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Advancing the Science of Behaviour Change

Advancing the Science of Behaviour Change. Susan Michie Professor of Health Psychology University College London UK. Connecticut, USA: September 2010. Starting point …. Interventions to change health-related behaviours amongst the general population, patients and health professionals

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Advancing the Science of Behaviour Change

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  1. Advancing the Science of Behaviour Change Susan Michie Professor of Health Psychology University College London UK Connecticut, USA: September 2010

  2. Starting point … • Interventions to change health-related behaviours • amongst the general population, patients and health professionals • have had variable success. • Behaviour change remains a formidable challenge • we lack a clear understanding of • effective techniques and • mechanisms of change • across behaviours, populations and settings.

  3. To develop more effective interventions … We need to improve our scientific methods in the following areas: • Specify intervention content in sufficient detail in trial protocols and published reports to allow accurate replication and evidence syntheses that can identify “active ingredients” within interventions. • Apply theories of behaviour change to intervention development and evaluation, and to evidence syntheses • allows questions to be answered about not just “what worked” in interventions but “how they worked”. • Match behaviour change techniques to mechanisms of action to inform theory-based intervention development and evaluation-based theory development. • Define the extent to which interventions, and comparison conditions, use theory and evaluate how this relates to effectiveness. • Develop a model of behaviour as a starting point for systematic, theory-based intervention development.

  4. 1. Specifying interventions more precisely • Interventions often “complex” • several, potentially interacting, techniques • Poorly described • Interventions often described vaguely e.g. “behavioural counselling” • Where protocols with more detail are available, terminology is variable • Impedes replication, implementation, evidence synthesis

  5. Guidelines for specifying interventions • CONSORT guidelines for reporting RCTs • Evaluators should report “precise details of interventions [as] actually administered”Moher et al, 2001 • Which precise details? • the content or elements of the intervention • characteristics of those delivering the intervention • characteristics of the recipients, • characteristics of the setting (e.g., worksite) • the mode of delivery (e.g., face-to-face) • the intensity (e.g., contact time) • the duration (e.g., number sessions over a given period) • adherence to delivery protocols Davidson et al, Annals of Beh Med, 2003

  6. Example of the problem: Descriptions of “behavioural counselling” in two interventions

  7. Biomedicine vs behavioural science … example of smoking cessation effectiveness • Varenicline JAMA, 2006 • Behavioural counselling Cochrane, 2005 • Intervention content • Review smoking history & motivation to quit • Help identify high risk situations • Generate problem-solving strategies • Non-specific support & encouragement • Mechanism of action • None mentioned • Intervention content • Mechanism of action • Activity at a subtype of the nicotinic receptor where its binding produces agonistic activity, while simultaneously preventing binding to a4b2 receptors

  8. To improve development and application of interventions to change behaviour …. • Need a reliable method for describing intervention content in terms of • distinct component techniques • standardised language • An example developed from 3 systematic reviews of “self-management” interventions to increase physical activity and healthy eating • A 26 item taxonomy Abraham & Michie (2008). A taxonomy of behavior change techniques used in interventions. Health Psychology.

  9. Behaviour change techniques: reliable taxonomyto change physical activity and healthy eating behaviours 1. General information 2. Information on consequences 3. Information about approval 4. Prompt intention formation 5. Specific goal setting 6. Graded tasks 7. Barrier identification 8. Behavioral contract 9. Review goals 10. Provide instruction 11. Model/ demonstrate 12. Prompt practice 13. Prompt monitoring 14. Provide feedback Involves detailed planning of what the person will do including, at least, a very specific definition of the behaviour e.g., frequency (such as how many times a day/week), intensity (e.g., speed) or duration (e.g., for how long for). In addition, at least one of the following contexts i.e., where, when, how or with whom must be specified. This could include identification of sub-goals or preparatory behaviours and/or specific contexts in which the behaviour will be performed. 15. General encouragement 16. Contingent rewards 17. Teach to use cues 18. Follow up prompts 19. Social comparison 20. Social support/ change 21. Role model 22. Prompt self talk 23. Relapse prevention 24. Stress management 25. Motivational interviewing 26. Time management The person is asked to keep a record of specified behaviour/s. This could e.g. take the form of a diary or completing a questionnaire about their behaviour.

