Behaviour change: theories, taxonomy and strategies. Susan Michie

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1 Behaviour change: theories, taxonomy and strategies Susan Michie Professor of Health Psychology Director of Centre for Behaviour Change University College Paris, June 2015

2 UCL Centre for Behaviour

3 This talk A model of behaviour Behaviour change interventions complexity specifying by behaviour change techniques Theories to inform intervention development An integrative framework for developing and evaluating interventions synthesising evidence

4 Major causes of disability and premature death globally Behaviour change is of critical importance in addressing all of these Lim et al Lancet 2012

5 When is behaviour important? Health Disease Death Behaviour Behaviour To prevent ill health, manage illness, deliver effective health care

6 Health professional behaviours affect health Many do not follow evidence-based guidelines for good practice e.g. making referrals giving advice prescribing drugs keeping hands clean Every one of these requires multiple behaviours at multiple levels individual, organisational, state/national Each behaviour differs in context, barriers and drivers

7 Effective interventions Intervene at many levels simultaneously & consistently NICE Guidance for Behaviour change at population, community and individual levels (2007) Community-level Population-level Individual-level Update for Behaviour change: individual level (2014)

8 Key steps in intervention development 1. Identify target behaviour precisely Who need to do what, when, where, how Recognise that behaviours are part of a system of other behaviours within and between people 2. Make a behavioural diagnosis Understand the behaviour you are trying to change A good behavioural diagnosis is more likely to lead to effective interventions

9 Key steps continued 3. Consider the full range of options open to you 4. Target many levels simultaneously The Behaviour Change Wheel is a comprehensive framework for this 5. Use a systematic method for selecting behaviour change techniques 6. Evaluate so it is possible to accumulate evidence to inform future interventions

10 Understanding behaviour: Need frameworks/ models/theories that. Can encapsulate the complexity of human behaviour in working and living contexts workplaces, communities, homes variation between them Are simple enough to be useable and useful by policy makers, intervention designers etc That link understanding of behaviour to intervention strategies To identify interventions likely to be effective

11 Behaviour: part of a system of behaviours. that facilitate and compete with each other Within and between individuals Understanding the system of behaviours is necessary to identify where best to intervene and how

12 Understand behaviours in context Why are behaviours as they are? What needs to change for the desired behaviour/s to occur? Answering this is helped by a model of behaviour COM-B Behaviour is part of a system and itself is a system

13 The COM-B system: Behaviour occurs as an interaction between three necessary conditions Psychological or physical ability to enact the behaviour Reflective and automatic mechanisms that activate or inhibit behaviour Physical and social environment that enables the behaviour Michie et al (2011) Implementation Science

14 Understanding behaviour: the problem of hand hygiene in hospital staff Which behaviours? Nurses and doctors Cleaning hands in identified situations Infection control nurses Conducting audits and feeding back results Staff responsible for distributing alcohol handrub Ensuring that dispensers contain alcohol handrub

15 Improving a national campaign: applying COM-B analysis Opportunity Alcohol hand rub beside every bed Motivation Persuasive posters Encouraging patients to ask Capability No intervention

16 Capability Nurses have the capability to clean their hands But not to pay attention to this behaviour over other competing behaviours develop routines for noticing when the behaviour does not occur, and plans for acting in future Starting point for developing an intervention based on behavioural theory Will return to this

17 Interventions to change behaviour Have had variable effects Cochrane database; NICE reviews If we are to improve interventions, need to Unpack the black box of interventions What is in the black box? How do components have their effect? [theory] How to use this information to design more effective interventions? Effect

18 Interventions are complex Several, potentially interacting, techniques Vary in content or elements of the intervention delivery of the intervention 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) characteristics of those delivering the intervention characteristics of the recipients, characteristics of the setting (e.g., worksite) adherence to delivery protocols Davidson et al, Annals of Beh Med, 2003

19 What is in the black box? Poor descriptions of interventions Vague and lacking detail Inconsistent and varying terminology We need good, clear descriptions Using language that is understood by all Same term used for same component Without this, we are limited in our ability to replicate, implement effective interventions, evaluate or improve interventions

20 Example of the problem: Descriptions of behavioural counselling in two interventions Title of journal article 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 Effects of internet behavioral counseling on weight loss in adults at risk for Type 2 diabetes Description of behavioural counseling educating patients about the benefits of lifestyle change, encouraging them, and suggesting what changes could be made (Steptoe et al. AJPH 2001) feedback on self-monitoring record, reinforcement, recommendations for change, answers to questions, and general support (Tate et al. JAMA 2003)

