Action, actor, context, target, time (AACTT): a framework for specifying behaviour

BACKGROUND: Designing implementation interventions to change the behaviour of healthcare providers and other professionals in the health system requires detailed specification of the behaviour(s) targeted for change to ensure alignment between intervention components and measured outcomes. Detailed behaviour specification can help to clarify evidence-practice gaps, clarify who needs to do what differently, identify modifiable barriers and enablers, design interventions to address these and ultimately provides an indicator of what to measure to evaluate an intervention's effect on behaviour change. An existing behaviour specification framework proposes four domains (Target, Action, Context, Time; TACT), but insufficiently clarifies who is performing the behaviour (i.e. the Actor). Specifying the Actor is especially important in healthcare settings characterised by multiple behaviours performed by multiple different people. We propose and describe an extension and re-ordering of TACT to enhance its utility to implementation intervention designers, practitioners and trialists: the Action, Actor, Context, Target, Time (AACTT) framework. We aim to demonstrate its application across key steps of implementation research and to provide tools for its use in practice to clarify the behaviours of stakeholders across multiple levels of the healthcare system. METHODS AND RESULTS: We used French et al.'s four-step implementation process model to describe the potential applications of the AACTT framework for (a) clarifying who needs to do what differently, (b) identifying barriers and enablers, (c) selecting fit-for-purpose intervention strategies and components and (d) evaluating implementation interventions. CONCLUSIONS: Describing and detailing behaviour using the AACTT framework may help to enhance measurement of theoretical constructs, inform development of topic guides and questionnaires, enhance the design of implementation interventions and clarify outcome measurement for evaluating implementation interventions

Charge ordering induces a smectic phase in oblate ionic liquid crystals

We report a computer simulation study of an electroneutral mixture of oppositely charged oblate ellipsoids of revolution with aspect ratio A = 1/3. In contrast to hard or soft repulsive ellipsoids, which are purely nematic, this system exhibits a smectic-A phase in which charges of equal sign are counterintuitively packed in layers perpendicular to the nematic director

Clinical Indications and Compassionate Use of Phage Therapy: Personal Experience and Literature Review with a Focus on Osteoarticular Infections.

The history of phage therapy started with its first clinical application in 1919 and continues its development to this day. Phages continue to lack any market approval in Western medicine as a recognized drug, but are increasingly used as an experimental therapy for the compassionate treatment of patients experiencing antibiotic failure. The few formal experimental phage clinical trials that have been completed to date have produced inconclusive results on the efficacy of phage therapy, which contradicts the many successful treatment outcomes observed in historical accounts and recent individual case reports. It would therefore be wise to identify why such a discordance exists between trials and compassionate use in order to better develop future phage treatment and clinical applications. The multitude of observations reported over the years in the literature constitutes an invaluable experience, and we add to this by presenting a number of cases of patients treated compassionately with phages throughout the past decade with a focus on osteoarticular infections. Additionally, an abundance of scientific literature into phage-related areas is transforming our knowledge base, creating a greater understanding that should be applied for future clinical applications. Due to the increasing number of treatment failures anticipatedfrom the perspective of a possible post-antibiotic era, we believe that the introduction of bacteriophages into the therapeutic arsenal seems a scientifically sound and eminently practicable consideration today as a substitute or adjuvant to antibiotic therapy

Understanding the Canadian adult CT head rule trial: use of the theoretical domains framework for process evaluation

