Table 3.

Operationalizing a multi-component implementation strategy for improving depression screening and treatment in CHD patients. Included are behavioral change techniques (BCTs), intervention functions, COM-B constructs, delivery mode, and implementation science (IS) outcomes.

Actor	BCTs	Intervention function	COM-B constructs					Tactics	Delivery Mode DOSE IS targeted outcome	Adapted delivery mode (e.g., due to COVID19)
			PC	SO	PO	RM	AM
System/Provider	Demonstration of the behavior: provide an observable sample of the performance of the behavior, directly in person or indirectly, e.g., via film, pictures, for the person to aspire to or imitate (includes modeling)	Training, Modeling	X	X	X	X	X	Provide content, e.g., clinical case/pictures demonstrating staff/provider screening, ordering and referral, showing an example of an ideal note	Grand Rounds ONCE AND ON-DEMAND Acceptability	Onboarding video delivered via clinic director or team member in newsletter or email with or without virtual presentation
	Instruction on how to perform a behavior: advise or agree on how to perform the behavior (includes skills training)	Training	X		X		X	Educational content (e.g., tutorial, step-by-step checklist, how-to infographic) about ordering/referring depression screening and treatment Demonstrate to provider how to broach issue of managing stress/depression with CHD patients	Grand Grounds ONCE AND ON-DEMAND Acceptability, fidelity	Onboarding video delivered via clinic director or team member in newsletter or email with or without virtual presentation
	Feedback on behavior: monitor and provide informative or evaluative feedback on performance of the behavior (e.g., form, frequency, duration, intensity)	Training Education Persuasion Incentivization	X		X	X	X	Feedback to providers on rates of screening, appropriate referrals	EHR dashboards; Align with Accountable Care Organization reports QUARTERLY TO ANNUALLY Acceptability, fidelity, feasibility, sustainability	Email notifications to providers; during virtual meetings with physical/mental health providers
	Adding objects to the environment: add objects to the environment in order to facilitate performance of the behavior	Environmental restructuring Enablement	X	X	X		X	Add iHeart DepCare eSDM tool elicited summary report of patient preferences and treatment recommendations	Summary Report of eSDM tool via email notification ONCE/PATIENT Acceptability, usability, fidelity	Summary report via email and Epic inbox/messaging
	Prompts and cues: introduce or define environmental or social stimulus with the purpose of prompting or cuing the behavior. The prompt or cue would normally occur at the time or place of performance	Environmental restructuring Education	X	X	X	X	X	- Enable point-of-care screening and referral reminder in EHR; enable automatic referral support when patient screens positive eSDM tool elicited summary report/decisional support to cue referral and treatment by cardiac and mental health providers	EHR prompt; Summary Report of iHeart DepCare eSDM tool via email notification ONCE/PATIENT Acceptability, fidelity, adoption, feasibility, sustainability	Summary report via email and Epic inbox/messaging
	Restructuring the physical environment: Change or advise to change the physical environment in order to facilitate performance of the wanted behavior or create barriers to the unwanted behavior (other than prompts/cue, rewards and punishments)	Environmental restructuring Enablement	X	X	X		X	Enable prompts, ordersets to facilitate/guide treatment by providers	EHR ONCE Acceptability, usability, fidelity	Epic smartphrase
	Problem solving: Analyze, or prompt the person to analyze, factors influencing the behavior and generate or select strategies that include overcoming barriers and/or increasing facilitators	Enablement	X	X	X		X	Review screening, referrals, initiation and barriers to implementation to brainstorm areas of improvement	In-person meetings among implementation team/researchers QUARTERLY TO ANNUALLY Fidelity, sustainability, feasibility	Virtual meetings to include physical/mental health providers and align with existing learning health collaborative to problem solve clinic-level concerns (screening quality, implementation, wait times, etc); Email notifications to providers
	Review behavior goal(s): review behavior goals jointly with the person and consider modifying goals or behavior change strategy considering achievement. This may lead to re-setting the same goal, a small change in that goal or setting a new goal instead of (or in addition to) the first, or no change	Enablement	X	X	X		X	Review screening and referral implementation, brainstorm areas of improvement	In-person meetings among implementation team/researchers; EHR dashboard QUARTERLY Fidelity, sustainability	Virtual meetings with physical/mental health providers; email notifications