21 Biomedicine vs behavioural science example of smoking cessation effectiveness Varenicline JAMA, 2006 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 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

22 New methodology: describe content in terms of behaviour change techniques Active ingredients within the intervention designed to change behaviour They are observable, replicable and discrete, low-level components of an intervention that on their own have potential to change behaviour Can be used alone or in combination with other behaviour change techniques

23 An early reliable taxonomy to change frequently used 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. Behavioural 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., 15. General encouragement 16. Con3ngent rewards 17. Teach to use cues 18. Follow up prompts 19. Social comparison 20. Social support/ change 21. be Role performed. model 22. Prompt self talk 23. Relapse preven3on 24. Stress management 25. Mo3va3onal interviewing 26. Time management 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 subgoals or preparatory behaviours and/or specific contexts in which the behaviour will 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. Abraham & Michie, 2008, Health Psychology

24 Taxonomies of BCTs Physical activity/healthy eating/mixed : 26 BCTs Abraham & Michie, 2008 Physical activity & healthy eating: 40 BCTs Michie et al, Psychology & Health, 2011 Smoking cessation: 53 BCTs Michie et al, Annals behavioural Medicine, 2010 Reducing excessive alcohol use: 42 BCTs Michie et al, Addiction, 2012 Condom use: 47 BCTs Abraham et al, 2012 General behaviour change: 137 BCTs Michie et al, Applied Psychology: An International Review, 2008 Competence framework: 89 BCTs Dixon & Johnston, 2011

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26 BCT Taxonomy v1 Applies to an extensive range of behaviour change interventions Agreed by an international consensus to be potential active components of interventions 400 participants from 12 countries Clearly labelled, well defined, distinct, precise; can be used with confidence by a range of disciplines and countries Hierarchically organised to improve ease of use Cane et al, BJHP, 2014

27 BCT Taxonomy v1: 93 items in 16 groupings

28 The BCTTv1 smartphone app Fully searchable version of BCTTv1 Search by BCT label, BCT grouping or alphabetically Increases familiarity with the taxonomy Increases speed and recall of BCT labels and definitions Search for: BCTs Search for: BCTs* bcts.23.co.uk* bcts.23.co.uk* * You ll need an internet connection to use the app

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30 BCT methodology provides an agreed, standard method to Describe interventions as accurately as possible Replicate interventions in research to build evidence Implement effective interventions Design interventions Translate general intervention functions into specific BCTs Evaluate e.g. in factorial designs Identify active ingredients (what) Investigate mechanisms of action (how) Synthesise published reports in systematic reviews

31 Applying theory to changing behaviour Apply formal theory 83 theories of behaviour change identified in cross-disciplinary review OR Use an integrative theoretical framework Behaviour Change Wheel, Michie et al, 2011

32 Cross-disciplinary review 83 theories Summary of original description List of constructs 1738; mean 19, range 5-84 Network diagram of source theories Future: Searchable website Davis et al, Health Psychology Review,

33 Example of applying formal theory: Interven5on to increase capability in hospital staff Based on behavioural theory (Control Theory) Train staff to set goals and make action plans Enable: observe their behaviour and give feedback support development of action plans

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

35 MONTHLY FEEDBACK INTERVENTION Co-ordinated by infection control team = individual level component Observe two staff member s behaviour for 20 minutes Give immediate verbal feedback Full compliance = certificate for use at staff appraisal OR < full compliance = immediate goal-setting and action planning regarding observed noncompliance & repeat observation next month Observe one group of staff members for 20 minutes Feedback displayed, and given at ward meeting Praise for compliance OR < full compliance = ward level goal-setting and action planning regarding observed noncompliance/s = group level component

36 = individual level component MONTHLY FEEDBACK INTERVENTION Co-ordinated by infection control team = group level component Observe two staff member s behaviour for 20 minutes Give immediate verbal feedback Full compliance = certificate for use at staff appraisal OR < full compliance = immediate goal-setting and action planning regarding observed noncompliance & repeat observation next month Observe one group of staff members for 20 minutes Feedback displayed, and given at ward meeting Praise for compliance OR < full compliance = ward level goal-setting and action planning regarding observed noncompliance/s

