Rebecca Lawton

Making psychological theory useful for implementing evidence based practice: a consensus approach

Background: Evidence-based guidelines are often not implemented effectively with the result that best health outcomes are not achieved. This may be due to a lack of theoretical understanding of the processes involved in changing the behaviour of healthcare professionals. This paper reports the development of a consensus on a theoretical framework that could be used in implementation research. The objectives were to identify an agreed set of key theoretical constructs for use in (1) studying the implementation of evidence based practice and (2) developing strategies for effective implementation, and to communicate these constructs to an interdisciplinary audience. Methods: Six phases of work were conducted to develop a consensus: (1) identifying theoretical constructs; (2) simplifying into construct domains; (3) evaluating the importance of the construct domains; (4) interdisciplinary evaluation; (5) validating the domain list; and (6) piloting interview questions. The contributors were a “psychological theory” group (n = 18), a “health services research” group (n = 13), and a “health psychology” group (n = 30). Results: Twelve domains were identified to explain behaviour change: (1) knowledge, (2) skills, (3) social/professional role and identity, (4) beliefs about capabilities, (5) beliefs about consequences, (6) motivation and goals, (7) memory, attention and decision processes, (8) environmental context and resources, (9) social influences, (10) emotion regulation, (11) behavioural regulation, and (12) nature of the behaviour. Conclusions: A set of behaviour change domains agreed by a consensus of experts is available for use in implementation research. Applications of this domain list will enhance understanding of the behaviour change processes inherent in implementation of evidence-based practice and will also test the validity of these proposed domains.

Prospective prediction of health-related behaviours with the Theory of Planned Behaviour: a meta-analysis

This meta-analysis explored the efficacy of the Theory of Planned Behaviour (TPB) dependent on behaviour and methodological moderators. A lack of hierarchical analysis in previous reviews risks confounding these moderators. Here moderating roles of behaviour type, length of follow-up, sample age and behavioural measure are explored hierarchically amongst prospective tests of the TPB, controlling for past behaviour where possible. Searching identified 237 prospective tests from 206 articles. Random-effects meta-analytic procedures were used to correcting correlations for sampling and measurement error. Behaviour type moderated the model; physical activity and diet behaviours were better predicted (23.9% and 21.2% variance explained, respectively) whilst risk, detection, safer sex and abstinence from drugs were poorly predicted (between 13.8 and 15.3% variance explained). Methodological moderators were also apparent: age of sample moderated relations with student samples better predicted for physical activity, and adolescent samples better predicted for abstinence behaviours. Behaviours assessed in the shorter term, and those assessed with self-reports (compared with objective measures) were also better predicted. Both behavioural and methodological characteristics moderated relations amongst model components. The results can aid selection of appropriate targets upon which to base interventions.

Desire or reason: predicting health behaviors from affective and cognitive attitudes.

OBJECTIVE The authors explore the role of affective attitudes in predicting 14 health-promoting or health-risk behaviors. DESIGN Participants (n = 390) completed questionnaire measures of affective and cognitive attitude and, 1 month later, reported their intentions and behavior. MAIN OUTCOME MEASURES The outcome measures in this study were the Time 2 self-report measures of intention and behavior. RESULTS A series of hierarchical regression analyses revealed that affective attitude was a significantly more powerful predictor of behavior than cognitive attitude for 9 behaviors. Also, affective attitude had a direct effect on behavior that was not fully mediated by intention for 9 behaviors. In a final series of regressions, higher divergence between affective and cognitive attitudes was shown to strengthen the relationship between affective attitudes and behavior for illegal drug use, binge drinking, and smoking. CONCLUSIONS The findings underscore the importance of affect in the performance of health-related behaviors and suggest that interventions could usefully target the affective consequences of engaging in these behaviors. The theoretical and practical implications of these findings are discussed.