	Salience of consequences: Use methods specifically designed to emphasize the consequences of performing the behavior with the aim of making them more memorable	Enablement Persuasion	X	X	X	X	X	Educational content (e.g., utorial, talking points) to address consequences of performing the behavior (focus on improvement of CVD if stress/emotional health addressed, discuss shocking rates of depression in CHD patients)	Grand Rounds ONCE AND ON-DEMAND Acceptability, fidelity	Onboarding video delivered via clinic director or team member in newsletter/email with or without virtual presentation
	Information about social and environmental consequences: provide info (written, verbal, visual) about social and environmental consequences of performing the behavior	Education Persuasion	X			X	X	Educational content (e.g., tutorial) about social and environmental effects of performing screening and referral (e.g., improving patient satisfaction and relationships)	Grand Rounds ONCE AND ON-DEMAND Acceptability, fidelity, adoption	Onboarding video delivered via clinic director or team member in newsletter/email with or without virtual presentation
	Information about health consequences: provide information (e.g. written, verbal, visual) about health consequences of performing the behavior	Education Persuasion	X			X	X	Educational content (e.g., video tutorial, testimonials) about health consequences of performing screening and referral among patient population (e.g., reducing risk of future heart attack)	Grand Rounds ONCE AND ON-DEMAND GRAND ROUNDS Acceptability, fidelity	Onboarding video delivered via clinic director or team member in newsletter/email with or without virtual presentation
	Credible source: present verbal or visual communication from a credible source in favor of or against the behavior	Persuasion	X			X		Present statements by high-status professionals (e.g., clinic director) and patients themselves to emphasize the importance of screening and referral to increase the well-being of the patient population	Grand rounds ONCE AND ON-DEMAND Acceptability, fidelity, feasibility, adoption	Onboarding video delivered via clinic director or team member in virtual newsletter/email with or without virtual presentation
	Verbal persuasion about capability: Tell the person that they can successfully perform the wanted behavior, arguing against self-doubts and asserting that they can and will succeed	Persuasion Enablement	X	X	X	X	X	Educational content (e.g., tutorial, testimonials) to tell provider that they can successfully conduct the referral and thereby improve the care of their cardiac patients	Grand rounds ONCE AND ON-DEMAND Acceptability, fidelity	Onboarding video delivered via clinic director or team member in virtual newsletter/email with or without virtual presentation
Patient	Demonstration of the behavior: provide an observable sample of the performance of the behavior, directly in person or indirectly, e.g., via film, pictures, for the person to aspire to or imitate (includes modeling)	Training Modeling	X	X	X	X	X	Multilingual content, e.g., Animation, with diverse patients (including minorities) modeling engagement, talking to doctor/provider, going to treatment	iPad-delivered web-based application in waiting room ONCE, ON DEMAND Acceptability, feasibility	Multi-modal web-based application (via e.g., phone, tablet, computer); printed materials (waiting room, home/mailer)
	Instruction on how to perform a behavior: advise or agree on how to perform the behavior (includes skills training)	Training	X		X		X	Multilingual educational content to promote patient activation (e.g., video tutorial, step-by-step checklist, how-to infographic) to manage conversation with provider about screening and referral, going to treatment, accessing/navigating preferred resources	iPad-delivered web-based application in waiting room ONCE, ON DEMAND Acceptability, feasibility
	Adding objects to the environment: add objects to the environment to facilitate performance of the behavior	Environmental restructuring Enablement	X	X	X		X	Add eSDM tool to the screening/referral process that provide multilingual information for patient activation, psychoeducation, and referral with flexible modality, and self-assessment prior to appointment with provider, including reminder to talk to provider	iPad-delivered web-based application in waiting room ONCE, ON DEMAND Acceptability, usability, fidelity	Web-based application (via e.g., phone, tablet, computer); printed materials (waiting room, home/mailer)
	Prompts and cues: introduce or define environmental or social stimulus with the purpose of prompting or cuing the behavior. The prompt or cue would normally occur at the time or place of performance	Environmental restructuring Education	X	X	X	X	X	eSDM acts to remind patient of importance of depression screening and treatment, talking to provider, appointment reminder (multiple language choices)	iPad-delivered web-based application in waiting room ONCE, ON DEMAND Acceptability, usability, fidelity, adoption	Web-based application (via e.g., phone, tablet, computer); printed materials (waiting room, home/mailer)
