title: Achieving behaviour change for detection of Lynch syndrome using the Theoretical Domains Framework Implementation (TDFI) approach: a study protocol.
abstract: BACKGROUND
  Lynch syndrome is an inherited disorder associated with a range of cancers, and found in 2-5 % of colorectal cancers. Lynch syndrome is diagnosed through a combination of significant family and clinical history and pathology. The definitive diagnostic germline test requires formal patient consent after genetic counselling. If diagnosed early, carriers of Lynch syndrome can undergo increased surveillance for cancers, which in turn can prevent late stage cancers, optimise treatment and decrease mortality for themselves and their relatives. However, over the past decade, international studies have reported that only a small proportion of individuals with suspected Lynch syndrome were referred for genetic consultation and possible genetic testing. The aim of this project is to use behaviour change theory and implementation science approaches to increase the number and speed of healthcare professional referrals of colorectal cancer patients with a high-likelihood risk of Lynch syndrome to appropriate genetic counselling services.
  
  
  METHODS
  The six-step Theoretical Domains Framework Implementation (TDFI) approach will be used at two large, metropolitan hospitals treating colorectal cancer patients. Steps are: 1) form local multidisciplinary teams to map current referral processes; 2) identify target behaviours that may lead to increased referrals using discussion supported by a retrospective audit; 3) identify barriers to those behaviours using the validated Influences on Patient Safety Behaviours Questionnaire and TDFI guided focus groups; 4) co-design interventions to address barriers using focus groups; 5) co-implement interventions; and 6) evaluate intervention impact. Chi square analysis will be used to test the difference in the proportion of high-likelihood risk Lynch syndrome patients being referred for genetic testing before and after intervention implementation. A paired t-test will be used to assess the mean time from the pathology test results to referral for high-likelihood Lynch syndrome patients pre-post intervention. Run charts will be used to continuously monitor change in referrals over time, based on scheduled monthly audits.
  
  
  CONCLUSIONS
  This project is based on a tested and refined implementation strategy (TDFI approach). Enhancing the process of identifying and referring people at high-likelihood risk of Lynch syndrome for genetic counselling will improve outcomes for patients and their relatives, and potentially save public money.
authors.affiliation: Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Faculty of Medicine and Health, Macquarie University, Sydney, NSW, 2109, Australia. n.taylor@mq.edu.au.
authors.forename: Natalie
authors.initials: N
authors.lastname: Taylor
authors.affiliation: Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Faculty of Medicine and Health, Macquarie University, Sydney, NSW, 2109, Australia.
authors.forename: Janet C
authors.initials: JC
authors.lastname: Long
authors.affiliation: Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Faculty of Medicine and Health, Macquarie University, Sydney, NSW, 2109, Australia.
authors.forename: Deborah
authors.initials: D
authors.lastname: Debono
authors.affiliation: Prince of Wales Hospital, Sydney, NSW, Australia.|Prince of Wales Clinical School, Faculty of Medicine, University of New South Wales, Sydney, Australia.
authors.forename: Rachel
authors.initials: R
authors.lastname: Williams
authors.affiliation: NSW Pathology (SEALS), Prince of Wales Hospital, Sydney, NSW, Australia.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Salisbury
authors.affiliation: International Governance and Research Centre, Faculty of Business and Economics, Macquarie University, Sydney, Australia.
authors.forename: Sharron
authors.initials: S
authors.lastname: O'Neill
authors.affiliation: NSW Pathology (SEALS), St George Hospital, Sydney, NSW, Australia.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Eykman
authors.affiliation: Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Faculty of Medicine and Health, Macquarie University, Sydney, NSW, 2109, Australia.
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Braithwaite
authors.affiliation: Prince of Wales Hospital, Sydney, NSW, Australia.
authors.forename: Melvin
authors.initials: M
authors.lastname: Chin
mesh_terms: D001315:Australia; D003123:Colorectal Neoplasms, Hereditary Nonpolyposis / Q000235:genetics*; D005260:Female; D017144:Focus Groups; D005817:Genetic Counseling; D005820:Genetic Testing; D006801:Humans; D008297:Male; D008962:Models, Theoretical; D011336:Probability; D012189:Retrospective Studies; D040242:Risk Reduction Behavior; D011795:Surveys and Questionnaires
keywords: Behaviour change; Hereditary cancer; Implementation; Pathology; Theoretical Domains Framework