Transcript The science of changing clinical behaviour Martin Eccles

Changing individuals:
from empiricism to theory
or
Lost In (knowledge) Translation?
Martin Eccles
Professor of Clinical Effectiveness
University of Newcastle upon Tyne
Credits & content
Credits
Jeremy Grimshaw, Marie Johnston, Jill Francis, Susan Hrisos, Eileen
Kaner, Heather Dickinson, Fiona Beyer, Nigel Pitts, Debbie Bonetti,
Liz Glidewell, Graeme McLennan, Ruth Thomas, Anne Walker, Ian
Graham, Jo Logan
Content
– What we know (about the effectiveness of interventions)
from empirical data
– If not empiricism then what?
• Theory
• Two studies
– Using theory to explore causal determinants
– Using theory to build behaviour change interventions
Researching changing clinical
behaviour
• Context
– The scientific study of methods to promote the
systematic uptake of clinical research findings and
other evidence-based practices into routine
healthcare
• To improve the quality and effectiveness of health care
• The study of influences on healthcare professional and
organisational behaviour
• What do we know?
– Systematic reviews
• What do we want to know?
– Predictable change
What do we know - EPOC
• EPOC [email protected]
– 41 Protocols
– 44 Reviews of specific type of interventions
What do we know?
Grimshaw JM, Thomas RE,
MacLennan G, Fraser C,
Ramsay C, Vale L et al.
Effectiveness and efficiency of
guideline dissemination and
implementation strategies.
Health Technol Assess 2004.
http://www.hta.nhsweb.nhs.uk/
Methods
• 285 reports of 235 studies, yielding 309 separate
comparisons
• Single effect size for each type of endpoint identified
for each study – either primary measure (as stated by
author) or median measure
Guidelines review conclusions
• Imperfect evidence base for decision makers
– Many current rigorous evaluations have methodological
weaknesses (e.g. unit of analysis errors)
– Poor reporting of study settings, barriers to change, content and
rationale of intervention
– Generalisability of study findings is frequently uncertain
• Only 27% of studies used theories and/or psychological constructs in any way
• Improvements in direction of effect in 86% of comparisons
– Reminders most consistently observed to be effective
– Educational outreach only led to modest effects
– Dissemination of educational materials may lead to modest but
potentially important effects (similar effects to more intensive
interventions)
– Multifaceted interventions not necessarily more effective than
single interventions
It’s all organisational
• A broad overview of research evidence on
organizational strategies
• “Planned re-arrangements of one or more aspects of
the organization of patient care”
• 36 reviews; 684 studies
Wensing, Wollersheim, Grol.
Implementation Science 2006.
Results
• Revision of professional roles: 9 reviews
• Can improve professional performance; preventive care
• Multidisciplinary teams: 5 reviews
• Can improve patient outcomes; chronic diseases
• Integrated care services: 8 reviews
• Can improve patient outcomes and save costs; chronic
conditions
• Knowledge management: 6 reviews
• Professional performance and patient outcomes can be
improved; across conditions
• Quality management: 2 reviews
• Effects remain uncertain
• Mixed interventions: 7 reviews
• 6 showed positive effects
Conclusions
• Authors
– There is a growing evidence base of rigorous evaluations of
organizational strategies
– The evidence underlying some strategies is limited
• Poorly contextualised studies
– None of the strategies produced consistent effects
– For no strategy can the effects be predicted with high
certainty
So … what do we know?
• Most things work some of the time – ~9% absolute improvement
– There are limitations
• Methodological quality variable and often poor
• Little economics (29%) or theory (27%)
– Results likely to be confounded
• Researchers didn’t randomly choose interventions
• Differences in context etc.
– Direct application of reviews problematic
Foy, Eccles et al. What do we know about how to do audit and
feedback? Pitfalls in applying evidence from a systematic
review. BMC Health Services Research 2005, 5:50.
And … what do we need to know?
•
What is the efficiency of
interventions?
– What do they do?
– How do they do it?
– What mediates or modifies
the effect?
•
How generalisable are effects?
Phase IV
Phase III
•
Phase II
How do you get to a trialable
intervention?
Which means what, exactly?
Phase I
Pre-clinical
Theory
Modelling
Exploratory trial
Definitive RCT
Long term
implementation
Which means what, exactly?
