Use of the Behaviour Change Wheel to design an intervention to improve the implementation of family-centred care in adult audiology services

Abstract

Objective

This study describes the development of an intervention to improve family-centred care in adult audiology services.

Design

The Behaviour Change Wheel (BCW) was followed to develop the intervention. The BCW involves eight steps across three stages: (1) understanding the behaviour, (2) identifying intervention options, and (3) identifying content and implementation options.

Study Sample

The data in Stage 1 comprised of 13 interviews with clinic staff. The research team drew on their own expertise and empirical research to complete Stages 2 and 3.

Results

A two-phase, face-to-face intervention was developed to change clinic staff’ behaviours to address two problem behaviours: (1) increase family member attendance to adult audiology appointments; and (2) increase family member involvement within appointments. Three target behaviours were chosen for the intervention to address the two problem behaviours. A variety of intervention functions and behaviour change techniques were incorporated into the intervention.

Conclusion

The BCW provided a useful framework for developing a whole-of-clinic intervention to increase family member attendance and involvement in adult audiology appointments. Recent research in social psychology has suggested that this type of family involvement and support in healthcare is a strong predictor of well-being for adult clients and their families.

Keywords:

• Hearing rehabilitation
• family-centred care
• Behaviour Change Wheel
• audiology
• well-being

Introduction

Recent research at the interface of social and clinical psychology demonstrates the beneficial role of the social groups that people belong to for determining health and well-being of people across the lifespan; an approach that has come to be known as ‘the social cure’ (Haslam et al. 2018). The evidence is that people who have more social connections live longer and have better health than those who have fewer connections (Steffens et al. 2016). Not surprisingly, when adults identify the various social connections they have, family is the most common group (Haslam et al. 2018). This understanding of the key role of family has increased the impetus for family to be actively involved in healthcare, and this can be achieved by implementing Family-Centred Care (FCC). A key goal of FCC is to promote the health and well-being of individuals and families and to maintain their control (Johnson and Abraham 2012).

The FCC model focuses on the family as the unit of care, rather than focussing solely on the individual with the health condition (Epley, Summers, and Turnbull 2010; Meyer, Scarinci, and Hickson 2019). Effective FCC approaches identify the impact of the health condition on the family and provide support for both individuals and their families. The term ‘family member’ is used in this context to include anyone who plays a significant role in an individual’s life whether they are related through a continuing biological, legal, or emotional relationship (Hanson 2005). Research in healthcare generally shows that FCC results in better outcomes for the individual as well as enhanced well-being for family members (Kokorelias et al. 2019).

The particular importance of FCC in audiology stems from the understanding that hearing impairment (HI) is a communication disorder which inevitably affects family members close to the person with a HI (known as third-party disability, see Scarinci, Worrall, and Hickson 2009). For example, one study found that spouses reported experiencing more difficulties as a result of their partner’s hearing difficulties than their partner with HI reported themselves (Stephens, France, and Lormore 1995) and another found third party disability in adult children of people with HI (Preminger, Montano, and Tjørnhøj-Thomsen 2015). For this reason, family members’ opinions are often a significant factor in whether a person with HI seeks help for their hearing (Meyer et al. 2014; van den Brink et al. 1996). Further, involving a supportive family member in hearing rehabilitation has been found to positively impact the client’s hearing outcomes (Hallberg and Barrenas 1993; Miller and Haworth Continuing Features Submission 1983). Previous research has established the usefulness of FCC within hearing health care (Hickson et al. 2014; Singh, Lau, and Pichora-Fuller 2015), however studies that have examined implementation have found it is not fully embraced in practice (Ekberg et al. 2014; Grenness et al. 2015b). For example, this research found that family members only participated in 12% of the total talk time during audiology appointments. Family members were not typically invited by clinicians to join the conversation. Further, when family members self-selected to speak, audiologists typically responded by shifting the conversation back to the client (Ekberg et al. 2014). The findings from these studies suggest that there is scope to improve the implementation of FCC within adult audiology services.

This study describes a method for the development of an intervention aimed at increasing the implementation of FCC in adult audiology services. Implementing FCC in hearing rehabilitation is a broad and complex concept but research has shown that interventions to change behaviour are most effective when they are simple and specific (Cutler 2004; Fishbein 1995). To address this issue, the Behaviour Change Wheel (BCW) was chosen as the method for intervention development as it combines behaviour analysis with a systematic method to select specific target behaviours to promote effective behaviour change (Michie, Atkins, and West 2014). At the core of the BCW is the question of whether the appropriate people have the capability (C), opportunity (O) and motivation (M) to perform the target behaviour (B) (referred to as the COM-B model). The BCW provides a pathway from the initial analysis of a target behaviour to selecting matching interventions that address identified barriers to performing the desired behaviour.

