Developing an intervention to implement an ICF-based e-intake tool in clinical otology and audiology practice

Figures & data

Figure 1. The Behaviour Change Wheel. Reprinted from The Behaviour Change Wheel: a guide to designing interventions. By Michie, S., Atkins, L., and West, R. (2014). London: Silverback Publishing. Copyright [2014] by Michie, S, Atkins L., and West, R. Reprinted with permission.

Table 1. Specification of the selected target behaviours.

	Hearing health professionals	Patients
Target behaviour	Use of an ICF-based e-intake tool.	Use of an ICF-based e-intake tool.
Who	All audiologists and ENT surgeons (otologists) of the Amsterdam UMC, location VUmc.	All adult patients with ear or hearing problems visiting the outpatient clinic of the Amsterdam UMC, location VUmc for the first time.
What	(1) Reviewing the patient’s responses in preparation on the intake and (2) using the intake tool during the intake to discuss the patient’s needs and to together specify a treatment plan that is tailored to the patient’s needs.	(1) Filling out the questionnaire-part of the intake tool prior to the intake.
When	Before and during the intake of each new patient with ear or hearing problems visiting the outpatient clinic of the Amsterdam UMC, location VUmc for the first time.	Before the intake.
Where	At the outpatient clinic in their consultation room (1 and 2).	At home or in the waiting room*
How often	(1) Prior to each intake consultation of each new patient; (2) During the intake consultation and treatment of these patients.	Once

*preference will be determined in this current study. Table derived from the worksheet adapted from The Behaviour Change Wheel: a guide to designing interventions (p 56) by Michie S, Atkins L and West R, 2014, Great Britain: Silverback Publishing. Copyright Year by “Susan Michie, Lou Atkins and Robert West”.

Figure 2. The stages and specific steps of the BCW method, related to the layers of the BCW. APEASE criteria: optimal affordability, practicability, effectiveness, acceptability, side effects and equity. TDF: Theoretical Domains Framework; COM-B: capability, opportunity, motivation-behaviour model; BCW: behaviour change wheel.

Table 2. Characteristics of the expert group.

Member	Background	Relevant experience	Years of experience
LvL	PhD researcher	Innovation and evaluation of ear and hearing health care, ICF	4
MP	Senior researcher	Determinants and consequences of hearing loss, innovation and evaluation of ear and hearing health care, ICF	10
SK	Professor	Auditory functioning and participation, neuro-psychologist, ICF, clinical ear and hearing practice	>15
HA	Professor	Evidence-based implementation	>15
PM	ENT-surgeon, senior researcher	Clinical ENT practice, research on innovation and evaluation of ear and hearing health care	>15
TG	Audiologists, senior researcher	Clinical audiology practice, residency, policy/governance, research on auditory functioning and participation	>15

ICF: International Classification of Functioning, disability and health.

Table 3. Intervention content targeting HHPs’ barriers (A) and enablers (B) towards using the intake tool.

