Change implementers’ resistance : considering power and resistance in IT implementation projects

Resistance is normally characterized as a set of behaviours located in and belonging to change recipients. Such behaviours are seen to thwart the legitimate aims of both change strategists and the change agents who implement systems and the associated organisational change on the strategists' behalf. However, results from our case study research indicate that resistance can be a property not only of change recipients’ behaviour, but also of change agents and change strategists. The resistance behaviours identified included the failure to follow a prescribed corporate method and template, a refusal to help or listen, a refusal to fix known problems, the display of an adversarial, confrontational, and/or condescending attitude, subversiveness, a poor work ethic, and a refusal to meet requests. This paper argues for a revised conceptualization of resistance as a behaviour that can be demonstrated by any IT project stakeholders, that cannot be divorced from considerations of power in the IT project context.

The impact of the quality of behaviour support plans on the use of restraint and seclusion in disability services

Background: Behaviour support plan (BSP) quality is known to be an important aspect of the support provided to people with disability who show challenging behaviours and has been found to lead to reductions in challenging behaviour. Preliminary evidence suggests that quality of plans is associated with reductions in the use of restraint
and seclusion.
Method and materials: Quality of a sample of behaviour support plans was assessed using the Behaviour Support Plan – Quality Evaluation II (BSP-QE II) Guide (Browning Wright, Saren & Mayer, 2003). Episodes of restraint and seclusion before and during implementation of plans were examined by comparing restraint and seclusion use between individuals with high quality versus low quality plans.
Results: Compared to individuals with low quality plans, individuals with high quality plans were found to be subjected to less restraint and seclusion over time, while those with low quality plans were subjected to increases. With the exception of one quality component, all components in high quality plans were found to be associated with decreases in restraint and seclusion use.
Conclusions: The results support earlier preliminary findings that quality of behaviour support plans are associated with reductions in restrictive intervention use. The findings are important because they suggest that increasing quality of behaviour support plans may lead to decreases in restraint and seclusion over time.

Multilevel analysis of the Be Active Eat Well intervention : environmental and behavioural influences on reductions in child obesity risk

Background: The Be Active Eat Well (BAEW) community-based child obesity prevention intervention was successful in modestly reducing unhealthy weight gain in primary school children using a multi-strategy and multi-setting approach.

Objective: To (1) examine the relationship between changes in obesity-related individual, household and school factors and changes in standardised child body mass index (zBMI), and (2) determine if the BAEW intervention moderated these effects.

Methods: The longitudinal relationships between changes in individual, household and school variables and changes in zBMI were explored using multilevel modelling, with measurement time (baseline and follow-up) at level 1, individual (behaviours, n=1812) at level 2 and households (n=1318) and schools (n=18) as higher levels (environments). The effect of the intervention was tested while controlling for child age, gender and maternal education level.

Results: This study confirmed that the BAEW intervention lowered child zBMI compared with the comparison group (−0.085 units, P=0.03). The variation between household environments was found to be a large contributor to the percentage of unexplained change in child zBMI (59%), compared with contributions from the individual (23%) and school levels (1%). Across both groups, screen time (P=0.03), sweet drink consumption (P=0.03) and lack of household rules for television (TV) viewing (P=0.05) were associated with increased zBMI, whereas there was a non-significant association with the frequency the TV was on during evening meals (P=0.07). The moderating effect of the intervention was only evident for the relationship between the frequency of TV on during meals and zBMI, however, this effect was modest (P=0.04).

Conclusions: The development of childhood obesity involves multi-factorial and multi-level influences, some of which are amenable to change. Obesity prevention strategies should not only target individual behaviours but also the household environment and family practices. Although zBMI changes were modest, these findings are encouraging as small reductions can have population level impacts on childhood obesity levels.