The BCW has been implemented in a number of studies addressing behaviour change in health professionals (e.g. Alexander, Brijnath, and Mazza 2014; Bérubé et al. 2015; Murphy et al. 2014; Sinnott et al. 2015). For example, research has explored the barriers and enablers to the delivery of the Healthy Kids Check in Australia (Alexander, Brijnath, and Mazza 2014), the early management of adults with traumatic spinal cord injury in Canada (Bérubé et al. 2015), medication management in multi-morbidity in the UK (Sinnott et al. 2015), and mental healthcare capacity building in pharmacists in Canada (Murphy et al. 2014). The BCW has also been proposed as an appropriate model for hearing research (Coulson et al. 2016). Barker, Atkins, and de Lusignan (2016) were the first to implement the BCW in the field of audiology, and designed an intervention to introduce support behaviours for consultations to improve hearing aid use among adults with hearing impairment. The aim of the present study was to follow the BCW steps in the development of an intervention to improve the implementation of FCC in adult audiology services.

Method

The BCW consists of three stages which are divided into eight steps (for details see Michie, Atkins, and West 2014). The first stage (Steps 1–4) is concerned with ‘understanding the behaviour’ and includes the COM-B model at Step 4. The second stage (Steps 5 and 6) ‘identifies the intervention options’ and the third stage (Steps 7 and 8) ‘identifies the content and implementation options’. All eight steps are outlined in detail in the Results section below, which also includes further details of the method. The study received ethical approval from The University of Queensland Human Ethics Committee (approval number 2017000626). Three private audiology clinics including staff and management within one hearing care organisation in Australia participated in the intervention design process.

Results

The overall results from the eight steps of the Behaviour Change Wheel (BCW) intervention design can be found in Figure 1. Each step is also described in more detail in the below sub-sections.

Figure 1. Overall results from the eight steps of the Behaviour Change Wheel (BCW) intervention design.

Stage 1: understand the behaviour

Step 1 – define the problem in behavioural terms

The definition of the problem in behavioural terms was based on the clinical and research experience of the research team as well as findings from previous relevant literature. Previous research had identified that family members were attending audiology appointments with clients less than 30% of the time and, when they did attend, were not typically engaged in the interaction during the appointment (Ekberg et al. 2015; Grenness et al. 2015a). In addition, the hearing care organisation involved in the study had made a commitment to adopt a more family-centred approach in their clinical care. So, the overall problem was defined in behavioural terms as: ‘Improving the implementation of family-centred care in audiology appointments with adults with hearing impairment and their family members’. The location of the problem was defined as adult audiology appointments. The people who were involved in performing the behaviour included all staff members in the audiology clinic (reception staff and clinicians). A requisite to increasing FCC within audiology appointments is that family members are first attending appointments. Because of this, the research team further defined two, inter-related problem behaviours: (1) increasing family member attendance; and (2) increasing family member involvement in adult audiology appointments. The BCW steps were followed for each of these two problem behaviours with the aim of developing a two-phase intervention.

Step 2 – select the target behaviour(s)

In order to select the target behaviour(s) for each problem behaviour, the multidisciplinary research team (including audiologists, speech pathologists, and psychologists) generated a list of 30 candidate behaviours potentially relevant to the two problem behaviours identified in Step 1. This list included eight candidate target behaviours for increasing the attendance of family members in appointments (e.g. Booking confirmation letters include a paragraph encouraging a family member to attend the appointment with the client.). Another list included 22 candidate target behaviours for increasing the involvement of family members within appointments (e.g. clinician asks how the hearing loss affects the family member of the client and their relationship with each other, clinician discusses communication strategies with the client and family member, clinician asks for goals from both client and family member).

In order to choose the target behaviours, the research team asked the following BCW questions about each behaviour: (1) the likely impact of changing the behaviour; (2) the likelihood that the behavioural change would be implemented; (3) the spill-over or knock-on effect of change on other behaviours; and (4) the ease with which the behaviour could be measured. For each potential behaviour, the research team scored them according to the following criterion: (1) the behaviour seemed very promising; (2) the behaviour seemed quite promising; (3) the behaviour seemed unpromising but worth considering; and (4) not acceptable as a behaviour to be targeted.

