Understanding and changing workplace health behaviour: The case of physical activity

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1 Understanding and changing workplace health behaviour: The case of physical activity Dr Benjamin Gardner Lecturer in Health Psychology University College London, UK 27 th & 28 th May 2014

2 Understanding and changing workplace health behaviour Dr Benjamin Gardner Lecturer in Health Psychology University College London, UK 27 th & 28 th May 2014

3 Understanding and changing health behaviour Dr Benjamin Gardner Lecturer in Health Psychology University College London, UK 27 th & 28 th May 2014

4 Understanding and changing behaviour Dr Benjamin Gardner Lecturer in Health Psychology University College London, UK 27 th & 28 th May 2014

5 Overview of topics The importance of behaviour for health A systematic approach to behaviour change The Behaviour Change Wheel and COM-B model Conducting a behavioural diagnosis Identifying intervention options A brief word on the importance of evaluation 5

6 Deaths attributable to lifestyle factors, USA Tobacco 21% Overweight 10% Physical inactivity 7% High cholesterol 5% High salt 4% Alcohol use 4% Low fruit and veg intake 3% Danaei et al (2009) 6

7 Health behaviours Activities that may help to prevent disease, detect disease and disability at an early stage, promote and enhance health, or protect from risk of injury (Steptoe, Gardner & Wardle, 2010) 7

8 Health behaviours in the workplace Food and drink consumption Smoking Health and safety behaviours Overworking Physical activity Sedentary behaviour 8

9 Sedentary behaviour: The new workplace health-risk behaviour Physical inactivity = not doing enough physical activity Sedentary behaviour = activities done in a seated or reclined posture, which involve minimal energy expenditure e.g. working at the office desk These are independent health risk factors 9

10 Sedentary behaviour: The new workplace health-risk behaviour Even when controlling for physical activity, sedentary behaviour is associated with: higher all-cause mortality, cardiovascular disease, cancer, diabetes Office workers are often highly sedentary 10

11 Weekday sedentary time in UK office workers Smith et al (in prep) 11

12 GROUP TASK 1 Choose a workplace health behaviour Brainstorm ideas for an intervention to change the behaviour 12

13 Health behaviours in the workplace Food and drink consumption Smoking Health and safety behaviours Overworking Physical activity Sedentary behaviour 13

14 How do we change behaviour? The traditional approach Information on importance of behaviour Behaviour change 14

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17 ISLAGIATT interventions Most interventions are based on unstated assumptions regarding causes of behaviour and what needs to change It Seemed Like A Good Idea At The Time Is this really the best we can do? 17

18 Some assumptions underlying these interventions Employees may not realise that the behaviour affects their health Health is the employee s priority Employees share the same values as employers People are rational and deliberative informationprocessors Whose assumptions are these? What evidence exists around these? 18

19 GROUP TASK 2 Look back at your intervention idea What are your implicit assumptions around: Why people do (or do not do) the behaviour? Who needs to change their behaviour? How the behaviour can be changed? 19

20 What determines behaviour? A basic framework e.g. Gollwitzer (1991) Action stages MOTIVATION VOLITION ACTION Motivation: wanting or needing to do an action Volition: acting on motivation 20

21 Volitional strategies to change behaviour (in relation to physical activity) Action planning Planning exactly what PA you will do and in what context Self-monitoring (internal feedback) Keeping a record of your PA and/or progress Providing (external) feedback on performance Informing the employee of their PA and/or progress Reviewing behavioural goals Deciding whether to change your PA goal in light of your progress 21

22 Is motivation always the problem? (Michie et al, 2009) Which techniques are most effective in changing diet and physical activity? Self-monitoring most effective Combining self-monitoring with action planning, reviewing goals or external feedback almost twice as effective People may need volitional, not motivational, support 22

23 The Behaviour Change Wheel Michie et al (2011, 2014) 23

24 Three layers of the wheel Michie et al (2011) Determinants of behaviour (COM-B) Describes what needs to change Intervention functions Describes appropriate ways to bring about change Policies Describes policy categories for implementing appropriate interventions 24

25 The COM-B framework Michie, van Stralen & West (2011) 25

26 Sub-components of COM Capability Physical capability Psychological capability Opportunity Physical opportunity Social opportunity Motivation Reflective motivation Non-reflective/automatic motivation 26

27 Conducting a behavioural diagnosis Michie et al (2014) What behaviour(s) need to be changed? What needs to change C, O, M? 27

28 An example: Reducing workplace sedentary behaviour (What is the desired outcome?) Reduction in sitting time What behaviour(s) need to change? Prolonged sitting at office desk without breaks Standing in the office Walking from desk to other areas 28

29 An example: Promoting standing in the office Capability Physically & psychologically capable of standing Opportunity Limited physical opportunity for standing while working Limited social opportunity for observing others standing Motivation Limited reflective motivation about importance of standing Limited automatic motivation: no routines or habits of standing 29

30 GROUP TASK 3 Leave your original intervention idea to one side. Focus on the behaviour itself. Conduct a COM-B analysis: Is the behavioural problem one of capability, opportunity, and/or motivation? 30

31 What should inform your COM-B analysis? Sources of evidence Need ground-level insight Speak to the people for whom the behaviour is relevant What are their priorities? Are there competing behaviours/priorities? Ideal sources: Experiments, surveys, interviews, focus groups 31

