is likely to vary between individuals.

 BCT 8: not within scope of project to implement future punishment or removal of reward as a consequence of HCPs performing an unwanted behaviour.

 BCT 9: intervention would likely need to be tailored to individual HCPs because if advised to identify and compare pros and cons of performing the target behaviours, assessments are likely to vary between individuals.

 BCT 12: difficult to have a credible source present evidence-based arguments in favour of the target behaviours as few interventions to date have examined clinically relevant outcomes (e.g. hospital admissions, ADEs) and where these outcomes have been evaluated, the findings have been inconsistent.

Environmental context and resources

1. Restructuring the physical environment

2. Discriminative (learned) cue

3. Prompts/cues

4. Restructuring the social environment

5. Avoidance/changing exposure to cues for the behaviour

6. Environmental changes (e.g. objects to facilitate behaviour)

Prompts/cues (BCT 3): HCPs will be asked to arrange for support staff (e.g. receptionists, pharmacy technicians) to prompt them to check that older patients who meet specific criteria are prescribed/dispensed appropriate polypharmacy when patients present in the practice/pharmacy.

Reasons for not selecting other BCTs

 BCT 1: not within scope of project to restructure HCPs’ physical work environment.

 BCTs 2: not within scope of project to offer reward (e.g. monetary fee) for performing target behaviour).

 BCT 4: not within scope of project to restructure HCPs’ social environment.

 BCT 5: not applicable as intervention is seeking to promote performance of target behaviours by HCPs as opposed to avoiding/reducing exposure to cues for the target behaviours.

 BCT 6: not within scope of project to restructure HCPs’ physical work environment.

Memory, attention and decision processes

None

1. Self-monitoring

2. Planning, implementation

3. Prompts, triggers, cues

Planning, implementation (BCT 2; equivalent to Action planning): HCPs would be asked to write an explicit plan of when and how they would ensure that patients meeting inclusion criteria are prescribed/dispensed appropriate polypharmacy.

Prompts, triggers, cues (BCT 3): outlined under ‘Environmental context and resources’ domain.

Reasons for not selecting other BCTs

 BCT 1: likely to require repeated administration and/or extended time periods to effect required changes in target behaviours.

Social influences

1. Social comparison

2. Social support or encouragement (general)

3. Information about others' approval

4. Social support (emotional)

5. Social support (practical)

6. Vicarious reinforcement

7. Restructuring the social environment

8. Modelling or demonstrating the behaviour

9. Identification of self as role model

10. Social reward

11. Social processes of encouragement, pressure, support

12. Modelling/demonstration of behaviour by others

Social processes of encouragement, pressure, support/ Social support or encouragement (BCT 2, 11 - equivalent): Pharmacists would receive a list of pre-approved patients from the GP practice which would encourage/support them in engaging with patients to ensure that they are dispensed appropriate polypharmacy.

Modelling /demonstration of behaviour by others/ Modelling or demonstrating the behaviour (BCT 8, 12 - equivalent): outlined above – see ‘Skills’ domain.

Reasons for not selecting other BCTs

 BCTs 6, 9, 10: likely to require repeated administration and/or extended time periods to effect required changes in target behaviours.

 BCT 1: difficult to draw meaningful comparisons between HCPs’ performance of target behaviours.

 BCT 3: difficult to establish older patients’ views on HCPs performing target behaviours due to clinical heterogeneity amongst older patients who are receiving polypharmacy in terms of clinical conditions and medication types.

 BCTs 4, 5: encapsulated by BCT 2.

 BCT 7: not within scope of project to restructure HCPs’ social environment.

Behavioural regulation

1. Self-monitoring of behaviour

2. Goal/target specified: behaviouror outcome

3. Contract

4. Planning, implementation

5. Prompts, triggers, cues

6. Use of imagery

Planning, implementation (BCT 4; equivalent to Action planning): see under ‘Memory, attention and decision processes’ domain above.

Prompts, triggers, cues (BCT 5): see under ‘Environmental context and resources’ domain above.

Reasons for not selecting other BCTs

 BCT 1: likely to require repeated administration and/or extended time periods to effect required changes in target behaviours.

 BCT 2: not possible to establish an acceptable goal/target in terms of the number of older patients that HCPs would perform target behaviours on because, ideally, the target behaviours should be performed on all older patients.

 BCT 3: not within scope of current project to impose additional contractual obligations on HCPs.

 BCT 6: used in the context of implementing other BCTs through the use of planned images (visual, motor, sensory); not applicable in the context of this research project.

Social/professional role and identity

None

1. Social processes of encouragement, pressure, support

Social processes of encouragement, pressure, support (BCT 1): see under ‘Social influences’ domain above.

Nature of the behaviours