Target behaviours to increase family member attendance

The target behaviour selected which was seen as the most likely to address the behavioural problem of family member attendance and was most promising was: clinic staff ask every client to bring a family member with them to their audiology appointment(s). This target behaviour was chosen for the following reasons: (1) most appointments were booked over the phone and asking clients over the phone would likely have more impact than asking within a letter (high impact); (2) judged to be fairly easy to change given that it would involve a small change to current booking phone calls (high likelihood for change); (3) inviting more family members to attend appointments could prompt more FCC behaviours while the family members are in the clinic (high spill-over); and (4) reliable observational measures of the behaviour (ease of measurement).

Target behaviours to increase family member involvement

Two target behaviours were chosen to address the behavioural problem of family member involvement within appointments, including: (1) clinic staff set up the clinic room to include a chair for the family member next to the client; and (2) clinicians set an agenda at the start of the appointment that sets expectations and encourages the involvement of both the client and family member. Room set-up was chosen as a target behaviour because: (1) it would be a visual indication that both client and family member are included in the appointment (high impact); (2) it was judged to be fairly easy to change as there were already sufficient chairs available and so the change involved re-positioning of chairs in the room (high likelihood for change); having the family member seated next to the client may encourage their involvement in the conversation during the appointment (high spill-over); and (4) reliable observational measures of the behaviour (ease of measurement). Agenda-setting was chosen as the other target behaviour for the following reasons: (1) setting an agenda sets up the inclusion of the family member in the appointment from the start so that they hopefully continue to be involved across the rest of the appointment (high impact and spill-over); (2) it reinforces the underlying motivation for FCC, that is, that HI is a communication disorder that affects both the person with HI and their family members so both people should have the opportunity to share their experience of the communication difficulties (high impact); (3) it was judged to be fairly easy to change given that it involves changing a specific behaviour at the beginning of the appointment (high likelihood for change); and (4) there are reliable observational measures (ease of measurement).

Step 3 – specify the target behaviours

The target behaviours were then further specified by detailing who needed to engage in each behaviour, when and where, how often, and with whom (see Figure 1).

Step 4 – identify what needs to change

The COM-B model was applied to identify barriers and facilitators to staff being able to implement the target behaviours. This step helps identify what needs to change in the person and/or environment in order to achieve the desired target behaviours (Michie, Atkins, and West 2014). This step involved conducting semi-structured interviews with staff from all roles across the organisation. The interviews were kept relatively broad and open-ended to explore staff members’ various perceptions of FCC overall, as well as more specific behaviours related to family member attendance and involvement in audiology appointments. The interview data was analysed to consider the (psychological and physical) capability of staff to currently engage in the target behaviours (C), the (physical and social) opportunity for the behaviours to occur (O), and the (automatic and reflective) motivation (M) of staff to perform the behaviours (B). The definitions of each of these components of the COM-B include:

• Physical capability: Physical skill, strength, or stamina.

• Psychological Capability: Knowledge or psychological skills, strength or stamina to engage in the necessary mental processes.

• Physical Opportunity: Opportunity afforded by the environment involving time, resources, locations, cues, physical ‘affordability’.

• Social Opportunity: Opportunity afforded by interpersonal influences, social cues and cultural norms that influence the way we think about things.

• Automatic Motivation: Automatic processes involving emotional reactions, desires (wants and needs), impulses, inhibitions, drive states and reflex responses.

• Reflective Motivation: Reflective processes involving plans (self-conscious intentions) and evaluations (beliefs about what is good and bad).

Thirteen staff members from the organisation were interviewed, including six managers, four front-of-house staff (administration/reception) and three clinicians (two audiologists and one audiometrist) from the participating clinics. The interview data was analysed following a deductive thematic analysis approach (Boyatzis 1998; Braun and Clarke 2006) in which the codes of the COM-B were applied (Michie, Atkins, and West 2014). The detailed procedure and results from the interviews are reported in detail elsewhere (Ekberg et al. 2020), but the key findings and the associated COM-B components are listed below in relation to what needed to change.

