For any behaviour to occur, an individual must have capability, opportunity and motivation (COM). These factors influence whether or not behaviour will occur in practice. Exploring these influences will identify potential barriers and strategies to promote behaviour change that supports antimicrobial stewardship.
There are two types of capability:
Psychological capability is having correct knowledge and information about the behaviour, e.g. “I know what the national guidelines are for prescribing antibiotics in this condition”.
Physical capability is having the skills required to carry out the behaviour, e.g. “I know how to complete a review of the patient to stop antibiotics”.
Opportunity is physical and social:
Physical opportunity relates to resources required to complete the behaviour such as time, equipment, staff support, e.g. “I have enough time to talk to the patient about not prescribing antibiotics for their condition”.
Social opportunity relates to influences from significant others beliefs towards the behaviour, sometimes described as social and cultural norms, e.g. “I have pressure from my patients and their families to prescribe antibiotics”.
Motivation is reflective and automatic:
Reflective motivation involves conscious decision-making such as weighing up the pros and cons of the behaviour including whether the behaviour is considered easy or difficult and thought to have a good result or not, e.g. “I don’t agree with the national guidelines about how long to prescribe antibiotics for”. Automatic motivation is habitual, and it involves behaviour occurring without thinking about it too much, e.g. “I have always prescribed this way and so I do it automatically”.
Exploring the influences on behaviours is important because interventions are more likely to lead to behaviour change if they address the key influences on behaviour. Improving knowledge and skills is often a key focus of health partnership interventions. Education and training are most useful interventions when they help people put their knowledge and skills into their real life working environment. This means that to design good training, we should explore the influences on people’s practice i.e., what helps and stops them from doing the IBOs. Then we can design our training to help overcome barriers and make the most of the things that help.
It is important that we do not assume what the influences are on others’ behaviour, even if we are from the same profession or department or we are working with one team. Influences on behaviour can be explored in different ways depending on the time and resources available. These include:
Often these are ad hoc interviews conducted with health professionals in their place of work. See the topic guide for the types of questions to ask.
Focus group discussions
Focus groups are a useful way to make behavioural interventions participatory, i.e., they can be a great way to involve your learners right from the start. Gathering a group of people whose behaviour would be expected to change after your partnership work, and asking them honestly about what the barriers and helpers of change are, for them, is a way of ensuring that you get good information but also that people understand that the intervention is to help them, as well as improve AMS.
It is tricky to create a good questionnaire, that is easy-to-use but also scientifically robust. There is a short questionnaire that has been validated in the UK for exploring the COM of health professionals, but so far this has not been validated in other countries. You can read more about it and see the questions here.
Observations and field notes
Sometimes just spending time in a location, shadowing colleagues with their permission particularly whilst observing intended behavioural outcomes, can give insights into what the barriers might be for AMS. This is usually as part of an overall scoping or implementation activity.
Tips: making a focus group participatory
It is good to share with your group that you are exploring COM and why. You can help embed an understanding of COM whilst you are conducting a group discussion. Every time something someone says makes you think about capability, opportunity or motivation, you can reflect that back e.g., “so you said that you weren’t sure of the guidelines for all the conditions because there were so many, that makes me think that you are motivated to use the guidelines but perhaps we need to support your opportunity to access the guidelines at the right time in the right place.”
Tips: Examples of points to make discussion groups work well
If you know the people and some are usually quiet in group discussions, position them opposite you if you can. Research has shown that people facing a facilitator are more likely to speak. When someone makes a comment, summarise by saying ‘that’s a really interesting point, what do others think about that’ and then catch people’s eyes to draw them into the conversation. Watch out for people making non-verbal cues that they agree, disagree or have an idea. This might be a slight nod or shake of the head, or an intake of breath (this is often a signal that someone is getting ready to speak). When you spot these, bring that person into the conversation by inviting them to say what they were thinking e.g., ‘you looked like you [agreed / disagreed] with that – did you or did you have something else you wanted to say?’ People are naturally dominant or quiet in a group and that is normal and OK. If you want to bring in a quieter person, sometimes lifting eyebrows whilst looking at them, helps them to feel invited into the conversation. Try to keep your own non-verbal reactions in check. It is important that people don’t feel judged and that they feel that their opinions are valuable. Try not to show emotions like surprise or shock. Do try to show emotions like curiosity, interest and gratefulness.
If you are unable to explore COM fully for each IBO, then see the part of the toolkit about designing training for practice change, which has activities to explore COM as part of a training intervention.
Defining intended behavioural outcomes will support teams to develop appropriate interventions. Exploring the influences on behaviours are important because interventions are more likely to lead to practice change if they address all the influences on behaviour, not only knowledge and skills. It is sometimes not possible to fully explore COM for each IBO, in which case, ensure that you explore COM during any training interventions.