Supporting Behavior Change After AECOPD – Development of a Hospital-Initiated Intervention Using the Behavior Change Wheel

Figures & data

Table 1 Scoping Review of Articles on the Impact of Health Behavior Interventions on the Chosen Respiratory-Related Outcomes

Respiratory-Related Outcome	Intervention	Reference(s)
Number of exacerbations	Vaccinations for influenza, pneumococcus and COVID-19	[29]
	Correct inhalation of medication, indicating adherence to inhaled medication during stable phases	[31]
	Smoking Cessation Intervention	[29]
Number of respiratory-related hospitalizations	Self-management-Intervention (characteristic: iterative process with ≥ 2 components*)	[5,7,29,31]
	Exacerbation action plan embedded in self-management intervention	[4,29,31]
	Interventions for integrated care (characteristics: multi-disciplinary; ≥ 2 healthcare providers; and multi-treatment; ≥ 2 components;** duration at least three months)	[6,8]
Health-related Quality of life	Exacerbation action plan embedded in self-management intervention	[4,32]
	Pulmonary Rehabilitation (characteristics: endurance and/ or strength exercise,^Citation11 exercise therapy^Citation36)	[11,36]
	Self-management-Intervention (characteristic: iterative process with ≥ 2 components*)	[5,7]
	Digital-based self-management-interventions (characteristic: behavior change intervention)	[33]
	Tele-healthcare intervention: patients measure and/or report signs or symptoms	[34]
	Home-care by COPD outreach nurse (characteristics: components of education, support, monitoring health, liaising with physician)	[37]
	Interventions for integrated care (characteristics: multi-disciplinary; ≥ 2 healthcare providers; and multi-treatment; ≥ 2 components;** duration at least three months)	[6,8]
	In malnourished patients: Nutritional supplementation	[35]
Stabilization of lung function	Smoking Cessation	[29]

Notes: *components: smoking cessation, self-recognition of exacerbation, use of an exacerbation action plan, home-based physical activity, diet, medication, and dyspnea management; ** components: 1) self-management education eg, exacerbation management, 2) exercise training, 3) psychosocial intervention(s), 4) smoking cessation, 5) medication adherence, 6) dietary intervention, 7) structured follow-up, 8) multidisciplinary team and 9) reimbursement for provision of integrated care.

Table 2 Overview of Intervention Packages and Behaviour Change Techniques (BCTs) - Exacerbation Management and Physical Activity

Target Behaviors	Exacerbation Management				Physical Activity
	Noting Change	Reacting According to Action Plan		Documenting Symptoms and Signs	Exercising 30 Min/Day			Exercise, Supervised
Health professional who delivers the BCTs	ANPT	ANPT		ANPT	ANPT	PT	PHY	ANPT	PT	PHY
Variation – based on assessment	No variation	With self-medication	Without self-medication	No variation	No variation			No variation
Intervention package number	1.	2.	3.	4.	5.	6.	7.	8.	9.	10.
No of different BCTs (of 93)	8	13	13	11	22	7	2	5	1	1
No of all BCTs per intervention package (with repetition)	11	21	19	17	33	10	3	6	1	1
Examples
Smoker with self-medication and smoking cessation counselling (Total 140 BCTs)	11	21		17	33	10	3	6	1	1
Non-smoker without self-medication (Total 106 BCTs)	11		19	17	33	10	3	6	1	1

Abbreviations: ANPT, advanced nursing practice nurse team; PT, physiotherapist; PHY, physician.

Table 3 Overview of Intervention Packages and Behaviour Change Techniques (BCTs) - Smoking Cessation

Target Behaviors	Smoking Cessation
Health professional who delivers the BCTs	PHY	ANPT
Variation – based on assessment	No variation	Smokers				Non-smokers
		Motivation 1–7	Motivation 8–10			Stopped <6 months before hospitalization	Stopped ≥6 months, ≤10 years	Never-smoker or stopped > 10 years
			Outsourced smoking cessation counselling	Smoking cessation counselling by ANPT	Immediate stop
Intervention package number	11.	12.	13.	14.	15.	16.	17.	18.
No of different BCTs (of 93)	2	12	9	27	7	12	3	2
No of all BCTs per intervention package (with repetition)	2	14	9	35	7	13	3	3
Examples
Smoker with self-medication and smoking cessation counselling (Total 140 BCTs)	2			35
Non-smoker without self-medication (Total 106 BCTs)	2							3

Abbreviations: ANPT, advanced nursing practice nurse team; PT, physiotherapist; PHY, physician.

Table 4 Algorithm for Follow-Up Interventions

Assessment	Performance of the (max.) six key behavior(s) since the last contact
Evaluation	Behavior(s) is/are in line with the planned behavior?
	Yes	No
	↓	↓
Intervention	Feedback on behavior (BCT 2.2)	Feedback on behavior (BCT 2.2)
	Acknowledgement (BCT 10.4)	Discrepancy (BCT 1.6)
	Focus on past success (BCT 15.3)	Problem Solving (BCT 1.2), including exploring barrier(s) via open questions
		↓
		Deliver the BCTs selected for each barrier^a
		↓
		Review behavior goal (BCT 1.5)

Notes: ^aBCT sets are offered for nine barriers: 1) missing physical skills (TDF: physical skills), 2) missing knowledge (TDF: knowledge), 3) missing habit (including the three TDFs: behavioral regulation; cognitive and interpersonal skills; and memory, attention and decision process); 4) missing belief about consequences (TDF: belief about consequences), 5) incongruence with self-identity (TDF: identity), 6) missing decision regarding the behavior (including the intentions and goals TDFs), 7) missing confidence (including two TDFs: optimism and beliefs about capabilities), 8) negative emotion and missing energy (TDF: emotions and reinforcement), 9) practical and social barriers (including two TDFs: environmental context and social influences).

