Changing Health Related Behaviour: What is the Role of Behavioural Science in Improving Public Health?

Transcription

1 Changing Health Related Behaviour: What is the Role of Behavioural Science in Improving Public Health? Falko Sniehotta, PhD Reader in Health Psychology

2 Where and how to intervene Individual interventions reduce motivation to engage in unhealthy behaviours increase motivation to engage in healthy behaviours motivation into action and sustain healthy behaviours (behavioural skills) enhance self-regulation Societal interventions attitudes and culture incentive structures restrict or enhance opportunities Dynamic process of interactionbetween societal and individual level. E.g. walking/cycling: motivation + opportunities Behaviour change at population, community and individual levels : NICE review 2007

3 Three models of intervention development and implementation 1. RE-AIM (Glasgow et al., 2001) 2. Precede Proceed Model (Green & Kreuter, 1992) 3. MRC Guidance for the development and evaluation of complex interventions for health (Craig et al., 2008)

4 RE-AIM: A model of sustainable implementation of effective, generalisable, evidence-based interventions. Reach-How do we reach the targeted population with the intervention? Efficacy-How do we know our intervention is effective? Adoption-How do we develop organizational support to deliver our intervention? Implementation-How do we ensure the intervention is delivered properly? Maintenance-How do we incorporate the intervention so that it is delivered over the long term? Glasgow et al. (2001) The RE-AIM Framework for Evaluating Interventions: What Can It Tell Us about Approaches to Chronic Illness Management? Pt Educ Couns 2001;44:

5 Green and Kreuter's (2005) Precede Proceed model of health program planning Green, L.W., Kreuter, M. W. (1992). CDC's Planned Approach to Community Health as an application of PRECEDE and an inspiration for PROCEED. Journal of Health Education 23:

6 Development and Evaluation of complex interventions the new MRC model Craig et al., 2008; BMJ

7 Structure of the evidence base Interventions for behaviour change interventions Behavioural determinants e.g. cognitive, social, motivational & environmental Behaviour e.g., exercise; physical activity Physiological & biochemical variables e.g. neurological & muscular processes Health outcomes health, mobility and quality of life Hardeman, et al. (2005) A causal modelling approach to the development of theory-based behaviour change programmes for trial evaluation. Health Education Research, 20(6):

8 Determinants of health

9 Structure of the evidence base Interventions for behaviour change interventions Behavioural determinants e.g. cognitive, social, motivational & environmental Behaviour e.g., exercise; physical activity Physiological & biochemical variables e.g. neurological & muscular processes Health outcomes health, mobility and quality of life Hardeman, et al. (2005) A causal modelling approach to the development of theory-based behaviour change programmes for trial evaluation. Health Education Research, 20(6):

10 Effects of behavioural interventions on Interventions health Good evidence from systematic reviews of RCTs for effectiveness of behavioural interventions on all outcome levels Key challenges: Considerable heterogeneity of effect sizes Small to medium effects Lack of sustainability Behavioural determinants e.g. cognitive, social, motivational & environmental Behaviour e.g., exercise; physical activity Physiological & biochemical variables e.g. neurological & muscular processes Health outcomes health, mobility and quality of life Hardeman, et al. (2005) A causal modelling approach to the development of theory-based behaviour change programmes for trial evaluation. Health Education Research, 20(6):

11 What is a complex intervention? Number of interacting components Number and difficulty of behaviours involved Number of groups or organisational levels targeted Number and variability of outcomes Degree of flexibility or tailoring permitted

12 Features of Behaviour Change interventions 1. Behaviour change techniques(bcts), e.g., prompt goal setting or self-monitoring of behaviour 2. Modes of delivery, e.g., individual vs. group delivery; intensity, duration, technology use, materials, facilitator variables, etc 3. Theory: theoretical mediators, rationale for combining elements, cover story of intervention 4. Procedural and clinical features: e.g., techniques and features to establish rapport, adherence, communication and fidelity as well as facilitator skills, features and training. Abraham & Michie, 2008; Hardeman et al., 2002; Araújo-Soares et al., 2009; French et al (submitted)

