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Introduction: Evidence indicates that there are major gaps in pharmaceutical care service provision and limited research on interventions to optimise medication use for patients with vision impairment. The United Kingdom's Medical Research Council (MRC) advocates a systematic approach for the development and evaluation of an intervention. The aim of this research was to develop a novel theory-based intervention to support medicines optimisation for patients with vision impairment. Methods: This research focuses on the development and feasibility testing of the IDC-VI (Intervention for Dispensing and Counselling for the Visually Impaired). Firstly, a systematic review was undertaken to assess the types and effectiveness of interventions provided by pharmacists. Qualitative interview-based research was then conducted with pharmacists and patients/caregivers. The Theoretical Domains Framework (TDF) was utilised as the underlying theoretical lens. Pharmacists' interviews investigated the barriers/facilitators to the provision of medication dispensing and counselling while patients'/caregivers' interviews explored the barriers/facilitators to obtaining and taking medications. Key TDF domains were identified from both sets of interviews. The planned intervention targeted the pharmacists' behaviour, and the key TDF domains from pharmacists' interviews were mapped to behaviour change techniques (BCTs). Finally, BCTs were operationalised into a workable intervention which was then tested in a small feasibility study. Results: The systematic review highlighted the paucity of pharmacist-led interventions. Findings from pharmacists' interviews led to the identification of eight key TDF domains which were linked to eight BCTs. Interviews with patients/caregivers identified six key TDF domains. The eight BCTs formed the IDC-VI. Feasibility testing demonstrated favourable opinions from pharmacists and patients/caregivers but a number of modifications were suggested. Discussion and conclusion: This thesis provides theory-informed insights into the determinants of patients', caregivers', and pharmacists' behaviours. The IDC-VI will require a number of amendments before being tested in a larger pilot trial in preparation for a randomised controlled trial.

Two chapters, including a systematic review chapter and an empirical chapter, followed by a brief reflective appendix. A range of qualitative research methodologies were employed to investigate neonatal pain related clinical practice guidelines in the neonatal intensive care unit. The systematic review provides a content analysis of the specific recommendations provided within existing clinical practice guidelines for the assessment and management of procedural pain in neonates. 20 clinical practice guidelines were included. The systematic review highlighted improvements are required in relation to the vagueness of recommendations and inconsistencies, given that clinical practice guidelines should facilitate the use of evidence in practice. However, translating evidence into practice is a complicated process that requires behavioural change amongst healthcare professionals. It would be important for future research to consider exploring and understanding these barriers further, especially with nursing staff as they are the individuals on the ground implementing recommended practice with neonates in the NICU, day to day. To establish from their perspective what the barriers are and how they believe they could be overcome to inform interventions to change behaviour and improve clinical practice. The second chapter is an empirical study that study adopted the Theoretical Domains Framework (TDF) to explore nurses' knowledge and attitudes of clinical practice guidelines related to neonatal pain assessment and nonpharmacological pain management techniques. Semi-structured interviews were completed with nurses. Twelve of the theoretical domains were identified as relevant to the implementation of clinical practice guidelines. Using the TDF, allowed this study to identify factors that influenced the implementation of neonatal pain assessment and nonpharmacological pain management related clinical practice guidelines. In terms of clinical implications The findings can be used to design theory-drive interventions by targeting specific behaviour change techniques to change the clinical practice of nurses.