Family member attendance (Target behaviour: inviting clients to bring a family member during booking phone calls)

1. All staff needed to possess relevant knowledge around FCC and its benefits (psychological capability);

2. Staff needed to acquire further skills around how to best phrase the question of family member attendance and how to provide clients with an explanation for this request upfront during bookings (psychological capability);

3. All staff needed to understand the reasons why family member attendance in audiology appointments is important (reflective motivation);

4. Facilitating an FCC-friendly environment by setting up reception in a way that encourages family member attendance (physical opportunity);

5. A supportive organisational culture of FCC (social opportunity);

6. Consistent provision of professional development and training around FCC to all staff (social opportunity);

7. Promoting the expectation that all clients are encouraged to bring a family member independently of client-related (or other) factors (reflective motivation);

8. Staff needed to feel more comfortable in asking clients to bring a family member and providing an explanation to clients for this request (automatic motivation).

Family member involvement within appointments (Target behaviours: Room set-up and inclusive agenda-setting)

1. All staff needed to possess relevant knowledge around FCC and its benefits (psychological capability);

2. Provision of resources and tools to support family member involvement such as scripts, letters, family member questionnaires (physical opportunity);

3. Facilitating a FCC-friendly environment by setting up appointment room in a way that encourages family member involvement (physical opportunity);

4. A supportive organisational culture of FCC (social opportunity);

5. Consistent provision of professional development and training around implementing FCC for all staff (social opportunity);

6. Clinicians needed to increase their confidence in their ability to include family members in the interaction (reflective motivation);

7. Clinicians needed to feel more comfortable in managing difficulties/conflict between client and their family member in the appointment (automatic motivation).

In sum, Step 4 identified that changes were needed within all COM-B components (except physical capability) for both problem behaviours. Importantly, the interviews in Step 4 adopted a whole-of-clinic perspective, exploring the perspectives of staff in different roles across the clinic and company, including front-of-house staff who typically made the bookings for appointments. Barriers were observed in staff members’ capability (knowledge and skills), opportunity (physical space, tools, training, and organisational culture), and motivation (comfort and decision-making processes).

Stage 2: identify intervention options

Step 5 – identify intervention functions

The results from Steps 5–8 are presented in Table 1.

Table 1. Results from BCW Steps 5–8.

Selected intervention functions	COM-B components served by intervention functions	Selected BCTs to deliver intervention functions	Translation of BCTs within the two-phase intervention
Education (Increasing knowledge or understanding)	Psychological capability: Increase knowledge and understanding of FCC as well as reasons why FM attendance and involvement is beneficial	Information about social and environmental consequences Feedback on outcome(s) of the behaviour Feedback on behaviour	First-phase: Provide information: ‘What is FCC?’ and the ‘Impact of HI on FM’ within workshop 1 Provide information on ‘Benefits of involving FM/FCC in hearing rehab’ & evidence from literature on benefits within workshop 1 Provide information on ‘Why to ask for FM to attend appointment with client’ within workshop 1 Second phase: Provide information on the importance of agenda-setting and seeking a history from both client and FM within workshop 2
Training (Imparting skills)	Psychological capability and reflective/ automatic motivation: Increasing skills, confidence, and comfort. Developing a routine/habit in staff to invite family members to all appointments and consistently involve them in appointments. Staff feeling responsible to carry out the behaviour.	Instruction on how to perform a behaviour Behavioural practice/ rehearsal	First-phase: Instructions when to ask question (e.g. during all appointment bookings and confirmations) Instructions how to ask question of FM attendance Instructions how to explain reason for FM attendance to client and role-playing different explanations with staff Practice responding to difficult questions/concerns of client - explore expected challenges/concerns that may come up and role-play/rehearse different ways to respond to ‘tricky’ questions from client Second phase: Instructions for staff to confirm who client has brought to appointment Instructions for staff to advise clinician who client has with them Instructions for clinicians to greet client and FM by name and invite FM into appointment room Instructions to clinicians for how and when to set agenda and ask FM open history-taking question Practice responding to disagreements between client and FM concerning the client’s hearing difficulties - explore expected challenges/concerns that may come up and role-play/rehearse different ways to respond to disagreements.
Environmental Restructuring (Changing the physical or social context)	Physical opportunity: Providing instructions and tools to assist staff with inviting family members to appointments, setting up the room, and setting an inclusive agenda.	Adding objects to the environment Prompts/cues Restructuring the physical environment	First-phase: Provide prompt card with instructions to use when asking for FM attendance Provide script (e.g. examples of how to word question & explanation to give to clients) Provide individually tailored cue card designed in training to stick on computer/desk Second phase: Individualised help with setting up room to have two chairs next to each other for client and family member Provide script for clinician to set an agenda that includes client and FM involvement Provide script for asking FM an open history-taking question Develop Communication Partner Questionnaire (CPQ) and have staff ask FM to complete it in waiting room.
Incentivisation (Creating an expectation of reward)	Reflective Motivation: To create an expectation of reward for increasing family member attendance and involvement in appointments	Rewarding completion Incentive	First and second-phase: Using a star reward system It allows for staff members to receive rewards for special achievements which are then provided in the form of vouchers.

