Additional File 6: Behavioural Analysis of HOME BP Using the Behaviour Change Wheel (BCW)

Additional file 6: Behavioural analysis of HOME BP using the Behaviour Change Wheel (BCW) and Normalisation Process Theory (NPT) Patient intervention components Target Barriers/ Evidence for Intervention ingredient Target Intervention BCT Target construct Behaviour facilitator to barrier/ facilitator/ [location in HOME BP] construct function (BCW) (using 93 BCT (NPT) the target intervention (BCW) taxonomy v1) behaviour ingredient Key behaviour: patient engagement with the intervention Patient log on Forgetting Martin et al., Patient email reminder Email Opportun Environmental 7.1 Cognitive (following 2011; to supporter (if patient not ity restructuring Prompts/cues; participation randomisation at Huff et al., 2011 logged on 2 weeks after (initiation) baseline) session 1 available) [email/ Initial log-on] Logging on to Limited time, SMILE feasibility Automated email prompts to Opportun Environmental 7.1 Collective action the website and competing study; McManus remind to enter BP readings; ity restructuring; Prompts/cues; (interactional entering priorities, et al, 2010 Flexible bi-weekly data 2.6 Biofeedback; workability) readings forgetting -TASMINH2; entry. Automated email 3.1 Social 2014, TASMIN- reminders and nurse follow- support Clear, SR ; Ahern et al, up; traffic light system for feedback 2012; Bostock et comprehension of BP messages al., 2010; Halifax readings when log in (blue – using traffic et al, low; green – target BP; light system, 2007;Fairbrother amber – above target BP; red focus on et al, 2013; – high BP). Patient BP health Rahimpour et al., readings sent by email for status; 2008 patient records. Free text knowing response option with the BP health status entry over time [BP entry] Key behaviour: patient home blood pressure self-monitoring Patient BP Willingness Huff et al., 2011; Building motivation for Reflectiv Education; 5.1 Inform of Coherence home to self- Ahern et al., 2012; monitoring; health benefits e Persuasion health (individual monitoring monitor Halifax et al., of self-monitoring; Motivatio consequences; specification) 2007; Hanley et motivational quiz outlining n 9.2 Pros and Concern al., 2013; Anthony links between BP and other cons

1 about HTN et al., 2012. conditions [Session 1]

Patient BP Anxiety that Agarwal et al., Information presented in Reflectiv Education 5.1 Inform of Collective action home home 2011; Bostock et session 1 reassuring that e health (relational monitoring readings will al., 2011; Halifax home monitoring is more Motivatio consequences; integration) not be as et al., 2007; accurate than clinic readings; n accurate as Fairbrother et al., it can lower BP readings and GP clinic 2013; Grant et al., result in faster changes to readings 2012; Rahimpour medication. et al., 2008 [Session 1] Reliability and accuracy; concern about BP variability Patient BP Not having SMILE feasibility Teaching patient how to Psycholo Training; 4.1 Instruction Collective action home the skills/ study; McManus monitor their own BP gical Education on how to (skill set monitoring confidence to et al, 2010; 2014; [Session 2] Capabilit perform the workability) monitor own Watson et al., y behaviour; BP at home 2012; Green et al., 6.1 2008; Rahimpour Demonstration of et al., 2008 the behaviour; 8.1 Behavioural practice/ rehearsal; Patient BP Not having Green et al., 2008; Reassurance there will be Social Environmental 3.1 Social Collective action home the Margolis et al., nurse support. opportuni restructuring; support (relational monitoring confidence to 2013; Hanley et [Session 1] ty Enablement integration) monitor BP al., 2013; Face to face nurse contact alone Rahimpour et al., and email support (every 2 2008; Haartman et weeks until BP stable). Perceived al., 2007; value of Fairbrother et al., [Supportive emails]

2 HCP contact 2013 and support

Patient to collect Limited time, Martin et al., Online notification and email Physical Environmental 7.1 Cognitive home BP competing 2011; Huff et al., prompt. Notify practice, Opportun restructuring Prompts/cues; participation monitor from priorities, 201 practice lead and GP of ity (initiation) practice forgetting randomisation to DI [Session 1 and 2]

Patient BP Limited time, SMILE feasibility Flexible weekly monitoring Opportun Environmental 2.4 Self- Collective action home competing study; Grant et al., to encourage habit formation; ity; restructuring; monitoring of (contextual monitoring and priorities, 2012; Anhoj & monitor twice a day (not 4 Automati Enablement outcome(s) of integration) entry forgetting Nielsen, 2004; times); email prompts as c behaviour; Langstrup, 2008; reminders. motivatio 8.1 Behavioural Free-text Specialist clinician [BP entry] n (habit practice/ responses input – (IP&D formation rehearsal accompanyin meetings) ) 8.3 Habit g data entry formation 7.1 Prompts/cues;

