Co-designing for behavioural change: understanding barriers and enablers to addressing sexuality after traumatic brain injury and mapping intervention strategies in a multi-disciplinary rehabilitation unit
Jill H. A. Hwang
A B * , Marina G. Downing A B , Riccarda A. G. Specht C and Jennie L. Ponsford A B
A
B
C
Abstract
Persistent changes in sexuality often follow traumatic brain injury (TBI). However, health professionals remain reticent about discussing sexuality and have reported barriers including uncertainties around whose role it is and limited educational and institutional support. This study employed a co-design and implementation process, aiming to promote team-wide behavioural change, whereby health professionals at a TBI rehabilitation unit would attempt to address sexuality with patients routinely.
Focus group sessions with multidisciplinary health professionals were conducted to identify barriers and enablers to behavioural change, identify areas for development, and co-design intervention options. Implementation deliverables were then finalised and provided to the team. The Theoretical Domains Framework was used to map factors influencing behaviours and the Behaviour Change Wheel was used to map interventions. Thematic analysis was used to further analyse barrier themes.
Thirty-five barriers and eight enablers falling within 12 theoretical domains to behavioural change were identified. Thematic analysis revealed highly correlated barriers in initiating and sustaining change. Nine co-designed intervention options aligned with five intervention functions of the Behaviour Change Wheel, resulting in six final implementation deliverables.
Barriers were highly interrelated, influencing the approach to implementation deliverables. Simultaneously addressing multiple barriers could potentially alleviate discomfort associated with discussing sexuality. Concerns around initiating change were related to confidence in achieving sustainable changes. Achieving change requires organisational and team-level environmental restructuring and enablement. The next step involves evaluating the effectiveness of the co-design and implementation process in driving behavioural change and potential impacts on patient satisfaction and sexuality outcomes.
Keywords: co-design, implementation, rehabilitation, sexual functioning, sexual health, sexual wellbeing, sexuality, traumatic brain injury.
References
Annon JS (1976) The PLISSIT model: a proposed conceptual scheme for the behavioral treatment of sexual problems. Journal of Sex Education and Therapy 2(1), 1-15.
| Crossref | Google Scholar |
Arango-Lasprilla JC, Olabarrieta-Landa L, Ertl MM, Stevens LF, Morlett-Paredes A, Andelic N, Zasler N (2017) Provider perceptions of the assessment and rehabilitation of sexual functioning after Traumatic Brain Injury. Brain Injury 31(12), 1605-1611.
| Crossref | Google Scholar | PubMed |
Atkins L, Francis J, Islam R, O’Connor D, Patey A, Ivers N, Foy R, Duncan EM, Colquhoun H, Grimshaw JM, Lawton R, Michie S (2017) A guide to using the Theoretical Domains Framework of behaviour change to investigate implementation problems. Implementation Science 12(1), 77.
| Crossref | Google Scholar | PubMed |
Auger L-P, Pituch E, Filiatrault J, Courtois F, Rochette A (2020) Priorities and Needs Regarding Sexual Rehabilitation for Individuals in the Subacute Phase Post-stroke. Sexuality and Disability 38(4), 653-668.
| Crossref | Google Scholar |
Baley M, Gargaro J, Kua A, Pagé E, Lanlancette-Hébert M, Patsakos E, Yaroslavtseva O, Nair A, Bennett P (2023) Canadian clinical practice guideline for the rehablitation of adults with moderate to severe traumatic brain injury. Available at https://kite-uhn.com/brain-injury/en/guidelines/intimacy-and-sexuality-considerations
Beenstock J, Sniehotta FF, White M, Bell R, Milne EM, Araujo-Soares V (2012) What helps and hinders midwives in engaging with pregnant women about stopping smoking? A cross-sectional survey of perceived implementation difficulties among midwives in the North East of England. Implementation Science 7(1), 36.
| Crossref | Google Scholar | PubMed |
Bonner C, Tuckerman J, Kaufman J, Costa D, Durrheim DN, Trevena L, Thomas S, Danchin M (2021) Comparing inductive and deductive analysis techniques to understand health service implementation problems: a case study of childhood vaccination barriers. Implementation Science Communications 2(1), 100.
| Crossref | Google Scholar | PubMed |
Cane J, O’Connor D, Michie S (2012) Validation of the theoretical domains framework for use in behaviour change and implementation research. Implementation Science 7(1), 37.
| Crossref | Google Scholar | PubMed |
da Silva MF, Oliveira LM, Ideta MML, de Oliveira Paschoalino MC, Gonçalves DB, Anghinah R, Paiva WS, de Amorim RLO (2022) Sexual dysfunction after Traumatic Brain Injury: an integrative review. Brazilian Journal of Neurosurgery 33(3), 323-336.