• Generalisable frameworks
– Empirical
– Theoretical
• Design better studies
– Ask and answer smarter questions
• Levels of engagement
• Improved designs
• Process evaluations
Theories and/or models?
• Classical theories/models of change can be informative and
helpful for identifying the determinants of change
• Provide organization for thinking, for observation, and for
interpreting what is seen
• They provide a systematic structure and a rationale for
activities
– Interventions are more likely to be effective if they target
causal determinants – these are theoretical constructs
• Models reflect the philosophical stance, cognitive orientation,
research tradition, and practice modalities of a particular group
of scholars
• Researchers, policy makers, and change agents tend to be
more interested in planned change theories/models that are
specifically intended to be used to guide or cause change
Ottawa Model of Research Use
Assess
barriers & supports
+
Monitor
+
strategy application
& degree of use
outcomes
Practice Environment
• structural
• social
• patients
• economic
Potential Adopters
• attitudes
• knowledge
• skill
Evidence - Based
Recommendations
• development process
• innovation attributes
Strategies
• barrier
management
• transfer
• uptake
Evaluate
Adoption
• intention
• use
Outcomes
• patient
• practitioner
• system
Logan & Graham, 2002
Theory of Planned Behaviour
Attitudes
Subjective
Norms
Behavioural
Intention
Behaviour
Perceived
Behavioural
Control
Ajzen & Madden, (1986), Journal of Experimental Social
Psychology, 22, 453
Do theories of human behaviour
(TPB) apply to clinicians?
• Non-clinicians
– Meta-analysis of 10 meta-analyses (Sheeran)
• Intention accounted for 28% of the variance in behaviour
– 185 independent studies (Armitage and Connor)
• TPB (intention and perceived behavioural control)
accounted for 27% of the variance in behaviour
– 31% if behaviour measures were self-reports
– 20% if behaviour measures were objective or observed
– Meta-analysis of 47 experimental tests of the
intention-behaviour relationship (Webb &
Sheeran)
• A “medium-to-large” change in intention leads to a
“small-to-medium” change in behaviour
Do theories of human behaviour
(TPB) apply to clinicians?
• Clinicians
• Is healthcare different?
– Systematic review of 10 studies included a total of 1623
subjects
» Eccles et al, Implementation Science, 2006
• Heterogeneous group of studies
• proportion of variance in behaviour explained by intention
was of a similar magnitude to that found in non-health
professionals
• More consistently the case for studies in which intentionbehaviour correspondence was good and behaviour was
self-reported
Levels
• Four levels at which interventions to improve the quality of
health care might operate:
– Individual health professional
– Health care groups or teams
– Organisations providing health care (e.g., Acute hospitals)
– The larger health care system or environment in which
individual organizations are embedded
Ferlie EB, Shortell SM. Improving the quality of health care in
the United Kingdom and the United States: a framework for
change. The Milbank Quarterly 2001; 79(2):281-315.
Levels
• Different theories will be relevant to interventions at
different levels
– Psychological theories will be more relevant to
interventions directed at individuals and teams
– Theories from of organisational change may be
more relevant to interventions directed at hospitals
or trusts
Choosing theories
• Theories of “behaviour” or of “behaviour
change”?
– Focus on theories that:
• Have been empirically tested
• Explain behavior in terms of factors that
are amenable to change
• Include non volitional factors
Michie et al. Making psychological theory useful for
implementing evidence based practice: a consensus
approach. QSHC 2005; 14: 26-33.
Francis et al. TPB Manual. www.rebeqi.org
Study 1: Beyond TPB – What are the
theoretical predictors of clinical
behaviours?
• To explore the usefulness of a range of psychological
frameworks to predict health professional behaviour relating to
the management of:
– upper respiratory tract infections without antibiotics
• Psychological measures were collected by postal questionnaire
survey from a random sample of general practitioners (GPs) in
Scotland
Eccles MP, Grimshaw JM, Johnston M, Steen N, Pitts NB, Thomas R,
Glidewell E, Maclennan G, Bonetti D, Walker A. Applying
psychological theories to evidence-based clinical practice: Identifying
factors predictive of managing upper respiratory tract infections
without antibiotics. Implementation Science, 2007, 2:26.