Key behaviour: patient medication adherence and titration Patient adhering Unconvinced Okonofua et al; Building motivation for Reflectiv Education 5.1 Inform of Cognitive to medication / concerned 2006; Lasserson et medication adherence and e health participation titration about al., 2012; titration (session 1 - Motivatio consequences; (legitimation); necessity of McManus et al, motivation to avoid harm to n Collective action medication 2010 - future health and motivation (interactional escalation TASMINH2; 2014 to receive appropriate workability) - TASMIN-SR; treatment) necessity/benefits Huff et al., 2011; and risks of BP medication; Gwadry-Sridhar et evidence that increasing BP al., 2013; Benson medication does not increase & Britten, 2002; side-effects. Svensson et al., [Session 1] 2000; Morrison et

3 al., 2015. Medication Unconvinced Langstrup, 2008; Rationale for necessity of Reflectiv Education; 5.1 Inform of Coherence titration in / concerned Bostock et al., medication escalation e Persuasion; health (differentiation) borderline cases about 2010; Jones et al., provided in Session 1; will Motivatio Environmental consequences; necessity of 2012; SMILE receive notification of n; restructuring; 9.1 Credible medication feasibility study. medication change in writing Social Source escalation from GP; opportunity to send opportuni 9.2 Pros and GP message with BP ty cons readings. [BP entry] Entering correct Awareness SMILE feasibility Rationale for necessity of Reflectiv Education; 5.1 Inform of Collective action blood pressure that this will study. medication escalation e Persuasion; health (interactional readings when prompt the provided in Session 1; Motivatio Environmental consequences; workability) second titration Opportunity to send n; restructuring; 9.1 Credible consecutive process additional information to GP; Opportun Source amber reading BP machine recordings can ity 9.2 Pros and be checked cons [BP entry] Making Patients may Grant et al., 2012; Opportunity to send Social Environmental 9.1 Credible Coherence medication be anxious Hartmann et al., additional information to GP opportuni restructuring; Source (individual change without about 2007; Bostock et when entering readings, will ty Enablement 3.1 Social specification) GP consultation titration, or al., 2010; receive notification of support doing it Jones et al., 2012; medication change in writing alone Figueiras et al., from GP; presenting 2010; medication change as ‘trial’; email support from nurse and face-to-face contact offered two weeks after titration. Collecting new Limited time, Grant et al., 2012;; Email/ post notification of Opportun Environmental 7.1 Cognitive medication competing Halifax et al., 2007 medication titration in ity restructuring Prompts/cues; participation prescription priorities, writing from GP; nurse 3.1 Social (initiation) forgetting contact two weeks after support titration Adhering to new Unconvinced Grant et al., 2012; Link back to rationale for Reflectiv Education; 5.1 Inform of Reflexive medication / concerned Halifax et al., medication escalation and e Persuasion; health monitoring

4 regime about 2007; Bokhour et information addressing Motivatio Environmental consequences; (reconfiguration) necessity of al., 2012; Benson concerns (minimal side n; restructuring; 7.1 medication & Britten, 2002; effects, opportunity to trial Social Enablement Prompts/cues; escalation medication); electronic opportuni 3.1 Social support and encouragement ty support; 9.1 from nurses, face-to-face Credible Source; support offered post-titration. 9.2 Pros and cons Key behaviour: patient lifestyle change

Adherence to Unconvinced Bennett et al., Online lifestyle module Reflectiv Education; 5.1 Inform of Reflexive lifestyle change or 2010; Hanley et describing the different e Persuasion; health monitoring modules unmotivated, al., 2013; Hyman lifestyle changes that people Motivatio consequences; (reconfiguration) lack of time. et al., 2007; Haber can make, provide guidance n et al., 2008. on selecting lifestyle changes (lifestyle changes optional) Nurse support provided. [Session 3] Health professional intervention components

Key behaviour: health professional engagement with the intervention Engaging with Concern that Halifax et al., Information outlining how Reflectiv Persuasion 5.3 Information Coherence study DI would 2007; Ahern et al., the intervention is evidence- e about the social (differentiation) increase 2012; Santaschi et based, and will facilitate best motivatio and workload or al., 2008; practice, increase efficiency n environmental disrupt McManus et al., through automated processes consequences; current 2010; Green et al., (based on accurate home 9.1 Credible workflow 2008; Margolis et readings and reduce source systems al., 2013. unnecessary consultations), with appropriately built-in DI can communication and safety overcome procedures. Information clinical about the study procedures inertia for participants (patient and health professionals).

