Making good quality care habitual : an exploration of the concept habit in relation to healthcare professional behaviour

PhD ThesisTranslating evidence-based guidance into practice involves healthcare professionals (HCPs) adopting new, and changing existing behaviours. Implementation research typically focuses on the reflective process that underlies HCPs’ behaviour, however there is a growing interest in the role that impulsive processes such as habit have on behaviour. Habit can be defined as a learned tendency to perform a behaviour automatically in response to a specific cue. This thesis presents four studies investigating how a habit perspective can contribute to understanding HCPs’ behaviour. Chapter 1 describes how a greater consideration of habit in the implementation literature could contribute to the field. Chapter 2 presents theory-based interviews conducted with HCPs who piloted a new self-management tool for diabetes. The study showed how HCPs formed a new habit of using the tool and how electronic reminders facilitated this process by promoting behavioural repetition. Chapter 3 describes a randomised controlled trial that aimed to test whether a planning intervention (using action- and coping planning) would be effective in supporting HCPs with habit change. While the study did not reach recruitment targets, it provided some first insights regarding the feasibility of using a planning intervention to support HCP behaviour change. Chapter 4 presents a secondary analysis of a large national data set, which found that the relationship between planning (action and coping planning) and six guideline-recommended behaviours operated indirectly on HCP behaviour via habit. Finally, Chapter 5 describes a systematic review and meta-analysis of studies investigating the association between habit and HCPs’ behaviour and showed that habit plays a significant role in predicting clinical behaviours. This thesis supports the consideration of habit when predicting HCPs’ behaviour and suggests that the use of conditional planning interventions may offer a feasible approach to support HCPs with creating and breaking habit.Health Foundatio

Planning to be routine : habit as a mediator of the planning-behaviour relationship in healthcare professionals

Background: Gaps in the quality of care provided to people with type 2 diabetes are regularly identified. Healthcare professionals often have a strong intention to follow practice guidelines during consultations with people with type 2 diabetes; however, this intention does not always translate into action. Action planning (planning when, where and how to act) and coping planning (planning how to overcome pre-identified barriers) have been hypothesised to help with the enactment of intentions by creating mental cue-response links that promote habit formation. This study aimed to investigate whether habit helps to better understand how action and coping planning relate to clinical behaviour in the context of type 2 diabetes care. Methods: The study utilised a prospective correlational design with six nested sub-studies. General practitioners and practice nurses (n = 427 from 99 UK primary care practices) completed measures of action planning, coping planning and habit at baseline and then self-reported their enactment of guideline-recommended advising, prescribing and examining behaviours 12 months later. Bootstrapped mediation analyses were used to test the indirect effect of action and coping planning on healthcare professionals' clinical behaviour via their relationship with habit. Results: Healthcare professionals who reported higher degrees of action or coping planning for performing six guideline recommended behaviours in the context of type 2 diabetes care were more likely to report performing these behaviours in clinical practice. All 12 bootstrapped mediation analyses showed that the positive relationship between planning (action and coping planning) and healthcare professionals' clinical behaviour operated indirectly through habit. Conclusions: These findings suggest that habit mediates the relationship between planning (action and coping planning) and healthcare professional behaviour. Promoting careful action and coping planning may support routinised uptake of guideline-recommended care by healthcare professionals in the primary care setting. Given the competing demands on healthcare professionals, exploring the behavioural processes involved in promoting more routinisation of behaviours where possible and appropriate could free up cognitive capacity for clinical behaviours that rely on more deliberation.Peer reviewe

Conceptualising Four Categories of Behaviours: Implications for Implementation Strategies to Achieve Behaviour Change