13 Features of Behaviour Change interventions 1. Behaviour change techniques(bcts), e.g., prompt goal setting or self-monitoring of behaviour 2. Modes of delivery, e.g., individual vs. group delivery; intensity, duration, technology use, materials, facilitator variables, etc 3. Theory: theoretical mediators, rationale for combining elements, cover story of intervention 4. Procedural and clinical features: e.g., techniques and features to establish rapport, adherence, communication and fidelity as well as facilitator skills, features and training. Abraham & Michie, 2008; Hardeman et al., 2002; Araújo-Soares et al., 2009; French et al (submitted)

14 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 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 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 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. The person is asked to keep a record 25. Motivational of specified interviewing behaviour/s. This 26. could Time e.g. management take the form of a diary or completing a questionnaire about their behaviour.

15 CALO-RE taxonomy for diet and PA 1. Provide information on consequences of behaviour in general 2. Provide information on consequences of behaviour for the 3. Individual 4. Provide information about others' approval 5. Provide normative information about others' behaviour 6. Goal setting (behaviour) 7. Goal setting (outcome) 8. Action planning 9. Barrier identification/problem solving 10. Set graded tasks 11. Prompt review of behavioural goals 12. Prompt review of outcome goals 13. Reinforcing effort or progress towards behaviour 14. Provide rewards contingent on successful behaviour 15. Shaping 16. Prompting generalisation of a target behaviour 17. Prompt self-monitoring of behaviour 18. Prompt self-monitoring of behavioural outcome 18. Prompting focus on past success 19. Provide feedback on performance 20. Provide instruction 21. Model/ Demonstrate the behaviour 22. Teach to use prompts/ cues 23. Environmental restructuring 24. Agree behavioural contract 25. Prompt practice 26. Use of follow up prompts 27. Facilitate social comparison 28. Plan social support/ social change 29. Prompt identification as role model/ position advocate 30. Prompt anticipated regret 31. Fear Arousal 32. Prompt Self talk 33. Prompt use of imagery 34. Relapse prevention/ Coping planning 35. Stress management 36. Emotional control training 37. Motivational interviewing 38. Time management 39. General communication skills training 40. Provide non-specific social support Michie, Ashford, Sniehotta, Dombrowski, Bishop & French (in press Psychology & Health)