Outcome measures
• Outcome measures were:
– clinical behaviour (proxied by antibiotic
prescription rates)
– behavioural simulation (scenario-based decisions
to managing URTI with or without antibiotics)
– behavioural intention (general intention to
managing URTI without antibiotics)
Explanatory variables
•
Explanatory variables were the constructs within:
1. Theory of Planned Behaviour (TPB)
2. Social Cognitive Theory (SCT)
3. Common Sense Self-regulation Model (CS-SRM)
4. Operant Learning Theory (OLT)
5. Implementation Intention (II)
6. Stage Model
7. Knowledge
Analyses
• For each of the outcome measures
1. Multiple regression analysis was used to examine
the predictive value of each theoretical model
individually
2. Stage analysis: Already decided v the rest
3. A “cross theory” analysis of constructs was
conducted to investigate the combined predictive
value of all significant individual constructs across
theories
Results
• Intention
– Theory level
• TPB 30%; SCT 29%; CS-SRM 27%; OLT 43%
– GPs who reported that they had already decided to change
their management to try to avoid the use of antibiotics had a
significantly higher intention to manage URTIs without
prescribing antibiotics
– Constructs across theories: 49% of the variance in intention
• OLT evidence of habitual behaviour, TPB attitudes, risk
perception, CS-SRM control by doctor, TPB perceived
behavioural control and CS-SRM control by treatment
Results
•
•
Behavioural simulation
– Theory level:
• TPB 31%; SCT 26%; II 6%; OLT 24%
– GPs who reported having already decided to change their
management to try to avoid the use of antibiotics made significantly
fewer scenario-based decisions to prescribe
– Constructs across theories: 36% of the variance
• perceived behavioural control (TPB), evidence of habitual
behaviour (OLT), CS-SRM cause (chance/bad luck) and
intention
Behaviour
– Theory level:
• OLT explained 6% of the variance
– Constructs across theories: 6% of variance in behaviour
• OLT “evidence of habitual behaviour”
Conclusions
• The management of URTI is a frequent behaviour
and the measure of self-reported habitual behaviour
consistently predicted the outcome measures
• Looking across the three outcome measures there
are also suggestions that issues of perceived control,
risk perception and attitudes may also be important
• Results suggest that GPs have considered this
frequently performed behaviour and operate in a
predominantly habitual manner backed up by beliefs
that support their habit
Conclusions
• The theories individually each explained a significant proportion
of the variance in our dependent variables
– Aggregated analysis suggested that they were measuring
similar phenomena within their own individual structures
• What would be an optimum core set of measures if the aim was
to cover most behaviours and clinical groups?
– Given our current limited understanding this would have to
be the subject of both studies replicating this one and further
work examining different combinations of theories and
models.
• Operationalising the constructs with theoretical purity was a
challenge
• Problems with measuring behaviour
• Response rates
Study 2: Intervention building
• Evaluate the impact of two theory-based
interventions on behavioural intention and simulated
behaviour of GPs in relation to the management of
uncomplicated URTI
– A randomised 2x2 factorial design with baseline
and post-intervention assessment
• Measures were delivered in two postal questionnaire
surveys, with the study interventions embedded within
the second questionnaire
• Participants responding to the first survey were included
in the second and were randomised twice to receive, or
not, each of the two study interventions.
Causal determinants
• Baseline survey identified causal determinants
– self-efficacy (from SCT)
– anticipated consequences and risk perception
(also from SCT)
• How do you change them?
BPS construct domains
• Six phases: (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)
• 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
How do behaviour change techniques map on to psychological constructs?
Results of a consensus process
Jill Francis1, Susan Michie2, Marie Johnston1, Wendy Hardeman3, Martin Eccles4 1University of Aberdeen, Scotland, UK;
2University
College, London; 3University of Cambridge; 4University of Newcastle on Tyne
BACKGROUND
• Theories of behaviour provide a basis for the choice of interventions to change health
related behaviours.
• However, theory can inform interventions only if there are clear links between the
theoretical constructs
(determinants of behaviour change) and techniques to
change the constructs. (Figure 1)
• This study explored a systematic way to select behaviour change techniques in order
to design interventions.
