Advancing the Science of Behaviour Change

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
Title of journal article Description of behavioural counseling
The impact of behavioral counseling on stage of change fat intake, physical activity, and cigarette smoking in adults at increased risk of coronary heart disease educating patients about the benefits of lifestyle change, encouraging them, and suggesting what changes could be made (Steptoe et al. AJPH 2001)
Effects of internet behavioral counseling on weight loss in adults at risk for Type 2 diabetes feedback on self-monitoring record, reinforcement, recommendations for change, answers to questions, and general support (Tate et al. JAMA 2003)
7
Biomedicine vs behavioural science example of
smoking cessation effectiveness
Varenicline JAMA, 2006
Behavioural counselling Cochrane, 2005

• 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

• 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

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 taxonomy
to change physical activity and healthy eating
behaviours
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

• 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

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 categorising complex,
  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 (n28,838)
• Target behaviour
• Physical activity /or Healthy eating
• Interventions ave. 6 techniques (range 1-14)
• Many different combinations
• Effect d0.37, 95 CI 0.29-0.54
• Very heterogeneous effects (I279)
• 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
• d0.57, 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
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
  (n28)
• compared with the other interventions (n56)
• were twice as effective
• d0.60 vs d0.26

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
Feedback Jamtvedt 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 AF
• (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 AF
• AF 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
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
Modes of delivery
Behaviour change techniques

• 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)
• Intensive AF
• (individual recipients) AND ((verbal format) OR
  (a supervisor or senior colleague as the source))
  AND (moderate or prolonged feedback)

• Feedback only
• Feedback goal
• Feedback goal action plan
• Additional BCTs
• 73 interventions 34 control arms

61 comparisons
8 comparisons
3 comparisons
29
Results

• Meta-analysis
• AF 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
Intervention techniques

1. Use prompts
2. Use rewards
3. Build support
4. Review goals
5. Build habits
6. Relapse prevention
7. Generalise skills

1. Give information
2. Elicit questions
3. Summarise message
4. Set goals
5. Self-monitor
6. Build motivation
7. Action plans

Theories

1. Theory of Planned Behaviour
2. Relapse Prevention Theory
3. Self-regulation Theory
4. 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 plt0.001 (Kruskal-Wallis test)
Sessions plt0.001 (Page test)
39
Consensus of at least 3 of 4 raters for
Techniques Theory
Build motivation Give information Theory of Planned Behaviour
Set goals Develop action plans Self-monitoring Review goals Self-regulation Theory
Use rewards Use prompts Build support Generalise skills Build habits Operant Learning Theory
Prepare for setbacks Relapse Prevention Theory
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.

Example from transcript Theoretical component Theory
Thinking about benefits of activity e.g. losing weight Attitude Theory of Planned Behaviour
Parking car further away so has to walk further Action plan Self-regulation Theory
Asking partner to remind him Cue to action Operant Learning Theory
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 Imeta-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,
  plt0.01)

51
Results application of theory (n92)
52
Theory use and effectiveness

• No association between theory use and
  intervention effectiveness
• Types of theory
• 27 Transtheoretical Model
• 8 Relapse Prevention Model
• 1 Lazarus Folkmans model of stress
• 1 compared Relapse Prevention Model with Health
  Belief Model

53
Results BCTs associated with intervention
effectiveness

• Two BCTs were associated with intervention
  effectiveness in psychological interventions
• Facilitate restructuring of social life (ß.56,
  R²13.18, p.02)
• Advise on/facilitate use of social support
  (ß.37, R²3.45 p.02)

54
Test of Theory II meta-analysis of internet
based interventions

• Webb, Joseph, Yardley, Michie (2010). Using the
  Internet to promote health behaviour change A
  systematic review and meta-analysis of the impact
  of theoretical basis, use of behavior change
  techniques, and mode of delivery on efficacy.
  Journal of Medical Internet Research, 12, e4.

55
Use of Theory
k Q 95 CI d
Theory used to select recipients 3 2.84 0.15 to 0.52 0.33
Group of intervention techniques linked to group of constructs 6 9.85 0.03 to 0.43 0.23
Theory used to select intervention techniques 37 191.40 0.13 to 0.29 0.21
Targeted construct mentioned as predictor of behaviour 18 60.07 0.11 to 0.31 0.21
Theory used to tailor intervention techniques to recipients 11 67.75 0.07 to 0.34 0.21
Theory or model of behaviour mentioned 30 161.33 0.11 to 0.28 0.19
At least one intervention technique is linked to theory 19 93.65 0.09 to 0.29 0.19
Intervention based on single theory 12 57.13 0.05 to 0.32 0.18
All constructs are linked to intervention techniques 10 47.70 -0.02 to 0.37 0.18
At least one construct is linked to an intervention technique 18 70.63 0.07 to 0.27 0.17
All intervention techniques are linked to theory 2
56
Use of theory associated with effect size
Effect size -.07 .03
57
Currently applying Theory Coding Scheme to .