BCW: Behaviour Change Wheel; FCC: family-centred care; FM: family member; COM-B: Capability, Opportunity, Motivation – Behaviour; BCTs: Behaviour Change Techniques.

In Step 5, based on the results from the COM-B analysis, intervention functions were chosen for each of the target behaviours. The nine intervention functions in the BCW are broad categories of means by which an intervention can change behaviour. They include education, persuasion, incentivisation, coercion, training, restriction, environmental restructuring, modelling, and enablement, and each is linked to its relevant COM-B categories (Michie, Atkins, and West 2014, p.116). For example, the COM-B category of psychological capability is linked with the intervention functions of education, training, and enablement.

Each of the nine intervention functions were rated against the relevant COM-B component(s). To decide which intervention functions were the most appropriate in the given context, the BCW APEASE criteria were applied by the research team to assess the Affordability, Practicability, Effectiveness/cost-effectiveness, Acceptability, Side effects/safety and Equity (APEASE) of each intervention function. Judgements were made based on team members’ experiences and expertise and also checked by members of the management team from the organisation.

To address gaps in psychological capability, the intervention functions of education and training met all of the APEASE criteria and were supported by management. In order to target reflective motivation (believing that family member attendance and involvement is important), education was identified as the most appropriate intervention function. Training was chosen as the best intervention function to address gaps in automatic motivation (emotional discomfort) and social opportunity (a supportive organisational culture of FCC that provides consistent training). Environmental restructuring was chosen to address aspects of physical opportunity which included a lack of FCC materials and the physical set-up of the appointment rooms. Lastly, incentivisation was chosen to address reflective motivation because there was already a staff reward program in place at the organisation and management supported staff receiving reward points for their participation in the intervention. The remaining intervention functions of persuasion, coercion, and restriction were determined to not be acceptable in the given context, and modelling and enablement were seen as impractical as organisational involvement at an interstate/international level would have been required. In summary, the following four intervention functions were chosen for each of the target behaviours: education, training, environmental restructuring, and incentivisation.

Step 6 – policy categories

The research team rated each of the policy categories that aligned with the intervention functions identified in Step 5 (i.e. education, training, environmental restructuring, and incentivisation), using the APEASE criteria. The following policy categories were considered: communication/marketing, guidelines, fiscal measures, regulation, legislation, environmental/social planning, and service provision. Of these, the policies that were rated as most likely to support the chosen intervention functions were the designing of guidelines (creating documents that recommend or mandate practice including service provision which includes producing and disseminating treatment protocols) and service provision (establishing support services in the workplace). However, after further consultation with the hearing care organisation, it was decided that policy categories were not going to be practical given that the intervention was being conducted within only three of the many clinics within the organisation.

Stage 3: identify content and implementation options

Step 7 – identify behaviour change techniques

Each selected intervention function was then linked to a number of Behaviour Change Techniques (BCTs) from the BCW guide (Michie, Atkins, and West 2014). After reviewing the list of possible BCTs linked to the selected intervention functions, the research team used the APEASE criteria to narrow the list down to the BCTs that were considered the most appropriate within the given context to address the identified barriers. Within the education intervention function, the most appropriate BCT was ‘information about social and environmental consequences’. For the training intervention function, selected BCTs were were ‘demonstration of the behaviour’, ‘instructions on how to perform a behaviour’ and ‘behavioural practice/rehearsal’. To address environmental restructuring, the BCTs selected were providing ‘prompts and cues’, ‘adding objects to the environment’ and ‘restructuring the physical environment’. Finally, to address incentivisation, the BCT ‘rewarding completion’ was selected. Further details of these BCTs can be found in Table 1.