A: HHPs’ barriers towards using the intake tool, COM-B components, TDF domains, selected intervention functions, selected policy categories, selected BCTs and BCT translation within the intervention
1. COM- component	2. Setting*	3. Barrier	4. TDF	5. Intervention Functions	6. Policy category	7. BCT	8. Translation of BCT into intervention content
Psychological capability	1,2	In current routine practice, assessing/discussing psychosocial and contextual factors are not included (or to a limited extent)	Behavioural regulation/ skills	Education	Guidelines	Information on health consequences	Provide information on the relevance of addressing the different components and items in the ICF Core Set for Hearing Loss on the functioning of patients with ear/hearing problems Provide information on improved health consequences for patients when using the ICF based intake tool
				Training	Service provision	Instruction on how to perform behaviour	Provide instructions on how to interpret and use the information provided by the ICF based intake tool
	1,2	In current practice, HHPs lack the skills address patients’ psychosocial complaints	Behavioural regulation/ skills	Modelling	Service provision	Demonstration of the behaviour	Demonstrate how to interpret and use the information provided by the intake tool Demonstrate how to raise the issues identified with the intake tool with patients
				Training	Service provision	Behavioural practice/rehearsal	Role play exercises to practice using the intake tool in the consultation room
						Feedback on behaviour	Audit and feedback after training and during adoption. Notifications should be provided and visible within the EMR to the treating HHP and his/her colleagues.
				Enablement	Environmental planning	Adding objects to the environment	Integration of supporting instruments providing information on possible treatment options/ referral pathways
	1	Lack of knowledge regarding internal referral pathways for patient problems relating to psychosocial factors	Knowledge	Education	Guidelines	Instruction on how to perform a behaviour	Inform HHPs on internal referral pathways; i.e. the social worker, and occupational health at the department of audiology/ ENT. And providing clear instructions on how to initiate a referral to these other HHPs.
					Environmental planning/ service provision	Adding objects to the environment	Integration of supporting instruments providing information on possible treatment options/ referral pathways
Physical opportunity	1,2,3,4	Reviewing a patient’s responses on a long intake tool and acting on them is not perceived as feasible in daily practice	Environmental context and resources	Environmental restructuring/ enablement	Environmental planning/ Service provision	Adding objects to the environment	Integrate the intake tool in the electronic patient record system to make the tool easily accessible Develop/integrate (graphical) summaries of patient responses and a quick overview of answers (i.e. the functioning profile) Limit the number of open questions in the ICF based intake tool
	1,3	High turnover practice limiting the time for the intake
	1,3	Limited timeframe per intake, restricting the number of topics to discuss
	1,2	Perceived (extra) time investment to use the intake tool
	2,4	Open-ended questions should be avoided, as they take too much time to review and are difficult to address				Prompts/cues	Integration of supporting instruments that flag the items that indicate a (possible) problem Integration of supporting instruments to prompt HHP’s to use the intake tool in every new patient that comes in (e.g. by a digital stimulus in EMR).
Reflective motivation	1,2,3	Feeling responsible for addressing any functioning topics that arise from the intake tool	Social/ professional role and identity	Education, persuasion	Guidelines	Information on health consequences	Provide information on the relevance of addressing the different components and items in the ICF Core Set for Hearing Loss on the functioning of patients with ear/hearing problems Provide information on improved health consequences for patients when using the ICF based intake tool
	1,2	Perception that the intake tool is suitable in an Audiological Centre or as an research tool, but is less suitable in the Otology intake practice
				Persuasion	Social planning	Credible source	Deploy opinion leaders to deliver the workshop and offer social support during adoption
	1,2	Attitude that it is sufficient to rely on own questions and own structure during the intake and consultation as compared to a pre-defined and structured format	Beliefs about capabilities	Education, persuasion	Guidelines	Information on health consequences	Provide information on the relevance of addressing the different components and items in the ICF Core Set for Hearing Loss on the functioning of patients with ear/hearing problems
					Social planning	Credible source	Deploy opinion leaders to deliver the workshop and offer social support
	1,2,3	Not feeling competent in using the intake tool with regard to having to address and/or handle patient problems in areas beyond the HHP’s expertise or capabilities	Beliefs about capabilities	Education, persuasion	Guidelines	Information on health consequences	Inform that intake tool is not intended to make the HHP treat complaints beyond their expertise, but to notice these complaints and weigh them in the treatment policy. Instructed that they can check whether important complaints are under care, or advice the patient to seek care of an appropriate health care provider.
				Modelling	Service provision	Demonstration of the behaviour	Demonstrate how to interpret and use the information provided by the intake tool Demonstrate how to raise the issues identified with the intake tool with patients
						Feedback on behaviour	Feedback during, and after training and during adoption.
				Enablement	Environmental planning/ Service provision	Adding objects to the environment	Integration of supporting instruments providing information on possible treatment options/ referral pathways
	1	Uncertainty about the patient’s satisfaction with the provided care	Optimism (pessimism)	Persuasion	Guidelines	Information on health consequences	Provide information on the relevance of addressing the different components and items in the ICF Core Set for Hearing Loss on the functioning of patients with ear/hearing problems Provide information on improved health consequences for patients when using the ICF based intake tool Present HHPs the results of patient’s positive perceptions on the intake tool (results patient interviews current study).
	1	Uncertainty about whether patients will perceive the intake tool as relevant or not
	1	Perception that the benefit to patient care is only theoretical, and does not work in practice
					Social planning	Credible source	Deploy opinion leaders to deliver the workshop and offer social support