• 146 papers reporting interventions to increase
  physical activity and healthy eating
• 3 systematic reviews UCL, Leeds, Aberdeen
• Total sample size
• intervention groups 12,282
• control groups 12,248
• Watch this space ..

Prestwich, Whittington, Sniehotta Michie, in
preparation
58
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.

59
Designing interventions

• Start from an analysis of the nature of the
  behaviour to be changed
• unless we understand the nature of the behaviours
  that need to change, unlikely our interventions
  will be maximally effective

60
Designing interventions ctd

• Use a systematic approach to selecting from the
  range of interventions and policies available
• Need a framework that meets criteria of
• comprehensive coverage,
• coherence
• categories mutually exclusive and same level of
  specificity
• linked to a model of behaviour
• Systematic review identified 18 existing
  frameworks, none met all these criteria

Michie, van Straalen West 2010
61
The Behaviour System Behaviour emerges from
interactions between .
Capability
Psychological or physical ability to enact the
behaviour
Behaviour
Motivation
Reflective and non-reflective mechanisms that
activate or inhibit behaviour
Opportunity
Physical and social environment that enables the
behaviour
62
The Behaviour System CMOB
Capability, Motivation and Opportunity must be
present for a Behaviour to occur
Capability
Behaviour
Motivation
Opportunity
The system is in dynamic equilibrium and a change
in behaviour may require a sustained change in
one or more of the other elements
63
The Behaviour Change Wheel A system for choosing
interventions and policies
Behaviour source
Interventions activities designed to change
behaviours
Capability
Physical
Psychol- ogical
Reflec- tive
Motivation
Physical
Non reflect- ive
Social
Opportunity
Policies decisions made by authorities
concerning interventions
64
Motivation
Beliefs about what is good and bad, conscious
intentions and decisions as per e.g. Theory of
Planned Behaviour
Reflective
Non-reflective
Emotional responses, desires and habits resulting
from associative learning and physiological states
Reflective-Impulsive Model, Strack Deutsch,
2004 PRIME Theory of Motivation, West, 2006
65
The Behaviour Change Wheel
Behaviour source
Intervention categories
Modelling
Training
Policy categories
Education
Restriction
Persuasion
Capability
Physical
Psychol- ogical
Reflec- tive
Motivation
Coercion
Physical
Non reflect- ive
Incentivisation
Social
Opportunity
Behaviour system influenced by an intervention
system which is enabled and/or supported by a
policy system
Environmental restructuring
Enablement/ resources
66
Intervention categories Intervention categories Intervention categories Intervention categories
Education Imparting knowledge e.g. on health risks
Persuasion Using communication to induce belief or knowledge
Incentivisation Creating expectation of reward
Coercion Creating expectation of punishment or cost
Training Imparting skills
Restriction Reducing availability
Environmental restructuring Changing the physical context
Modelling Providing an example for people to aspire to
Enablement/ resources Increasing means/reducing barriers
67
The Behaviour Change Wheel
Behaviour source
Service provision
Intervention categories
Regulation
Modelling
Training
Education
Fiscal
Restriction
Policy categories
Persuasion
Capability
Physical
Psychol- ogical
Reflec- tive
Environmental/ social planning
Motivation
Coercion
Physical
Non reflect- ive
Incentivisation
Social
Opportunity
Legislation
Environmental restructuring
Enablement/ resources
Guidelines
Communication/marketing
68
Policy types Policy types Policy types Policy types
Communication/ marketing Using print, electronic, telephonic or broadcast media
Guidelines Creating documents that recommend or mandate practice
Fiscal Using the tax system
Regulation Establishing rules or principles of behaviour or practice
Legislation Making or changing laws
Environmental/ social planning Designing and/or controlling the physical or social environment
Service provision Delivering a service
69
Conclusions If we are to .

• most efficiently build evidence about BC
  interventions
• need to specify intervention content and link to
  theory
• design more effective interventions to change
  behaviour need to increase understanding of
• nature of behaviour
• range and nature of interventions/policies
• mechanisms of action
• and links between these

70
More information from s.michie_at_ucl.ac.uk

• He who loves practice without theory is like the
  sailor who boards ship without a rudder and
  compass and never knows where he may cast
• Leonardo Da Vinci, 1452-1519