37 Findings: 60 wards in 16 hospitals in England Use of soap and alcohol hand rub tripled from 21.8 to 59.8 ml per patient bed day Rates of MRSA bacteraemia and C difficile infection decreased Stone, Fuller, Savage, Cookson et al, BMJ, 2012 Giving 1-1 feedback led to staff being 13-18% more likely to clean their hands Fuller, Michie, Savage, McAteer et al, PLoS One, 2012

38 Applying theory to changing behaviour Apply formal theory 83 theories of behaviour change identified in cross-disciplinary review OR Use an integrative theoretical framework Behaviour Change Wheel, Michie et al, Implementation Science,

39 Developing interventions: Start with understanding the behaviour in context

40 Intervening: Consider full range of options Frameworks make life easier Need a framework that is Comprehensive So don t miss options that might be effective Coherent So can have a systematic method for intervention design Linked to a model of behaviour So that can draw on behavioural science

41 Do we have such a framework? Systematic literature review identified 19 frameworks of behaviour change interventions related to health, environment, culture change, social marketing etc. E.g Mindspace, Intervention Mapping None met all these three criteria So. Developed a synthesis of the 19 frameworks Michie et al (2011) The Behaviour Change Wheel: a new method for characterising and designing behaviour change interventions, Implementation Science

42 Behaviour at the hub. COM-B Behaviour at the hub. COM-B

43 Interventions: activities designed to change behaviours Interventions

44 Policies Intervention functions Policies: decisions made by authorities concerning interventions Michie et al (2011) The Behaviour Change Wheel: a new method for characterising and designing behaviour change interventions Implementation Science

45 Use these frameworks to 1. Design interventions and policies COM-B links to intervention functions link to BCTs 2. Retrofit identify what is in current interventions and policies 3. Provide a framework for evaluation How are interventions working? 4. Structure systematic reviews

46 Which behaviour change techniques to select (from 93)?

47 The APEASE criteria Affordability Practicability Effectiveness/ cost-effectiveness Acceptability Side-effects/ safety Equity Can it be delivered to budget? Can it be delivered as designed? Does it work (ratio of effect to cost)? Is it judged appropriate by relevant stakeholders (publicly, professionally, politically)? Does it have any unwanted side-effects or unintended consequences? Will it reduce or increase the disparities in health/ wellbeing/standard of living?

48 Some applications of Behaviour Change Wheel India Smartphone app to reduce cardiovascular disease risk Kenya Improve paediatric health care Netherlands An organisational intervention tool Thailand Preventing melioidosis USA Improving colorectal cancer screening Providing long-acting reversible contraception to adolescents Improve parenting practices for children with challenging behaviour UK Smartphone app for parents of overweight children Promote recycling behaviours in university staff and students Reduce cardiovascular disease risk in people with severe mental illness Improve management of postnatal depression Smartphone app to promote attentive eating Internet intervention to promote condom use International Red Cross Train volunteers

49 Maintaining behaviour change Changing behaviour is hard Maintaining that change is harder Effective strategies Don t rely on individual choice and decision-making Do rely on the environment and making behaviour automatic environmental support and prompts building routines feedback rewards and incentives

50 In summary. To change behaviour. Start by understanding the problem Identify the behaviours to change Who, what, where, when Understand the behaviours COM-B Before designing the intervention Consider the full range of effective interventions and supporting policies Select behaviour change techniques using a systematic method

51 And evaluate.. so it is possible to accumulate evidence to inform future interventions Plan evaluation in advance using a theoretical framework to increase understanding of mechanisms of action reasons for variation

52 Acknowledgements Key collaborators in this work Prof Robert West, UCL Prof Marie Johnston, Aberdeen Health Psychology Research Group Key funders

53 For more information Susan Michie Books UCL Centre for Behaviour Change All proceeds from CBC teaching, training, books and products go to further development

54 EXTRA SLIDES

55 Frameworks included in systematic review 1. Epicure taxonomy West (2006) Taxonomy of approaches designed to influence behaviour patterns 2. Culture capital framework Knott et al. (2008) Framework of knowledge about culture change, offering practical tools for policymaking 3. EPOC taxonomy of interventions Cochrane Effective Practice and Organisation of Care Review Group (EPOC) (2010) Checklist to guide systematic literature reviewers about the types of information to extract from primary studies 4. RURU: Intervention implementation taxonomy Walter et al. (2003) Taxonomy covering a wide range of policy, practice and organisational targets aimed at increasing impact of research 5. MINDSPACE Institute for Government and Cabinet Office (2010) Checklist for policy-makers aimed at changing or shaping behaviour 6. Taxonomy of behaviour change techniques Abraham et al. (2010) Taxonomy of behaviour change techniques grouped by change targets 7. Intervention Mapping Bartholomew et al. (2011) Protocol for a systematic development of theory- and evidence-based interventions 8. People and places framework Maibach et al. (2007) Framework that explains how communication and marketing can be used to advance public health 9. Public health: ethical issues Nuffield Council on Bioethics (2007) Ladder of interventions by government, industry, organisations and individuals to promote public health.

