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 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.

To develop more effective interventions … We need to improve our scientific methods in the following areas: 1.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. 2.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”. 3.Match behaviour change techniques to mechanisms of action to inform theory-based intervention development and evaluation- based theory development. 4.Define the extent to which interventions, and comparison conditions, use theory and evaluate how this relates to effectiveness. 5.Develop a model of behaviour as a starting point for systematic, theory-based intervention development.

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

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

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) Example of the problem: Descriptions of “behavioural counselling” in two interventions Title of journal articleDescription 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)

Biomedicine vs behavioural science … example of smoking cessation effectiveness 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 Varenicline JAMA, 2006 Behavioural counselling Cochrane, 2005

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.

Behaviour change techniques: reliable taxonomy to 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 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. 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.

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, identified by –consulting textbooks for training applied psychologists in BC techniques Michie et al, Applied Psychology: An International Review, in interventions to reduce excessive alcohol use Three year MRC grant to put taxonomy approach onto a more scientific basis –Expert coders needed!

Applications of taxonomy approach 1.Identifying active ingredients in interventions –Meta-regression in evidence synthesis Physical activity & healthy eating Audit & Feedback 2.Investigating mechanisms of action (theoretical mediation) –The intervention “ProActive” 3.Designing interventions –A classification based on comprehensive coverage, coherence and a model of behaviour

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

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

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, 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,

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 Very heterogeneous effects (I 2 =79%) –not explained by 10 moderators examined e.g. Setting, population, intervention characteristics, target behaviour

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

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

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

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=0.60 vs d=0.26

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

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?

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)

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)

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

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.

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

Theory-based hypotheses Feedback more effective when goal/target is set Most effective where goal/target and action plan 1.Feedback only Effective 2.Feedback + goal More effective 3.Feedback + goal + action plan Most effective

Modes of delivery Feedback only Feedback + goal Feedback + goal + action plan Additional BCTs –73 interventions & 34 control arms Behaviour change techniques 61 comparisons 8 comparisons 3 comparisons 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 A&F –(individual recipients) AND ((verbal format) OR (a supervisor or senior colleague as the source)) AND (moderate or prolonged feedback)

Results Meta-analysis: –A&F effective: OR = 1.43 (95% CI = 1.28, 1.61) –Moderate to strong heterogeneity (I 2 = 61%) Meta-regression: –Feedback vs Feedback + Goal &/or Action plan 61 vs 24 comparisons, adj. p = 1.0 ?power –Additional BCTs (intervention) p =.006

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

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

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, 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,

Intervention techniques 1.Give information 2.Elicit questions 3.Summarise message 4.Set goals 5.Self-monitor 6.Build motivation 7.Action plans 8.Use prompts 9.Use rewards 10.Build support 11.Review goals 12.Build habits 13.Relapse prevention 14.Generalise skills Theories 1.Theory of Planned Behaviour 2.Relapse Prevention Theory 3.Self-regulation Theory 4.Operant Learning Theory

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

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

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

Percentage of techniques delivered by professionals 45% %

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

Consensus of at least 3 of 4 raters for: TechniquesTheory 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

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

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

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 AttitudeTheory of Planned Behaviour Parking car further away so has to walk further Action planSelf-regulation Theory Asking partner to remind him Cue to actionOperant Learning Theory

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

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

To develop more effective interventions … We need to improve our scientific methods in the following areas: 1.Specify intervention content in sufficient detail … 2.Apply theories of behaviour change to intervention development and evaluation, and to evidence syntheses 3.Match behaviour change techniques to mechanisms of action … 4.Define the extent to which interventions, and comparison conditions, use theory and evaluate how this relates to effectiveness. 5.Develop a model of behaviour as a starting point for systematic, theory-based intervention development.

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

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.

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?