Hearing protection behaviour (e.g., use of earplugs) during noisy recreational activities (e.g., concerts, sporting events) to help mitigate against the risk of noise-induced hearing loss and tinnitus is uncommon. Research aimed at understanding and increasing hearing protection behaviour lacks application of health psychology theory, and current literature comparing those who use (ever-performers) and those who do not use hearing protection (never-performers) is limited. The aim of this thesis was to provide an empirical, theory driven, evidence base assessing what needs to change in order to increase uptake, and regular use of hearing protection behaviour within noisy recreational settings, whilst providing content for future interventions. Firstly, a systematic review assessed effectiveness and behavioural content of previous interventions (i.e., behaviour change techniques). Secondly, a cross-sectional survey helped identify potential groups of people and content for interventions by assessing ever- and never-performers' capabilities, opportunities and motivations (COM-B model) to engage with hearing protection. Thirdly, qualitative interview data of ever- and never-performers was mapped to the Theoretical Domains Framework (TDF) to help identify variables necessary for the implementation of interventions to increase hearing protection behaviour (i.e., earplug use). Study 1 found previous interventions had limited effectiveness, and suggested environmental restructuring (adding object to the environment; e.g., provision of earplugs) as a potential starting point for interventions. Study 2 found interventions may benefit from targeting women, older adults, and people in non-manual occupations. Never-performers lacked reflective and automatic motivation compared to ever-performers, suggesting that increased motivation is a requirement of future interventions. Study 3 highlighted 'social influences', 'environmental context and resources', 'beliefs about consequences', 'memory, attention, and decision processes', 'reinforcement' and 'emotion' as priority variables to target in order to increase earplug use during noisy recreational activities. This thesis has compiled the first comprehensive body of empirical evidence derived from theory assessing what needs to change in order to increase uptake, and regular use of hearing protection within noisy recreational settings, whilst providing potential content for intervention development. The evidence generated within this thesis may be valuable to hearing conservationists attempting to increase use and acceptance of hearing protection within adults exposed to recreational noise, and help provide insights into overcoming challenges that hearing conservationists will face.

Background: Pharmacogenomics (PGx) is the use of Deoxyribonucleic Acid (DNA) to predict an individuals' response to a drug. Through the lower cost of DNA sequencing and advances in genomic medicine, PGx testing is a viable and valuable tool in improving medicines optimisation for patients. Over recent years, the role of the community pharmacist in England has evolved from dispensing medicines to delivering increasingly complex pharmacy services. In addition, community pharmacy is accessible and convenient for patients, and therefore potentially an appropriate setting for this testing service. Whilst in some parts of the world, community pharmacists have begun offering PGx testing, there is no evidence of any activity in England. There is therefore a research gap in knowledge to establish if this service could be implemented in the culture and context of the healthcare infrastructure and system in England, which differs somewhat from other countries. Method: The principles of co-design were deployed following three sequential phases using action-orientated frameworks and tools. In Phase One, three focus groups were conducted with community pharmacists (n= 10), prescribers (General Practitioners) (n= 8) and patients (n=8) to identify the barriers and enablers to implementing a community pharmacy based PGx service in England. The focus groups were recorded, transcribed and thematically analysed. In Phase Two, barriers and enablers from Phase One were mapped onto the Theoretical Domains Framework (TDF) followed by use of the Theory and Techniques Tool (TATT) to link the identified TDF domain with corresponding Behaviour Change Techniques (BCTs). A consensus questionnaire followed by a Nominal Group Technique workshop were used to facilitate community pharmacists (n=11) selecting their preferred BCTs to include in a service specification. Finally, in Phase Three, a draft service specification was developed, and a joint participant (n=12) consensus panel was convened for critical comment. The service specification was refined based on the feedback. Results: Five barrier and enabler themes were developed in Phase One: (1) In-principle receptiveness, (2) Appreciation of the benefits, (3) Lack of implementation resources (4) Ambiguity about implications for implementation and (5) Interprofessional relationship challenges. In Phase Two, the qualitative data from the pharmacist focus group were mapped onto six TDF domains: Knowledge, Skills, Social/ professional role and identity, Optimism, Beliefs about Consequences, and Environmental context and resources. Forty-six BCTs were identified using the TATT, of which nine BCTs were selected by the target audience: Review outcome goal(s) (1.7), Information about emotional consequences (5.6), Pros and Cons (9.2), Social support (Practical) (3.2), Feedback on behaviour (2.2), Instruction on how to perform behaviour (4.1), Demonstration of the behaviour (6.1), Credible source (9.1) and Adding objects to the environment (12.5). Finally, in Phase Three, the draft service specification was produced, and progressed into the final version following critical feedback from the mixed participant consensus panel. Conclusion: The co-design methodology using action-orientated frameworks and tools has resulted in the production of a novel service specification for implementation of a PGx community pharmacy testing service in England to fill a gap in research knowledge. This can now be used to implement the service and further research should be carried out to evaluate the service post implementation.