  10. Further work …. • Extended to 40 techniques reliably identified with improved definitions Michie et al, British Journal of Health Psychology, in press • 71 techniques used in smoking cessation interventions Michie et al, Annals Behavioral Medicine, 2010 • 137 identified by • consulting textbooks for training applied psychologists in BC techniques Michie et al, Applied Psychology: An International Review, 2008 • 42 in interventions to reduce excessive alcohol use • Three year MRC grant to put taxonomy approach onto a more scientific basis • Expert coders needed!

  11. Applications of taxonomy approach • Identifying active ingredients in interventions • Meta-regression in evidence synthesis • Physical activity & healthy eating • Audit & Feedback • Investigating mechanisms of action (theoretical mediation) • The intervention “ProActive” • Designing interventions • A classification based on comprehensive coverage, coherence and a model of behaviour

  12. Evidence syntheses of BC interventions • Often find no clear patterns, inconsistent results and small effects • Synthesis depends on categorisingcomplex, multi-component interventions • Categories often ad hoc • Specifying content as BCTs allows theoretically based categorisation & analysis

  13. Identifying active ingredients in interventions Usual meta-analysis overall effect of heterogeneous interventions Technique-based meta-regression similar to traditional regression, except data at study rather than individual level classify interventions into component BCTs meta-regression to investigate effects of individual techniques across interventions theoretically based combination of techniques

  14. What BCTs are effective in interventions to increase physical activity and healthy eating? Inclusion criteria Interventions using behavioural &/or cognitive techniques in adults designs experimental or quasi-experimental outcome measures objective or validated self-report 6 electronic databases, 1990-2007 Intervention content analysed using a reliable taxonomy of 26 techniques a theoretically derived combination of techniques Random effects meta-analysis and meta-regression isolates unique contribution of specific techniques to heterogeneity Michie, Abraham, et al (2009) Effective techniques in healthy eating and physical activity interventions: A meta-regression. Health Psychology, 28, 690-701

  15. The interventions 84 interventions (n=28,838) Target behaviour Physical activity &/or Healthy eating Interventions ave. 6 techniques (range 1-14) Many different combinations Effect d=0.37, 95% CI 0.29-0.54 Very heterogeneous effects (I2=79%) not explained by 10 moderators examined e.g. Setting, population, intervention characteristics, target behaviour

  16. Results Only one technique, self-monitoring, had a significant effect for both behaviours across interventions d=0.57, 14.6% variance Next step Use psychological theory to predict combinations of techniques that might be more effective Control Theory suggests how feedback may interact with other techniques to change behaviour Carver & Scheier, 1982

  17. A Self-regulation (control) Theory: Carver & Scheier, 82 GOAL Compare behaviour with standard No discrepancy – goal reached Discrepancy noted Disengage from goal – give up Act to reduce discrepancy Environmental influences SELF-MONITORING/FEEDBACK GOAL-SETTING ACTION-PLANNING

  18. Theoretical combination of techniques self-monitoring of behaviour Other core self regulatory processes: setting goals reviewing goals specifying action plans feedback on performance

  19. Findings Interventions comprising self-monitoring with at least one other “self-regulatory” techniques (n=28) compared with the other interventions (n=56) were twice as effective d=0.60vs d=0.26

  20. 2. & 3. Applying theories of behaviour change and matching BCTs to mechanisms of action • Re-analysis of a Cochrane review of professional practice (Audit & Feedback) • ProActive intervention to increase physical activity in those at risk of Type 2 diabetes

  21. Re-analysis of Cochrane review of Audit & FeedbackJamtvedt et al. Audit and feedback: effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews 2006 • Intervention categorised as“intensive”, “moderate” or “non-intensive” What is “intensive” Audit & Feedback?

