Table 1.

Implementation intervention strategies

Implementation strategy	TDF domain/s [56]	Identified barriers strategy seeks to overcome	Mapped behaviour change techniques [43]	Strategy description
1. Leadership/managerial supervision [65]	• Professional role • Belief about consequences	• Clinician belief that it is not their responsibility to routinely address alcohol consumption during pregnancy. • Clinician and manager belief that there are more important things to do. • Manager belief that they lack support from colleagues to manage staff performance and that staff are resistant to clinical practice change. • Clinician belief that they will not be held accountable if they do not address alcohol consumption. • Clinician belief that their managers do not expect alcohol care to be delivered.	• Social processes of encouragement, pressure and support • Persuasive communication	• Throughout planning and implementation, monthly meetings will be held with management from antenatal services within each of the participating sectors to gather feedback on planned strategies and elicit support. • Antenatal service managers will be asked to distribute key documents/communications to staff and attended all training sessions. • Antenatal service managers will have performance measures related to the model of care added to their operational plans.
2. Local clinical practice guidelines [66]	• Knowledge • Environmental context and resources	• Clinician lack of knowledge of the procedure for addressing alcohol consumption, including referral pathways for women requiring further support. • Clinician feedback that IT systems/forms do not support required care. • Clinician belief that they do not have a clear plan for addressing alcohol consumption during pregnancy and if they have a problem they do not know how to solve it.	• Information regarding behaviour/outcome • Environmental changes • Goal target specified: behaviour or outcome • Contract • Planning and implementation	• A service level guideline and procedure document will detail the required care for addressing alcohol consumption during pregnancy, including assessment, brief advice and referral pathways. • The guidelines and procedure will be uploaded onto the health service’s policy, procedure and guidelines directory and disseminated by service managers to all staff via email and hard copies will be placed in staff common areas.
3. Electronic prompt and reminder system [67]	• Memory, attention and decision processes • Environmental context and resources • Behavioural regulation	• Clinician feedback that they often forget to address alcohol consumption during pregnancy and do not unless the woman expresses it as a priority. • Clinician feedback that IT systems/forms do not support required care. • Clinician feedback that there is a lot to cover in antenatal appointments. • Clinician belief that they do not have a clear plan for addressing alcohol consumption during pregnancy and if they have a problem they do not know how to solve it.	• Environmental changes • Prompts, triggers and cues	• Modifications will be made to existing point-of-care and medical record systems used by maternity clinicians to electronically prompt standardised assessment of alcohol consumption using the validated AUDIT-C alcohol screening tool. Brief advice scripts will be displayed on the point-of-care system based on the woman’s AUDIT-C risk score, as will prompts and tools for referral to appropriate services.
4. Local opinion leaders/ champions [65, 68, 69]	• Social/professional role and identity • Motivation and goals • Social influences	• Clinician belief that it is not their responsibility to routinely address alcohol consumption during pregnancy. • Clinician and manager belief that there are more important things to do. • Clinician belief that other staff do not routinely undertake the model of care and there is no one who can provide support if a problem is encountered. • Manager belief that they lack support from colleagues to manage staff performance and that staff are resistant to clinical practice change.	• Social processes of encouragement, pressure, support • Persuasive communication • Modelling, demonstration of behaviour by others	• Project-specific Clinical Midwife Educators (CMEs) will be appointed to support staff to uptake the model of care and will provide support at a one-on-one, team and service level. The CMEs will be appointed based on their ability to engage and influence staff and model-required behaviours. The role of the CME will be to deliver and monitor each of the implementation support strategies and be responsive to the specific implementation needs of each antenatal service. • Additional local antenatal clinical leaders will be engaged to provide encouragement and demonstration of required behaviours in each antenatal services as required (e.g. for specific professional disciplines).