Technique for
behaviour change
Goal/target specified: behavr
or outcome
Monitoring
Contract
Rewards; incentives (inc Selfevaluation)
Graded task: start with easy
tasks
Increasing skills: problem
solving, decision making, goal
setting
Stress management
Coping skills
Rehearsal of relevant skills
Role-play
predictors
Determinants
Behaviour
Change
Techniques
clinical
practice
Knowledge
Skills
Beliefs about
capabilities
Beliefs about
consequences
Motivation and
goals
1
2 1
3 2 3
1
3 1
3 3 3 3
1
2
3 3 3
1 2 2
1 2 2
2 3 3
3 3 2 3
3 2 2 2
1
1
2 1
AIM
To pilot a method for achieving consensus to identify behaviour change techniques for
use in altering a range of theoretical constructs (determinants of behaviour change).
RESULTS
Out of the 385 cells in the 35 x 11 matrix, judges agreed in 71% of cells (12%
agreement would use technique to change construct; 59% agreement would not use
technique) and disagreed in only 8% of cells (Figure 2). 20% of cells were classified as
‘indefinite’.
Each construct had at least one technique identified with it. Three out of the 11
constructs (skills; beliefs about capabilities; motivation and goals) were judged to be
changeable by 8 to 10 techniques. Five constructs (bolded in Figure 2), had only 1 or 2
techniques identified with them.
1 1 2
2
3 2
1 3
2 2 2
1 2
1 2 1
2 1 1
1
1
3 3 2
2 2 3
2
2 3 2 2
1 2
1
1
1 1
2 1*
3 3 3 3
2 2 3 2
1
2 3 2
1 2
1
2
3 1
1 2
To change behaviour …
role of techniques
1
1
1 2
1 1 1
1
1 2 1
1 2 1
1
3 3 2 1
1
1
1
1 1
1 1
3 2 2
1/2
2 1
2 1
3 2
3 1 1
1
1 1
2 1
2 3 3 3
1
2
2 3 3 3
3 3 3 3
11 2
2/3 3 1
2 2 2
1
3 3 3 3
2 3 2
1 2 1
1 3 1
1 3 2 1
Modelling /demonstration of
behaviour by others
1 3 3 1
2 3 3 2
‘common
sense’
1 1 1? 1
2 2
3 1?
3 3 3
1 2 2? 1
2 3
3 1
clinical
1 1
practice
Feedback
2 1?
Self talk
1 1
Use of imagery
1
1
1
3 2 1
2/3 3 2
1
3 3 3
3
3 2 2
1
2 3 1 1
2 3 2 3
2 2 2
1 2
3 3 3 3
3 3 2 2
1
Techniques
1 1 1
32 3 2
Determinants
1
2 3 1
3 3 3 3
1 1
1
2 2 1
Behaviour
2
Change
1 1 1
1
3 1
2
1 2 1
2 2
2 2 1
2 2
2 3 3
1 3 2
1
1 1
1
3 2 2
3
3
2 2
1 1
1 1
1 2 3 1
1 2 2
1 2
2
1 1? 2
1
1 3 2
2
3
3 2 3
3 3 2
2 2
1 2
2
1 1
2 1 2 2
1 1
1 2 2
2 2
1
1 1
1 1 2 1
1 1
1 2 2
2 1 2
3 3 2
2 2
1
2 2
1 3 3
1 2
1
1
3 3 2
2
2 2
2
1
2 2
2 2
1
2 1
1
1
1 1 2
2 3 2
1
Relapse prevention
1
2
1
3
predictors
3 1
1/2
1
2 3
2 2
3 1 2
3 1
1 1
1 2
Theories
Desensitisation
2 2
1
1
2 1
1 3 3 2
1
1 2
1
2 2
1
1
1 1
2
1 2
1
1 1 2
1 2
2 1 2 2
1
1 1 2
1
2
1
Time management
METHOD
Eleven theoretical construct domains were identified by Michie et al. (20051) as factors
that explain behaviour. Behaviour change techniques (n=35) were identified by
independent reviews of different literatures (Hardeman et al, 20002; Michie et al.,
20033). Four experienced psychologists judged which techniques they would use as
part of an intervention to change each construct domain. Judgements were
aggregated to represent four outcome categories: agreement (would use technique
to change construct); agreement (would not use technique to change construct);
indefinite; and disagreement.
