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Table 1 Intervention mapping and operationalising after sorting of barriers and enablers to TDF domains from the dietitians surveyed

From: Using the theoretical domains framework to inform strategies to support dietitians undertaking body composition assessments in routine clinical care

TDF domain n survey question respondents (from 22 dietitians) Survey identified Barriers
(% who reported barrier)
Survey identified
Enablers
(% who reported enablers)
BCW Intervention components
and intervention definition
Behaviour change techniques (BCTs) Potential strategies, operationalised as:
Knowledge 16 Unsure of clinical areas BCA would benefit
54.5% unsure who to use on
50.0% unsure when to do
50.0% unsure what to do
45.5% unsure how to interpret
  Psychological capability
Education
Training
Enablement
Increasing knowledge or understanding:
E.g.
Feedback on the behaviour/ outcome(s) of the behaviour
Self-monitoring of behaviour/ of outcome of behaviour
Prompts/cue
Information about social and environmental consequences
Information about others’ approval
Imparting skills
Reducing barriers to increase capability or opportunity (beyond education, training and environmental restructuring)
E.g.
Social support
Reduce negative emotions
Conserve mental resources
Self-monitoring of behaviour and outcome of behaviour
Graded tasks
Adding objects to the environment
Restructuring the social environment
Focus on past success
Verbal persuasion about capability
Self-reward
Goal setting (behaviour, outcome)
Commitment
Action planning
Review behaviour and outcome goal(s)
Discrepancy between current behaviour and goal
Problem solving
Pros and cons
Monitoring of emotional consequences
Anticipated regret
• PD sessions (KPI: ≥ 3/y, ≥ 15 attendees) (Topics: Body Composition Assessment - overview; Practical on how to assess and interpret BCA; Case Study – diagnosis and follow up; Implementation plan; Sarcopenia)
• Workshops to practice all BCA procedures (KPI:≥ 2/y, ≥ 2 attendees)
• BPI and WAR updating exercise by dietitians: literature review and integrating evidence and procedures into BPIs and WARs
• Information sharing from WARs and BPIs amongst teams in the department
• Clinical champions – 6 month graded WAR adoption project using accountability, peer modelling and influence.
• Set goals on increasing numbers of BCAs in eligible patients in each area
• Feedback in department meeting after 3 months, new goal setting
• Use social support: peer support within streams, clinical champions assisting and upskilling peers, reporting in streams and department meetings, BC team members meeting with individual staff members and helping to get body comp Ax running.
• Discussion and sufficient preparation and support to decrease negative emotions.
• Problem solving: provide resources (lanyards, literature, information folder)
• Monthly meetings including mentoring to allow reflection on wins; set personal goals and rewards; action planning (also provided by 6 month project plan with action planning)
Skills 16 27.3% Don’t know how to use
18.2% Lack of confidence (and enabler)
18.2% Don’t have time to perform
Never use: skinfold 90.9%, BIS 81.8%, handgrip 68.2%, MUAC 68.2%
54.5% unsure who to use on
50.0% unsure when to do
50.0% unsure what to do
45.5% unsure how to interpret
Training and awareness in a variety of areas
Had any training in BCA: 54.5%, mostly in MUAC (40.9%); skinfolds (40.9%%), BIS (22.7%); DXA (4.5%)
The majority of the team are aware that skinfold callipers (68.2%), BIS device (77.3%), handgrip dynamometer (68.2%), and tape measures (68.2%) are available. A smaller number is aware of the existence of a BIS scale (40.9%)
Confident to use skinfold (4.5%), BIS (27.3%), MUAC (63.6%), PG-SGA (77.3%), handgrip (45.5%, tape measure (68.2%)
Reflective motivation (Cognitive/ interpersonal skills)
Education
Persuasion and/or
Incentivisation and/or
Coercion
Physical capability (physical skills)
Training
Enablement
Increasing knowledge or understanding
E.g. as above
Using communication to induce positive or negative feelings or stimulate action
E.g. Feedback on the behaviour/ on the outcome(s) of the behaviour,
Focus on past success,
Verbal persuasion about capability,
Persuasive source
Identity associated with changed behaviour
Identification of self as role model,
Information about social and environmental consequences,
Information about health consequences,
Salience of consequences,
Information about others’ 
Social comparison
Creating expectation of reward
E.g.