16 1. Goal: set behavioural goal 2. Standard: decide target standard of behaviour (specified and observable) 3. Monitoring: record specified behaviour (person has access to recorded data ofbehavioural performance e.g. from diary) 4. Record antecedents and consequences of behaviour (social and environmental situations and events, emotions, cognitions) 5. Feedback: of monitored (inc. self-monitored) behaviour 6. Comparison: provide comparative data (cf. standard, person s own past behaviour, others behaviour) 7. Social comparison: provide opportunities for social comparison e.g. contests and group learning 8. Discrepancy assessment: highlight nature of discrepancy (direction, amount) between standard, own or others behaviour (goes beyond simple self-monitoring) 9. Contract: of agreed performance of target behaviour with at least one other, written and signed 10. Planning: identify component parts of behaviour and make plan to execute each one or consider when and/or where a behaviour will be performed, i.e. schedule behaviours (not including coping planning see Coping planning: identify and plan ways of overcoming barriers (note, this must include identification of specific barriers e.g. problem-solving how to fit into weekly schedule would not count) 12. Goal review: assess extent to which the goal/target behaviour is achieved, identify the factors influencing this and amend goal if appropriate 13. Discriminative (learned) cue: environmental stimulus that has been repeatedly associated with contingent reward for specified behaviour 14. Prompt: stimulus that elicits behaviour (inc. telephone calls or postal reminders designed to prompt the behaviour) 15. Reward: contingent valued consequence, i.e. if and only if behaviour is performed (inc. social approval, exc. general non-contingent encouragement or approval) 16. Punishment: contingent aversive consequence, i.e. if and only if behaviour is not performed 17. Omission: contingent removal of valued consequence, i.e. if and only if behaviour is not performed 18. Negative reinforcement: contingent removal of aversive consequence, i.e. if and only if behaviour is performed 19. Threat: offer future punishment or removal of reward contingent on performance 20. Fear arousal: induce aversive emotional state associated with the behaviour 21. Anticipated regret: induce expectations of future regret about non-performance of behaviour 22. Graded tasks: set easy tasks to perform, making them increasingly difficult until target behaviour performed 23. Instruction: teach new behaviour required for performance of target behaviour (not as part of graded hierarchy or as part of modelling) e.g. give clear instructions 24. Shaping: build up behaviour by initially reinforcing behaviour closest to required behaviour and systematically altering behaviour required to achieve contingent reinforcement 25. Chaining: build up behaviour by starting with final component; gradually add components earlier in sequence 26. Behavioural rehearsal: perform behaviour (repeatedly) 27. Mental rehearsal: imagine performing the behaviour repeatedly 28. Habit formation: perform same behaviour in same context 29. Role play: perform behaviour in simulated situation 30. Behavioural experiments: testing hypotheses about the behaviour, its causes and consequences, by collecting and interpreting data 31. Modelling: observe the behaviour of others 32. Vicarious reinforcement: observe the consequences of others behaviour 33. Self talk: planned self-statements (aloud or silent) to implement behaviour change techniques 34. Imagery: use planned images (visual, motor, sensory) to implement behaviour change techniques (inc. mental rehearsal) 35. Cognitive restructuring: changing cognitions about causes and consequences of behaviour 36. Relapse prevention: identify situations that increase the likelihood of the behaviour not being performed and apply coping strategies to those situations 37. Behavioural information: provide information about antecedents or consequences of the behaviour, or connections between them, or behaviour change techniques 38. Personalised message: tailor techniques or messages from others to individual s resources and context (includes stages of change-based information; doesn t include personal plans and feedback) 39. Verbal persuasion/persuasive communication: credible source presents arguments in favour of the behaviour. Note, there must be evidence of presentation of arguments; general pro-behaviour communication does not count. 40. Social support (instrumental): others perform component tasks of behaviour or tasks that would compete with behaviour e.g. offering childcare 41. Social support (emotional): others listen, provide empathy and give generalised positive feedback 55. Anti-depression skills training 56. Biofeedback 57. Differential reinforcement 58. Escape 59. Extinction 60. Flooding 61. Group contingencies 62. Implosive therapy 63. Avoidance 64. Counter-conditioning 65. Distraction 66. Exposure 67. Fading; thinning 68. Flooding in imagination 69. Habit reversal 70. Negative punishment 71. Non-contingent delivery of reinforcing stimuli 72. Overcorrection 73. Peer-administered contingencies 74. Problem identification 75. Rational emotive therapy 76. Reinforcer sampling 77. Response cost 78. Response priming 79. Satiation 80. Screening 81. Social skills training 82. Stress inoculation program 83. Symbolic desensitisation 84. Thought stopping 85. Time out 86. Token economy 87. Activity scheduling 88. Adventitious reinforcement/superstitious conditioning 89. Altering antecedent chains 90. Anger control training 91. Assertion training 92. Buddy system 93. Clarification (supportive therapy) 94. Classical conditioning 95. Community reinforcement 96. Covert conditioning 97. Covert sensitisation 98. Deflection techniques 99. Discrimination training 100. Emetic therapy 101. Encounter (existential analysis) 102. Fishbowl 103. Fogging 104. Functional communication training 105. Functional family therapy 106. Identification (psychoanalysis) 107. Instigation 108. Interpretation (psychoanalysis) 109. Least-to-most prompting 110. Lottery 111. Most to least prompt sequences 112. Motivational techniques 113. Multiple exemplar training (generalisation) 114. Natural maintaining contingencies (generalisation) 115. Negotiation training 116. Paradoxical instructions 118. Positive reinforcement 119. Positive scanning 120. Premackian reinforcers 121. Rate reduction 122. Reassurance (supportive therapy) 123. Recapitulation 124. Reframing 125. Reinforcer displacement 126. Response priming 127. Restitution 128. Rule release 129. Self-exploration 130. Self-help 131. Small group exercises 132. Stimulus generalisation 133. Stimulus narrowing 134. Systematic rational conditioning 135. Thinning 136. Turtle technique 137. Vicarious punishment Michie et al., (2008) Applied Psychology: An International Review