2
2
1
1 1 2 1
Problem solving
2 3 1 2
3 2 3 3
1 2
1 1 2
Environmental changes (eg,
objects to facilitate behavr)
Social processes of
encouragement, pressure,
support
Persuasive
communication
Information re
behaviour, outcome
Personalised message
Identify/ prepare for difficult
situation/ problems
1 1
Action
planning
1 1
2 3 3 3
1
Relaxation
2
2 23
Emotion
1
2 1 2
Prompts, triggers, cues
Cognitive restructuring
1 2 2
1 3 2 1
Social
influences
2 1
Planning, implementation
Motivational interviewing
1 2 2
1
3 3 3
2 2
Perform behaviour in different
settings
Shaping of behaviour
Environmental context
and resources
1 1
1
Personal experimnts, data
collection (not beh selfmonitoring)
Experiential: tasks to gain
experces to change motivation
and techniques relating
Memory,
attention,
decision
processes
1 2 1
Homework
Theories
Figure 1.
Representation of the links between theories, determinants
to behaviour change
Social/ Professional
role & identity
Self-monitoring
To change behaviour …
role of techniques
‘common
sense’
Which techniques would you use as part of an intervention to change each construct domain?’
Blank=NO; 1=possibly, 2=probably, 3 =definitely
Construct domain
‘
2 1
1 1
1 1 1
2
1 2 1
1
1 1
1
1
1
1 2
1 1
1
2 2
2 1
2
2
2 3
Agreement: would use
Disagreement
( > three 2s or 2s & 3s)
(Not meeting previous, containing a 3)
Agreement: would not use
Figure 2. ‘Which techniques would
use<as
part
ofone
an 2)
intervention to change each construct
(Blankyou
or with
two
1s or
consensus
Indefinite
(All other cells)
domain?’
Matrix representing levels of
CONCLUSIONS
The consensus task illustrated that:
•
It is possible to identify techniques for use in altering determinants of behaviour change.
•
This approach may facilitate the design of theory-based interventions and testing hypotheses about the effectiveness
of techniques.
•
This study highlights the need for further work to develop a replicable, comprehensive taxonomy of techniques and to
map the techniques onto theory.
•
The evidence base for development of behaviour change interventions may be strengthened using this method; a
further step would be to conduct systematic reviews on the effects of techniques specified in the green cells (Figure
2).
REFERENCES
1
Michie S, Johnston M, Abraham C, Lawton R, Parker D, Walker A. (2005) Making psychological theory useful for implementing evidence based practice: a
consensus approach. Quality & Safety in Health Care, 14, 26-33.
2
Hardeman W, Griffin S, Johnston M, Kinmonth AL, Wareham NJ. (2000) Interventions to prevent weight gain: A systematic review of psychological
models and behaviour change methods. International Journal of Obesity, 24, 131-143.
Michie S, Abraham C, Jones C. (2003) Achieving the "Fully Engaged Scenario": what works and why. Unpublished review, Department of Health.
3
J. Francis, Health Services Research Unit, University of Aberdeen, Polwarth Building, Foresterhill, Aberdeen. Scotland AB25 2ZD; Tel: +44 1224 559672; Fax: +44 1224 554580; Email: [email protected]
Intervention 1
• Intervention 1 targeted the construct of self-efficacy (from SCT).
• Mapped on to the theoretical construct domain, “beliefs about
capabilities”.
• The main behaviour change technique selected was “graded
task”
– to increase GPs’ beliefs in their capabilities of managing
URTI without prescribing antibiotics
– does this by promoting incrementally greater levels of
“mastery” by building on existing abilities.
• Two further behaviour change techniques, “rehearsal” and
“action planning” were additional components of this
intervention.
Intervention 1:
Graded Task
Target construct:
• Self efficacy
Intervention 2
• Intervention 2 targeted anticipated consequences and risk
perception (also from SCT)
• Mapped on to the theoretical construct domain, “beliefs about
consequences”
• The main behaviour change technique selected was “persuasive
communication”
– The aim of this intervention was to encourage GPs to
consider some potential consequences for themselves, their
patients and society of managing URTI with and without
prescribing antibiotics.
• This intervention also incorporated the behaviour change
technique, “provide information regarding behaviour, outcome
and connection between the two”
Intervention 2:
Persuasive
Communication
Target construct:
• Anticipated
consequences
No. 001
Age 26 years
Miss Kay Hamilton, 104 Dene View Place , Othertown
Clinical Records
A Add
V Values
H Health
X All non-values
I Immunisations
T Templates
C Consultations
M Medications
F Forms & Admin
P Problems
N Investigations
B Allergies
J IOS Claims
L Patient notes
Q More
Active Problems: Nil
Smoker: 10 / day
Significant past : Substance Misuse 1999
Therapeutic termination of pregnancy 1997
Occupation: Beautician
Current medication: Microgynon, Co-codamol
HISTORY: Sore throat 2 days, “can’t swallow”, Feels awful. “I always need
antibiotics”
EXAMINATION: Red throat, tonsils not enlarged, nodes +, tender
DIAGNOSIS:___________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________
MANAGEMENT: ________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________
____________________________________________
______________________________________________
______________________________________________
On the scale 1 to 10, how difficult was it for you to make a decision for this scenario?
