Assignment 3 Forum

This has improved a lot Kadia! I really like your two first paragraphs - very convincing!

While I am far from being an expert on the COM-B model, it seems that your capacity and opportunity boxes overlap a lot. Going back to our reading by Michie et al:

"Capability is defined as the individual’s psychological and physical capacity to engage in
the activity concerned. It includes having the necessary knowledge and skills. Motivation is defined as all those brain processes that energize and direct behaviour, not just goals and conscious decision-making. It includes habitual processes, emotional responding, as well as analytical decision-making. Opportunity is defined as all the factors that lie outside the individual that make the behaviour possible or prompt it."

You mention time pressure in both capacity and opportunity, but it seems like it would be more of an opportunity issue. Training seems like it would be more of a capacity issue. Lack of integrated care seems like more of an opportunity issue.

Anyways, better defining these might then allow you to better reflect on whether you want to first focus on capacity building through training, or opportunity building through practice redesign and having your standard instrument be available.

Hi Kadi,

Well done! This has definitely progressed nicely and I think you have made great progress to having a strong argument with evidence supporting your gap and potential intervention. I would encourage you to look at Kevin's DAG to better see how to draw the arrows to show associations between certain variables and the outcome you desire. I think by reorganizing your DAG you will be better able to see how to implement an intervention and where the biggest effect would be. I honestly think the issue regarding mandated reporting might be your biggest barrier. I know in various other organizations such as a school, child care center, church etc. all the personnel dreaded hearing about any sort of ACEs because of this mandated reporting. If there is a way you can brainstorm to have this reporting taken care of by another member in the community such as a social worker or other staff I think that would be something to consider when designing your intervention. Just a thought. Huge improvement overall though for this assignment, try to redo your DAG just to help with clarification. 

Hi Kadiatou,

Great topic. While you explore the physician motivation really well, such as creating incentives, I wonder if there are brief screening tools that could be used to predict whether patients have ACEs. Also, is there a validated tool for screening? For instance, in depression screening, the PHQ-2 is a 2 question questionnaire that is asked of primary care patients at the time of intact, typically by a head assistant. If the patient screens positive, the physician will be notified and they can do a longer survey (PHQ-9). From this decisions about interventions (including referrals) can be made. Similarly, is there a possibility of exploring brief screening tool in this setting? has a brief screening tool been validated in this clinic setting?

It's great to see this coming together!

Asa

Nice analysis and important area.  My question for you, taking a step back, is what is the evidence based practice that is missing and the resulting implementation gap?  Is there a clear intervention that ameliorates ACE?  If there were then the issue of screening and barriers to screening might come into focus a little more. Happy to discuss this more. 

Thanks again for this post - let me elaborate a bit more on my rather terse last message.  So, there is consensus it seems that people feel screening should be done – as expressed through guidelines, and you want to find a way to systematize and standardize this screening.

 This differs from the traditional framing because as far as I can tell there is no intervention that has been shown to reduce bad outcomes from ACE.  But perhaps you could look further into why the guidelines recommend screening.  Perhaps even if there is no treatment for ACE that has happened, there is an opportunity to remove children from settings where that is happening?  On the one hand it is usual to recommend screening unless something can be done about it.  On the other hand this is a problem in which finding interventions will be complicated and take perhaps years, and there might be other actions that can be taken to mitigate the effects of aces – such as screening for early drug use or early sexual debut or risky sexual behavior…

 (I think this also illustrates the challenge that face prevention efforts especially those upstream prevention efforts in general.  It is difficult to identify the effects of interventions even if those interventions are common sense). 

So to be concrete – why don’t you think a little about what you or the community wants clinicians to do with the information.  Let’s say they screen for ACE – what next?  And what is your opinion about what to do next even if it is not evidence based at the moment… Or do you want to gather more practice –based epidemiological data about ACE?  If you can find a way forward with the former it feels more like implementation science, the latter feels less so…

 Hope this is useful and I do think your topic is hugely important.