17 Identifying Effective Change Techniques in Interventions Designed to Promote Physical Activity and Healthy Eating Systematic review and meta-analysis 84 interventions average of 6 techniques small effect d = 0.37 (95% CI 0.29 to 0.54, N= 28,838) self-monitoring associated with effectiveness (14.6% variance explained). Interventions including this technique had a medium effect size of d= Interventions combining self-monitoring with at least one other technique derived from control theory were more than twice as effective as the other interventions with d= 0.60 d= 0.26 respectively Michie S, et al (in press) Identifying Effective Techniques in Interventions: A meta-analysis and meta-regression Health Psychology

18 Features of Behaviour Change interventions 1. Behaviour change techniques(bcts), e.g., prompt goal setting or self-monitoring of behaviour 2. Modes of delivery, e.g., individual vs. group delivery; intensity, duration, technology use, materials, facilitator variables, etc 3. Theory: theoretical mediators, rationale for combining elements, cover story of intervention 4. Procedural and clinical features: e.g., techniques and features to establish rapport, adherence, communication and fidelity as well as facilitator skills, features and training. Abraham & Michie, 2008; Hardeman et al., 2002; Araújo-Soares et al., 2009; French et al (submitted)

19 Modes of delivery Face to face vs. telephone vs. online Group vs. single intervention Nurse delivered vs. GP delivered Home based vs. hospital based Use of materials Duration, intensity, frequency, lengths etc. Training of facilitator Etc

20 Features of Behaviour Change interventions 1. Behaviour change techniques(bcts), e.g., prompt goal setting or self-monitoring of behaviour 2. Modes of delivery, e.g., individual vs. group delivery; intensity, duration, technology use, materials, facilitator variables, etc 3. Theory: theoretical mediators, rationale for combining elements, cover story of intervention 4. Procedural and clinical features: e.g., techniques and features to establish rapport, adherence, communication and fidelity as well as facilitator skills, features and training. Abraham & Michie, 2008; Hardeman et al., 2002; Araújo-Soares et al., 2009; French et al (submitted)

21 Why theory? What does theory do? Enables cumulative science Provides a shared language Summarises known evidence Explains observations Allows prediction Enables intervention Problem of implicit theory a theory is a set of statements that organizes, predicts and explains observations; it tells you how phenomena relate to each other, and what you can expect under still unknown conditions Bem, S and Looren de Jong, H (1997) Theoretical issues in Psychology, Sage publications: London. p. 15

22 How does Theory help in developing and delivering interventions? Identify targets (e.g., cognitive or social determinants of behaviour) Suggest behaviour change techniques Suggest sequences or combinations of techniques and determinants Allows for tailoring of interventions (e.g., stage theories such as the TTM / stages of change model Evidence very weak! Provides a cover story for intervention content

23 Choosing a theoretical approach many theories of behaviour 33 theories and 128 constructs generated In four overlapping areas: motivation action organisation behaviour change Simplified into 11 domains of theoretical constructs Interview questions associated with each domain Michie, S., Johnston, M., Abraham, C., Lawton, R., Parker, D. and Walker, A. (2005) Making psychological theory useful for implementing evidence based practice: a consensus approach, Quality and Safety in Health Care, 14,