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

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

Results: application of theory (n=92)

Theory use and effectiveness No association between theory use and intervention effectiveness Types of theory –27 Transtheoretical Model –8 Relapse Prevention Model –1 Lazarus & Folkman’s model of stress –1 compared Relapse Prevention Model with Health Belief Model

Results: BCTs associated with intervention effectiveness Two BCTs were associated with intervention effectiveness in psychological interventions –Facilitate restructuring of social life (β=.56, R²=13.18%, p=.02) –Advise on/facilitate use of social support (β=.37, R²=3.45% p=.02)

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.

Use of Theory kQ95% CId+d+ Theory used to select recipients to Group of intervention techniques linked to group of constructs to Theory used to select intervention techniques to Targeted construct mentioned as predictor of behaviour to Theory used to tailor intervention techniques to recipients to Theory or model of behaviour mentioned to At least one intervention technique is linked to theory to Intervention based on single theory to All constructs are linked to intervention techniques to At least one construct is linked to an intervention technique to All intervention techniques are linked to theory 2

Use of theory associated with effect size Effect size =

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

To develop more effective interventions … We need to improve our scientific methods in the following areas: 1.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. 2.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”. 3.Match behaviour change techniques to mechanisms of action to inform theory-based intervention development and evaluation- based theory development. 4.Define the extent to which interventions, and comparison conditions, use theory and evaluate how this relates to effectiveness. 5.Develop a model of behaviour as a starting point for systematic, theory-based intervention development.

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

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

The Behaviour System: Behaviour emerges from interactions between …. Opportunity Capability Motivation Behaviour Psychological or physical ability to enact the behaviour Reflective and non-reflective mechanisms that activate or inhibit behaviour Physical and social environment that enables the behaviour

The Behaviour System: CMOB Opportunity Capability Motivation Behaviour Capability, Motivation and Opportunity must be present for a Behaviour to occur The system is in dynamic equilibrium and a change in behaviour may require a sustained change in one or more of the other elements

The Behaviour Change Wheel: A system for choosing interventions and policies Behaviour source Interventions: activities designed to change behaviours Policies: decisions made by authorities concerning interventions Capability Opportunity Motivation Physical Psychol- ogical Reflec- tive Non reflect- ive Physical Social

Motivation Beliefs about what is good and bad, conscious intentions and decisions as per e.g. Theory of Planned Behaviour Emotional responses, desires and habits resulting from associative learning and physiological states Non- reflective Reflective Reflective-Impulsive Model, Strack & Deutsch, 2004 PRIME Theory of Motivation, West, 2006

The Behaviour Change Wheel Behaviour source Intervention categories Policy categories Persuasion Education Coercion Environmental restructuring Incentivisation Enablement/ resources Capability Opportunity Motivation Training Restriction Modelling Physical Psychol- ogical Reflec- tive Non reflect- ive Physical Social Behaviour system influenced by an intervention system which is enabled and/or supported by a policy system

Intervention categories EducationImparting knowledge e.g. on health risks PersuasionUsing communication to induce belief or knowledge IncentivisationCreating expectation of reward CoercionCreating expectation of punishment or cost TrainingImparting skills RestrictionReducing availability Environmental restructuring Changing the physical context ModellingProviding an example for people to aspire to Enablement/ resources Increasing means/reducing barriers

The Behaviour Change Wheel Behaviour source Intervention categories Policy categories Regulation Environmental/ social planning Communication/ marketing Legislation Fiscal Persuasion Education Coercion Environmental restructuring Incentivisation Enablement/ resources Capability Opportunity Motivation Training Restriction Service provision Guidelines Modelling Physical Psychol- ogical Reflec- tive Non reflect- ive Physical Social

Policy types Communication/ marketingUsing print, electronic, telephonic or broadcast media GuidelinesCreating documents that recommend or mandate practice FiscalUsing the tax system RegulationEstablishing rules or principles of behaviour or practice LegislationMaking or changing laws Environmental/ social planning Designing and/or controlling the physical or social environment Service provisionDelivering a service

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

More information from “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,