The use of implementation intentions and the decision balance sheet in promoting exercise behaviour

Although increasing exercise and fitness has often been associated with positive health outcomes, infrequent exercise participation has remained a problem. Since two distinct motivational and volitional phases to goal pursuit have been proposed, a combined motivational (decision balance sheet, DBS) and volitional (implementation intentions) intervention was predicted to be more effective in increasing exercise behaviour than a control or either strategy alone. A total of 86 students were randomly assigned to one of the four conditions, and were all asked to try to exercise two more times a week than they currently did, over a four week period. Their fitness levels were measured through fitness tests conducted pre- and post-intervention. A priori orthogonal contrasts indicated that the experimental strategies produced a greater increase in exercise frequency and total time spent exercising per week and accordingly showed greater fitness improvements than the control group. Moreover, the volitional groups taken together produced greater increase in time spent exercising and a marginally greater improvement in frequency than the DBS alone. The combined intervention led to improvements in fitness and marginal increases in frequency over the implementation intention alone group. It is proposed that for the combined group the DBS may have aided recall of the implementation intention or increased commitment to it, as remembering and then acting on the plan, in the stated place and time, mediated the implementation intention–behaviour relationship. The combined intervention produced the greatest fitness improvements, indicating that this strategy can lead to important health benefits.

Development of an evidence-based framework of factors contributing to patient safety incidents in hospital settings: a systematic review

Objective The aim of this systematic review was to develop a ‘contributory factors framework’ from a synthesis of empirical work which summarises factors contributing to patient safety incidents in hospital settings. Design A mixed-methods systematic review of the literature was conducted. Data sources Electronic databases (Medline, PsycInfo, ISI Web of knowledge, CINAHL and EMBASE), article reference lists, patient safety websites, registered study databases and author contacts. Eligibility criteria Studies were included that reported data from primary research in secondary care aiming to identify the contributory factors to error or threats to patient safety. Results 1502 potential articles were identified. 95 papers (representing 83 studies) which met the inclusion criteria were included, and 1676 contributory factors extracted. Initial coding of contributory factors by two independent reviewers resulted in 20 domains (eg, team factors, supervision and leadership). Each contributory factor was then coded by two reviewers to one of these 20 domains. The majority of studies identified active failures (errors and violations) as factors contributing to patient safety incidents. Individual factors, communication, and equipment and supplies were the other most frequently reported factors within the existing evidence base. Conclusions This review has culminated in an empirically based framework of the factors contributing to patient safety incidents. This framework has the potential to be applied across hospital settings to improve the identification and prevention of factors that cause harm to patients.

Coping with medical error: a systematic review of papers to assess the effects of involvement in medical errors on healthcare professionals' psychological well-being

Background Previous research has established health professionals as secondary victims of medical error, with the identification of a range of emotional and psychological repercussions that may occur as a result of involvement in error.2 3 Due to the vast range of emotional and psychological outcomes, research to date has been inconsistent in the variables measured and tools used. Therefore, differing conclusions have been drawn as to the nature of the impact of error on professionals and the subsequent repercussions for their team, patients and healthcare institution. A systematic review was conducted. Methods Data sources were identified using database searches, with additional reference and hand searching. Eligibility criteria were applied to all studies identified, resulting in a total of 24 included studies. Quality assessment was conducted with the included studies using a tool that was developed as part of this research, but due to the limited number and diverse nature of studies, no exclusions were made on this basis. Results Review findings suggest that there is consistent evidence for the widespread impact of medical error on health professionals. Psychological repercussions may include negative states such as shame, self-doubt, anxiety and guilt. Despite much attention devoted to the assessment of negative outcomes, the potential for positive outcomes resulting from error also became apparent, with increased assertiveness, confidence and improved colleague relationships reported. Conclusion It is evident that involvement in a medical error can elicit a significant psychological response from the health professional involved. However, a lack of literature around coping and support, coupled with inconsistencies and weaknesses in methodology, may need be addressed in future work.

Application of the theory of planned behaviour to the prediction of objectively assessed breaking of posted speed limits

In two studies the Theory of Planned Behaviour (TPB) including moral norms, anticipated regret and past behaviour was applied to predicting intention to exceed the posted speed limit across different roads and objectively assessed speeding behaviour. All measures except behaviour were taken by self-report questionnaires referring to different driving scenarios. The behaviour measures were based on performance in a simulator (Study 1) or unobtrusive on-road speed camera assessment taken without driver awareness (Study 2) across roads with varying posted speed limits. Results are reported averaged across road types in both studies. In Study 1 (N=83), 82% of the variance in intentions to speed was explained, with attitudes, subjective norms, perceived behavioural control (PBC), moral norms, anticipated regret and past behaviour being significant predictors. A total of 35% of the variance in speed as assessed on a driving simulator was accounted for with intentions, PBC, moral norms and previous accidents being significant predictors. In Study 2 (N=303), 76% of the variance in intentions to speed was explained with attitudes, moral norms, anticipated regret and past behaviour being significant predictors. A total of 17% of the variance in speed as assessed on-road was accounted for with intentions and moral norms being significant. Practical implications of the findings for road safety are discussed.