24 Motivation theories explain why people want to do things Theory of Planned Behaviour Theory of Reasoned Action Protection Motivation Theory Health Belief Model) Social Cognitive Theory Locus of control theories Social Learning Theory Social Comparison Theory Cognitive Adaptation Theory Social Identity Theory Elaboration Likelihood Model Goal Theories Intrinsic Motivation Theories Self-determination theory Attribution Theory Decision making theories eg. social judgment theory, fast and frugal model, systematic vs. heuristic decision making Fear arousal theory

25 Action theories explain why people do things Learning theory Operant theory Modelling Self-regulation theory Implementation theory/automotive model Goal theory Volitional control theory Social cognitive theory Cognitive Behaviour therapy Transtheoretical model Social identity theory

26 Organisation theories explain how groups and organisations influence what people feel and do Effort-reward imbalance Demand-control model Diffusion theory Group theory eg. group minority theory Decision making theory Goal theory Social influence Person situation contingency models

27 Simplifying theory: domains of behavioural determinants 1. Knowledge 2. Skills 3. Role and identity 4. Beliefs about capabilities 5. Beliefs about consequences 6. Motivation and goals 7. Memory, attention and decision processes 8. Environmental context and resources 9. Social influences 10. Emotion 11. Plans Self-efficacy Control of behaviour, and material and social environment Perceived competence Self-confidence Empowerment Self-esteem Perceived behavioural control Optimism/pessimism Michie, S., Johnston, M., Abraham, C, Parker, Lawton, R, Walker,A (2005) Making psychological theory useful for implementing evidence based practice: a consensus approach. Quality in Health Care, 14,

28 Buildings blocks of behaviour change Self-regulation Self-monitoring Awareness of standards Means and skills Planning Action Planning Coping Planning Motivation Attitudes Perceived Norms Self-efficacy Emotion Knowledge & Skills Environment & Social influence

29 Buildings blocks of behaviour change Self-regulation Self-monitoring Awareness of standards Means and skills Planning Action Planning Coping Planning Motivation Attitudes Perceived Norms Self-efficacy Emotion Knowledge & Skills Environment & Social influence

30 Buildings blocks of behaviour change Implemental phase Self-regulation Self-monitoring Awareness of standards Means and skills Planning Action Planning Coping Planning Decisional phase Motivation Attitudes Perceived Norms Self-efficacy Emotion Knowledge & Skills Environment & Social influence

31 Buildings blocks of behaviour change Implemental phase Self-regulation Self-monitoring Awareness of standards Having means and skills Planning Action Planning Coping Planning How can I change? Decisional phase Motivation Attitudes Perceived Norms Self-efficacy Emotion Would I like to change? Knowledge & Skills Environment & Social influence

32 Features of Behaviour Change interventions 1. Behaviour change techniques(bcts), e.g., prompt goal setting or self-monitoring of behaviour 2. Modes of delivery, e.g., individual vs. group delivery; intensity, duration, technology use, materials, facilitator variables, etc 3. Theory: theoretical mediators, rationale for combining elements, cover story of intervention 4. Procedural and clinical features: e.g., techniques and features to establish rapport, adherence, communication and fidelity as well as facilitator skills, features and training. Abraham & Michie, 2008; Hardeman et al., 2002; Araújo-Soares et al., 2009; French et al (submitted)

33 The problem with behaviour change Attempts to change people s behaviour are often geared towards: Raising Knowledge (lecturing) Did you know that Providing Advice (instructing) Why don t you Motivating (scaring) If you don t then

34

35 Persuasive communications and targeted cognitions: UK safer sex leaflets 1. disease severity 2. knowledge/info 3. susceptibility 4. self-efficacy others attitudes 6. attitudes to behaviour 7. intention to change Impact on behaviour (correlation) Average number of messages in UK health leaflets Abraham, C., Krahé, B., Dominic, R., & Fritsche, I. (2002). Does research into the social cognitive antecedents of action contribute to health promotion? A content analysis of safer-sex promotion leaflets. British Journal of Health Psychology, 7,