Table 5 Example of a Specified Intervention - Smoking Intervention for Ex-Smokers > 6 Months

Target Behavior		TDF	BCT No	BCT	Intervention	Illustration
Maintain smoking cessation		Memory, attention and decision processes	2.2	Feedback on behavior	That’s great that you have managed to stop smoking for (x months/ years). By doing so, you are helping to reduce the rate at which your lung function declines. It is therefore highly recommended for the course of COPD that you continue not to smoke.
Maintain smoking cessation		Knowledge	4.2	Information about antecedents	You may be disappointed that you have a lung deterioration even though you have not smoked for so long. I’d like to show you the influence of smoking cessation on the number of lung attacks, using the example of a large study from the US. In this study, 5887 smokers were observed during 5 years.^Citation59 It is also important to know that after a lung attack in smokers, the lung function generally decreases. In non-smokers the decrease in lung function is absent or less pronounced.	Present slide: “Impact of smoking cessation on lung function”
If confidence < 7	Maintain smoking cessation	Optimism	15.1	Verbal persuasion about capability	Regarding your confidence to remain a non-smoker, you rated a(n) x (lower than 7) on the scale when asked about that: What will it take to get to a y (higher score)? Or why did you report an x and not a z (lower score)?

Table 6 Overview of the Nurse-Led Integrated Care COPD (NICCO) Intervention

		Mode of Delivery	Face-to-Face In-Hospital Meetings with Multi-Professional Team		Telephone Outpatient Follow-Up by ANPT
		Week	0	0	1	2	3	5	7	9	11	13
Self-Management Intervention	Behavioral	Exacerbation Management	Assess	Int	Re-Assess & Int	Re-Assess & Int	Re-Assess & Int	Re-Assess & Int	Re-Assess & Int	Re-Assess & Int	Re-Assess & Int	Re-Assess & Int
		Physical Activity	Assess	Int	Re-Assess & Int	Re-Assess & Int	Re-Assess & Int	Re-Assess & Int	Re-Assess & Int	Re-Assess & Int	Re-Assess & Int	Re-Assess & Int
		Smoking Cessation	Assess	Int	Smokers: Re-Assess & Int		Smokers: Re-Assess & Int		Smokers: Re-Assess & Int		Smokers: Re-Assess & Int
	Complementary	Inhalation Adherence	x	x				x		x		x
		Nutrition	x			x
		Dyspnea Management	x	x	x	x	x	x	x	x	x	x
		Emotional Distress Management	x	x	x	x	x	x	x	x	x	x
		Advance Care Planning	x
Integrated care intervention		Integrated care interventions	x	x	x	x	x	x	x	x	x	x

Abbreviations: Assess, assessment; Re-Assess, re-assessment; Int, intervention.

Table 7 Patient Criteria for Action Plan with Self-Medication

All Applicable Questions Must Be Answered with “Yes”:
1	Does the patient have a confirmed diagnosis of COPD?
2	Is the patient in good psychological health; in case of a psychiatric diagnosis, is the condition stable?
3	Does the patient have cognitive skills adequate for safe self-medication? (In case of doubt: take a decision based on an assessment with the Mini-Cog Test)
4	Is the patient aware of having COPD?
5	If severe comorbidities require complex self-management (eg, acute heart failure), does the patient have the required self-management skills to manage the comorbidities and the COPD?
6	Is the patient’s life expectancy > 6 months?
7	Is he/she not listed for lung transplantation?
8	Is the patient willing to participate in the behavioral intervention to acquire the necessary knowledge and skills to handle self-medication safely?
9	Only in patients who have experienced an earlier AECOPD: did he/she react in a health-fostering and commonly agreed way (seeking help promptly)?

Table 8 Intervention Packages for Different Patient Smoking Situations After AECOPD

Assessment	Smoking Status
	Smoker				Ex-Smoker		Never-Smoker or Non-Smoker > 10 Years
	Motivation 1–7	Motivation 8–10			< 6 Months	≥ 6 Months- 10 Years
	↓	↓	↓	↓	↓	↓	↓
Intervention	Intervention to increase motivation	Intervention with referral to smoking cessation counselling	Intervention to support future smoking cessation without referral to smoking counselling	Intervention to support immediate smoking cessation	Intervention to keep up ex-smoker status If confidence < 7 an additional BCT is added	Intervention to keep up ex-smoker status If confidence < 7 an additional BCT is added	Intervention to maintain non-smoker status
No	SMO 01	SMO 02	SMO 03	SMO 04	SMO 05	SMO 06	SMO 07

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