Background: Effectiveness of implementation strategies is influenced by the extent to which they are based on appropriate theories concerning the behaviours that the strategies intend to impact. Effectiveness may be limited simply because the strategies are based on theories that are limited in scope or are derived from partially inaccurate assumptions about the behaviours in question. It may therefore be important to combine insights from various theories to cover the range of influences on the behaviours that will be changed. Aim: This article aims to explore concepts, theories and empirical findings from different disciplines to categorise four types of behaviours and discuss the implications for implementation strategies attempting to change these behaviours. Influences on behaviours: Multilevel influences on behaviours are dichotomized into individual-level and collective-level influences, and behaviours that are guided by conscious cognitive processes are distinguished from those that rely on non-conscious processing. Combining the two dimensions (levels and cognitive modes) creates a 2 x 2 conceptual map consisting of four categories of behaviours. Explicitly conceptualising the levels and cognitive modes is crucial because different implementation strategies are required depending on the characteristics of the behaviours involved in the practise that needs to be changed. Conclusion: The 2 x 2 conceptual map can be used to consider and reflect on the nature of the behaviours that need to be changed, thus providing guidance on the type of theory, model or framework that might be most relevant for understanding and facilitating behaviour change

The Relationship between Habit and Healthcare Professional Behaviour in Clinical Practice: A Systematic Review and Meta-Analysis

Theories of behaviour used to understand healthcare professional behaviour often focus on the deliberative processes that drive their behaviour; however, less is known about the role that implicit processes such as habit have on healthcare professional behaviour. This systematic review aimed to critically appraise and synthesise research evidence investigating the association between habit and healthcare professional behaviour. A search of five databases (PsycINFO, EMBASE, Scopus and CINAHL) was conducted up until 29 February 2016 to identify studies reporting correlations between habit and healthcare professional behaviours. Meta-analyses were conducted to assess the overall habit-behaviour association across all behaviours. A subgroup analysis assessed whether the habit-behaviour relationship differed depending on whether the behaviour was objectively measured or assessed by self-report. We identified nine eligible studies involving 1975 healthcare professionals that included 28 habit-behaviour correlations. A combined mean r+ of 0.35 (medium effect) was observed between habit and healthcare professional behaviour. The habit-behaviour correlation was not affected by whether behaviour was measured objectively or by self-report. This review suggests that habit plays a significant role in healthcare professional behaviour. Findings may have implications for considering health professionals’ habit when promoting the provision of evidence-based health care, and for breaking existing habit when de-implementing outdated, non-evidence-based practices

Implementation from a habit perspective

In their efforts to provide evidence-based care, health care professionals engage in a range of clinical behaviours. Their clinical actions are characteristically performed repeatedly, in the same physical locations with the same colleagues and patients, under constant time pressure and competing demands. This repetition under pressure in a stable setting provides ideal circumstances for creating contingencies between physical and social cues and clinical actions. Health care professional behaviour provides an ideal setting in which to advance theory, methods and interventions to better understand habit formation and habit reversal. Contemporary theoretical and methodological development in the psychology of habit has begun to be applied to understand and promote forming, breaking and replacing habitual behaviour among health care professionals. This chapter highlights key theoretical approaches, methods and intervention techniques that have been applied to conceptualize, measure, develop and break habit and automaticity in health care professionals. These insights have the potential to synergistically contribute novel perspectives to the wider habit literature

“Pororo Ká”. Flujo diastólico paradójico y aneurisma apical del ventrículo izquierdo. A propósito de un caso

A 71-year-old male with mechanical aortic valve replacement evolves with progressive impairment of functional capacity. Transthoracic echocardiography showed dilatation and moderate systolic dysfunction of the left ventricle. An apical aneurysm with systolic influx to the aneurysmal cavity and diastolic paradoxic flow of the aneurysm to the midventricular region was found. This flow was counterposed to the passive diastolic filling of the left atrium. The identification of this alteration has a prognostic role in relation to the association with increased incidence of sudden death, thromboembolic events and impairment of functional capacity and left ventricular systolic function.Hombre de 71 años con reemplazo mecánico de válvula aórtica que evoluciona con deterioro progresivo de la capacidad funcional. La ecocardiografía transtorácica mostró dilatación y disfunción sistólica moderada del ventrículo izquierdo. Se encontró un aneurisma apical con flujo sistólico hacia la cavidad aneurismática y flujo paradójico diastólico del aneurisma a la región medioventricular. Este flujo se contraponía al llenado diastólico pasivo de la aurícula izquierda. La identificación de esta alteración tiene un papel pronóstico en relación con la asociación de aumento de incidencia de muerte súbita, eventos tromboembólicos y deterioro de la capacidad funcional y la función sistólica ventricular izquierda

