Psychological Theory and theory-based intervention. Marie Johnston University of Aberdeen

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1 Psychological Theory and theory-based intervention Marie Johnston University of Aberdeen Behavioural Approaches to knowledge Transfer Symposium Ottawa: 16th October 2007

2 Using Theory in Intervention Theory as a basis for intervention: why? Identifies general principles that can be applied to many interventions Accumulation of evidence Theory as a basis for intervention: how? Theory specifies how to change behaviour Theory specifies antecedents to behaviour which can be changed using behaviour change techniques

3 Choosing Theory for Intervention Many theories to explain behaviour Few theories of how to change behaviour Social Cognitive Theory (Bandura) Self-Regulation/Control Theory (Carver & Scheier) Operant Learning Theory (Skinner) Focus on theories that predict/explain To identify target theoretical constructs for intervention Restricted range of theories used Problem of using theories that lack cognitive predictors e.g. theories of automaticity

4 Operant Learning Theory Consequences Reinforcement Reward/punishment Antecedents predict reinforcement A B C Change behaviour by changing A or C

5 Operant Learning Theory (OLT) Behaviour change depends on changing antecedents and/or consequences A antecedents B behaviour C Consequences e.g. reward/punishment

6 Using OLT to predict Does not theorise about cognition Skinner abhorred the idea as being beyond the scope of scientific methods Consequences such as reinforcement require some alteration to the enduring state of the organism Plausible that there might be some cognitive representation of this alteration

7 Operationalising OLT constructs to predict evidence-based behaviours (PRIME) Anticipated Consequences (2 items) e.g. If I routinely take radiographs then on balance, my life will be easier in the long run Rewarding and punishing consequences (4 items) Think about the last time: 1. you took a radiograph and felt pleased that you had done so 2. you took a radiograph and felt sorry that you had done so 3. you decided not to take a radiograph and felt pleased that you had not done so 4. you decided not to take a radiograph and felt sorry that you had not done so Habit (2 items) e.g. When I see a patient, I automatically consider taking a radiograph

8 PRIME Predicting 5 evidence-based clinical behaviours Doctors and dentists Multiple theories OLT SCT TPB + others Walker, A., Grimshaw, J.M., Johnston, M., Pitts, N., Steen, N. and Eccles, M.P. (2003) PRIME: PRocess modelling in ImpleMEntation research: selecting a theoretical basis for interventions to change clinical practice. BMC Health Services Research 2003, 3:22

9 Predicting behaviour from theories (%variance explained) Doctors Referring for lumbar spine Xray Doctors prescribing antibiotics for URTIs Dentists taking oral radiographs Dentists restoring carious teeth OLT ns SCT ns ns TPB 3.5 ns 14.2 ns

10 Predicting behaviour from theories (%variance explained) Doctors Referring for lumbar spine Xray OLT 2.3 consequences Doctors prescribing antibiotics for URTIs 5.1 consequences habit Dentists taking oral radiographs 7.4 consequences habit Dentists restoring carious teeth SCT ns ns ns TPB 3.5 ns 14.2 ns

11 Predicting intention from theories (%variance explained) Doctors Referring for lumbar spine Xray OLT 26.3 consequences habit Doctors prescribing antibiotics for URTIs 42.6 consequences habit Dentists taking oral radiographs 40.5 consequences habit Dentists restoring carious teeth 48.1 SCT TPB

12 Changing behaviour using OLT contingent reinforcement 133 dentists Placing fissure sealants on 2 nd molars 2833 children Cluster randomised trial 2 x 2 factorial design Contingent reinforcement EBP education Clarkson, Turner, Maclennan, Ramsay, Scott, Bonetti, Grimshaw, Ibbetson, Johnston, Pitts et al.

13 Using Theory in Interventions Operant Model vs Education Model Trial to enhance dentists management of childrens second molars 2 x 2 factorial design Education vs Operant model Additional psychological models as explanatory models Evidence from Research Used in Preventive Treatment Clarkson et al (2006) The effects of remuneration and education on the implementation of research evidence to reduce inequalities in oral health. Report to CSO

14 Intervention for Dentists (sealants) Operant Model vs Education Model Education OPERANT financial contingency Education + OPERANT financial contingency neither Evidence from Research Used in Preventive Treatment Clarkson et al (2006) The effects of remuneration and education on the implementation of research evidence to reduce inequalities in oral health. Report to CSO

15 Clarkson et al (2006) The effects of remuneration and education on the implementation of research evidence to reduce inequalities in oral health. Report to CSO Intervention for Dentists (sealants) Operant Model vs Education Education Education + OPERANT financial contingency Model OPERANT financial contingency neither RESULTS: Operant increased rate of Evidencebased practice (fissure sealants) Education had no effect

16 Effects of Contingent Reinforcement on Dental EBP Mean % children with sealant per dentist no EBP education EBP education not reinforced contingent reinforcement

17 Predicting behaviour and intention from theories (%variance explained) Dentists Placing sealants on children s teeth behaviour intention OLT SCT 7 31 TPB 31 16

18 Predicting behaviour and intention from theories (%variance explained) Dentists Placing sealants on children s teeth Behaviour and intention were behaviour intention correlated with all 3 OLT OLT variables: Anticipated SCT consequences 7 31 Experienced consequences Habit TPB 31 16

19 Predicting behaviour and intention from theories (%variance explained) Dentists Placing sealants on children s teeth behaviour intention But OLT variables did not mediate OLT the effect of the intervention (nor did SCT any cognitive 7variable) 31 TPB 31 16

20 Interpretation Wrong idea? Wrong operationalisation? OLT powerful intervention OLT operationalisations at least as predictive as other models Influence on behaviour that appears not to be cognitively recognised Potentially valuable

21 Evidence-based behaviour change techniques from OLT research Changing behaviour Schedules of reinforcement Intermittent Variable interval/ratio shaping chaining Reinforcers Social Premack principle Maintaining behaviour Fading reinforcement (extinction) Training schedules Secondary reinforcement

22 Summary of OLT and EBP Cognitive operationalisations of OLT constructs predicted behaviour (and intention) as well as SCT and TPB Intervention based on OLT (contingent reinforcement) increased EBP Effect of contingent reinforcement intervention was not mediated by OLT cognitions [or cognitions from other models] Potential theory-based techniques without cognitive mediators

23 Additional slides

24 QOF targets Implications of OLT for interventions in EBP UK general medical practitioners paid for delivering certain EBPs e.g. % patients with diagnosis of depression on anti-depressant medication Intrinsic vs. extrinsic motivation Extrinsic e.g. contingent remuneration, may reduce intrinsic motivation (Deci & Ryan) Potential danger of contingent remuneration

25 Michie, Johnston, Francis, Hardemen, Eccles (submitted) From theory to intervention: mapping theoretically derived behavioural determinants to behaviour change techniques Behaviour change techniques from Positive reinforcement Reward Punishment Extinction Negative reinforcement Vicarious reinforcement OLT Techniques directly related to OLT Differential reinforcement Stimulus generalisation Stimulus narrowing Shaping chaining Token economy Habit reversal Techniques not directly related to OLT but describing OLT techniques Goal Feedback Behavioural rehearsal Graded tasks Prompt Environmental change

26 Effects of Contingent Reinforcement on Habit Contingent reinforcement did not affect habit but EBP education did Confidence intervals Contingent reinforcement EBP education

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