Feedback on behaviour or
on the outcome(s) of behaviour,
Self-monitoring of behaviour or outcome of behaviour,
Monitoring of (outcome of) behaviour by others without evidence of feedback,
Situation-specify reward,
Reward incompatible behaviour,
Reduce reward frequency,
Reward alternate behaviour,
Remove punishment,
Social reward,
Self-reward,
Behavioural contract,
Commitment,
Discrepancy between current behaviour and goal
Creating expectation of punishment or cost
As above
As above; incorporate some of the information (in PD or in mentoring) to tap persuasion:
• ‘past’ successes (report on project process – either champion or BC team),
• Goal setting and verbal persuasion about capability in mentoring
Incorporated into project plan and engagement and reporting strategy for and with clinical champions (6 month project)
As above, esp. technical skill development
Social/ professional role and identity 6 18.2% I think these measures are more appropriate for research
18.2% I do not think these measurements are appropriate for my area of work
  Reflective motivation
Education
Persuasion
Incentivisation
Coercion
As ‘Skills’ As above
Beliefs about capabilities 12 27.3% I don’t think I could perform these measures accurately
18.2% I do not have time to perform these measurements
  Reflective motivation
Education
Persuasion
Incentivisation
Coercion
As ‘Skills’ As above, especially how to be accurate
As above, especially workflow practices (decide and discuss as a team/s)
Beliefs about consequences 5 (barriers)
19 (enablers)
13.6% Don’t think these measurements would benefit my practice/tell me anything new/useful
9.0% I do not expect these measurements to change my practice
77.3% Ability to more accurately assess energy requirements
72.3% Ability to provide objective measures/ evaluations of dietetic interventions
68.2% Assist in motivation (i.e. to continue on weight loss journey)
63.6% Would make practice more interesting
54.5% Assist in persuading patients to increase intake/supplements
50.0% Assist in identifying malnutrition
45.5% Would improve my practice
22.7% Leverage for nasogastric tubes
22.7% Leverage for pre-surgical provision of enteral/parenteral nutrition
4.5%With training and time BCAs could become routine
Reflective motivation
Education
Persuasion
Incentivisation
Coercion
As ‘Skills’ As above, especially reflected in the BPIs and WARs – how this may be clinically relevant to measure and monitor; how to make routine; how to monitor; also areas for future research
Goals 16 54.5% unsure who to use on
50.0% unsure when to do
50.0% unsure what to do
45.5% unsure how to interpret
72.2% I would like to learn more about BCA
68.2% I would like to apply measurement of body composition to my practice
4.5%Make results more meaningful in practice
4.5% Applicable in some patient groups
Reflective motivation
Education
Persuasion
Incentivisation
Coercion
As ‘Skills’ As above
Memory, attention and decision processes 16 59.1% Not in my daily routine
40.9% Hassle to find reference ranges
31.8% Too much time to do
22.7% I forget about doing or scheduling a measurement
4.5% Difficulties – practicalities
4.5% Great that we will have support to routinize Psychological capability
Education
Training
Enablement
As ‘Knowledge’ As above, especially eventually formalise a process of documenting, trialling, evaluation in each WAR; also to consider new staff orientation
Environmental context and resources 10
15
31.8% We do not have procedures or forms to report these measurements
54.5% I don’t know how to book these devices
27.3% I don’t know where these devices are kept
18.2% I know where these devices are kept but I don’t know how to get them to the ward
18.2% I don’t have access to the devices I need to perform body composition assessment
4.5% If you can get access to the peapod for routine assessments that would be great Physical opportunity
Restrictions
Environmental restructuring
Using rules to reduce the opportunity to engage in the target behaviour (or to increase the target behaviour by reducing the opportunity to engage in competing behaviours)
Changing the physical or social context
As above
As above, plus purchase of new equipment; process of storing; booking; transporting; cleaning; lanyard ready reckoners
Social influences 13 18.2% My peers do not perform these measurements, so why should I?
4.5% I think they are burdensome to patients
4.5% I feel this would add value to Dietitians and patient care in relevant populations Social opportunity
Restrictions
Persuasion
As above As above
Intentions 18 59.1% Not in my daily routine
31.8% I never think of doing these measurements when I see or evaluate a patient
4.5%I would like to know more about what technology we have available and where it would be applicable.
4.5%I would certainly consider integrating into practice if and where appropriate.
4.5% I would like to add these measurements to my daily routine
Reflective motivation
Education
Persuasion
Incentivisation
Coercion
As ‘Skills’ As above
Emotion 14 27.3% Feel stressed about the time required
9.1% Don’t want to break device
4.5% Keen to get started Automatic motivation
Persuasion
Incentivisation
Coercion
Environmental restructuring
Modelling
Enablement
As above ‘Operationalise and integrate’ into BAU; 6/12 clinical champions project; reported back at teams (EBP & Research Dept meeting) – standing agenda item; future reporting ideas - Audit and feedback (w/ outcomes/positive wins to be shared)
Formalised as “Best BCA adopter” – acknowledged at end of year
Optimism 19 4.5% Unsure if it’ll be burdensome to patients
4.5% Unsure how receptive the patients will be
63.6% Will make practice more interesting
45.5% Would improve my practice
4.5% May increase patients’ motivation to see me to get results
4.5% I am ready – bring it on
Reflective motivation
Education
Persuasion
Incentivisation
Coercion
As ‘Skills’ As above, especially ensure
Monitor and reflect upon benefits (e.g. for next 6 months as extra KPI for reflection – actual measures or ease of measuring outcomes and patient process)
Reinforcement 18 18.2% Nothing that prompts me 63.6% BCA team makes this possible
54.5% More training would prompt me
4.5% Integrate into WARs
Automatic motivation
Persuasion
Incentivisation
Coercion
Environmental restructuring
Modelling
Enablement
As above Ensure prompts are incorporated into standard procedures and documents (i.e. WARs) at end of 6/12 BCA clinical champion project
Behavioural regulation 18 45.5% I would need to change my practice regarding assessing nutritional status
31.8% Would need to change practice
18.2% Happy with the way I assess nutritional status
4.5% Happy to practice if measurements will improve patient care Psychological capability
Education
Training
Enablement
As ‘Knowledge’ BPIs and WARS; especially focussing on Ax of nutritional status
Incorporate into standard processes and procedures – explore and refine with Dept in subsequent PDs and Dept meetings in a planned way
  1. BPI Best Practice Investigation; WAR Work Area Resource; Dept Department; PD professional development; BCA Body Composition Analysis; TDF Theoretical Domains Framework, Ax assessment, DXA Dual X-ray Absorptiometry