Venous thromboembolism is a preventable disease that causes morbidity and mortality in hospitalised patients. Evidence-based clinical practice guidelines include recommendations to prevent venous thromboembolism (VTE) in hospitalised patients. However, available published literature suggests that they are not always followed, and theory is underutilised in investigating guidelines adherence and developing interventions for the prevention of venous thromboembolism in hospitalised patients. This thesis explored physicians' uptake of Venous thromboembolism prevention clinical practice guidelines informed by the Theoretical Domain Framework (TDF) and investigated the barriers and facilitators to implementing venous thrombosis embolism prevention clinical practice guidelines in-hospital care to understand how to improve adherence to VTE prevention guidelines in healthcare settings, thus reducing patient morbidity and mortality. The dissertation work utilised a mixed-method approach for data collection and analysis. It included a systematic review of existing evidence on VTE guidelines effectiveness and interventions. A qualitative study explored factors affecting physicians' adherence to guidelines informed by the theoretical domain Framework (TDF). A quantitative study (pre-post process evaluation) assessed the extent to which VTE risk assessment is being performed after a quality improvement intervention implementation. The final chapter integrated the significant common findings of the three studies and discussed them in relation to emerging literature, their practical significance, and recommendations to improve the VTE clinical practice in hospitals.

Introduction: Physical activity has been recognised to offer health benefits and reduce the risks of developing chronic diseases such as diabetes, cardiovascular diseases, hypertension, cancer, depression, and atherosclerosis. However, even with the known health benefits of physical activity, over a quarter of adults globally are physically inactive, which is a serious public health concern and thus calls for concerted efforts to increase physical activity levels in diverse settings. A university is a unique setting in which to promote health enhancing behaviours, such as physical activity, because it offers opportunity to be active (e.g., in-built sports facilities), provides flexible working conditions to enable staff and students a reasonable level of autonomy in managing their individual time and endowed with highly educated and well-informed staff base, which has been previously shown to influence individuals' engagement in physical activity. Therefore, the overall aim of the PhD research project was to understand the barriers and enablers to physical activity among university staff and students, design an intervention informed by this understanding and implement intervention to address these barriers, in order to create behaviours that lead to better engagement in physical activity. Methods: A mixed-methods experimental design was utilised throughout the research, incorporating both qualitative (group interviews) and quantitative (surveys) data collection. The four experimental studies that make up this programme of work were designed using established behaviour change models, i.e., the Behaviour Change Wheel (BCW), the Capability, Opportunity, Motivation-Behaviour (COM-B) model and/or the Theoretical Domains Framework (TDF). The qualitative data were analysed in Nvivo12 using deductive content analysis, while the qualitative data were analysed using SPSS Statistical software 26.0, with significance level set at 0.05. Results: Six prominent domains were identified as enablers and barriers to physical activity among university staff and students, i.e., knowledge; social influences; social/professional role and identity; environmental context and resources; beliefs about capabilities; and intentions (study 1). About 78.0% of the administrative staff and 67.0% of the PhD students were physically inactive, i.e., achieving less than 600 MET-minutes/week of moderate intensity physical activity. A multiple regression analysis showed that of the 14 domains of the TDF, the 'physical skills' domain (t 106 = 2.198, p=0.030) was the only significant predictor of physical inactivity among the administrative staff, while the 'knowledge' (t 99 = 2.018, p= 0.046) and 'intentions' (t 99 = 4.240, p=0.001) were the only predictors of physical inactivity amongst the PhD students (study 2). The administrative staff that were assigned to engage in supervised exercise sessions (experimental group) reported higher physical skills scores and overall physical activity levels compared to the control (study 3). The PhD students that were allocated to the education and intentions group, who received educational materials and asked to form implementation intentions of times, days and places they intend to carry out physical activity, reported higher overall physical activity levels compared to other treatment groups, i.e., intentions only, education only and control groups (study 4). Conclusion: This thesis contributes to the knowledge on adult's physical activity by detailing the development, implementation, and assessment of a bespoke brief 4-week behaviour change intervention that effectively increased university administrative staff and PhD students' total physical activity levels, as well as time spent in physical activity weekly. The university was established as a unique setting to promote health-enhancing behaviour such as promotion of physical activity. Therefore, theory-based interventions underpinned by the BCW, COM-B model and TDF may provide an effective strategy to improve university staff and students' engagement in physical activity, as well as their overall wellbeing.

