Applying behavioural science to understanding and solving implementation problems Susan Michie

Applying behavioural science to understanding and solving implementation problems Susan Michie Department of Psychology, University College London, UK Implementation Science Summer School, Dublin 2012

An approach to developing behaviour change interventions

Which behaviours? Identify key specific behaviours (often several) Who needs to do what differently, when, where, how? Does recommended practice involve others?

Understand the behaviour 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

An approach to developing behaviour change interventions

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

Further analysing the problem: using theories of behaviour To make theory more usable, a consensus exercise of 18 researchers in health psychology 14 implementation researchers from UK, Netherlands and Canada Generated and synthesised 33 theories and 128 constructs... into 14 domains: the Theory Domains Framework Elaboration of COM-B 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

COM-B Theory Domains Physical capability Psychological capability Reflective motivation Automatic motivation Physical opportunity Social opportunity Physical skills Knowledge Cognitive and Interpersonal skills Memory, Attention and Decision processes Behavioural regulation Professional/Social Role & Identity Beliefs about Capabilities Optimism Beliefs about Consequences Intentions Goals Reinforcement Emotion Environmental Context and Resources Social Influences

Interview questions to identify relevant domains 1. Knowledge 2. Skills 3. Memory, attention and decision processes 4. Behavioural regulation 5. Professional/social role and identity 6. Beliefs about capabilities 7. Optimism 8. Emotion 9. Beliefs about consequences 10. Intentions 11. Goals 12. Reinforcement 13. Environmental context and resources 14. Social influences How difficult or easy is it for them to do x? What problems have they encountered? What would help them? How confident are they that they can do x despite the difficulties? How capable are they of maintaining x? How well equipped/comfortable do they feel to do x?

An example of using this approach to 1. understand an implementation problem 2. intervene to change the behaviour

Example: Using the Theory Domains Framework

GPs managing low back pain: Australia The implementation problem: 1. Too frequent referral for lumbar X-rays 2. Too infrequent recommendation to stay active McKenzie et al (2008) IMPLEmenting a clinical practice guideline for acute low back pain evidence-based management in general practice (IMPLEMENT): cluster randomised controlled trial study protocol, Implementation Science 3:11.

Assessing the problem Theoretical assessment of implementation problem Theory domain questions about the 2 GP behaviours 11 Focus Groups of 42 GPs Thematic analysis: barriers & enablers, GP & patient perspective Surveys based on interviews Intervention development: Matrix of domains and techniques Evaluation in cluster RCT

Interviews: Domains in which problems identified Skills Knowledge Beliefs about capabilities Environmental context and resources Professional role and identity Social influences Beliefs about consequences Emotion Motivation and goals Behavioural regulation Nature of the behaviours Memory and decision processes

Survey: Domains predicting intention to manage patients without x-ray Beliefs about capabilities 0.21 (0.11, 0.32), p=0.000 Beliefs about consequences 0.36 (0.25, 0.46), p=0.000 Social influences 0.28 (0.17, 0.38), p=0.000 Professional role 0.44 (0.30, 0.57), p=0.000 Behaviour Environment -0.03 (-0.07, 0.02), p=0.285 Knowledge -0.18 (-0.84, 0.48), p=0.590

Domains predicting intention to advise patients to stay active Beliefs about capabilities 0.24 (0.15, 0.33), p=0.000 Beliefs about consequences 0.12 (0.04, 0.21), p=0.003 Social influences 0.10 (0.02, 0.18), p=0.011 Professional role 0.21 (0.10, 0.32), p=0.000 Behaviour Environment 0.00 (-0.08, 0.09), p=0.965 Knowledge -0.03 (-0.17, 0.10), p=0.617 Memory 0.17 (0.05, 0.30), p=0.007

A system for designing effective behaviour change interventions 1. Which behaviour/s? 2. Understand the target behaviour/s 3. Consider full range of possible interventions 4. Identify specific behaviour change techniques

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

Interventions: activities designed to change behaviours Interventions

Intervention function Definition Intervention functions Example Education Increasing knowledge or understanding Providing information to promote healthy eating Persuasion Using communication to induce positive or negative feelings or stimulate action Using imagery to motivate increases in physical activity Incentivisation Creating expectation of reward Using prize draws to induce attempts to stop smoking Coercion Creating expectation of punishment or cost Raising the financial cost to reduce excessive alcohol consumption Training Imparting skills Advanced driver training to increase safe driving Restriction Environmental restructuring Modelling Enablement Using rules that limit engagement in the target behaviour or competing or supporting behaviour Changing the physical or social context Providing an example for people to aspire to or imitate Increasing means/reducing barriers to increase capability or opportunity Prohibiting sales of solvents to people under 18 to reduce use for intoxication Providing on-screen prompts for GPs to ask about smoking behaviour Using TV drama scenes involving safe-sex practices to increase condom use Behavioural support for smoking cessation, medication for cognitive deficits, surgery to reduce obesity, prostheses to promote physical activity

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

Policy categories Policy category Example Example Communication / marketing Using print, electronic, telephonic or broadcast media Conducting mass media campaigns Guidelines Fiscal Creating documents that recommend or mandate practice. This includes all changes to service provision Using the tax system to reduce or increase the financial cost Producing and disseminating treatment protocols Increasing duty or increasing antismuggling activities Regulation Establishing rules or principles of behaviour or practice Establishing voluntary agreements on advertising Legislation Making or changing laws Prohibiting sale or use Environmental/ social planning Designing and/or controlling the physical or social environment Using town planning Service provision Delivering a service Establishing support services in workplaces, communities etc.

