Changing behaviour ‘more or less’—do theories of behaviour inform strategies for implementation and de-implementation? A critical interpretive synthesis

Abstract

BackgroundImplementing evidence-based care requires healthcare practitioners to do less of some things (de-implementation) and more of others (implementation). Variations in effectiveness of behaviour change interventions may result from failure to consider a distinction between approaches by which behaviour increases and decreases in frequency. The distinction is not well represented in methods for designing interventions. This review aimed to identify whether there is a theoretical rationale to support this distinction.MethodsUsing Critical Interpretative Synthesis, this conceptual review included papers from a broad range of fields (biology, psychology, education, business) likely to report approaches for increasing or decreasing behaviour. Articles were identified from databases using search terms related to theory and behaviour change. Articles reporting changes in frequency of behaviour and explicit use of theory were included. Data extracted were direction of behaviour change, how theory was operationalised, and theory-based recommendations for behaviour change. Analyses of extracted data were conducted iteratively and involved inductive coding and critical exploration of ideas and purposive sampling of additional papers to explore theoretical concepts in greater detail.ResultsCritical analysis of 66 papers and their theoretical sources identified three key findings: (1) 9 of the 15 behavioural theories identified do not distinguish between implementation and de-implementation (5 theories were applied to only implementation or de-implementation, not both); (2) a common strategy for decreasing frequency was substituting one behaviour with another. No theoretical basis for this strategy was articulated, nor were methods proposed for selecting appropriate substitute behaviours; (3) Operant Learning Theory makes an explicit distinction between techniques for increasing and decreasing frequency.DiscussionBehavioural theories provide little insight into the distinction between implementation and de-implementation. Operant Learning Theory identified different strategies for implementation and de-implementation, but these strategies may not be acceptable in health systems. Additionally, if behaviour substitution is an approach for de-implementation, further investigation may inform methods or rationale for selecting the substitute behaviour.Electronic supplementary materialThe online version of this article (10.1186/s13012-018-0826-6) contains supplementary material, which is available to authorized users.

De-implementing wisely: developing the evidence base to reduce low-value care

“…Evidence shows that all available strategies work some of the time but none work all the time, the observed effects are often modest and it is not always clear why this is the case 52–54. Despite increasing policy interest in de-implementation, with international programmes such as the Choosing Wisely campaign,8 9 relatively little has been reported that elucidates and addresses systematic methods for designing de-implementation interventions 30. It is likely that de-implementation will involve different strategies than those used for implementation, but there is little evidence to indicate what they may be 18 39.…”

“…Interventions to translate evidence into practice can be effective with the application of behavioural approaches 27–29. While behavioural theories, for the most part, do not distinguish between implementation and de-implementation, techniques grounded in psychology can specifically target de-implementation (eg, behavioural substitution) 30 31. Evidence and theory from behavioural science have informed methods for identifying factors that explain and influence behaviour, selection of techniques to address the barriers, and guidance about reporting behaviour change interventions 29 31–34.…”

Barriers and facilitators to reduce low-value care: a qualitative evidence synthesis

“…This is supported by a theoretical model that showed that physicians will adopt new treatments more readily than they abandon existing ones. 51 …”

Active change interventions to de-implement low-value healthcare practices: a scoping review protocol

“…Some researchers regard de-implementation or de-adoption as the reverse of implementation or adoption,6 7 10 and decry the dearth of knowledge translation strategies and tools included in current efforts to de-implement low-value practices, advocating that implementation and de-implementation should both be part of the same agenda. Others argue that the complexities involved in reversing the often long-standing practices are unique and can be complicated by habituation, egos and inertia 11–14. Authors have also noted that traditional fee-for-service remuneration systems provide perverse incentives for overutilisation of procedures and medications and may add to the complexity of efforts to de-implement certain practices 12 13 15.…”