| Crossref | Google Scholar |
Downing MG, Stolwyk R, Ponsford JL (2013) Sexual changes in individuals with traumatic brain injury: a control comparison. Journal of Head Trauma Rehabilitation 28(3), 171-178.
| Crossref | Google Scholar | PubMed |
Dyer K, das Nair R (2013) Why Don’t Healthcare Professionals Talk About Sex? A Systematic Review of Recent Qualitative Studies Conducted in the United Kingdom. The Journal of Sexual Medicine 10(11), 2658-2670.
| Crossref | Google Scholar | PubMed |
Dyer K, das Nair R (2014) Talking about sex after traumatic brain injury: perceptions and experiences of multidisciplinary rehabilitation professionals. Disability and Rehabilitation 36(17), 1431-1438.
| Crossref | Google Scholar | PubMed |
Fraser EE, Downing MG, Ponsford JL (2020) Understanding the Multidimensional Nature of Sexuality After Traumatic Brain Injury. Archives of Physical Medicine and Rehabilitation 101(12), 2080-2086.
| Crossref | Google Scholar | PubMed |
Fraser EE, Downing MG, Ponsford JL (2021) Survey on the experiences, attitudes, and training needs of Australian healthcare professionals related to sexuality and service delivery in individuals with acquired brain injury. Neuropsychological Rehabilitation 32, 2248-2268.
| Crossref | Google Scholar |
Fraser EE, Downing MG, Haines K, Bennett L, Olver J, Ponsford JL (2022) Evaluating a Novel Treatment Adapting a Cognitive Behaviour Therapy Approach for Sexuality Problems after Traumatic Brain Injury: A Single Case Design with Nonconcurrent Multiple Baselines. Journal of Clinical Medicine 11(12),.
| Crossref | Google Scholar | PubMed |
Grindell C, Coates E, Croot L, O’Cathain A (2022) The use of co-production, co-design and co-creation to mobilise knowledge in the management of health conditions: a systematic review. BMC Health Services Research 22(1), 877.
| Crossref | Google Scholar | PubMed |
Hibbard MR, Gordon WA, Flanagan S, Haddad L, Labinsky E (2000) Sexual dysfunction after traumatic brain injury. NeuroRehabilitation 15(2), 107-120.
| Crossref | Google Scholar | PubMed |
Hsieh H-F, Shannon SE (2005) Three Approaches to Qualitative Content Analysis. Qualitative Health Research 15(9), 1277-1288.
| Crossref | Google Scholar | PubMed |
Humanity & Inclusion (2018) Rehabilitation guideline for the management of persons with traumatic brain injury. Available at https://pdf.usaid.gov/pdf_docs/PA00TTGM.pdf
Hwang JHA, Fraser EE, Downing MG, Ponsford JL (2022) A qualitative study on the attitudes and approaches of Australian clinicians in addressing sexuality after acquired brain injury. Disability and Rehabilitation 44, 8294-8302.
| Crossref | Google Scholar | PubMed |
Islam R, Tinmouth AT, Francis JJ, Brehaut JC, Born J, Stockton C, Stanworth SJ, Eccles MP, Cuthbertson BH, Hyde C, Grimshaw JM (2012) A cross-country comparison of intensive care physicians’ beliefs about their transfusion behaviour: a qualitative study using the theoretical domains framework. Implementation Science 7(1), 93.
| Crossref | Google Scholar | PubMed |
Jagosh J, Macaulay AC, Pluye P, Salsberg J, Bush PL, Henderson J, Sirett E, Wong G, Cargo M, Herbert CP, Seifer SD, Green LW, Greenhalgh T (2012) Uncovering the Benefits of Participatory Research: Implications of a Realist Review for Health Research and Practice. The Milbank Quarterly 90(2), 311-346.
| Crossref | Google Scholar | PubMed |
Khajeei D, Smith D, Kachur B, Abdul N (2019) Sexuality Re-education Program Logic Model for People with Traumatic Brain Injury (TBI): Synthesis via Scoping Literature Review. Sexuality and Disability 37(1), 41-61.
| Crossref | Google Scholar |
Latella D, Maggio MG, De Luca R, Maresca G, Piazzitta D, Sciarrone F, Carioti L, Manuli A, Bramanti P, Calabro RS (2018) Changes in sexual functioning following traumatic brain injury: an overview on a neglected issue. Journal of Clinical Neuroscience 58, 1-6.
| Crossref | Google Scholar | PubMed |
Mahajan C, Prabhakar H, Bilotta F (2023) Endocrine Dysfunction After Traumatic Brain Injury: An Ignored Clinical Syndrome? Neurocritical Care 39, 714-723.
| Crossref | Google Scholar |
Marier Deschênes P, Lamontagne M-E, Gagnon M-P, Moreno JA (2019) Talking About Sexuality in the Context of Rehabilitation Following Traumatic Brain Injury: An Integrative Review of Operational Aspects. Sexuality and Disability 37(3), 297-314.