56 10. Injury control framework Geller et al. (1990) Heuristic framework for categorising and evaluating behaviour change strategies aimed at controlling injuries 11. Implementation taxonomy Leeman et al. (2007) Theory-based taxonomy of methods for implementing change in practice 12. Legal framework Perdue et al. (2005) Conceptual framework for identifying possible legal strategies used for preventing cardiovascular diseases 13. PETeR White (in prep.) Comprehensive and universally applicable model or taxonomy of health 14. DEFRA s 4E model DEFRA (2008) Process model for policy makers aimed at promoting pro-environmental behaviours in accordance with social marketing principles 15. STD/ HIV framework Cohen and Scribner (2000) Taxonomy to expand the scope of interventions that can be used to prevent STD and HIV transmission 16. Framework on public policy in physical activity Dunton et al. (2010) Taxonomy aimed at understanding how and why policies successfully impact on behaviour change 17. Intervention framework for retail pharmacies Goel et al. (1996) Framework that presents factors that may affect retail pharmacy describing and strategies for behaviour change to improve appropriateness of prescribing 18. Environmental policy framework Vlek (2000) A taxonomy of major environmental problems, their different levels and global spheres of impact, and conceptual modelling of environmental problem- solving 19. Population Services International (PSI) framework PSI (2004) A conceptual framework to guide and help conduct research on social marketing interventions

57 Changing the physical or social context Using rules to reduce the opportunity to engage in the behaviour (or to increase behaviour by reducing opportunity to engage in compe3ng behaviours) Increasing knowledge or understanding Using communica3on to induce posi3ve or nega3ve feelings to s3mulate ac3on Provide an example for people to aspire to or emulate Crea3ng an expecta3on of reward Increasing means or reducing barriers to increase capability (beyond educa3on or training) or opportunity (beyond environmental restructuring) Impar3ng skills Crea3ng an expecta3on of punishment or cost

58 Crea3ng documents that recommend or mandate prac3ce. This includes all changes to service provision Designing and/or controlling the physical or social environment Using the tax system to reduce or increase the financial cost Using print, electronic, telephonic or broadcast media Establishing rules or principles of behaviour or prac3ce Crea3ng an expecta3on of punishment or cost Delivering a service

59 Design: which interven5on func5ons to use? Cap Phys Cap Psy Opp Phys Opp Soc Mot Aut Mot Ref Educ Pers Incen Coer Train Res Envir Mod Enabl

60 An example Target behaviour: Increasing participation in cycle to work scheme Target population: Employees Behavioural diagnosis: Employees unlikely to take up scheme because they don t have a bike to use : Physical opportunity Summer School 2014

61 An example Target behaviour: Increasing participation in cycle to work scheme Target population: Employees Behavioural diagnosis Employees unlikely to take up scheme because they don t have a bike to use : Physical opportunity Select intervention functions Physical opportunity maps onto: Environmental restructuring Select BCTs Environmental restructuring can include the BCTs Adding objects to the environment Restructuring the physical environment E.g. Employees were given bikes to use and cycle racks were installed in the office car park Summer School 2014

62 Which policy categories should be used? Intervention Functions Educ Persuas Incent Coerc Train Restric Envir Model Enabl Comm Guid Fiscal Regul Legis Envir Servic

63 Elaboration of COM-B: Theoretical Domains Framework Michie et al (2005) Making psychological theory useful for implementing evidence based practice: a consensus approach, Quality and Safety in Health Care Cane et al (2011) Validation of the theoretical domains framework for use in behaviour change and implementation research, Implementation Science

64 COM- B Theory Domains Physical capability Psychological capability Reflec5ve mo5va5on Automa5c mo5va5on Physical opportunity Social opportunity Physical skills Knowledge Cogni5ve and Interpersonal skills Memory, ALen5on and Decision processes Behavioural regula5on Professional/Social Role & Iden5ty Beliefs about Capabili5es Op5mism Beliefs about Consequences Inten5ons Goals Reinforcement Emo5on Environmental Context and Resources Social Influences

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