BACKGROUND: The Canadian CT Head Rule was prospectively derived and validated to assist clinicians with diagnostic decision-making regarding the use of computed tomography (CT) in adult patients with minor head injury. A recent intervention trial failed to demonstrate a decrease in the rate of head CTs following implementation of the rule in Canadian emergency departments. Yet, the same intervention, which included a one-hour educational session and reminders at the point of requisition, was successful in reducing cervical spine imaging rates in the same emergency departments. The reason for the varied effect of the intervention across these two behaviours is unclear. There is an increasing appreciation for the use of theory to conduct process evaluations to better understand how strategies are linked with outcomes in implementation trials. The Theoretical Domains Framework (TDF) has been used to explore health professional behaviour and to design behaviour change interventions but, to date, has not been used to guide a theory-based process evaluation. In this proof of concept study, we explored whether the TDF could be used to guide a retrospective process evaluation to better understand emergency physicians’ responses to the interventions employed in the Canadian CT Head Rule trial. METHODS: A semi-structured interview guide, based on the 12 domains from the TDF, was used to conduct telephone interviews with project leads and physician participants from the intervention sites in the Canadian CT Head Rule trial. Two reviewers independently coded the anonymised interview transcripts using the TDF as a coding framework. Relevant domains were identified by: the presence of conflicting beliefs within a domain; the frequency of beliefs; and the likely strength of the impact of a belief on the behaviour. RESULTS: Eight physicians from four of the intervention sites in the Canadian CT Head Rule trial participated in the interviews. Barriers likely to assist with understanding physicians’ responses to the intervention in the trial were identified in six of the theoretical domains: beliefs about consequences; beliefs about capabilities; behavioural regulation; memory, attention and decision processes; environmental context and resources; and social influences. Despite knowledge that the Canadian CT Head Rule was highly sensitive and reliable for identifying clinically important brain injuries and strong beliefs about the benefits for using the rule, a number of barriers were identified that may have prevented physicians from consistently applying the rule. CONCLUSION: This proof of concept study demonstrates the use of the TDF as a guiding framework to design a retrospective theory-based process evaluation. There is a need for further development and testing of methods for using the TDF to guide theory-based process evaluations running alongside behaviour change intervention trials

Collagen α5 and α2(IV) chain coexpression: Analysis of skin biopsies of Alport patients

Alport syndrome is a collagen type IV disease caused by mutations in the COL4A5 gene with the X-linked form being most prevalent. The resultant α5(IV) collagen chain is a component of the glomerular and skin basement membranes (SBMs). Immunofluorescent determination of the α5(IV) chain in skin biopsies is the procedure of choice to identify patients. In 30% of patients, however, the mutant protein is still found in the SBM resulting in a normal staining pattern. In order to minimize or eliminate false results, we compared the distribution of the α2(IV) chain (another SBM component) and the α5(IV) chain by standard double label immunofluorescence (IF) and by confocal laser scanning microcopy. The study was performed on 55 skin biopsies of patients suspected of Alports and five normal control specimens. In normal skin, IF showed the classical linear pattern for both collagens along the basement membrane. Additionally, decreased α5(IV) was found in the bottom of the dermal papillary basement membrane. Confocal analysis confirmed the results and show α5(IV) focal interruptions. In suspected patients, both techniques showed the same rate of abnormal α5(IV) expression: segmental in women and absent in men. Our results show a physiological variation of α5(IV) location with focal interruptions and decreased expression in the bottom of the dermal basement membrane. Comparison of α5(IV) with α2(IV) expression is simple and eliminates technical artifacts

Professional barriers and facilitators to using stratified care approaches for managing non-specific low back pain: a qualitative study with Canadian physiotherapists and chiropractors

Background: Recent clinical practice guidelines for the management of non-specific low back pain (LBP) recommend using stratified care approaches. To date, no study has assessed barriers and facilitators for health professionals in using stratified care approaches for managing non-specific LBP in the Canadian primary care setting. This study aimed to identify and contrast barriers and facilitators to using the stratified care approaches for non-specific LBP among Canadian physiotherapists and chiropractors. Methods: Individual telephone interviews, underpinned by the Theoretical Domains Framework (TDF), explored beliefs and attitudes about, and identified barriers and facilitators to the use of stratified care approaches for managing non-specific LBP in a purposive sample of 13 chiropractors and 14 physiotherapists between September 2015 and June 2016. Interviews were digitally recorded, transcribed verbatim and analysed by two independent assessors using directed content analysis. Results: Three and seven TDF domains were identified as likely relevant for physiotherapists and chiropractors, respectively. Shared key beliefs (and relevant domains of the TDF) for both physiotherapists and chiropractors included: lack of time, cost, and expertise (Environmental Context and Resources); and consulting more experienced colleagues and chronic patients with important psychological overlay (Social Influences). Unique key domains were identified among physiotherapists: incompatibility with achieving other objectives (Goals), and chiropractors: confidence in using stratified care approaches (Beliefs about Capabilities); intention to use stratified care approaches (Intentions); awareness and agreement with stratified care approaches (Knowledge); assessment of readiness for change and intentional planning behaviour (Behavioural Regulation); and improving the management of non-specific LBP patients and the uptake of evidence-based practice (Beliefs about Consequences). Conclusions: Several shared and unique barriers and facilitators to using the stratified care approaches for non-specific LBP among Canadian physiotherapists and chiropractors were identified. Findings may help inform the design of tailored theory-based knowledge translation interventions to increase the uptake of stratified care approaches in clinical practice. © The Author(s). 2019

Changing behaviour, 'more or less': do implementation and de-implementation interventions include different behaviour change techniques?