5 Completing Limited time, SMILE feasibility Training completion Opportun Environmental 7.1 Prompts/cues Collective action online training competing study. monitored, automated ity restructuring (skillset priorities, reminders, follow-up by workability) forgetting practice lead prior to recruitment. [Prescriber training session and Supporter training session] Follow-up PN As above. SMILE feasibility Automated reminders/ email. Opportun Environmental 7.1 Cognitive and GPs who study. Practice lead to also liaise ity restructuring Prompts/cues; participation have not with staff who have not 2.1 Other(s) (initiation) completed completed the training. Study monitoring with training team to liaise with practice awareness lead to ensure this is 2.2 Feedback on completed. behaviour Key behaviour: enacting medication titration procedures Prescribing Awareness SMILE feasibility Online prescribing algorithm Psycholo Education 4.1 Instruction Coherence medication of NICE and study; Expert provided to all HOME BP gical on how to (communal escalation BHS clinician input; prescribers. Example capability perform a specification) appropriately prescribing Onysko et al, 2006. scenarios will be provided behaviour guidelines (illustrating how to increase 7.1 and change anti-hypertensive Prompts/cues; medication). Prescribers can 8.2 Behaviour access online medication substitution titration records (or can record pre-planned changes in patient notes). [Prescriber training session] Medication Not SMILE feasibility Evidence that clinical inertia Reflectiv Education; 5.1 Inform of Cognitive titration and convinced study; Wolf-Maier is a problem for patients with e Persuasion health participation escalation about clinical et al, 2007; Lawes hypertension, outlining the motivatio consequences; (enrolment) procedures appropriaten et al, 2008, Waksh health related risks of n ess of et al, 2006. uncontrolled hypertension escalating and how this can be treatment overcome with reliable home

6 BP readings, and that these reading will be persuasive for patients. [Prescriber training session] Implementing Unconvinced SMILE feasibility Provide evidence that HOME Opportun Environmental 9.2 Pros and Coherence intervention of feasibility study; Hyman et BP can overcome the ity restructuring cons of (individual titration in general al, 2012. problems in general practice implementing specification) procedures practice by increased confidence in escalating clinical decisions, as these treatment are made in line with 5.1 Inform of national guidelines and based health on accurate BP readings (i.e. consequences; an average taken over two 12.2 weeks over two months). restructuring the Further evidence for reduced social patient inertia, HOME BP environment will increase patient 9.1 Credible motivation for BP control, source increase patient understanding about the necessity of medication and provide the skills and equipment to accurately self- monitor at home. [Prescriber training session] Implementing Limited time, SMILE feasibility Titration procedure to Opportun Environmental 7.1 Collective action intervention competing study; McManus et facilitate target behaviours ity restructuring Prompts/cues; (skill set prescription priorities, al, 2010; Green et automated reminders; 8.2 Behaviour workability) procedures forgetting al, 2008; Ahern et providing a template email. substitution al, 2012; Grant et Patient to be notified of 2.7 feedback on al, 2012. medication change and outcome(s) of HOME BP will ask the behaviour patient if they have been awareness contacted by the practice. [Prescriber training session]

7 Prescribing Uncertain SMILE feasibility HOME BP will Motivatio Education; 5.1 Inform of Cognitive escalating about clinical study; Halifax et automatically recommend a n health participation medication necessity al, 2007; Grant et medication titration when BP consequences; (enrolment, appropriately in al, 2012; is above target for too long 7.1 Prompts/cues legitimation) borderline cases Langstrup, 2008; (automating the decision) Hyman et al, 2012 based upon BP readings that are consistently above target. [BP entry] Prescribing Concern SMILE feasibility Provision of safeguards Psycholo Education; 5.1 Inform of Coherence/ escalating about patient study; Halifax et (patients given the gical environmental health cognitive medication acceptance, al, 2007; Grant et opportunity to provide capability restructuring consequences; participation appropriately in safety al, 2012 additional information at the ; 7.1 (enrolment, borderline or BP entry if important; an Opportun Prompts/cues; legitimation) complex cases offline procedure for very ity 8.2 Behaviour high or very low BP substitution readings; patient and 1.5 review prescriber can revise or reject behavioural medication titration if goals appropriate). Automated 1.6 Discrepancy online provision of between current persuasive advice to patients behaviour and (including template letter to goal accompany prescription) [BP entry] Key behaviour: behavioural support provision Email contact Nurses SMILE feasibility Supporter training will Opportun Environmental 7.1 Collective action providing unsure when study; Ahern et al, introduce the CARE ity restructuring Prompts/cues; (skill set encouragement to make 2012; Green et al, (Congratulate, Ask, 2.2 Feedback on workability) to participants contact; 2008; Margolis et Reassure, Encourage) behaviour Nurse al, 2013; Uhlig et approach for providing commitment al, 2013; Bosworth behavioural support for the et al, 2009 patient, Examples of how to implement CARE support provided for each of the key behavioural issues (i.e.

8 supporting the patient to correctly use the BP monitor, not measuring blood pressure in support appointments, encouraging lifestyle change). HOME BP prompts to initiate contact, email scripts provided. Study team copied into email correspondence. [Supporter training session] Providing face- Nurse As above DI prompts to initiate contact Opportun Environmental 7.1 Collective action to-face (or forgetting sent to usual email address. ity restructuring Prompts/cues; (skill set telephone) Patients will be reminded workability) support sessions when these are available at with patients key points, the patient will initiate these, and can request them at different points.