| Crossref | Google Scholar |
Marier-Deschênes P, Gagnon M-P, Déry J, Lamontagne M-E (2020) Traumatic Brain Injury and Sexuality: User Experience Study of an Information Toolkit. Journal of Participatory Medicine 12(1), e14874.
| Crossref | Google Scholar | PubMed |
Mark JJ, Carl RM (2015) Promoting professional behaviour change in healthcare: what interventions work, and why? A theory-led overview of systematic reviews. BMJ Open 5(9), e008592.
| Crossref | Google Scholar |
Michie S, van Stralen MM, West R (2011) The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implementation Science 6(1), 42.
| Crossref | Google Scholar | PubMed |
Morris ZS, Wooding S, Grant J (2011) The answer is 17 years, what is the question: understanding time lags in translational research. Journal of the Royal Society of Medicine 104(12), 510-520.
| Crossref | Google Scholar | PubMed |
Peters DH, Adam T, Alonge O, Agyepong IA, Tran N (2013) Implementation research: what it is and how to do it. BMJ 347, f6753.
| Crossref | Google Scholar |
Ponsford J (2003) Sexual changes associated with traumatic brain injury. Neuropsychological Rehabilitation 13(1–2), 275-289.
| Crossref | Google Scholar | PubMed |
Royal College of Physicians and British Society of Rehabilitation Medicine (2003) Rehabilitation following acquired brain injury: national clinical guidelines. Available at https://www.headway.org.uk/media/3320/bsrm-rehabilitation-following-acquired-brain-injury.pdf
Sander AM, Maestas KL, Pappadis MR, Sherer M, Hammond FM, Hanks R, NIDRR Traumatic Brain Injury Model Systems Module Project on Sexuality After TBI (2012) Sexual Functioning 1 Year After Traumatic Brain Injury: Findings From a Prospective Traumatic Brain Injury Model Systems Collaborative Study. Archives of Physical Medicine and Rehabilitation 93(8), 1331-1337.
| Crossref | Google Scholar | PubMed |
Sander AM, Maestas KL, Nick TG, Pappadis MR, Hammond FM, Hanks RA, Ripley DL (2013) Predictors of sexual functioning and satisfaction 1 year following traumatic brain injury: a TBI model systems multicenter study. The Journal of Head Trauma Rehabilitation 28(3), 186-194.
| Crossref | Google Scholar | PubMed |
Simpson GK, Sabaz M, Daher M (2013) Prevalence, clinical features, and correlates of inappropriate sexual behavior after traumatic brain injury: a multicenter study. The Journal of Head Trauma Rehabilitation 28(3), 202-210.
| Crossref | Google Scholar | PubMed |
Suntornsut P, Wongsuwan N, Malasit M, Kitphati R, Michie S, Peacock SJ, Limmathurotsakul D (2016) Barriers and Recommended Interventions to Prevent Melioidosis in Northeast Thailand: A Focus Group Study Using the Behaviour Change Wheel. PLoS Neglected Tropical Diseases 10(7), e0004823.
| Crossref | Google Scholar | PubMed |
Tavender EJ, Bosch M, Gruen RL, Green SE, Knott J, Francis JJ, Michie S, O’Connor DA (2014) Understanding practice: the factors that influence management of mild traumatic brain injury in the emergency department-a qualitative study using the Theoretical Domains Framework. Implementation Science 9(1), 8.
| Crossref | Google Scholar | PubMed |
Tavender EJ, Bosch M, Gruen RL, Green SE, Michie S, Brennan SE, Francis JJ, Ponsford JL, Knott JC, Meares S, Smyth T, O’Connor DA (2015) Developing a targeted, theory-informed implementation intervention using two theoretical frameworks to address health professional and organisational factors: a case study to improve the management of mild traumatic brain injury in the emergency department. Implementation Science 10(1), 74.
| Crossref | Google Scholar | PubMed |
Tong A, Sainsbury P, Craig J (2007) Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. International Journal for Quality in Health Care 19(6), 349-357.
| Crossref | Google Scholar | PubMed |
World Health Organization (2006) Defining sexual health: report of a technical consultation on sexual health. Available at https://www.who.int/teams/sexual-and-reproductive-health-and-research/key-areas-of-work/sexual-health/defining-sexual-health
Yang Y-J, Chien W-C, Chung C-H, Hong K-T, Yu Y-L, Hueng D-Y, Chen Y-H, Ma H-I, Chang H-A, Kao Y-C, Yeh H-W, Tzeng N-S (2018) Risk of erectile dysfunction after traumatic brain injury: a nationwide population-based cohort study in Taiwan. American Journal of Men’s Health 12(4), 913-925.
| Crossref | Google Scholar | PubMed |