Beyond cognition: Predicting health risk behaviors from instrumental and affective beliefs.

OBJECTIVE Two studies assessed the relative contribution of affective and instrumental beliefs to the prediction of 2 risk behaviors: driving above the speed limit and smoking. DESIGN Both studies took the form of large-scale questionnaire surveys (Study 1, N=292; Study 2, N=500) measuring instrumental and affective beliefs and self-reported behavior. In both cases, behavior was also measured objectively. OUTCOME MEASURES In Study 1, speeding behavior was measured via infrared camera along sections of road with 30 mph, 40 mph, and 60 mph speed limits. Self-reports of speeding in these same contexts represented a 2nd dependent variable. In Study 2, level of smoking was measured via a carbon monoxide monitor, and participants were asked to indicate the number of cigarettes they smoked in a week. RESULTS In Study 1, positive and negative instrumental and affective beliefs were significant predictors of self-reported speed. The most powerful predictor was negative affective beliefs. Observed speed was predicted by negative affective beliefs only. In Study 2, the significant predictors of self-reported smoking and objective measures of smoking were positive and negative affective beliefs. CONCLUSION The findings indicate the importance of affective beliefs across 2 health risk behaviors. Implications for social cognition models and interventions are discussed.

The role of message framing in promoting MMR vaccination: Evidence of a loss-frame advantage

Abstract This study examined the effects of message framing on intentions to obtain the measles, mumps and rubella (MMR) vaccine for ones child and investigated whether Theory of Planned Behaviour (TPB) and perceived outcome efficacy variables mediate and/or moderate message framing effects. One hundred and forty women read either a loss-framed or gain-framed message and then completed measures assessing their intentions to obtain the MMR vaccine for their child, and TPB and outcome efficacy variables. Exposure to the loss frame increased intentions to obtain the MMR vaccine and influenced perceptions of outcome efficacy. This suggests that outcome efficacy, but not other TPB variables may mediate framing effects within the context of MMR vaccination. Message frame, in addition to TPB variables, significantly predicted unique variance in behavioural intentions. These findings are discussed within the context of Prospect Theory, perceived risk and prevention/detection behaviours.

The impact of theory on the effectiveness of worksite physical activity interventions: a meta-analysis and meta-regression

Abstract Background. Despite the potential importance of worksite physical activity interventions, reviews suggest there is currently a lack of clarity regarding their effectiveness. Aim. This meta-analysis assessed the effectiveness of worksite interventions designed to promote physical activity and investigate whether (1) interventions explicitly designed based on theory are more effective, and (2) inclusion of specific behaviour change techniques (BCTs) improves effectiveness. Methods. Worksite interventions with a primary aim of increasing physical activity were systematically reviewed. Designs were experimental or quasi-experimental and outcome measures were objective or validated self-report. Interventions were coded based on the extent to which theory/predictors were used to select/develop intervention techniques. A standardised theory-linked taxonomy of 26 BCTs was also used to code interventions. Effects of explicit use of theory, individual techniques and number of BCTs used were assessed using meta-analysis and meta-regression. Results. Twenty-six studies reporting 27 evaluations were included in the meta-analysis and a random effects model produced an overall effect size (d) of 0.21 (95% CI 0.17–0.26). Subgroup analysis indicated that interventions using theory more explicitly were more effective, producing an effect size of 0.34 (95% CI 0.23–0.45; I 2=0%). No significant differences in effect sizes were found between studies that had used individual BCTs and those that had not, and studies that used more techniques were not more effective. Conclusion. Overall, worksite physical activity interventions were effective, but only produced small sized effects on physical activity. Theory-based interventions were more effective.