	1,2,3	Perception that the intake tool will not affect the choice of a treatment strategy (for most patients)	Goals	Education, enablement	Guidelines	Information on health consequences	Inform that intake tool is not intended to make the HHP treat complaints beyond their expertise, but to notice these complaints and weigh them in the treatment policy. Instructed that they can check whether important complaints are under care, or advice the patient to seek care of an appropriate health care provider.
	1,2	Attitude that the psychosocial factors included in the intake tool do not match the expertise and interest of the HHP	Goals	Education, persuasion	Guidelines	Information on health consequences	Provide information on the relevance of addressing the different components and items in the ICF Core Set for Hearing Loss on the functioning of patients with ear/hearing problems Provide information on improved health consequences for patients when using the ICF based intake tool
					Social planning	Credible source	Deploy opinion leaders to deliver the workshop and offer social support
	1	Perception that there is no need for a comprehensive list of questions, as there are only a few questions that have to be asked to the patient to know what is going on	Intentions	Education, persuasion	Guidelines	Information on health consequences	Provide information on the relevance of addressing the different components and items in the ICF Core Set for Hearing Loss on the functioning of patients with ear/hearing problems Provide information on improved health consequences for patients when using the ICF based intake tool
				Modelling	Service provision	Demonstration of the behaviour	Demonstrate how to interpret and use the information provided by the intake tool Demonstrate how to raise the issues identified with the intake tool with patients
	1,2,3	Perception that the intake tool has no added value in patients with well-defined ear/hearing problems (e.g. ear infection, presbyacusis) for whom the treatment options are evident in their view (e.g. medication, hearing aids)	Beliefs about consequences	Education, persuasion	Guidelines	Information about social consequences	Present HHPs the results of patient’s positive perceptions on the intake tool (results patient interviews current study) and planning a feasibility-study before deciding to implement the questionnaire for all ear and hearing patients.
					Service provision	Information on health consequences	Field-test study in a large, heterogeneous group of patients to test feasibility in all patient
	1,2,3	Fear that additional questions in the intake tool (as compared with current practice) will raise additional problems the HHP has to assess	Beliefs about consequences	Education, enablement	Guidelines	Information on health consequences	Inform that intake tool is not intended to make the HHP treat complaints beyond their expertise, but to notice these complaints and weigh them in the treatment policy. Instructed that they can check whether important complaints are under care, or advice the patient to seek care of an appropriate health care provider.
	1,3	Fear that the HHPs are considered responsible for every problem that arises from the intake tool	Beliefs about consequences	Education, persuasion	Guidelines	Information on health consequences	Inform that intake tool is not intended to make the HHP treat complaints beyond their expertise, but to notice these complaints and weigh them in the treatment policy. Instructed that they can check whether important complaints are under care, or advice the patient to seek care of an appropriate health care provider.
	1,2,3	Fear that patients expect that the intake tool is used and topics are discussed, while the HHPs may not consider it relevant: mismatch between expectations of the patients and the HHP’s actions	Beliefs about consequences	Education, persuasion	Guidelines	Information on health consequences	Provide information on the relevance of addressing the different components and items in the ICF Core Set for Hearing Loss on the functioning of patients with ear/hearing problems Provide information on improved health consequences for patients when using the ICF based intake tool
				Modelling	Service provision	Demonstration of the behaviour	Demonstrate how to interpret and use the information provided by the intake tool Demonstrate how to raise the issues identified with the intake tool with patients
	1,2	Concern that the use of the intake tool would create more work	Beliefs about consequences	Education, persuasion	Guidelines	Information on health consequences	Provide information on the relevance of addressing the different components and items in the ICF Core Set for Hearing Loss on the functioning of patients with ear/hearing problems Provide information on improved health consequences for patients when using the ICF based intake tool
				Modelling	Service provision	Demonstration of the behaviour	Demonstrate how to interpret and use the information provided by the intake tool Demonstrate how to raise the issues identified with the intake tool with patients
	3	Fear that questions will only be asked because these are part of the intake tool, and not because these are relevant to the patient	Beliefs about consequences	Education, persuasion	Guidelines	Information on health consequences	Provide information on the relevance of addressing the different components and items in the ICF Core Set for Hearing Loss on the functioning of patients with ear/hearing problems Provide information on improved health consequences for patients when using the ICF based intake tool
						Information about social consequences	Present HHPs the results of patient’s positive perceptions on the intake tool (results patient interviews current study) and planning a feasibility-study before deciding to implement the questionnaire for all ear and hearing patients.
	1,3	Concern that the cause of the problems reported by may not always be ear/hearing-related	Beliefs about consequences	Education, persuasion	Guidelines	Instruction on how to perform a behaviour	Provide instructions on how to interpret and use the information provided by the ICF based intake tool
				Modelling	Service provision	Demonstration of the behaviour	Demonstrate how to interpret and use the information provided by the intake tool Demonstrate how to raise the issues identified with the intake tool with patients
	2	Fear that the format of the tool could cause a fixed frame for the intake consultation, without room for nuance	Beliefs about consequences	Education, persuasion	Guidelines	Instruction on how to perform a behaviour	Inform on the liberty to employ the intake tool, i.e. inform the HHP to implement/use the intake tool in the consultations in a way that is personally convenient to them and to use the supporting instruments in the intake tool when needed.