32 Does your target population always know best? People may give inaccurate information on COM barriers Knowingly or unknowingly Self-presentation, social desirability People do not always know what the barriers are Especially for non-reflective/automatic motivation May reveal their theories of the main barriers

33 Other potential sources of evidence Evidence from others involved in the behaviour? E.g. employers, managers Research studies? What has already been documented about barriers to the behaviour, effective techniques etc? Site visits? Are there any clear capability/opportunity barriers? Expert opinion? 33

34 GROUP TASK 4 What other sources could you realistically consult to inform your COM-B analysis? 34

35 Non-reflective influences on behaviour: Harnessing the built environment Perceived proximity of tea/coffee points predicts workplace standing time (Smith et al, in prep) Those closer to these points stood for ~2h more per week Stair avoidance is predicted by: Weight (heavier people less likely to use) Age (over 60s less likely to use) Luggage (people with bags less likely to use) Physical capacity predicts perceived steepness and effort expenditure greater physical cost (Eves et al, 2011) 35

36 Nudging Changing the choice architecture 36

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39 Nine intervention functions Michie et al (2011) Education Increasing knowledge or understanding e.g. Providing information to promote healthy eating Persuasion Using communication to induce positive or negative feelings to stimulate action e.g. Using imagery to motivate stair-climbing Incentivisation Creating expectation of reward e.g. Using prize draws to induce stop-smoking attempts 39

40 Nine intervention functions Michie et al (2011) Coercion Creating expectation of punishment or cost e.g. Raising price of unhealthy foods at work Training Imparting skills necessary to do behaviour e.g. Showing people how to use sit-stand desks Restriction Using rules to reduce or increase opportunities to do behaviour e.g. Banning smoking at the worksite 40

41 Nine intervention functions Michie et al (2011) Environmental restructuring Changing the physical or social context e.g. Providing sit-stand desks Modelling Providing an example for people to aspire to or imitate e.g. Video showing employee engaging in correct safety procedures Enablement Increasing means or reducing barriers to increase capability or opportunity e.g. Advising people on places to walk at the worksite 41

42 Moving from COM-B to functions Michie et al (2011) 42

43 An example Promoting standing at work Barriers identified by COM-B analysis Opportunity (phys & soc) and motivation (refl & auto) the main COM barriers Appropriate intervention functions Environmental restructuring (O-P & M-A) Education (M-R) Enablement (M-A, O-P, O-S) 43

44 A possible intervention to promote standing at work Introduction of sit-stand desks Environmental restructuring Provision of information on importance of standing vs sitting (poster & campaign) Education Individual consultations, and opportunity to monitor standing time with accelerometer and receive feedback Enablement 44

45 GROUP TASK 5 Based on your COM-B analysis, identify which intervention functions are most appropriate to use Start planning your intervention. How will you educate, persuade, incentivise, etc? Describe your intervention in as much detail as possible. 45

46 Moving from COM-B to functions Michie et al (2011) 46

47 Initiation vs maintenance Many interventions have only short-term effects Behaviour patterns return to baseline when active intervention ends (e.g. Jeffery et al, 1990) Will behaviour change be reversed when your intervention is withdrawn? 47

48 Habit formation as a means to maintenance Gardner, Lally & Wardle (2012) Promoting habit formation Repeat the behaviour consistently in the same context This strengthens context-behaviour association Behaviour becomes the default option Alternatives become less mentally accessible Behaviour comes to be automatically initiated by the context, rather than consciously and effortfully initiated 48

49 Habit formation in the workplace Lally, Wardle & Gardner (2011) Workplace stability lends itself to habit formation Dietary habits: I made myself start bringing in fruit and rice cakes to work, and the chocolate bar and chips completely went I would have my breakfast as soon as I got into the office. That was constant, Monday to Friday 49

50 Habit formation in the workplace Lally, Wardle & Gardner (2011) Physical activity habits: Every lunchtime I ve been out for a walk I found that if I walked from work to home, that wasn t actually that difficult. That s how I incorporated that into my routine Workdays are more predictable, so better for habit formation My last two weeks, I was on holiday and had takeaways every night. But since I ve been back at work, I ve got straight back into it 50

51 GROUP TASK 6 Does your intervention target initiation or maintenance? If applicable, how might your intervention be refined to promote maintenance? 51

52 Summary: Designing behaviour change interventions 1) Select the behaviour 2) Conduct a COM-B analysis, based on all available evidence 3) Map COM-B analysis to intervention functions 4) Select most appropriate intervention content 52

53 GROUP TASK 7 Look back over your COM-based intervention and compare with your original intervention idea. What are the main differences? 53

54 The importance of intervention evaluation Interventions must be evaluated Why? Increases knowledge on what works (or not) and why (not) Can prevent re-inventing the wheel Can provide input into COM-B analysis How? Obtain and compare pre- and post-intervention data Use same sample at both timepoints Employ a matched control group or a stepped wedge design 54

55 Conclusions Behaviour is important for health Too many behaviour change interventions are based on ISLAGIATT A systematic approach requires specifying what behaviour you are trying to change what needs to change for the behaviour to occur (COM-B) intervention functions appropriate to COM-B analysis Evaluating interventions builds knowledge 55

56 Want to know more? Week-long Summer School in London Hosted by world-leading experts in behaviour change, Profs Susan Michie and Robert West Opportunities for one-to-one support from experts 56

57 A new guide to behaviour change 57

58 Free online training programme on behaviour change techniques 58

59 Thank you 59