Background Decreasing ineffective or harmful healthcare practices (de-implementation) may require different approaches than those used to promote uptake of effective practices (implementation). Few psychological theories differentiate between processes involved in decreasing, versus increasing, behaviour. However, it is unknown whether implementation and de-implementation interventions already use different approaches. We used the behaviour change technique (BCT) taxonomy (version 1) (which includes 93 BCTs organised into 12 groupings) to investigate whether implementation and de-implementation interventions for clinician behaviour change use different BCTs. Methods Intervention descriptions in 181 articles from three systematic reviews in the Cochrane Library were coded for (a) implementation versus de-implementation and (b) intervention content (BCTs) using the BCT taxonomy (v1). BCT frequencies were calculated and compared using Pearson’s chi-squared (χ2), Yates’ continuity correction and Fisher’s exact test, where appropriate. Identified BCTs were ranked according to frequency and rankings for de-implementation versus implementation interventions were compared and described. Results Twenty-nine and 25 BCTs were identified in implementation and de-implementation interventions respectively. Feedback on behaviour was identified more frequently in implementation than de-implementation (Χ2(2, n=178) = 15.693, p = .000057). Three BCTs were identified more frequently in de-implementation than implementation: Behaviour substitution (Χ2(2, n=178) = 14.561, p = .0001; Yates’ continuity correction); Monitoring of behaviour by others without feedback (Χ2(2, n=178) = 16.187, p = .000057; Yates’ continuity correction); and Restructuring social environment (p = .000273; Fisher’s 2-sided exact test). Conclusions There were some significant differences between BCTs reported in implementation and de-implementation interventions suggesting that researchers may have implicit theories about different BCTs required for de-implementation and implementation. These findings do not imply that the BCTs identified as targeting implementation or de-implementation are effective, rather simply that they were more frequently used. These findings require replication for a wider range of clinical behaviours. The continued accumulation of additional knowledge and evidence into whether implementation and de-implementation is different will serve to better inform researchers and, subsequently, improve methods for intervention design

The big six: key principles for effective use of Behavior substitution in interventions to de-implement low-value care

Healthcare professionals provide care to help patients; however, sometimes that care is of low value – at best ineffective and at worst harmful. To address this, recent frameworks provide guidance for developing and investigating de-implementation interventions; yet little attention has been devoted to identifying what strategies are most effective for de-implementation. In this paper, we discuss Behavior substitution, a strategy whereby an unwanted behavior is replaced with a wanted behavior, thereby making it hypothetically easier to reduce or stop the unwanted behavior. We discuss why Behavior substitution may be a useful de-implementation strategy, and why it may not be suitable for all circumstances. On the basis of the body of knowledge in behavioral science, we propose a list of principles to consider when selecting a substitute behavior for a de-implementation intervention. Applying these principles should increase the likelihood that this technique will be effective in reducing low-value care

The Wonder of Colors and the Principle of Ariadne

The Principle of Ariadne, formulated in 1988 ago by Walter Carnielli and Carlos Di Prisco and later published in 1993, is an infinitary principle that is independent of the Axiom of Choice in ZF, although it can be consistently added to the remaining ZF axioms. The present paper surveys, and motivates, the foundational importance of the Principle of Ariadne and proposes the Ariadne Game, showing that the Principle of Ariadne, corresponds precisely to a winning strategy for the Ariadne Game. Some relations to other alternative. set-theoretical principles are also briefly discussed

Orientational Ordering in Spatially Disordered Dipolar Systems

This letter addresses basic questions concerning ferroelectric order in positionally disordered dipolar materials. Three models distinguished by dipole vectors which have one, two or three components are studied by computer simulation. Randomly frozen and dynamically disordered media are considered. It is shown that ferroelectric order is possible in spatially random systems, but that its existence is very sensitive to the dipole vector dimensionality and the motion of the medium. A physical analysis of our results provides significant insight into the nature of ferroelectric transitions.Comment: 4 pages twocolumn LATEX style. 4 POSTSCRIPT figures available from [email protected]