	Restructuring the physical environment: change or advise to change the physical environment to facilitate performance of the wanted behavior or create barriers to the unwanted behavior (other than prompts/cue, rewards and punishments)	Environmental restructuring Enablement	X	X	X		X	Provide internet-, community, home-based treatment options to restructure the mental health environment and supplement healthcare system environment	iPad-delivered web-based application in waiting room ONCE, ON DEMAND Acceptability, sustainability, adoption	Web-based application (via e.g., phone, tablet, computer); printed materials (waiting room, home/mailer)
	Information about social and environmental consequences: provide info (written, verbal, visual) about social and environmental consequences of performing the behavior	Education Persuasion	X			X	X	Provide multilingual information to about social and environmental consequences, e.g., inform patient that the treatment may impact/improve social relationships	iPad-delivered web-based application in waiting room ONCE, ON DEMAND Acceptability	Web-based application (via e.g., phone, tablet, computer); printed materials (waiting room, home/mailer)
	Information about emotional consequences: Provide information (e.g., written, verbal, visual) about emotional consequences of performing the behavior	Persuasion	X			X		Provide multilingual information to about social and environmental consequences, e.g., explain that depression treatment increases well-being and life satisfaction	iPad-delivered web-based application in waiting room ONCE, ON DEMAND Acceptability	Web-based application (via e.g., phone, tablet, computer); printed materials (waiting room, home/mailer)
	Information about health consequences: provide information (e.g., written, verbal, visual) about health consequences of performing the behavior	Education Persuasion	X			X	X	Provide multilingual information to about health consequences, e.g., explain treatment may improve heart health	iPad-delivered web-based application in waiting room ONCE, ON DEMAND Acceptability	Web-based application (via e.g., phone, tablet, computer); printed materials (waiting room, home/mailer)
	Credible source: present verbal or visual communication from a credible source in favor of or against the behavior	Persuasion	X			X		Provide content, e.g., physician video, to emphasize the importance and positive impact of depression treatment	iPad-delivered web-based application in waiting room ONCE, ON DEMAND Acceptability
	Verbal persuasion about capability: Tell the person that they can successfully perform the wanted behavior, arguing against self-doubts and asserting that they can and will succeed	Persuasion Enablement	X	X	X	X	X	Provide content, e.g., animation and provider video, that the patient can successfully reduce their risk of a future heart attack if their depression gets treated	iPad-delivered web-based application in waiting room ONCE, ON DEMAND Acceptability	Web-based application (via e.g., phone, tablet, computer); printed materials (waiting room, home/mailer)
	Framing/reframing: Suggest the deliberate adoption of a perspective or new perspective on behavior (e.g., its purpose) in order to change cognitions or emotions about performing the behavior (includes ‘Cognitive structuring’)	Enablement Persuasion	X	X	X	X	X	Provide multilingual content, e.g., video, infographic, suggesting that the patient might think of, e.g., the task of depression screening and treatment as reducing the risk of another heart attack rather than mental health treatment	iPad-delivered web-based application in waiting room ONCE, ON DEMAND Acceptability	Web-based application (via e.g., phone, tablet, computer); printed materials (waiting room, home/mailer)
	Social comparison: Draw attention to others’ performance to allow comparison with the person’s own performance	Persuasion	X			X		Provide multilingual content, e.g., animation/provide video to show the patient how patients like them improved their well-being and quality of life after depression treatment	iPad-delivered web-based application in waiting room ONCE, ON DEMAND Acceptability	Web-based application (via e.g., phone, tablet, computer); printed materials (waiting room, home/mailer)
	Salience of consequences: Use methods specifically designed to emphasize the consequences of performing the behavior with the aim of making them more memorable (goes beyond informing about consequences)	Enablement Persuasion	X	X	X	X	X	Provide content, e.g., a provoking animation that demonstrates heart attack and how the patient coped afterward	iPad-delivered web-based application in waiting room ONCE, ON DEMAND Acceptability, Sustainability	Web-based application (via e.g., phone, tablet, computer); printed materials (waiting room, home/mailer)

Abbreviations: Behavior Change Techniques (BCTs), COM-B Capability, Opportunity, Motivation-Behavior; PC: Psychological capability, SO: Social opportunity, PO: Physical opportunity, PO: Physical opportunity, RM: Reflective motivation, AM: Automatic motivation; EHR electronic health record; eSDM electronic shared decision-making tool.