Treatment acceptability and psychosocial outcomes of a randomised controlled trial of a cognitive behavioural lifestyle intervention for overweight and obese adolescents

This study explores the impact of a cognitive behavioural lifestyle program, the CHOOSE HEALTH Program, on psychosocial wellbeing in overweight and obese adolescents. The sample comprised 29 male and 34 female adolescents aged 11.5 to 18.9 years (M = 14.3, SD = 1.9) and classified as overweight (n = 15) or obese (n=48). Participantswere randomly allocated to treatment or wait-list control conditions; participants allocated the wait-list condition were offered treatment after 6 months. Adolescents and parents completed self-report measures of psychopathology, psychosocial and family functioning. Treatment did not have detrimental effects on the psychosocial factors assessed. It resulted in significant improvements in weight control behaviour, impulse regulation, social support from family and parent–adolescent problem communication (p<.05). Similar results were obtained with completer and intention-to-treat analyses. Treatment acceptability was high, with all respondents indicating that they made progress. Combined, results indicate that treatment did not have detrimental effects on psychopathology, psychosocial functioning, or family functioning. Treatment resulted in significant improvements in impulse regulation, social support from family and parent–adolescent communication. Thus, parents and professionals can be assured that a comprehensive, multifaceted, parent-supported, cognitive behavioural intervention for overweight and obese adolescents does not cause psychological harm.

Evaluation of an alcohol intervention training program for nurses in rural Australia

Aim: This paper reports on the development, implementation and evaluation of the Alcohol Intervention Training Program (AITP) designed to enhance nurses’ capacity to work with farming men and women who misuse alcohol.

Background: In rural and regional areas where alcohol-related behaviours and problems are relatively elevated, nurses may be the key health professionals dealing with individuals who misuse alcohol. However, they are often ill-equipped to do this, have low confidence in their ability to do so, and perceive numerous barriers. Training is required for these nurses.

Methods: We developed the AITP to enhance nurses’ capacity to work with people with alcohol-related problems. The data were collected during 2010. An intervention group of 15 rural nurses completed the AITP. Nurses’ perceived barriers, attitudes, and perceived performance in working with clients with alcohol problems, and the frequency of engaging with this client group were evaluated. Scores on these measures were compared to those of a control group of 17 nurses’ pre-treatment, post-treatment and at 3-month follow-up.

Results: Participation in the AITP resulted in initial improvements in attitudes to working with alcohol problems, but no change in perceived barriers to doing so. The level of engagement with clients having alcohol-related problems increased, as did perceptions of work performance.

Conclusion: The AITP enhances the ability of rural nurses to address the alcohol and associated health issues of clients in rural and regional areas. However, the program needs refinement and further evaluation.

Using the theory of planned behaviour and implementation intentions to predict and facilitate upward family communication about mammography

Regular mammography facilitates early detection of breast cancer, and thus increases the chances of survival from this disease. Daughter-initiated (i.e. upward) communication about mammography within mother–daughter dyads may promote mammography to women of screening age. The current study examined this communication behaviour within the context of the Theory of Planned Behaviour (TPB), and aimed to bridge the intention-behaviour gap by trialling an implementation intention (II) intervention that aimed to facilitate upward family communication about mammography. Young women aged 18–39 (N = 116) were assigned to either a control or experimental condition, and the latter group formed IIs about initiating a conversation with an older female family member about mammography. Overall, those who formed IIs were more likely to engage in the target communication behaviour, however the intervention was most effective for those who reported low levels of intention at baseline. Perceived behavioural control emerged as the most important variable in predicting the target behaviour. The altruistic nature of this behaviour, and the fact that it is not wholly under volitional control, may have contributed to this finding. Future studies that systematically explore the relative roles of intention and perceived behavioural control in behaviours of this nature are warranted.