  22. Intensive A&F • (individual recipients) AND ((verbal format) OR (a supervisor or senior colleague as the source)) AND (moderate or prolonged feedback) • Non-intensive • ((group feedback) NOT (from a supervisor or senior colleague)) OR ((individual feedback) AND (written format) AND (containing information about costs or numbers of tests without personal incentives)) • Moderate • (any other combination of characteristics than described in Intensive or Non-intensive group)

  23. No rationale for these categories in the published review or when authors contacted • Results: • 118 RCTs with objective measures of performance • Variable effects, from 16% decrease to 70% increase • Small effect of “higher intensity” of A & F • No clear trend: Adjusted RR 1.55, 1.11 & 1.45 for high, moderate and low intensity • Limited use in informing evidence-based A&F • ‘A&F will continue to be an unreliable approach … until we learn how and when it works best’(Foy et al, 2005)

  24. Our re-analysis • Published reports usually inadequate for meaningful data synthesis • Therefore, intervention details requested from authors • 59 contacted, 44 responses,16 (27%) sent us additional information (8 protocols) • Updated, 12 new RCTs, 69 excluded, 61 reporting 85 comparisons • Theory and evidence used to identify • Intervention components • 40 separate components coded, combined into BCTs • Theory-based hypotheses about effectiveness Gardner, Whittington, McAteer, Eccles, Michie (2010) Using theory to synthesise evidence from behaviour change interventions: The example of audit and feedback. Social Science & Medicine

  25. Coding and analysis • Interventions coded for: • Goals (yes vs no) • Action plans (yes vs no) • Additional intervention BCTs (yes vs no) • Baseline compliance (continuous) • Control conditions coded for: • Additional intervention BCTs (yes vs no) Michie, Prestwich, de Bruin M. (2010) Importance of the Nature of Comparison Conditions for Testing Theory-Based Interventions: Reply to Commentary. Health Psychology.

  26. GOAL Compare behaviour with standard No discrepancy – goal reached Discrepancy noted Disengage from goal Act to reduce discrepancy Environmental influences Self-regulation (control) Theory: Carver & Scheier, 82 FEEDBACK GOAL-SETTING ACTION-PLANNING

  27. Theory-based hypotheses • Feedback more effective when goal/target is set • Most effective where goal/target and action plan • Feedback only Effective • Feedback + goal More effective • Feedback + goal + action plan Most effective

  28. Behaviour change techniques Modes of delivery • Feedback only • Feedback + goal • Feedback + goal + action plan • Additional BCTs • 73 interventions & 34 control arms 61 comparisons • Non-intensive • ((group feedback) NOT (from a supervisor or senior colleague)) OR ((individual feedback) AND (writtenformat) AND (containing information about costs or numbers of tests without personal incentives)) • Moderate • (any other combination of characteristics than described in Intensive or Non-intensive group) • Intensive A&F • (individual recipients) AND ((verbal format) OR (a supervisor or senior colleague as the source)) AND (moderate or prolonged feedback) 8 comparisons 3 comparisons

  29. Results • Meta-analysis: • A&F effective: OR = 1.43 (95% CI = 1.28, 1.61) • Moderate to strong heterogeneity (I2= 61%) • Meta-regression: • Feedback vs Feedback + Goal &/or Action plan • 61 vs 24 comparisons, adj. p = 1.0 • ?power • Additional BCTs (intervention) • p = .006

  30. The intervention “ProActive”Kinmonth et al, The Lancet, 2008 • Used BCT taxonomy approach to • Assess fidelity of delivery • Evaluate mechanism of action • By linking intervention content to theory

  31. The intervention and evaluation • Based on psychological theory and evidence • Specified in detailed protocols/manuals • Delivered by trained professionals in 5 sessions over 12 months • Results of RCT • Increased activity by equivalent of 20 minutes per day • No difference between intervention and “control” groups

  32. Implementation “add-on” study • What worked? • Assess implementation Hardeman, Michie et al (2008) Fidelity of delivery of a physical activity intervention: Predictors and consequences. Psychology and Health, 23, 11-24. • How did it work? • Link component techniques to theory Michie, Hardeman et al (2008) Investigating Theoretical Explanations for Behaviour Change: The Case Study of ProActive. Psychology and Health, 23, 25-39.

