Table 5.
Identified barriers and enablers mapped to proposed implementation interventions using the BCW
| COM-B Model* | TDFDomain | Barriers and enablers to improving current PPH detection and management and implementing E-MOTIVE | Intervention Type | Behaviour Change Techniques | Proposed Implementation Interventions |
|---|---|---|---|---|---|
| Capabilities (Physical and Psychological) | Skills | Inconsistent ongoing training on PPH; lacking in some core skills (Barrier) |
Training, Education, Modelling, Enablement |
Demonstration of the behaviour; Instruction on how to perform a behaviour; Behavioural rehearsal/practice; Habit formation; Action planning; Feedback on behaviour; Feedback on outcome of behaviour; Salience of consequences |
- Training to provide core or new skills required to deliver the bundle; for example, using new calibrated drape, administering tranexamic acid by midwives Additional education and training to improve knowledge of PPH detection and management and an understanding of a bundled approach of care (i.e., use all components of the bundle), provide setting specific guidelines - Introduce audit and feedback as a way to monitor bundle uptake and to prompt implementation by providing feedback to staff; set targets |
| Knowledge | Varying understanding of PPH aetiologies including signs and symptoms (Mixed) | ||||
| Behaviour Regulation | Acknowledged missed opportunities to improve current PPH practice (Enabler) | ||||
| Memory, Attention & Decision-making | Visual estimation of blood loss and deciding to use the bundle and to use the bundle as intended (Barrier) | ||||
| Opportunity (Physical and Social) | Environmental Context and Resources |
Varying accessibility of stock of consumables, equipment and drugs (Mixed) More staff is needed to deliver the bundle (Barrier) |
Enablement, Environmental Restructuring, Training, Modelling |
Prompts/Cues; Adding objects to the environment; Credible source; Social support (Practical); Social support (Emotional) |
- Introduce a trolley/kit to organise stock of consumables, equipment and drugs for PPH into one place to reduce time taken to fetch everything; reduce the sense of panic felt by staff by sudden and unpredictable onset of PPH |
| Social Influence | Teamwork is required to deliver the bundle (Barrier) | ||||
| Motivation (Automatic and Reflective) | Beliefs about Capabilities | Relying on subjective estimation of blood loss leading to delayed or inaccurate detection of PPH (Barrier) |
Enablement, Environmental Restructuring, Persuasion, Modelling, Education, Training |
Demonstration of behaviour; Behavioural rehearsal/ practice; Pros and cons; Information on health consequences; Information on emotional consequences; Verbal persuasion to boost self-efficacy; Social support (Practical); Social support (Emotional); Social support (Unspecified) |
- Calibrated drape as a new tool to both prompt and facilitate detection; provide more accurate blood loss - Introduce a bundle champion in a leadership role who can encourage, support and model bundle use; promote collective use of the bundle as a means to motivate staff to adopt new clinical practices or adapt existing practice and to overcome any resistance to change |
| Beliefs about Consequences | Beliefs that quicker and accurate PPH detection can reduce maternal mortality (Enabler)varying confidence in delivering some elements of the bundle (Enabler) | ||||
| Goals | Reducing PPH is important; it is main cause of maternal fatalities (Enabler) | ||||
| Social/Professional Role and Identity | Mixed views on both doctors and midwives or nurses performing some or all parts of the bundle (Mixed) | ||||
| Intention | Potential lack of buy-in to the bundle over existing practice (Barrier) | ||||
| Emotion | Coping with negative feelings of panic and stress from unpredictably of PPH (Barrier) |
*COM-B Model (C=Capability; O=Opportunity; M=Motivation and B=Behaviour) Michie et al. 2011
Other BCW intervention types considered unacceptable included Incentivisation, Coercion and Restriction