A therapist‐assisted internet‐based CBT intervention for posttraumatic stress disorder : preliminary results

Posttraumatic stress disorder (PTSD) is a debilitating mental health condition frequently associated with psychiatric comorbidity and diminished quality of life, and it typically follows a chronic, often lifelong, course. Previous research has shown that trauma‐related psychopathology (but not necessarily clinical PTSD) can be effectively treated via the Internet. This study is the first of its kind to report on the online treatment of patients with a Diagnostic and Statistical Manual of Mental Disorders (fourth edition) clinical diagnosis of PTSD with therapist support by e‐mail only. Preliminary findings are presented of an open trial involving a 10‐week Internet‐based therapist‐assisted cognitive behavioural treatment for PTSD (PTSD Online). Pre and posttreatment measures of PTSD and related symptomatology were compared for 16 participants with a variety of trauma experiences. Participants showed clinically significant reductions in PTSD severity and symptomatology, moderate tolerance of the program content, and high therapeutic alliance ratings. No significant change was found on measures of more general psychological symptoms. The results suggest that PTSD Online appears to be an effective and accessible clinical treatment for people with a confirmed PTSD diagnosis.

A cluster randomised trial of an internet-based intervention program for tinnitus distress in an industrial setting

The effectiveness of a therapist-supported Internet intervention program for tinnitus distress in an industrial setting was evaluated using a cluster randomised design. Fifty-six Australian employees of two industrial organisations were randomly assigned, based on their work site (18 work sites from BP Australia and five from BHP Billiton), to either a cognitive behavioural therapy (CBT) program or an information-only control program. Participants were assessed at pre- and postprogram, measuring tinnitus distress, depression, anxiety, stress, quality of life, and occupational health. The CBT program was not found to be superior to the information program for treating tinnitus distress. A high attrition rate and small sample size limit the generalisability of the findings, and further developments of the program and assessment process are needed to enhance engagement and compliance.

Introducing mental health and substance use screening into a community-based health service in Australia : usefulness and implications for service change

Mental health issues such as depression or anxiety and alcohol or other drug (AOD) problems often remain undiagnosed and untreated despite their prevalence in the community. This paper reports on the implementation and evaluation of an AOD and depression/anxiety screening programme within two Community Health Services (CHS) in Australia. Study 1 examined results from 5 weeks of screening (March–April 2008) using the Patient Health Questionnaire (two- and nine-item, Kroenke et al. 2001, 2003), the Conjoint Screen for Alcohol and other Drug Problems (Brown et al. 2001) and the Alcohol, Smoking and Substance Involvement Screening Test (Humeniuk & Ali 2006). Of the 55 clients screened, 33% were at risk of depression or anxiety, 22% reporting moderate-severe depression. Thirteen per cent were at risk of substance use disorders. A substantial proportion of at-risk clients were not currently accessing help for these issues from the CHS and therefore screening can facilitate identification and treatment referral. However, the majority of eligible clients were not screened, limiting screening reach. A second study evaluated the screening implementation from a process perspective via thematic analysis of focus group data from six managers and 14 intake/assessment workers (April 2008). This showed that when screening occurred, it facilitated opportunities for education and intervention with at-risk clients, although cultural mores, privacy concerns and shame/stigma could affect accuracy of screen scores at times. Importantly, the evaluation revealed that most decisions not to screen were made by workers, not by clients. Reasons for non-screening related to worker discomfort in asking sensitive questions and/or managing client distress, and a reluctance to spend long periods of time screening in time-pressured environments. The evaluation suggested that these problems could be resolved by splitting screening responsibilities, enhancing worker training and expanding follow-up screening. Findings will inform any community-based health system considering introducing screening.

Primary prevention of gestational diabetes for women who are overweight and obese : a randomised controlled trial

Background: Gestational Diabetes Mellitus (GDM) has well recognised adverse health implications for the  mother and her newborn that are both short and long term. Obesity is a significant risk factor for developing GDM and the prevalence of obesity is increasing globally. It is a matter of public health importance that clinicians have evidence based strategies to inform practice and currently there is insufficient evidence regarding the impact of dietary and lifestyle interventions on improving maternal and newborn outcomes. The primary aim of this study is to measure the impact of a telephone based intervention that promotes positive lifestyle modifications on the incidence of GDM. Secondary aims include: the impact on gestational weight gain; large for gestational age babies; differences in blood glucose levels taken at the Oral Glucose Tolerance Test (OGTT) and selected factors relating to self-efficacy and psychological wellbeing. 

