Aligning intuition and theory: enhancing the replicability of behaviour change interventions in cancer genetics

Abstract

Background Despite considerable encouragement for healthcare professionals to use or be clear about the theory used in their improvement programmes, the uptake of these approaches to design interventions or report their content is lacking. Recommendations suggest healthcare practitioners work with social and/or behavioural scientists to gain expertise in programme theory, ideally before, but even during or after the work is done. We aim to demonstrate the extent to which intuitive intervention strategies designed by healthcare professionals to overcome patient barriers to communicating genetic cancer risk information to family members align with a theoretical framework of behaviour change. Methods As part of a pre-post intervention study, a team of genetic counsellors aimed to understand, and design interventions to overcome, the major barriers a group of familial cancer patients face around communicating hereditary cancer risk information to their relatives. A behavioural change specialist worked with the team to review and recode barriers and interventions according to the Theoretical Domains Framework (TDF) and 93 behaviour change techniques (BCTs). Resulting BCTs were cross-referenced against the Theory and Techniques Tool to examine whether evidence-based mechanistic links have been established to date. Results Five themes emerged from the genetic counsellor coded barriers, which when recoded according to the TDF represented seven domains of behaviour change. Forty-five experiential and intuitive interventions were used to tackle key barriers. These were represented by 21 BCTs, which were found to be used on 131 occasions. The full mapping exercise is presented, resulting in a suite of intervention strategies explicitly linked to a theoretical framework. Structured, written reflections were provided retrospectively by the core clinical team. Conclusions Although the ideal is to use theory prospectively, or even whilst a project is underway, making links between theory and interventions explicit, even retrospectively, can contribute towards standardising intervention strategies, furthering understanding of intervention effects, and enhancing the opportunities for accurate replicability and generalisability across other settings. Demonstrating to healthcare professionals how their intuition aligns with theory may highlight the additional benefits that theory has to offer and serve to promote its use in improvement.

Investigating the Adoption of Clinical Genomics in Australia. An Implementation Science Case Study

“…For example, during TBA 1, three barriers (the process of "doing" genomics, developing genomic (clinical) skills and gaining genetic knowledge) i.e., TDF codes knowledge and skills may logically respond to an education intervention [21]. However, other barriers are less clear cut and using the TDF allows for systematic identification of theory-informed behaviour change techniques [34] alongside participants' intuitive enablers [35]. The COM-B, while informative, does not narrow down attention and so behaviour change strategies may not reach the underlying cause of a presenting barrier.…”

A Toolkit for Implementation of Clinical Genomic Testing: Using a Combined Stakeholder and Evidence-Driven Approach

“…Stage 4 -assessing alignment of intuitively derived enabling strategies and theory: In line with recently reported methods [35], a counting exercise was undertaken to assess the number of barriers and intuitively derived barrier-matched enablers. The number of intuitively derived enablers that aligned with BCTs demonstrating mechanistic links with the associated TDF domains, according to the Theory and Techniques Tool[6], were next counted.…”

“…It can also signal where theory is most needed (e.g., to address more complex barriers such as social in uences or emotion) and can be best utilised -potentially making the process of theory guided interventions more e cient. Furthermore, recording and coding these intuitive approaches to implementation strategy design against theory can allow for the study of effects, and contribute to the evidence-base for establishing and explaining the mechanistic links between those strategies that lead to clinical practice change [35,40].…”

“…These challenges are exacerbated when the intricacies of theory application can be inaccessible to non-experts [5], and slow, relative to demands for rapid evidence translation [19,30,31]. Although theory-driven stakeholder codesign methodology is evolving [32][33][34], theory-based approaches to elicit key barriers to implementation of a particular intervention to inform a theory-driven approach to implementation strategy design often lead to 'on the spot' solutions [35]. These solutions may or may not align with theoretical recommendations, and stakeholders may also decide to enact them immediately, despite deviation from the implementation protocol [19,23,36].…”

“…One recent area of exploration is the role of healthcare professional intuition in the identi cation of barriers and solutions to implementation, and the extent to which this intuition aligns with theory-driven recommendations [18,35,[37][38][39][40]. Enhancing understanding about the alignment of intuition and theory can tell us more about where healthcare professionals generate relevant implementation strategies (e.g., education/training) to address identi ed barriers (e.g., knowledge/skills) without the need for in depth use of theory.…”