Closing the evidence-practice gap: developing a behaviour change intervention in post-stroke aphasia management

Abstract

Aphasia is common post-stroke, and has significant negative effects on quality-of-life and functional communication in the long term.  While there are high quality clinical practice guidelines available to guide speech pathologists’ aphasia management practices, there is variation in the services that people with aphasia are offered.  This variation in practice leads to evidence practice gaps in aphasia care.  Evidence-practice gaps can be closed by applying behaviour change interventions to health professionals who deliver care.The overarching objective of this thesis was to investigate speech pathologists’ implementation of clinical practice guideline recommendations in the management of post-stroke aphasia, and design and evaluate a behaviour-change intervention aimed at improving speech pathologists’ practice.  The research in this thesis involved four serial phases, whereby the outcomes of each phase informed the subsequent phase. The aim of Phase I was to identify aphasia recommendations from high quality clinical practice guidelines.  Phase II aimed to prioritise the evidence-practice gaps in aphasia rehabilitation. The aim of Phase III was to describe speech pathologists’ current practice and identify the barriers and facilitators to meeting guideline recommendations in aphasia management. This process identified the theoretical domains that should be targeted by an implementation intervention. Phase IV used a small cluster randomised controlled trial to design, pilot and test an acceptable, feasible, and effective implementation intervention. A secondary aim of Phase IV was to determine whether the implementation intervention was successful in addressing the hypothesised predictors of behaviour.In Phase I, a systematic review was used to identify and evaluate clinical practice guidelines relevant to post-stroke aphasia rehabilitation, and evidence-based recommendations were identified. This was an update of a previous systematic review, and identified and assessed the quality of clinical practice guidelines published since April 2012.  Following the identification of high quality Clinical Practice Guidelines, recommendations relevant to aphasia management were extracted and categorised according to the area of practice (e.g., assessment, treatment).  The identified clinical guideline recommendations were evaluated according to the applicability of the underlying evidence to speech pathology practice, and whether the recommendation could be clearly linked to the underlying evidence. Recommendations from four high-quality clinical practice guidelines relevant to aphasia management were extracted. From these guidelines, 34 evidence-based recommendations were identified.Since 34 recommendations would be difficult to implement by any aphasia service, the targets of implementation efforts needed to be prioritised. In Phase II, a scoping search was used to identify the implementation priorities in post-stroke aphasia.  Seven priority-setting criteria were identified in the implementation literature: strength of the evidence; current evidence-practice gap; clinician preference; client preference; modifiability; measurability; and health impact.  These criteria were applied to the 34 aphasia recommendations categorised into 13 topic areas. Using systematised searches, evidence was identified and extracted for each criterion per topic area. This evidence was extracted and placed in an evidence matrix.  Following this, evidence was summarised, then aphasia rehabilitation topics prioritised using an approach developed by the research team. Four implementation priorities were identified: Timing, Amount and Intensity of Therapy; Goal Setting; Information, Education and Aphasia-friendly information; and Constraint-Induced Language Therapy.To determine the barriers and facilitators to implementing these priorities, semi-structured interviews were conducted with 20 hospital-based speech pathologists in two Australian states in Phase III. The Theoretical Domains Framework was used to categorise their responses. The domains of ‘Environmental Context and Resources’, ‘Beliefs about Consequences’, and ‘Social Influences’ were identified as key influencing factors for all topic areas.  For those speech pathologists working only in inpatient rehabilitation settings, the majority of recommended behaviours were reportedly performed consistently, with few implementation barriers identified. However, for clinicians working in the acute setting, the majority of behaviours were performed inconsistently or rarely. The findings from the study provided a basis for the development of a behaviour-change intervention that could be tailored to address the identified barriers.  Furthermore, the results indicated that an intervention targeting acute clinicians was a priority, due to the reported inconsistencies in their practice and the number of barriers reported.In Phase IV, participants from four speech pathology teams in acute hospitals received an intervention targeted at one of two target behaviours: Information, Education and Aphasia-friendly information; and Collaborative Goal Setting.  The interventions were developed by mapping the known barriers to intervention functions using the Behaviour Change Wheel, and were delivered to teams in a single, face-to-face interactive workshop.  While significant improvements were seen in the two teams that received the Information Provision intervention, there was no significant change in the teams that received the Goal Setting intervention. Factors that may have influenced success included: buy-in from participants, the organisational culture, and the complexity of the behaviour requiring change.  Surveys, used to measure the effect of the interventions in overcoming the barriers, showed a positive change in some but not all of the targeted domains, highlighting the need for sensitive outcome measures in this area and further research into how behaviour change occurs.Overall this study showed that a tailored, theoretically informed implementation intervention was feasible, acceptable and potentially effective in changing speech pathologists’ management of people with aphasia in the acute hospital setting.  However more research is needed into the ‘essential’ components of a successful intervention. In addition, future research needs to include patient-oriented outcome measures to show that implementation efforts can improve outcomes for people with aphasia.