Defining the content and delivery of an intervention to Change AdhereNce to treatment in BonchiEctasis (CAN-BE): a qualitative approach incorporating the Theoretical Domains Framework, behavioural change techniques and stakeholder expert panels

Background
Low patient adherence to treatment is associated with poorer health outcomes in bronchiectasis. We sought to use the Theoretical Domains Framework (TDF) (a framework derived from 33 psychological theories) and behavioural change techniques (BCTs) to define the content of an intervention to change patients’ adherence in bronchiectasis (Stage 1 and 2) and stakeholder expert panels to define its delivery (Stage 3).

Methods
We conducted semi-structured interviews with patients with bronchiectasis about barriers and motivators to adherence to treatment and focus groups or interviews with bronchiectasis healthcare professionals (HCPs) about their ability to change patients’ adherence to treatment. We coded these data to the 12 domain TDF to identify relevant domains for patients and HCPs (Stage 1). Three researchers independently mapped relevant domains for patients and HCPs to a list of 35 BCTs to identify two lists (patient and HCP) of potential BCTs for inclusion (Stage 2). We presented these lists to three expert panels (two with patients and one with HCPs/academics from across the UK). We asked panels who the intervention should target, who should deliver it, at what intensity, in what format and setting, and using which outcome measures (Stage 3).

Results
Eight TDF domains were perceived to influence patients’ and HCPs’ behaviours: Knowledge, Skills, Beliefs about capability, Beliefs about consequences, Motivation, Social influences, Behavioural regulation and Nature of behaviours (Stage 1). Twelve BCTs common to patients and HCPs were included in the intervention: Monitoring, Self-monitoring, Feedback, Action planning, Problem solving, Persuasive communication, Goal/target specified:behaviour/outcome, Information regarding behaviour/outcome, Role play, Social support and Cognitive restructuring (Stage 2). Participants thought that an individualised combination of these BCTs should be delivered to all patients, by a member of staff, over several one-to-one and/or group visits in secondary care. Efficacy should be measured using pulmonary exacerbations, hospital admissions and quality of life (Stage 3).

Conclusions
Twelve BCTs form the intervention content. An individualised selection from these 12 BCTs will be delivered to all patients over several face-to-face visits in secondary care. Future research should focus on developing physical materials to aid delivery of the intervention prior to feasibility and pilot testing. If effective, this intervention may improve adherence and health outcomes for those with bronchiectasis in the future.

Characteristics of change triggered temper outbursts in children with PWS and ASD and how these may impact on the efficacy of behavioural intervention strategies.

Background
Temper outbursts are prevalent in individuals with PWS and are often triggered by unexpected changes to routines or plans. However, such outbursts are also common in individuals with several other neurodevelopmental disorders, including those with a diagnosis of autism spectrum disorder (ASD). We compared the profile of temper outbursts in children with PWS to that in children with ASD. We examined whether differences in the temper outburst profile predicted differences in the outcomes of two caregiver led intervention strategies aiming to reduce change triggered outbursts.
Methods and results
Thirteen 7-15 year olds with PWS – taking part in a larger study involving 60 children evidencing temper outbursts following changes – were individually matched for age to children with ASD (mean ages: 10.70; 10.76 yrs). Caregivers participated in a structured/semi-structured interview on children's outbursts; completed a web-based outburst diary over a 6 month baseline; and are currently using either a change signalling intervention to reliably warn children of forthcoming changes; or a planning ahead intervention to reduce children's exposure to unexpected changes.
As reported at interview, on average, children with PWS showed more frequent temper outbursts than those with ASD (closer to daily vs. weekly). For seven children with PWS and six with ASD, 60% or more of their temper outbursts were reported to be triggered by changes. Whilst outbursts had similar durations when triggered by changes or by other events in children with PWS; change triggered outbursts in children with ASD were generally shorter. The most commonly reported outburst components in children with PWS included indicators of heightened emotional arousal but this was not the case for children with ASD. Data on behavioural change associated with each of the intervention strategies will be discussed.
Conclusions
Change triggered temper outbursts can be a problem for children PWS and ASD, however subtle differences appear to exist in the profile of these outbursts. Some of these differences may be relevant for the expected efficacy of different behavioural intervention strategies that target outbursts.
Summary
Temper outbursts (tantrums) were compared in children with PWS or autism spectrum disorder before and during use of one of two helping strategies. Helping strategies were led by caregivers and aimed to reduce outbursts that follow changes to routines or plans by making such changes more predictable, or by reducing the quantity of changes. Characteristics of outbursts may be important to help us predict which helping strategies may be most effective.