Table 4. Intervention content targeting patients’ barriers (A) and enablers (B) towards using the intake tool.

A. Patients’ barriers towards using the intake tool, COM-B components, TDF domains, selected intervention functions, selected policy categories, selected BCTs and BCT translation within the intervention
1. COM-component	2. Barrier	3. TDF	4. Intervention Function	5. Policy category	6. BCT	7. Translation of BCT into intervention content
Psychological capability	Information and instructions of the intake tool should not be too long or extended	Skills/Memory, attention, and decision processes	Enablement	Service provision	Information	Avoid long or too extended information and instructions
	Use of medical jargon should be avoided	Skills/Memory, attention, and decision processes	Enablement	Service provision	Information	Efforts to ensure readability and interpretability by patients (avoiding medical jargon)
Physical opportunity	The time that is needed to complete the questionnaire should not be too long	Environmental context and resources	Enablement/ environmental restructuring	Service provision	Information	Restrict the length of the questionnaire to approximately 15 minutes completion time
Motivation	The questions in the questionnaire should not be duplicated in the intake conversation, i.e. the patient’s responses should be reviewed by the HHP before the intake visit The intake should not be shortened or dominated by the intake tool	Goals	Education, persuasion	Service provision	Information	Inform the patient on the purpose of the intake tool, i.e. to avoid overlooking patient’s needs and to facilitate the communication between patient and HPP
	Providing the patient’s responses to the HHP prior to the intake visit should not negatively affect or replace the (open) conversation with the HHP Use of the intake tool should not reduce the personal attention of the HHP for the patient and his/her problems.	Beliefs about consequences	Education, persuasion	Service provision	Information	Inform the patient on the purpose of the intake tool, i.e. to avoid overlooking patient’s needs and to facilitate the communication between patient and HPP

Table 5. Intervention content targeted at HHPs.

Intervention component	Intervention content
Education and training	Provision of a concise manual with educational and instructional materials: Educational materials presenting the key information on the evidence base, and potential benefits of using the intake tool in clinical practice; Educational material on HHPs’ role in using the intake tool; Instructional material explaining how to use the intake tool; Specific guidelines suggesting clinical actions and referral pathways to manage psychosocial problems and other problems that may potentially be identified based on patient’s scores on the intake tool for which the HHPs currently do not have guidelines yet. These guidelines will be developed in close collaboration with the HHPs.
	Offering a workshop divided in an educational- and a training part: Educational part to: (1) provide and improve knowledge and understanding about the background and use of the intake tool; (2) motivate HHPs to use the intake tool and explain to them that the use of the intake tool is potentially beneficial, in that it will presumably help improve the quality of the patient’s intake process and the subsequent care pathway, and subsequently patient satisfaction; (3) explain the intake tool with respect to layout, content, interpretation and use; (4) explain the HHPs’ role in the use of the intake tool and how it may fit within their clinical practice. Training part to: develop skills/competencies to use and interpret the scores obtained with the intake tool.
	Provision of audit and feedback on HHP’s performance during implementation.
Opinion leaders	Identification and training of opinion leaders to deliver the workshop and offer support during implementation.
Environmental factors	Integration of the intake tool in the electronic patient record system.
	Provision of environmental resources, including design and functionalities of the intake tool: digital reminders to use the intake tool for every new patient; clear graphical summaries of patient responses facilitating a quick overview of answers; flagging system to flag the items of the intake tool that indicate the areas in which the patient reports problems in; supporting instruments to link patient results with treatment options and/or referral pathways.
Field-test study of the intake tool to test feasibility in all patient groups.

Table 6. Intervention content targeted at patients.

Intervention component	Intervention content
Education and instructions	Provision of clear and concise educational/instructional information letter, including: Information about the purpose and relevance of the intake tool; Persuasive communication techniques to motivate patients to use the intake tool by creating awareness about the potential benefits of the tool and how potential barriers of using the intake tool are addressed (for example explain that the intake tool could improve patient-clinician communication be used to aid the communication with the clinician during the intake consultation, but does not replace the face-to-face conversation during the consultation); Instructions on how to fill out the intake tool; Instructions explaining that the intake tool can be filled in with the help of a family member or caretaker in case the patient is not able to complete the intake tool by him/herself.
Environmental factors	Remote administration of the questionnaire (option to fill it in at home prior to the intake appointment);
	Availability of different modes of administration (both digital and paper and pencil versions, the latter for digitally illiterate patients);
	Provision of environmental resources, including different design features and functionalities: An easily accessible and simple user interface: accessibility to the digital intake tool via one click on a link; adequate readability and interpretability of the questions by patients (i.e. avoid medical jargon, reading level and font size, and general appearance); Offering assistance or help when the patient experiences difficulties (i.e. provide helpdesk number); Reducing the length of the intake tool to ensure completing does not take more than 15 minutes.