An approach to developing behaviour change interventions Use Behaviour Change Wheel to select broad categories of intervention type Use Taxonomy of Behaviour Change Techniques to select active ingredients aimed at bringing about behaviour change

Linking COM-B to intervention functions Ed Pers Inc Coer Tra Res Env Mod Ena CPh CPs OPh OSo MA MR

Intervening to change GP management of lower back pain CPh CPs OPh OSo MA MR Ed Pers Inc Coer Tra Res Env Mod Ena

Interventions are made up of specific behaviour change techniques (BCTs) 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 15. General encouragement 16. Contingent rewards 17. Teach to use cues 18. Follow up prompts will be performed. 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 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 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). A taxonomy of behavior change techniques used in interventions. Health Psychology.

Which intervention techniques appropriate for which domain? 35 techniques identified from behaviour change literature Independently mapped by 4 behavioural and implementation researchers Which behaviour change techniques would you use as part of an intervention to change each construct domain? 71% agreement Michie, Johnston, Francis, Hardeman & Eccles (2008) Applied Psychology: an International Review, 57, 660-680

Technique for behaviour change Social/ Professional role & identity Knowledge Skills Beliefs about capabilities Beliefs about consequence s Motivatio n and goals Memory, attention, decision processes Environment al context and resources Social influence s Emotio n Action planning Goal/target specified: behaviour or outcome 1 2 1 3 2 3 1 3 1 3 3 3 3 1 1 1 1 1 1 3 2 3 3 Monitoring 1 2 3 3 3 1 2 2 1 2 2 1 2 2 1 2 2 2 1 2 2 1 1 2 Self-monitoring 2 3 3 3 3 2 3 3 2 2 2 1 3 2 1 2 2 3 2 1 3 Contract 2 1 1 1 1 1 2 3 1 2 2 3 2 2 2 2 Rewards; incentives (inc Self-evaluation) 1 2 1 1 3 3 3 2 1 2 1 2 2 3 3 3 1 1 2 1 1 2 1 2 1 2 1 1 Graded task, starting with easy tasks 1 1 3 3 2 2 2 3 2 2 3 2 2 1 2 1 1 1 1 2 1* Increasing skills: problem solving, decision making, goal setting 1 2 3 3 3 3 2 2 3 2 1 2 3 2 1 2 1 2 3 1 Stress management 1 1 2 1 1 1 1 1 2 1 1 2 1 1 3 3 2 1 1 Coping skills 1 2/3 3 1 2 2 2 1 1 1 1 1 1 3 2 2 1/2 Rehearsal of relevant skills 1 3 3 3 3 2 3 2 2 1 2 1 3 2 3 1 1

An approach to developing behaviour change interventions

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

Which policy categories should be used? Ed Pers Inc Coer Tra Res Env Mod Ena Com Guid Fisc Reg Leg Envir Serv

Modes of delivery Face-to-face Individual Group Distance Population-level Mass-media: internet, TV, radio, billboard, print media, leaflet Individually-tailored Phone: helpline, text, app. Individually accessed computer programme

An approach to developing behaviour change interventions

Considerations when selecting interventions, mode of delivery and policy categories Evidence of effectiveness Local relevance Practicability Affordability Acceptability o public o professional o political

The GP back management intervention Delivered to GPs as Educational small group workshops Increase knowledge Led by GP facilitator Social influence Behaviour change techniques persuasive communication Change beliefs about consequences modelling, role playing and rehearsal scripting, action planning Increase skills and beliefs about capabilities

The GP back management intervention educational workshops Increase knowledge GP facilitator Social influence persuasive communication Change beliefs about consequences modelling, role playing and rehearsal scripting, action planning Increase skills and beliefs about capabilities

Summary Start by understanding the problem Identifying the behaviours Who, what, where, when Understand the behaviours Drawing on theories of behaviour Then identify the techniques and the strategy Consider the full range of effective strategies to use when working with colleagues to implement guidance

Extra slide

Education: Increasing knowledge or understanding Restrictions: Using rules to reduce the opportunity to engage in the target behaviour Environmental restructuring: Changing the physical or social context Modelling: Providing an example for people to aspire to or imitate Enablement: Increasing means/reducing barriers to increase capability (beyond education and training) or opportunity Interventions: activities designed to change behaviours (beyond environmental restructuring) Training: Imparting skills Coercion: Creating an expectation of punishment or cost Incentivisation: Creating an expectation of reward Persuasion: Using communication to induce positive or negative feelings or stimulate action