Indigenous knowledge and climate change : the Wathaurong and Gadubanud narrative for the Great Ocean Road region

For more than forty thousand years Aboriginal people of Australia have been confronted with major climate, ecological and geological changes as well as annual seasonal variations. Many of these changes have been captured in the cultural traditions of Maar (the people) of the south-west Victorian coast and the knowledge has been transferred from generation to generation through Dreaming stories. Many Dreaming stories recount the forming of the coastal landscape and Sea Country. Weather patterns and climate change were gauged by the occurrence of natural events such as the tidal changes, sea level rise, landscape changes, behaviour of animals, and the availability of food sources. Can this ancient knowledge provide answers for adaptation and resilience to a rapid changing climate? Drawing upon recent literature on coastal climate change in the Great Ocean Road Region (GORCC, 2012), literature review of indigenous environmental planning (Kooyang Sea Country Plan, 2004), and investigation of settlement patterns of the Wathaurong and Gadubanud people, this paper reviews the changes in the landscape due to climate change and explores traditional knowledge as input to a potential design based adaptation model for coastal settlements of the Great Ocean Road Region.

Can a motivational intervention overcome an unsupportive environment for walking : findings from the step-by-step study

Background : Interventions to promote walking have rarely examined how their effects varied by the attributes of the physical environment.

Purpose : The purpose of this study is to examine whether perceptions of environmental walkability predicted change in walking behavior following an individual-based intervention to promote walking and whether the intervention buffered the effects of unsupportive environment for walking.

Methods : Inactive adults (aged 30–65 years, 85% women) who completed a 3-month randomized control trial comparing the effect of a single mail-out of a theoretically based self-help walking program (WP, n = 102); the same program plus a pedometer (WPP, n = 105); and a “no-treatment” control group (C, n = 107). Measures included change in self-reported walking time for all purposes and in the proportion of people reporting regular walking (i.e., ≥150 min/week and ≥5 sessions/wk). Perceptions of environmental esthetics, safety from crime, proximity to destinations, access to walking facilities, traffic, streetlights, connectivity, and hilliness were assessed at baseline and dichotomized into “low” or “high” by the median score. Covariates were social support, self-efficacy, intention to change behavior, and sociodemographic characteristics.

Results : Adjusting for baseline walking, significant covariates, and study groups, walking time at follow-up was lower if streetlights or esthetics were perceived to be “low” (−24% and −22%, respectively) compared with “high” (p < 0.05). In “low” esthetic conditions, those in the WPP were significantly more likely than controls to increase total walking time (Exp (b) = 2.53, p < 0.01) and to undertake regular walking (OR = 5.85, 95% CI 2.60–12.2), whereas in esthetically pleasing environments, the between-group differences were nonsignificant.

Conclusions : Walkability attributes can influence individual-based walking programs. Some environmental barriers for walking can be overcome by motivational aids.

Steps in the design, development and formative evaluation of obesity prevention-related behavior change trials

Obesity prevention interventions through dietary and physical activity change have generally not been effective. Limitations on possible program effectiveness are herein identified at every step in the mediating variable model, a generic conceptual framework for understanding how interventions may promote behavior change. To minimize these problems, and thereby enhance likely intervention effectiveness, four sequential types of formative studies are proposed: targeted behavior validation, targeted mediator validation, intervention procedure validation, and pilot feasibility intervention. Implementing these studies would establish the relationships at each step in the mediating variable model, thereby maximizing the likelihood that an intervention would work and its effects would be detected. Building consensus among researchers, funding agencies, and journal editors on distinct intervention development studies should avoid identified limitations and move the field forward.