36 Stroke Cancer of mouth, throat, oesophagus Cancer of larynx Coronary heart disease COPD Asthma exacerbations Lung Cancer Pancreatic Cancer Peptic ulcer Bladder Cancer Osteoporosis Cervical Cancer Peripheral artery disease Health Risks

37 Other effects of smoking Yellowing of teeth/fingers Hair, skin, breath and clothes smell of tobacco Skin around eyes and mouth wrinkled Reduced fertility Increase risk LBW baby Increased risk spontaneous abortion Increased risk premature labour Cost (20 cigs/day costs 1000 per year)

38 The benefits of quitting Within hours... 8hours Nicotine and carbon monoxide levels halved, Blood oxygen levels return to normal 24hours Carbon monoxide eliminated from the body 48hours Nicotine eliminated from the body, Taste buds start to recover Action on Smoking and Health (ASH) Factsheet Number 11: Stopping Smoking.

39 The benefits of quitting Within months... 1month Appearance improves skin loses greyish pallor, less wrinkled Regeneration of respiratory cilia starts Withdrawal symptoms have stopped 3-9months Coughing and wheezing decline Action on Smoking and Health (ASH) Factsheet Number 11: Stopping Smoking.

40 The benefits of quitting Within years... 5years The excess risk of a heart attack reduces by half 10years The risk of lung cancer halved Action on Smoking and Health (ASH) Factsheet Number 11: Stopping Smoking.

41 The Sums Certain short term consequences are often more Smoking important is bad for for you decision making than uncertain long term + consequences Giving up smoking is good for you = ¼of people smoke?

42 Designing interventions Start from an analysis of the nature of the behaviour to be changed 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) and linked to a model of behaviour Systematic review identified 18 existing frameworks, none met all these criteria Michie, van Straalen & West 2010

43 The Behaviour Change Wheel Service provision Behaviour source Regulation Intervention type Policy type Modelling Fiscal Restriction Education Training Capability Persuasion Environmental/ social planning Legislation restructuring CoercionEnvironmental Psychological Reflective Motivation Incentivisation Non reflective Physical Opportunity Social Physical Enablement/ resources Communication/ marketing Guidelines Michie, van Straalen & West 2010

44 Intervention types Education Persuasion Imparting knowledge e.g. on health risks Using communication to induce belief or knowledge Incentivisation Creating expectation of reward Coercion Training Restriction Environmental restructuring Modelling Enablement/ resources Creating expectation of punishment or cost Imparting skills Reducing availability Changing the physical context Providing an example for people to aspire to Increasing means/reducing barriers

45 Policy types Communication/ marketing Guidelines Fiscal Regulation Legislation Environmental/ social planning Service provision Using print, electronic, telephonic or broadcast media Creating documents that recommend or mandate practice Using the tax system Establishing rules or principles of behaviour or practice Making or changing laws Designing and/or controlling the physical or social environment Delivering a service

46 The Behaviour Change Wheel Service provision Behaviour source Regulation Intervention type Policy type Modelling Fiscal Restriction Education Training Capability Persuasion Environmental/ social planning Legislation restructuring CoercionEnvironmental Psychological Reflective Motivation Incentivisation Non reflective Physical Opportunity Social Physical Enablement/ resources Communication/ marketing Guidelines Michie, van Straalen & West 2010

47 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, falko.sniehotta@ncl.ac.uk

48 Spare slides

49 Matrix based approach Theory / Mediators Modes of Delivery Behaviour Change Techniques

50 Theories of Howto change behaviour Self-Regulation Operant Learning Social Cognitive 3 theories which not only explain behaviour, but explain how to change behaviour have evidence of changing behaviour

51 Social Cognitive Theory (Bandura) CHANGE BEHAVIOUR by changing self-efficacy by: Mastery experience Vicarious experience Verbal persuasion Physiological attributions Bandura, A (1977 Self-efficacy: toward a unifying theory of behavioral change. Psychological Review 84,