Climate change adaptation : a decision support framework to encourage environmentally responsible behaviour

Structured Abstract:
Purpose: Very few studies investigate environmentally responsible behaviour (ERB). This paper presents a new 'Awareness Behaviour Intervention Action' (ABIA) Decision Support Framework to sustain ERB.

Design/methodology/approach: Previous ERB programmes have failed to deliver lasting results; they have not appropriately understood and provided systems to address ERB (Costanzo et al., 1986). These programmes were based on assumptions (Moloney et al., 2010), which this paper addresses. The ABIA Framework has been developed through a case study of social housing tenants waiting for low or zero carbon homes.

Findings: The ABIA Framework enables a better understanding of current attitudes to environmental issues and provides support for ERB alongside technological interventions employed to promote and sustain carbon reduction.

Research limitations/implications: The ABIA Framework should be tested on individuals and communities in a variety of socio-economic, political and cultural contexts. This will help unpack how it can impact on the behaviours of individuals and communities including stakeholders.

Practical implications: This type of research and the ABIA Framework developed from it are crucial if the UK pledge to become the first country in the World where all new homes from 2016 are to be zero carbon.

Social implications: The Framework encourages both individual and community discussion and solving of sustainability issues.

Originality/value: There are few, if any, studies that have developed a framework which can be used to support behavioural change for adaptation to sustainable living in low or zero carbon homes.

Apolipoprotein E e4 allele influences aggressive behaviour in Alzheimer's disease

The rising number of people with cognitive impairment is placing health care budgets under significant strain. Dementia related behavioural change is a major independent risk factor for admission to expensive institutional care, and aggressive symptoms in particular are poorly tolerated by carers and frequently precipitate the collapse of home coping strategies. Aggressive change may result from known genetic risk factors for Alzheimer's disease (AD) and therefore accompany conventional markers such as apolipoprotein E (ApoE). We tested this hypothesis in 400 moderately to severely affected AD patients who were phenotyped for the presence of aggressive or agitated behaviour during the month prior to interview using the Neuropsychiatric Inventory with Caregiver Distress. The proportion of subjects with aggression/agitation in the month prior to interview was 51.8%. A significantly higher frequency of the e4 allele was found in individuals recording aggression/agitation in the month prior to interview (chi2 = 6.69, df = 2, p = 0.03). The additional risk for aggression/agitation conferred by e4 was also noted when e4 genotypes were compared against non-e4 genotypes (chi2 = 5.45, df = 1, p = 0.02, OR = 1.60, confidence interval (CI) 1.06 to 2.43). These results indicate that advanced Alzheimer's disease patients are at greater risk of aggressive symptoms because of a genetic weakness in apolipoprotein E.

The (Soft) Power of Commitment:The EU and Conflict Resolution in Northern Ireland

This paper examines the potential of international actors to contribute to conflict resolution by analysing the evolving role of the European Union (EU) in embedding Northern Ireland's peace process. Scrutiny of the EU's approach to conflict resolution in Northern Ireland offers useful insights into the scope and potential of soft power for facilitating behavioural change from governmental to grass-roots levels. This paper traces the development of the EU's approach to conflict resolution in Northern Ireland from one concentrated on encouraging state-level agreement, to nurturing peace through multilevel funding, through now to consolidating the peace by facilitating regional-level empowerment. The core argument is that, in sum, the most critical element of the EU's contribution to peace in Northern Ireland has been, quite simply, that of enduring commitment.

Six-year follow-up of the SPHERE RCT: secondary prevention of heart disease in general practice.

Objective: To determine the long-term effectiveness of a complex intervention in primary care aimed at improving outcomes for patients with coronary heart disease.

Design: A 6-year follow-up of a cluster randomised controlled trial, which found after 18 months that both total and cardiovascular hospital admissions were significantly reduced in intervention practices (8% absolute reduction).

Setting: 48 general practices in the Republic of Ireland and Northern Ireland.

Participants: 903 patients with established coronary heart disease at baseline in the original trial.

Intervention: The original intervention consisted of tailored practice and patient plans; training sessions for practitioners in medication prescribing and behavioural change; and regular patient recall system. Control practices provided usual care. Following the intervention period, all supports from the research team to intervention practices ceased.