Step 8 – identify mode of delivery

The final step of the BCW was the selection of a mode of delivery for the intervention. Mode of delivery options considered included face-to-face (individual or group) or distant (individual). This decision was informed by a meeting between the research team and the management of the organisation using the APEASE criteria and reflected the organisation’s overall commitment to the process of improving FCC. Based on the feedback from management, the education, training, and environmental restructuring components were designed to be delivered as two separate group face-to-face workshops within each of the clinics; workshops were 60–90 min each. In order to positively impact the organisational culture of support for FCC, the intervention would be designed as a whole-of-clinic approach in which all staff would attend both workshops (i.e. front-of-house, clinicians, and managers attended both workshops). The training and environmental restructuring resources would be provided to staff in both printed and electronic form and all resources would be reviewed and approved by management prior to the intervention delivery.

The intervention

After completing each step of the BCW, a two-phase intervention was developed to (1) increase family member attendance; and (2) increase family involvement in adult audiology appointments. The intervention comprises two training workshops for all clinic staff, the provision of cue cards with scripts, and follow-up individual coaching.

The first workshop focusses on the first problem behaviour (increasing family member attendance) by implementing the first target behaviour (clinic staff ask every client to bring a family member with them to their audiology appointments). In this workshop, the research team instruct and demonstrate how staff can effectively ask a family member to attend an appointment (via phone and text) when making appointment bookings with clients. Staff are instructed how to first provide clients with an explanation as to why family attendance is important before then asking who the client might be able to bring with them. The following script is provided to staff as an example: “Hearing difficulties can affect you as well as the people close to you. We need to understand both perspectives for us to be able to help with your hearing and communication. Who is someone close to you who could attend the appointment with you?” The ‘explanation + question’ format was designed to overcome the barriers identified in Step 4 where staff expressed a discomfort around asking for family member attendance because they felt that clients did not understand the reasoning and may feel that their independence was being threatened. The question is framed as an open “who” information-seeking question, rather than a closed yes/no question so that the staff could record the family member’s name with the client’s information. Staff are provided with printed cue cards and are advised to place them on their desk in eyesight to prompt the desired behaviour. Cue cards have an example of the above desired script on the front of the card and a designated space on the back of the card for the staff member’s own preferred script (see Figure 2). Wording that staff feel comfortable with is developed with each individual staff member, rehearsed, and inserted on the back of the cue card. In addition, three other cue cards are provided that have suggested responses to potential objections from clients, which staff had expressed concerns about in the interview phase (Step 4).

Figure 2. Cue cards provided to staff in the first workshop.

The second workshop (delivered after the first phase of the intervention) focuses on the second problem behaviour (increasing family member involvement in audiology appointments) by implementing the second and third target behaviours (staff set up room with chair for family member next to client; and clinician sets an agenda at the start of the appointment that encourages the involvement of both the client and family member). In this workshop, the research team provide a review of the educational component of FCC and its benefits before instructing and demonstrating how staff can further involve family members within appointments. In particular, the second workshop focusses on how to: (1) greet both client and family member when entering the clinic and invite them both into the clinic room; (2) set up the room to include a family member; (3) set an agenda that included both the client and family member; and (4) ask the family member an open history-taking question in addition to the client. The following script is provided to clinicians for how to set an agenda to include both client and family member: “Today I’m going to ask you both some questions about how things are going. First, I’m going to ask you (the client) some questions, and then I will ask some questions to you (the family member). Does that sound ok?” In addition, the following scripted wording is provided as an example of how to ask the family member an open history-taking question: “And how do you find (client’s name)’s hearing?”. Staff are also instructed as to how they might respond to disagreements between clients and family members during appointments. Again, staff are provided with printed cue cards with the above scripts on the front of the card and a designated space on the back of the card for the staff member’s own preferred script (see Figure 3). This workshop also includes individualised coaching to clinicians on how to rearrange seating in the clinic rooms to position family members’ chairs next to clients’ chairs so that they are an equal distance from the clinician (see Figure 4). During the second workshop, the research team works with the staff to actively rearrange the seating in their appointment room in a way that would best include the attending family member. Following a suggestion from clinic staff during the collaborative intervention development, a questionnaire for family members to complete in the waiting room has also been developed. The two-page questionnaire asks the family member several questions related to their own experience of the client’s hearing difficulties.

Figure 3. Cue cards provided to staff in second workshop.

Figure 4. Example of the triangular seating arrangements suggested in the second workshop (client and family member seated equally distanced from clinician).

