Using theory to synthesise evidence from behaviour change interventions: The example of audit and feedback

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Abstract

Evidence syntheses are used to inform health care policy and practice. Behaviour change theories offer frameworks for categorising and evaluating interventions and identifying likely mechanisms through which effects are achieved. Yet systematic reviews rarely explicitly classify intervention components using theory, which may result in evidence syntheses and health care practice recommendations that are less than optimal. This paper outlines a method for applying theory to evidence syntheses of behaviour change interventions. We illustrate this method with an analysis of ‘audit and feedback’ interventions, based on data from a Cochrane review. Our analysis is based on Control Theory, which suggests that behaviour change is most likely if feedback is accompanied by comparison with a behavioural target and by action plans, and we coded interventions for these three techniques. Multivariate meta-regression was performed on 85 comparisons from 61 studies. However, few interventions incorporated targets or action plans, and so meta-regression models were likely to be underfitted due to insufficient power. The utility of our approach could not be tested via our analysis because of the limited nature of the audit and feedback interventions. However, we show that conceptualising and categorising interventions using behaviour change theory can reveal the theoretical coherence of interventions and so point towards improvements in intervention design, evaluation and synthesis. The results demonstrate that a theory-based approach to evidence synthesis is feasible, and can prove beneficial in understanding intervention design, even where there is insufficient empirical evidence to reliably synthesise effects of specific intervention components.

Section snippets

Using theory to synthesise evidence from behaviour change interventions

Behaviour change theories represent integrated summaries of hypothesized causal processes, and so offer a standardized and systematic framework for categorising and evaluating intervention content. Applying theory to evidence synthesis allows scientific knowledge about behaviour change to be used in specifying intervention techniques and likely mechanisms by which any effects are achieved. Theory-based explanations offer explicit causal pathways and so avoid use of implicit assumptions

The example of ‘audit and feedback’ as a change technique

Audit and feedback (A&F) is defined as ‘any summary of clinical performance of health care over a specified period of time’ aimed at changing health professional behaviour, as indexed by ‘objectively measured professional practice in a healthcare setting or healthcare outcomes’ (Jamtvedt, Young, Kristoffersen, O'Brien, & Oxman, 2006, p. 3). A systematic review of interventions reported in 118 study datasets found effects to vary from a 16% decrease in adherence to recommended practice to a 70%

The present study

The present study proposes a robust method for selection and application of theory to evidence synthesis around behaviour change interventions, drawing on recent developments in behaviour change techniques (Abraham & Michie, 2008) and statistical methodology (Sutton & Higgins, 2008). This paper adds a methodological innovation to evidence synthesis, by using theory to systematically categorize intervention components, and multivariate meta-regression to isolate the unique contribution of these

Overview of a theory-based method for evidence synthesis

Our method involves several sequential stages. First, the focal behaviour change intervention is deconstructed into component techniques, which are then mapped onto the most relevant behaviour change theory or theories, as identified via an examination of the extant theory literature. Second, hypotheses are subsequently generated, in accordance with theory, concerning the effectiveness of (configurations of) intervention techniques. Third, literature searches are conducted to identify eligible

Results

Eighty-five comparisons reported in 61 studies were included in the analysis (see Table 1). Fifty-nine interventions (69%) were assessed as part of a cluster randomized controlled trial, and 26 interventions (31%) used a patient randomized controlled trial design.

Discussion

Health care policy and practice are increasingly based on summaries of research evidence, but such reviews rarely use theory to understand intervention content. We have outlined a systematic theory-based approach to synthesising evidence of the effectiveness of behaviour change interventions. This approach involves: deconstructing interventions into component techniques, selecting a theory of behaviour change which offers predictions about how these techniques bring about change; coding

Acknowledgements

We thank Theresa Moore, Tony Ades, Gro Jamtvedt and Doris Kristoffersen for input into the early stages of this work. This study was supported by the MRC Health Services Research Collaboration.

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