Outcome measures: Primary outcome: hospital admissions, all cause and cardiovascular; secondary outcomes: mortality; blood pressure and cholesterol control.

Results: At 6-year follow-up, data were collected from practice records of 696 patients (77%). For those who had died, we censored their data at the point of death and cause of death was established. There were no significant differences between the intervention and control practices in either total (OR 0.83 (95% CI 0.54 to 1.28)) or cardiovascular hospital admissions (OR 0.91 (95% CI 0.49 to 1.65)). We confirmed mortality status of 886 of the original 903 patients (98%). There were no significant differences in mortality (15% in intervention and 16% in control) or in the proportions of patients above target control for systolic blood pressure or total cholesterol.

Conclusions: Initial significant differences in the numbers of total and cardiovascular hospital admissions were not maintained at 6 years and no differences were found in mortality or blood pressure and cholesterol control. Policymakers need to continue to assess the effectiveness of previously efficacious programmes.

Trial registration number: Current Controlled Trials ISRCTN24081411.

Plasticity varies with boldness in a weakly-electric fish

The expression of animal personality is indicated by patterns of consistency in  individual behaviour. Often, the differences exhibited between individuals are consistent across situations. However, between some situations, this can be biased by variable levels of individual plasticity. The interaction between individual plasticity and animal personality can be illustrated by examining situation-sensitive personality traits such as boldness (i.e. risk-taking and exploration tendency). For the weakly electric fish Gnathonemus petersii, light condition is a major factor influencing behaviour. Adapted to navigate in low-light conditions, this species chooses to be more active in dark environments where risk from visual predators is lower. However, G. petersii also exhibit individual differences in their degree of behavioural change from light to dark. The present study, therefore, aims to  examine if an increase of motivation to explore in the safety of the dark, not only affects mean levels of boldness, but also the variation between individuals, as a result of differences  in individual plasticity.  Results: Boldness was consistent between a novel-object and a novel-environment situation in bright light. However, no consistency in boldness was noted between a bright (risky) and a  dark (safe) novel environment. Furthermore, there was a negative association between boldness and the degree of change across novel environments, with shier individuals  exhibiting greater behavioural plasticity.  Conclusions: This study highlights that individual plasticity can vary with personality. In  addition, the effect of light suggests that variation in boldness is situation specific. Finally,  there appears to be a trade-off between personality and individual plasticity with shy but  plastic individuals minimizing costs when perceiving risk and bold but stable individuals  consistently maximizing rewards, which can be maladaptive.

Using protocols in ICU practice. Engaging the staff.

Aims/Purpose: Protocols are evidenced-based structured guides for directing care to achieve improvements. But translating that evidence into practice is a major challenge. It is not acceptable to simply introduce the protocol and expect it to be adopted and lead to change in practice. Implementation requires effective leadership and management. This presentation describes a strategy for implementation that should promote successful adoption and lead to practice change.
Presentation description: There are many social and behavioural change models to assist and guide practice change. Choosing a model to guide implementation is important for providing a framework for action. The change process requires careful thought, from the protocol itself to the policies and politics within the ICU. In this presentation, I discuss a useful pragmatic guide called the 6SQUID (6 Steps in QUality Intervention Development). This was initially designed for public health interventions, but the model has wider applicability and has similarities with other change process models. Steps requiring consideration include examining the purpose and the need for change; the staff that will be affected and the impact on their workload; and the evidence base supporting the protocol. Subsequent steps in the process that the ICU manager should consider are the change mechanism (widespread multi-disciplinary consultation; adapting the protocol to the local ICU); and identifying how to deliver the change mechanism (educational workshops and preparing staff for the changes are imperative). Recognising the barriers to implementation and change and addressing these locally is also important. Once the protocol has been implemented, there is generally a learning curve before it becomes embedded in practice. Audit and feedback on adherence are useful strategies to monitor and sustain the changes.
Conclusion: Managing change successfully will promote a positive experience for staff. In turn, this will encourage a culture of enthusiasm for translating evidence into practice.

Islands of pain in a sea of change: Behaviour analysis and bereavement,

The paper Bereavement: A behavioural process (Dillenburger & Keenan, 1994) was first published within a vacuum of behaviour analytic thinking or research in this field. The paper was meant to be a first step in stimulating others to contribute to the understanding of one of the most complex, yet most universal, human behavioural processes. The only behaviour analyst addressing the issues directly was Calkin (1990). Recently, after reading our original 1994 paper, Beth Sulzer-Azaroff suggested that we should solicit comments directly from the behaviour analytic community. This we did with the help of Erik Arntzen and now the reprint and the commentaries in this edition of the European Journal of Behaviour Analysis (EJBA) fully embrace and extend the contribution of behaviour analysis to the understanding of the behavioural process that is bereavement.