52 Operant Learning Theory (Skinner) CHANGE BEHAVIOURby changing antecedents and/or consequences A Antecedents B Behaviour C Consequences e.g. environment predicts reinforcement e.g. reward/punishment

53 Behaviour change techniques from OLT Techniques directly related to OLT Positive reinforcement Reward Punishment Extinction Negative reinforcement Vicarious reinforcement fundamentals of reward/punishment Differential reinforcement Reinforcement of alternative behaviour Stimulus generalisation Stimulus narrowing Shaping Chaining Thinning Token economy Habit reversal

54 Action Control Self-regulation theory CHANGE BEHAVIOUR by Goal setting GOAL Compare behaviour with standard No gap - goal met Self-Monitoring Comparison Effort to reduce discrepancy Act to reduce discrepancy Discrepancy noticed Disengage from goal Carver C & Scheier M 1998 On the self-regulation of behaviour. New York, Cambridge University Press

55 Identifying Effective Change Techniques in Interventions Designed to Promote Physical Activity and Healthy Eating Systematic review and meta-analysis 84 interventions average of 6 techniques small effect d = 0.37 (95% CI 0.29 to 0.54, N= 28,838) self-monitoring associated with effectiveness (14.6% variance explained). Interventions including this technique had a medium effect size of d= Interventions combining self-monitoring with at least one other technique derived from control theory were more than twice as effective as the other interventions with d= 0.60 d= 0.26 respectively Michie S, et al (in press) Identifying Effective Techniques in Interventions: A meta-analysis and meta-regression Health Psychology

56 Intention-Behaviour Gap Physical Exercise Following Cardiac Rehabilitation I Intend to engage in vigorous exercise at least three times a week for at least 30 min after my discharge. Behaviour 4 months following discharge agree not agree Exercise at least 3 x 30 minutes Inclined Actors 53.2% Disinclined Actors 0% Exercise less than 3 x 30 minutes Inclined Abstainers 38.9% Disinclined Abstainers 7.9% Sniehotta, F. F., Scholz, U., & Schwarzer, R. (2006). Action plans and coping plans for physical exercise: A longitudinal intervention study in cardiac rehabilitation. British Journal of Health Psychology, 11,

57 Societal influences Individual psychology Food Production Individual activity Activity Food Consumption environment Biology Foresight, 2007

58 e.g. Personality, Identity Beliefs and cognitions PERSON Bandura, A. (1986). "Social Foundations of Thought and Action: A Social Cognitive Theory." Englewood Cliffs, NJ: Prentice- Hall. BEHAVIOR e.g. Verbal Responses Motor Responses Social Interactions ENVIRONMENT e.g. Physical surroundings Family and Friends Other social influences

59 Behaviour change practice Traditional approach Health professional as expert Patient told what to do Extrinsic motivators Collaborative approach Patient as expert in own life Supporting patient finds own solutions Intrinsic motivators Patient required to facilitate change Ignores barriers to change Collaboration & assistance in facilitating change Addresses barriers to change

60 Technique for behaviour change Goal/target specified: behaviour or outcome Social/ Professional role & identity Knowled ge Skills Beliefs about capabiliti es Beliefs about consequenc es Motivati on and goals Memory, attention, decision processe s Environme ntal context and resources Social influenc es Emoti on Action planning Monitoring Self-monitoring Contract Rewards; incentives (inc Self-evaluation) Graded task, starting with easy tasks * Increasing skills: problem solving, decision making, goal setting Stress management Coping skills 1 2/3 3 1 Rehearsal of relevant skills /2 Michie S, Johnston M, Francis JJ, Hardeman W, Eccles MP. (2008) Applied Psychology: An International Review. Special Issue Applied Psychology: an International Review

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

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

63 system for choosing interventions and policies Behaviour source Intervention type: activities designed to change behaviours Policy type: decisions made by authorities concerning interventions Motivation Psychological Reflective Physical Non reflective Social Capability Physical Opportunity

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