5. Educational meetings and educational materials [70, 71]	• Knowledge • Skills • Beliefs about capabilities • Beliefs about consequence • Environmental context and resources • Emotion	• Clinician lack of knowledge in the procedure for addressing alcohol consumption, including referral pathways for women requiring further support. • Clinician lack of skill in assessing alcohol consumption during pregnancy using a validated tool and offering referrals to women requiring further support. • Clinician lack of training in addressing alcohol consumption according to guidelines. • Clinician belief that they have limited capability to assess alcohol consumption during pregnancy using a validated tool and offer appropriate referrals. • Manager belief that they have limited capability to competently use performance monitoring tools and reports and have conversations with staff regarding performance. • Clinician belief that pregnant women will react negatively if asked about alcohol consumption and that it will have a negative impact on their client-clinician relationship. • Clinician feedback that they are hesitant to address alcohol due to child protection implications. • Clinician belief that they do not have access to appropriate information resources and there is a lack of support services to refer women to. • Clinician lack of confidence in addressing alcohol consumption in appointment time, when other clinicians are present and when women show lack of interest. • Clinician feedback that they feel nervous and uncomfortable addressing alcohol consumption with women.	• Goal/target specified behaviour or outcome • Increasing skills- through problem solving, decision-making, goal-setting • Rehearsal of relevant skills • Modelling/ demonstration of behaviour by others • Perform behaviour in different settings • Social process of encouragement/ pressure support • Persuasive communication • Information regarding behaviour/ outcome • Coping skills	• Training will be provided to all antenatal service clinicians via a 30-minute online training module and face-to-face sessions. Content will be adapted from the accredited ‘Women Want to Know’ courses [72]. The CME will facilitate clinicians completing the online training and coordinate face-to-face training sessions, which will be rostered into routine clinical meetings and include, lecture style sessions, interactive, case-study based sessions and one-on-one sessions. • Training content will include: − The effects of alcohol consumption during pregnancy and associated health outcomes. − Guideline recommendations for alcohol consumption during pregnancy. − Prevalence of alcohol consumption by pregnant women. − The model of care for addressing alcohol consumption during pregnancy: 1) alcohol consumption assessment; 2) brief advice; and 3) referral for ongoing care. − Effectiveness and acceptability of addressing alcohol consumption during pregnancy in routine antenatal care. − Culturally appropriate practices when addressing alcohol consumption with Aboriginal women. • Clinicians will also be provided with written resources (hardcopy and electronic) to support the model of care, including standard drink measure charts and point-of-care written prompts/reminders (e.g. stickers in charts).
6. Academic detailing, including audit and feedback [45, 73, 74]	• Behavioural Regulation • Skills • Beliefs about consequences • Social Influences	• Clinician belief that they do not have a clear plan for addressing alcohol consumption during pregnancy and if they have a problem they do not know how to solve it. • Clinician lack of skill in addressing alcohol consumption according to guidelines. • Manager belief that additional burden will be placed on clinicians, that staff will react negatively if performance is discussed and that staff will not take on board feedback about performance. • Manager feedback that it is difficult to release clinicians from clinical work to attend training. • Clinician belief that pregnant women do not expect alcohol to be addressed in antenatal appointments.	• Goal/target specified behaviour or outcome • Monitoring • Contract • Planning, implementation • Increasing skills- problem solving, decision-making, goal-setting • Rehearsal of relevant skills • Social process of encouragement/pressure support • Feedback • Persuasive communication • Information regarding behaviour and outcome	• Data from both medical records and telephone surveys conducted with women who attended the antenatal services will be used to provide feedback on levels of care provision for addressing alcohol consumption during pregnancy. • Data will routinely be fed back to antenatal service teams by the CME. The CME will visit service teams in their antenatal clinics to support discussion of the feedback and development of action plans in response to such in order to improve care. • Women’s acceptability of their antenatal service team providing each of the care elements will also be fed back.
7. Monitoring and accountability for the performance of the delivery of healthcare [73]	• Social Influences • Beliefs about capabilities • Environmental context and resources • Memory, attention, decision processes	• Clinician belief that their managers do not expect alcohol care to be delivered. • Manager belief that they have limited capability to competently use performance monitoring tools and reports and have conversations with staff regarding performance. • Manager feedback that they do not have adequate data entered from staff to use for performance measurement, have competing work tasks and do not have the supports/resources to manage performance. • Managers’ feedback that they forget about tools to manage performance and are less likely to manage performance of staff resistant to change. • Manager feedback that it is stressful to manage performance.	• Social processes of encouragement, pressure, support • Environmental changes • Contract • Prompts, triggers, cues • Feedback	• Antenatal service managers will be supported by the CME to report, interpret and monitor performance measures for the model of care for addressing alcohol consumption during pregnancy. The CME will also support these mangers to disseminate these results to their antenatal service staff through team meetings, emails and other usual communication mechanisms. • Performance measures will be built into the existing monitoring and accountability frameworks for antenatal services, including service-level operational plans and performance measures at service manager and team manager level.