Behavioural and psychological syndromes in Alzheimer's disease

The origins of behavioural and psychological symptoms of dementia are still poorly understood. By focusing on piecemeal behaviours as opposed to more robust syndrome change valid biological correlates may be overlooked. Our understanding of BPSD via the identification of neuropsychiatric syndromes.

Behavioural consequences of imagining intergroup contact with stigmatized outgroups

We investigated whether imagining contact with an outgroup member would change intergroup behaviour. Participants who had imagined a positive interaction with an outgroup member or an unspecified stranger were told that they were about to take part in a discussion task with an outgroup member. They were taken to a room and asked to set out two chairs ready for the discussion while the experimenter left, ostensibly to find the other participant. The distance between the two chairs was then measured. Undergraduate students who imagined talking to an obese individual (Experiment 1) or a Muslim individual (Experiment 2) placed the chairs significantly closer than those in the control condition. They also reported more positive feelings and beliefs regarding Muslims. These findings highlight an important practical application of imagined contact: preparing people for successful face-to-face contact.

An Investigation into the Effects of Organisational Change on Occupational Stress in Further Education Lecturers

The aim of this study is to investigate the stress experienced by full-time
maingrade lecturers as a result of changes in college organisation and factors that relate to stress. A questionnaire was constructed to identify possible sources of stress at work and the amount of stress experienced. Two psychometric measures were included—the General Health Questionnaire and the Maslach Burnout Inventory. The former looked at the physiological and psychological effects of stress and the latter, the emotive, cognitive and
behavioural effects, together referred to as 'burnout'. The study sought to investigate stress responses between lecturers employed in colleges that have undergone organisational change compared to those that have not. Two hundred questionnaires and psychometric measures were distributed, by opportunity, to 100 lecturers employed in FE colleges in the north of England and 100 employed in colleges in Northern Ireland. Colleges in the former region had undergone changes in college organisation as a result of incorporation. Colleges in the
latter had not. Incorporation referred to the process whereby colleges became independent of local government control. This led to a series of changes, some of which affected lecturers' terms and conditions. Overall, the indices of reported stress were comparable or markedly greater than earlier research findings, and the trend was for lecturers who had experienced organisational change to report higher measures of stress. GHQ measures showed a significant difference between samples, with the majority of the English sample (69.49%, compared to 40.91%) categorised as 'at risk' of developing symptoms associated with a
transient stress-related disorder, and whilst measures of 'burnout' were more pronounced in the English sample there were no significant differences between samples. In relation to a number of factors, the experience of stress and burnout was more pronounced in the Northern Ireland sample and explanations were offered, such as the influence of cultural variables and the increasing presence of stress-related features in these colleges as they move to incorporation.

Behavioural context of multi-scale species distribution models assessed by radio-tracking

Incorporating ecological processes and animal behaviour into Species Distribution Models (SDMs) is difficult. In species with a central resting or breeding place, there can be conflict between the environmental requirements of the 'central place' and foraging habitat. We apply a multi-scale SDM to examine habitat trade-offs between the central place, roost sites, and foraging habitat in . Myotis nattereri. We validate these derived associations using habitat selection from behavioural observations of radio-tracked bats. A Generalised Linear Model (GLM) of roost occurrence using land cover variables with mixed spatial scales indicated roost occurrence was positively associated with woodland on a fine scale and pasture on a broad scale. Habitat selection of radio-tracked bats mirrored the SDM with bats selecting for woodland in the immediate vicinity of individual roosts but avoiding this habitat in foraging areas, whilst pasture was significantly positively selected for in foraging areas. Using habitat selection derived from radio-tracking enables a multi-scale SDM to be interpreted in a behavioural context. We suggest that the multi-scale SDM of . M. nattereri describes a trade-off between the central place and foraging habitat. Multi-scale methods provide a greater understanding of the ecological processes which determine where species occur and allow integration of behavioural processes into SDMs. The findings have implications when assessing the resource use of a species at a single point in time. Doing so could lead to misinterpretation of habitat requirements as these can change within a short time period depending on specific behaviour, particularly if detectability changes depending on behaviour. © 2011 Gesellschaft für ökologie.