Pragmatic approaches for addressing alcohol in general practice: Development of a tailored implementation intervention

Introduction: Alcohol consumption is a leading global risk factor for ill-health and premature death. Alcohol screening and brief interventions (SBI) delivered in primary care is effective at reducing alcohol consumption, but routine implementation remains problematic. Screening all patients for excessive drinking (universal screening) is resource-intensive and may be at odds with general practitioners' (GPs') perceived professional role. This study aimed to develop a tailored, theory-based training intervention to strengthen GPs' ability to address alcohol and to manage alcohol-related health problems through a pragmatic approach based on clinical relevance. Methods: A qualitative study design involving focus group interviews and a structured questionnaire for free text replies with GPs in Norway. Behavioral analysis assessed factors influencing delivery of SBI according to the ‘capability, opportunity, motivation and behavior' (COM-B) model to inform intervention development using the Behavior Change Wheel. Qualitative data were analyzed using framework analysis and an iterative approach was adopted to develop the training. Results: A purposive sample of GPs attended the focus groups (n = 25) and completed the questionnaire (n = 55). Four areas required additional support including: understanding the link between alcohol use and health problems; opening up the conversation on alcohol use; addressing alcohol and dealing with obstacles; and following-up and maintaining change. Findings informed the development of a four-session interactive training intervention and a digital intervention for providing support for patients between consultations to address the identified needs. Conclusion: This work highlights the value of pragmatic, relevance-based clinical strategies, as opposed to universal screening approaches to addressing alcohol in primary care. A pragmatic approach is more in line with GPs existing sclinical skill set and holds the potential to improve widespread uptake and implementation of SBI in routine primary care

White Paper: Open Digital Health – accelerating transparent and scalable health promotion and treatment

In this White Paper, we outline recommendations from the perspective of health psychology and behavioural science, addressing three research gaps: (1) What methods in the health psychology research toolkit can be best used for developing and evaluating digital health tools? (2) What are the most feasible strategies to reuse digital health tools across populations and settings? (3) What are the main advantages and challenges of sharing (openly publishing) data, code, intervention content and design features of digital health tools? We provide actionable suggestions for researchers joining the continuously growing Open Digital Health movement, poised to revolutionise health psychology research and practice in the coming years. This White Paper is positioned in the current context of the COVID-19 pandemic, exploring how digital health tools have rapidly gained popularity in 2020–2022, when world-wide health promotion and treatment efforts rapidly shifted from face-to-face to remote delivery. This statement is written by the Directors of the not-for-profit Open Digital Health initiative (n = 6), Experts attending the European Health Psychology Society Synergy Expert Meeting (n = 17), and the initiative consultant, following a two-day meeting (19–20th August 2021)

Translational framework for implementation evaluation and research: Protocol for a qualitative systematic review of studies informed by Normalization Process Theory (NPT)

Background: Normalization Process Theory (NPT) identifies mechanisms that have been demonstrated to play an important role in implementation processes. It is now widely used to inform feasibility, process evaluation, and implementation studies in healthcare and other areas of work. This qualitative synthesis of NPT studies aims to better understand how NPT explains observed and reported implementation processes, and to explore the ways in which its constructs explain the implementability, enacting and sustainment of complex healthcare interventions. Methods: We will systematically search Scopus, PubMed and Web of Science databases and use the Google Scholar search engine for citations of key papers in which NPT was developed.  This will identify English language peer-reviewed articles in scientific journals reporting (a) primary qualitative or mixed methods studies; or, (b) qualitative or mixed methods evidence syntheses in which NPT was the primary analytic framework. Studies may be conducted in any healthcare setting, published between June 2006 and 31 December 2021. We will perform a qualitative synthesis of included studies using two parallel methods: (i) directed content analysis based on an already developed coding manual; and (ii) unsupervised textual analysis using Leximancer® topic modelling software. Other: We will disseminate results of the review using peer reviewed publications, conference and seminar presentations, and social media (Facebook and Twitter) channels. The primary source of funding is the National Institute for Health Research ARC North Thames. No human subjects or personal data are involved and no ethical issues are anticipated