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Table 2 Using COM-B model to identify behaviours which need to change so that GPs intensify medications and prescribe more appropriately for patients with poorly controlled T2DM

From: Development of a complex intervention to promote appropriate prescribing and medication intensification in poorly controlled type 2 diabetes mellitus in Irish general practice

Health problem:
 • Poorly controlled T2DM
Health behaviour:
 • Intensification and appropriate prescribing of anti-diabetic and cardiovascular medications for adults with poorly controlled T2DM, by GPs
COM-B components What needs to happen for the target behaviour to occur?
The first workshop involved a discussion between the research team and wider stakeholders on the components of the COM-B behavioural diagnosis, after a consideration of the literature review and health problem.
Is there a need for change?
Using a structured discussion with the stakeholders, having been presented with the evidence base and sample cases studies, the need for change for each COM-B component (capability, opportunity and motivation) was discussed and how that could happen.
Capability Physical capability
Physical skills
None. No change needed.
Psychological capability
The capacity to engage in the necessary thought processes—comprehension and reasoning
• A recognition of which patients have poor control by GPs in their practice is needed. Also a mechanism to easily find these patients would be needed, ideally as part of the routine workflow, and as part of the Diabetes Cycle of Care.
• That prompt intensification of T2DM anti-diabetic and cardiovascular medications is necessary, which should be performed by the GP.
• Interpretation of recent evidence changes is necessary: Multiple new medications and two recent guidelines for the management of T2DM have made interpretation and decision making difficult. GPs must integrate this knowledge with the patient specific information to make an intensification decision.
• GPs require the ability to synthesise guidelines with patient specific information and then act on the recommendations from this guidance.
There is a need for change.
Without addressing these issues (finding patients with poor control, promoting intensification and updating GPs on guidance), it is unlikely that change in the behaviour is likely to occur.
Finding patients with poor control, addressing knowledge deficits and gaps in intensification will be necessary to reduce poor control and lack of intensification.
Opportunity Physical opportunity
Opportunity afforded by the environment
None. No change needed.
Social
Opportunity afforded by the cultural milieu that dictates the way we think about things
• Specific time and remuneration is necessary to enable GPs and practice nurses to focus on patients with poor control of T2DM, before they consider the intensification of medications. Some GPs mentioned that a further financial incentive for such practitioners may be necessary to enable them focus on those patients with poor control of T2DM.
• Advice on how to restructure the practice in accordance with best-evidence could be offered through structured education or academic detailing.
Since October 2015 a new Diabetes Cycle of Care has provided the time and opportunity for GPs and practice nurses to manage T2DM for medical card holders (see Box 1).
The increase in workload focusing on patients with poor control of T2DM may require more remuneration.
EHR integration would be ideal, but is not necessary for this behaviour to change.
Motivation Reflective
Reflective processes, involving evaluations and plans
Nil NA
Automatic
Automatic processes involving emotions and impulses that arise from associative learning and/or innate dispositions
Nil NA
Behavioural diagnosis of the relevant COM-B components for this health problem: Psychological capability, and to a small extent social opportunity, were deemed to be important in allowing appropriate prescribing by GPs for poorly controlled T2DM.
Addressing psychological capability (the capacity to engage in the necessary thought processes- comprehension and reasoning) was deemed the most important behaviour to enable intensification of medications and appropriate prescribing by GPs for poorly controlled T2DM.
  1. NA not applicable