  33. Give information Elicit questions Summarise message Set goals Self-monitor Build motivation Action plans Use prompts Use rewards Build support Review goals Build habits Relapse prevention Generalise skills Intervention techniques Theories • Theory of Planned Behaviour • Relapse Prevention Theory • Self-regulation Theory • Operant Learning Theory

  34. The implementation process Theories of behaviour change Techniques in manual Delivery of techniques by professional Participant response to intervention Physical activity

  35. Method • 27 participants selected to study in depth • Intervention manual specified 208 behaviours for delivering the 14 techniques • Intervention sessions tape recorded & transcribed • All discussion in sessions relevant to behaviour change was reliably coded into techniques and theories • Both of professionals and of participants

  36. Question: How did the intervention work? • 27 participants selected to study in depth • Tape recorded and transcribed sessions • All discussion in sessions relevant to behaviour change was reliably coded into techniques and theories • Both of professionals and of participants

  37. Percentage of techniques delivered by professionals 45% %

  38. Variation in implementation Facilitators: p<0.001 (Kruskal-Wallis test) Sessions: p<0.001 (Page test)

  39. Consensus of at least 3 of 4 raters for:

  40. How were techniques distributed over the theories? (a) in protocol (b) delivered Relapse Prevention Theory Self-regulation Theory Operant Learning Theory Theory of Planned Behaviour

  41. Process linking theory and behaviour change Theories of behaviour change Techniques in manual Delivery of techniques by professional Participant response to intervention Physical activity

  42. How was the intervention received by participants? Participants talk about behaviour change or maintenance was reliably coded into 17 components of four theories e.g.

  43. How was (a) professional (b) participant talk about behaviour distributed over the theories? Relapse Prevention Theory Self-regulation Theory Operant Learning Theory Theory of Planned Behaviour

  44. Which theories best accounted for change? Although Self-regulation theory is the basis of the most commonly delivered intervention techniques, Operant learning theory may be a better explanation for behaviour change among participants

  45. To develop more effective interventions … We need to improve our scientific methods in the following areas: • Specify intervention content in sufficient detail … • Apply theories of behaviour change to intervention development and evaluation, and to evidence syntheses • Match behaviour change techniques to mechanisms of action … • Define the extent to which interventions, and comparison conditions, use theory and evaluate how this relates to effectiveness. • Develop a model of behaviour as a starting point for systematic, theory-based intervention development.

  46. 4. Use of theory • Many literature reviews conclude that behavioural interventions based on theory are more effective than those that are not • E.g. Albarracin et al (2005), Downing et al (2006), Fisher & Fisher (2000), Gehrman & Hovell (2003), Glanz & Bishop (2010), Jemmott & Jemmott (2000), Kim et al (1997), Noar (2008), Wingood & DiClemente (1996) • HOWEVER • Researchers of reviewed studies generally state rather than demonstrate a theoretical base for the intervention

  47. Need a method …. • of assessing the extent to which interventions are based on theory • Theory Coding Scheme: Checklist of 19 items in following categories: • is a theory mentioned • are relevant theoretical constructs targeted? • is theory used to select recipients or tailor interventions? • are relevant theoretical constructs measured? • is theory tested? • is theory refined? Michie S, Prestwich A. (2010) Are interventions theory-based? Development of a Theory Coding Scheme. Health Psychology, 29,1-8.

  48. Application of the framework: to address … • To what extent are interventions said to be theory based, actually theory based? • Are theory-based interventions more effective than those not explicitly based on theory? • Is intervention effect associated with • particular theories • particular use of theories • e.g. to select techniques, target participants • What is the association between theoretical base and intervention content?

  49. Test of Theory I:meta-regression of smoking cessation counselling • 3 Cochrane reviews • Individual, group, telephone behavioral support • Inadequate intervention descriptions • Authors contacted • 70 item taxonomy of BCTs for smoking cessation interventions • Theory Coding Scheme Stavri, Beard, Whittington, Michie & West, 2010

  50. Results: published intervention descriptions • For 14 studies where protocols available, more BCTs reported in the protocols (t(14)=3.63, p<0.01)

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