Not at all
difficult
0
1
2
3
4
5
6
7
8
9
10
Extremely
difficult
If you wish to comment on this decision please do so here
____________________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Results
• 1225 GPs at 289 practices were sent the pre-intervention
survey booklet and 397 (32.4%) from 191/289 (66%) practices,
returned a completed questionnaire
• Overall, GPs responding to the first mailing had been qualified
for a mean (SD) of 19.9 (8.0) years, 21% were GP trainers, 94%
were from multi-practitioner surgeries and 57% were male
• 397 respondents were randomised to receive the study
interventions and were mailed the post-intervention survey
booklet
• Three hundred and forty (86%) GPs returned the postintervention survey booklet, from 178/191 (93%) practices
Results
• Intervention 1 Graded Task
– Significant effect on the constructs targeted (PBC [Power]
and Self-efficacy)
– No effect of this intervention on intention or simulated
behaviour
• Intervention 2 Persuasive Communication
– Significant effect on the constructs targeted (Anticipated
consequences and risk perception)
– Significant effect of this intervention on intention and
behavioural simulation
– Significant effect was also observed on a number of
constructs not specifically targeted by this intervention
Issues
• Matching constructs to techniques
• No measure of behaviour
• Response rates
Conclusions/Issues
• Theory has the potential to lead to greater
understanding
• Theory potentially addresses generalisability
• Which theory/theories to choose?
– Theories of “what”?
– “Behaviour” or “Behaviour change”?
• Many unresolved methodological challenges in
operationalising theory
?
References
Armitage CJ, Conner M. Efficacy of the theory of planned behaviour: a meta-analytic
review. British Journal of Social Psychology 2001;40:471-99.
Eccles MP, Hrisos S, Francis J, Kaner E, Dickinson HO, Beyer F, Johnston M. Do
self- reported intentions predict clinicians’ behaviour: a systematic review.
Implementation Science, 2006; 1: 28.
Eccles MP, Grimshaw JM, Johnston M, Steen N, Pitts NB, Thomas R, Glidewell E,
Maclennan G, Bonetti D, Walker A. Applying psychological theories to
evidence-based clinical practice: Identifying factors predictive of managing
upper respiratory tract infections without antibiotics. Implementation Science,
2007, 2:26.
Ferlie EB, Shortell SM. Improving the quality of health care in the United Kingdom
and the United States: a framework for change. The Milbank Quarterly 2001;
79(2):281-315.
Foy R, Eccles MP et al. What do we know about how to do audit and feedback?
Pitfalls in applying evidence from a systematic review. BMC Health Services
Research 2005, 5:50.
References
Grimshaw JM, Thomas RE, MacLennan G, Fraser C, Ramsay C, Vale L, Whitty P,
Eccles M, Matowe L, Shirren L, Wensing M, Dijkstra R, Donaldson C.
Effectiveness and efficiency of guideline dissemination and implementation
strategies. Health Technol Assess 2004; 8(6).
Michie S, M Johnston, C Abraham, R Lawton, D Parker, A Walker, on behalf of the
‘‘Psychological Theory’’ Group. Making psychological theory useful for
implementing evidence based practice: a consensus approach. Qual Saf Health
Care 2005;14:26–33.
Sheeran P. Intention-behavior relations: A conceptual and empirical review. In:
Stroebe W, Hewstone M, editors. European Review of Social Psychology. John
Wiley & Sons Ltd.; 2002. p. 1-36.
Webb TL, Sheeran P. Does Changing Behavioural Intention Engender Behaviour
Change? A Meta-analysis of the Experimental Evidence. Psychol Bull
2006;132(2):249-68.
Wensing, Wollersheim, Grol. Organizational interventions to implement
improvements in patient care: a structured review of reviews. Implementation
Science 2006, 1:2.