At each workshop, staff are encouraged to be interactive in discussions and instructions are individually tailored to staff at each clinic. Staff are also asked to express any concerns about their ability to respond to difficult questions or objections from clients in these situations, so that possible responses can be suggested and discussed. Staff will also have the opportunity to have individualised 1:1 coaching with a member of the research team following the workshops to aid the behaviour change transition.

Staff who participate in the intervention receive points within a star system. This reward system was already implemented within the organisation and provides staff who engage in special achievements/endorsed behaviours with rewards in the form of points within a star system which translate into vouchers.

Discussion

In this study, a two-phase intervention was designed following the steps of the BCW with the aim to improve the implementation of two FCC behaviours in adult audiology appointments. Following the steps of the BCW, a two-phase tailored intervention was designed which aims to encourage behaviour change in order to increase family member attendance and involvement in audiology appointments. Together the workshops focus on three target changes to the implementation of FCC in the clinic:

1. Inviting a family member to appointments and explaining the reasons why it is important for them to attend.

2. Setting up the physical environment so that family members are included in the appointment.

3. Starting the appointment by letting the client and family member know that input from both of them will be sought during the appointment.

Strengths and challenges of the BCW model

The research team found strengths and challenges in using the BCW for the development of the intervention. The model was chosen because it combined 19 health behaviour change models into one comprehensive model for intervention design (Michie, Atkins, and West 2014). We found the model comprehensive and structured, which allowed for a systematic intervention design process. A major strength of the model was that it encouraged the research team to specify the target behaviours for change into simpler and more focussed behaviours rather than attempting to change too many or too complex behaviours at once. The research team thus found Phase 1 of the BCW process particularly useful. The model also encouraged a high level of involvement with stakeholders across the intervention design process, which was highly valuable for successful behaviour change within an organisation.

One challenge of using the model was that the BCW process was time-consuming and labour intensive in completing the specified worksheets for each step. The period from the start of the intervention design process to the point of delivering the training workshops was 4–6 months for each intervention and this timeline is not acknowledged within the model. In addition, the model provides the impression that the design process is a linear, stepwise process. However, the research team found that there were times across the process, particularly in Phase 1, where it was necessary to loop back to a previous step and further specify actions within that step before moving forward again. There were also some steps in the BCW that relied completely on decisions of the research team, and these steps thus seemed more subjective than other steps in the process. This is a challenge that has been noted by other research teams developing healthcare interventions (Casey, Coote, and Byrne 2019). While the use of the APEASE criteria were helpful in reducing some subjectivity, the process involved forecasting by the research team and stakeholders and this forecasting may not always be accurate. The research team also found that Step 6 (Policy categories) was not necessarily relevant for all types of intervention design (particularly smaller scale interventions) but this is not acknowledged in the model.

A final challenge was that the descriptions of individual BCTs were sometimes ambiguous and did not always reflect the complexity of what was required for the BCT to successfully promote behaviour change. For example, the BCTs ‘instruction on how to perform…’ and ‘behavioural practice/rehearsal’ involve differing levels of complexity and require different levels of engagement with the individuals whose behaviours are being targeted. It may have been helpful during the design process if the BCW acknowledged differing levels of complexity for each BCT.

Conclusions

FCC in adult audiology services has the potential to improve well-being for adult clients and family members. This research indicates that implementation requires a two-step process. Staff first need to invite family members to attend appointments at the time of booking. Next, when family members do attend appointments, staff need to involve them in the interactions within the clinic and appointment room. Implementing FCC thus needs to be a whole clinic approach. In the next phases of the study, the intervention will be implemented and evaluated to examine whether it results in the desired behaviour change. In addition to aiding intervention design, the BCW can be used in the process of intervention evaluation as it enables intervention outcomes to be linked to specific mechanisms of action to help diagnose where an intervention has succeeded/failed to achieve its desired goal (Michie, Atkins, and West 2014). Standard care data collected at baseline (including client questionnaires, clinic data, family member attendance rate, audio-recorded booking calls, and video-recorded appointments) will be compared with data collected following the implementation of each phase of the intervention.

Acknowledgements

This study was supported by research funding from Sonova AG. We would like to thank the clinic staff who were involved in the intervention design process. We would also like to thank Anthea Bott for her help with the design of the second intervention workshop.

Disclosure statement

No potential conflict of interest was reported by the author(s).