Background: Many nursing home residents are at risk of developing a pressure ulcer, which is an area of localised damage to the skin and/or underlying tissue due to immobility, increasing age and co-morbidities. Whilst guidelines for the prevention of pressure ulcers exist, their implementation can be sub-optimal. Care bundles are a set of research-informed practices used to facilitate the implementation of evidence into practice and incorporating psychological theory within their development may enhance their effectiveness. I aimed to co-design and assess the feasibility of implementing a theory and research-informed pressure ulcer prevention care bundle intervention in a nursing home setting. Method: This thesis comprised four separate studies as part of an overall mixed methods research design. Firstly, I conducted a systematic review and meta-analysis to determine the effects of care bundles per se on patient outcomes. I then conducted theory-informed qualitative, semi-structured interviews with nursing home care staff and NHS community-based nurses to explore the context of, and the barriers and facilitators to, pressure ulcer prevention in nursing homes. Next I co-designed a pressure ulcer prevention care bundle with 13 healthcare workers during a four hour workshop and supplemental email consultation. Using the Nominal Group Technique, we reached a consensus about the content of the care bundle. Following the steps of the Behaviour Change Wheel, I finalised the care bundle intervention. The final study involved a before-after study design where one nursing home implemented the care bundle intervention. I collected and analysed quantitative and qualitative data to gain a more holistic understanding of the feasibility issues related to the implementation. Findings: Findings from the systematic review suggested that care bundles may reduce the risk of negative outcomes in patients. These findings were based on very low quality evidence and the original study authors rarely reported adherence to the care bundle interventions. The theoretical understanding of the complexities in the prevention of pressure ulcers in nursing homes suggested there were four barriers and six facilitators, which my final care bundle intervention addressed. The co-designed care bundle intervention comprised three elements: support surfaces, skin inspection, repositioning; alongside three intervention functions and seven behaviour change techniques. In the final feasibility study, during the baseline period, there were 462 resident bed days and 5 new pressure ulcers recorded and in the intervention phase there were 1,181 resident bed days and no new pressure ulcers. The care bundle intervention appeared to be acceptable to the nursing home care staff and we have identified specific issues relating to the feasibility of implementing the care bundle intervention. Conclusions: The current research evidence-base for care bundles is poor. However, it was possible to co-design and implement a pressure ulcer prevention care bundle intervention for a nursing home setting. Further feasibility research is necessary before we can assess whether the care bundle intervention is effective in preventing pressure ulcers in nursing homes.

