Who needs to do what differently

Designing training to change behaviours

In a complex system issue like AMS, we all need to act together to help keep antibiotics working. The first task may be to work out who the most important groups are for your project to focus on. It may be that you already know this, e.g. if the brief is to develop training for prescribers, or you may have more flexibility to offer multi-disciplinary support. In that case, each professional group or sub-group will play its own important role, and multi-disciplinary communication practice (e.g. pharmacy staff challenging out-of-stock prescriptions) is crucial. It is worth spending time understanding which groups have the most influence on AMR in your setting and the structures which are in place already to facilitate this. For example, perhaps your work could achieve most by supporting the existing medicines committee in your hospital? What do they want to do differently in order to influence whose behaviour? Often there are layers of behaviour changes for different groups, meaning that each group may be both an ‘actor’ and a ‘target’ e.g. nurses (actor) giving information about adherence to carers (target), so that carers (actor) administer doses correctly to patients (target).

You should list the IBOs taking care to consider all aspects of the behaviour, namely AACTT:

Action: WHAT and HOW is the action being performed?
Actor: WHO performs the behaviour (e.g., nurse, doctor, family member)
Context: WHERE is the behaviour being performed?
Target: WITH WHOM is the behaviour performed e.g., patient or colleague
Time: WHEN is the behaviour being performed e.g., after admission, before touching a patient.

If you were trying to reduce antibiotic prescribing in primary care centres for upper respiratory tract infection you might have as an IBO:

The prescriber (Actor) in the primary care centre (Context) will counsel the patient and not prescribe antibiotics (Action) to a patient with an upper respiratory tract infection but no symptoms indicating bacterial infection (Target) during a consultation (Time).

Our research has shown that training interventions, in AMS and more generally, often aim to change around 50 practice behaviours. It would be impossible to create IBOs for each of these. Rather, we suggest that the team decide which ones are the most important to target. Importance might be because they are the hardest behaviours to change, or because they are the behaviours that would have the most impact if changed or even because they were the easiest to change and would therefore bring the most success. There may be many behaviours under an ‘umbrella’ overall behaviour e.g. ‘ensuring prescribers follow local AMS guidelines’, which could include several behaviours such as ‘ensure guidelines are reviewed by prescribers at the time of writing a prescription’ or ‘the medicines committee to produce guidelines that can be accessed at the time of writing prescriptions’, etc.

Our experience has shown that specifying IBOs and creating AACTT statements is hard for project teams. For more information see our eLearning and our briefing.

We would suggest that specifying IBOs and creating AACTT statements is done in a focus group by the whole team, or iteratively during project scoping and, if possible, facilitated by a behavioural scientist.


Topic guide and cues for behavioural specification focus group

What are the key outcomes for the project?
Encourage team to list outcomes (they might have these already noted) and note these on flipchart / white board.
Taking each outcome in turn, can you think about what the health professionals would have to do if that outcome was to happen?
Take outcomes one at a time, ask for practices. If teams give knowledge, skills, attitudes, ask them to restate these as behaviours – observable, things people do.
Can we take each behaviour and specify who, where, when and to whom each behaviour would happen? Create ACCTT statements for each behaviour.

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