Introduction: Medication adherence is vital to ensuring optimal patient outcomes, particularly amongst older adults prescribed polypharmacy. However, complex interventions aimed at improving adherence have shown only limited effectiveness. To maximise effectiveness, the Medical Research Council (MRC) supports the use of both evidence and theory in developing interventions. Feasibility and pilot testing is then recommended to optimise interventions in advance of definitive trials. The aim of this research was to develop a novel complex intervention (using evidence and theory) to improve adherence in older adults (prescribed polypharmacy) and to test the feasibility of delivering this in community pharmacies. Methods: The presented research models the MRC complex intervention framework and focuses on development and feasibility testing phases. Firstly, a systematic review was conducted to address an identified evidence gap in relation to theory-based adherence interventions previously delivered to older adults prescribed polypharmacy. Qualitative research was then conducted to explore older patients’ adherence behaviour and identify determinants (barriers, facilitators) to target for change. Using the Theoretical Domains Framework (TDF) as a lens, key domains were selected for targeting and mapped to behaviour change techniques (BCTs) using established methods. These BCTs formed the basis of a complex intervention that was delivered to older patients by community pharmacists (CPs) as part of a small-scale feasibility study. In addition to exploring older patients’ adherence behaviours, further research focused on CPs’ clinical behaviour in relation to providing medication adherence support (MAS). The qualitative TDF-based methods used in the patient study were extended and a mixed methods (qualitative, quantitative) approach was used to identify determinants influencing CPs’ behaviour. Key target domains were identified and mapped to BCTs that could be directed at CPs (e.g. in a training package) to improve future implementation of the patient intervention. Results: The systematic review found that adherence interventions delivered to older patients prescribed polypharmacy were rarely based on theory, supporting the need for further research. The qualitative research conducted with older patients identified eight key domains (e.g. ‘Beliefs about consequences’, Memory, attention and decision process’) that could be targeted and these domains were mapped to 11 BCTs (e.g. ‘Prompts/cues’, ‘Self-monitoring’) which formed the basis of a complex intervention. The feasibility study demonstrated that the intervention was highly acceptable to both patients and CPs but some modifications were suggested. It also highlighted the need for additional research that focuses on CPs’ behaviour (i.e. MAS provision). Findings from the mixed methods study on CPs’ behaviour led to the identification of seven key domains that could be targeted for change (e.g. ‘Skills’, ‘Motivation and goals’). Eighteen BCTs were then selected for inclusion in a training package (e.g. ‘Demonstration of the behaviour’) or for delivery alongside the patient intervention in future research (e.g. ‘Rewards/incentives’) to improve implementation. Discussion/Conclusion: The MRC framework served as a useful guide for developing a complex intervention to improve adherence in older patients prescribed polypharmacy. This systematic theory-based approach that involved explicitly linking theoretical domains to intervention components (BCTs) will aid future replication and understanding of how the intervention aims to bring about behaviour change. Aside from targeting patients’ adherence behaviours, this research emphasised the importance of exploring the behaviours of intervention providers (i.e. CPs) to enhance implementation. Future research will involve pilot testing a refined version of the patient intervention and CP training package to establish if a definitive trial of effectiveness (e.g. randomised controlled trial) is warranted.

Non-medical prescribers make an increasing contribution to healthcare across the UK yet little is known about influences on their prescribing decision-making. The aim of this programme of research was to explore and describe prescribing decision-making by non-medical prescribers. A two stage programme of research was carried out. Stage 1 was a systematic review of the social and cognitive influences on prescribing decision-making by non-medical prescribers. Despite a paucity of research, various influences on prescribing decision-making were reported including evidence based guidelines, peer support and patient (or parental) relationships and expectations. While confidence and clinical experience as a practitioner were cited as influences, the lack of prescribing experience and aspects of pharmacological knowledge also impacted on prescribing decision-making, resulting in a cautious approach. Stage 2 of the research employed a phenomenological methodology underpinned by the Theoretical Domains Framework of behavioural determinants (TDF). It comprised three phases. In Phase 1, semi-structured interviews with five nurse prescribers and eight pharmacist prescribers in NHS Grampian explored their experiences and perceptions of influences on their prescribing decision-making, and the impact of these influences. Multiple and sometimes contradictory influences were uncovered. Twelve of the fourteen domains of the TDF were found to be influential along with multi-disciplinary working and experience; optimism and reinforcement did not feature. In Phase 2, these participants recorded reflections on prescribing decisions which they considered noteworthy in relation to their practice, and in Phase 3 participants were interviewed about their reflections. Complexity was a feature of many, in the patients’ clinical or social circumstances or in relation to wider concerns. The same 12 domains were found to be influential as were multi-disciplinary working, experience and complexity. This programme of research has produced original findings which it is hoped will impact on the education, training and practice of these increasingly important prescribers.

Hospital electronic prescribing and medicines administration (HEPMA) system implementation is advocated by national e-health strategies to produce patient safety benefits. No previous study has evaluated HEPMA implementation impacting discharge information communication or assessed discharge prescribing errors. The aims were to assess HEPMA system implementation impact on medicines related discharge communication and prescribing errors, and to gain the perspective of hospital staff involved in the communication process. Following a narrative literature review, a convergent parallel mixed methods was selected, consisting of interpretative phenomenology and experimental before and after study design. Face-to-face semi-structured interviews of a purposive sample of hospital staff involved in discharge information communication were undertaken using the Theoretical Domains Framework (TDF) as a theoretical lens. In addition a quasi experimental retrospective case notes review, both before and after implementation was completed. Pre-implementation, staff described patient safety concerns with traditional discharge communication processes. They cited frequent prescribing errors, and associated adverse events and hospital readmissions. HEPMA implementation was anticipated to improve patient safety and create more efficient discharge communication. Post-implementation staff articulated improved information quality highlighting fewer omitted medicines and improved patient safety. TDF findings of behaviour change highlighted behavioural alteration including adaption of processes to improve discharge quality. Quantitative data collection (n=159 before and after) confirmed qualitative findings; increased compliance with discharge documentation, for example staff grade recorded increased from 40% to 100% (p<0.001). Prescribing error quantity and severity were reduced; errors reduced from 99% to 23% of patients (p<0.001); only 22% of identified errors likely to cause harm. Omitted medicines decreased from 42% to 11% of patients (p<0.001). The findings contribute original knowledge concerning HEPMA implementation impacting discharge information communication and prescribing errors. The study demonstrated reduced prescribing errors and improved patient safety which potentially impacted health and wellbeing. Qualitative findings and quantitative results are transferable and applicable to other NHS organisations or similar healthcare settings.

Improving the effectiveness and efficiency of medication error reporting is key to enhancing patient safety. The aim of this research was to explore medication error reporting in the United Arab Emirates (UAE), examining the attitudes, beliefs, behaviors and experiences of health professionals. The first phase was a Joanna Briggs Institute registered systematic review of the beliefs, attitudes and experiences of health professionals relating to medication error reporting. Findings indicated the need for original research employing a mixed methods approach to quantify and generate in-depth information, grounded in theories of behaviour change. In the second phase, a cross-sectional survey of health professionals in the UAE was conducted to determine the behavioural determinants and facilitators and barriers of medication error reporting. Principal component analysis of responses from 294 health professionals identified six components: knowledge and skills related; feedback and support related; action and impact related; motivation related; effort related; and emotions. Responses were neutral for the motivation and effort related components, but negative for the emotions component. Comparison of component scores identified that, nurses, females, those with greater experience and being older were more likely to be positive in their responses (p<0.05). In terms of emotions, the component with the lowest scores, older respondents with greater experience gave more positive responses (p<0.05). In the final phase, face-to-face semi-structured interviews with 29 health professionals explored in-depth the behavioural determinants of medication errors reporting in the UAE. The theoretical domains framework was employed in constructing the interview schedule and interpreting the findings. ‘Goals’ and ‘intentions’ were determinants which acted as facilitators while ‘beliefs of the consequences’, ‘emotions’,’ ‘social influences and environmental context’ were barriers. This doctoral research has generated original findings which can support the development of interventions, based on behaviour change techniques, to enhance medication error reporting. These changes could impact at the levels of the organisation, health professional and patient.

Reducing medication wastage is a paramount objective in promoting appropriate utilisation of finite resources and preventing negative consequences. The aim of this research was to investigate aspects of medication wastage in Malta by applying mixed methods research and, by doing so, contribute original knowledge to this area. A systematic review was conducted to appraise critically, synthesize and present the available evidence on the possible causative factors associated with medication wastage and the effectiveness of any interventions focusing on wastage reduction as an outcome measure. Findings indicated that only one published paper reported a definition of medication wastage. The main factors contributing to wastage were ‘change in medication’, ‘patient's death’, ‘resolution of patient's condition’ and ‘passed expiry date’. Very few studies reported medication wastage as an outcome measure. The Delphi technique was applied to define ‘medication wastage’ and its contributory factors in the context of the Maltese population. A definition for medication wastage was generated with 86% of panellists agreeing/totally agreeing and sixty-one possible factors leading to wastage were identified by the panellists. The perspectives of the Maltese population, healthcare professionals and students on medication wastage were investigated through cross-sectional surveys. Results of questionnaires indicate lack of patient education and knowledge with the free healthcare system and the overstocking of medication by patients due to previous or potential out of stock situations as contributors to medication wastage. The beliefs and behaviours regarding medication wastage of the Maltese public and healthcare professionals were explored during focus groups. The theoretical domains framework was adopted to design the focus group guide and to interpret systematically the findings. Five key themes emerged which were proposed as solutions to minimise medication wastage: system effects, practitioner effects, patients effects, political effects and awareness and educational effects Research results and findings from all four phases will facilitate the systematic development of strategies and policies, with emphasis on prioritisation, with the aim of minimising medication wastage at all levels.