Is theory under-used in the development of behavioral interventions?

Transcription

1 Is theory under-used in the development of behavioral interventions? Susan Michie & Marie Johnston Professors of Health Psychology University College London, UK Aberdeen University, UK SBM Scientific Conference, Washington, 2011

2 The Panel Discussion: speakers and planned timing Opening (20 mins) Susan Michie & Marie Johnston First discussion (15 mins) Cross-cutting commentaries (10 mins) Russ Glasgow Deputy director of dissemination and implementation science, National Cancer Institute, US Bonnie Spring Prof of Preventive Medicine. Northwestern University, US Editor, Translational Behavioral Medicine Second discussion (15 mins)

3 What is theory? A theory is a coherent set of statements or ideas used to organise, generalise, explain and predict phenomena. Theories are based on observations, experimentation and abstract reasoning, and play a fundamental role in scientific research. Allan J. (2011), Encyclopedia of Behavioural Medicine

4 Why use theory? To summarise what we know about phenomena and their relationships To provide a common framework within which to integrate evidence Why use theory to develop behavioural interventions? To identify the determinants of behaviour behaviour change To understand why interventions work, as a basis for selecting and developing interventions To advance the science of behaviour change

5 How has theory been used in developing behavioural interventions? Enough? Implicit Inappropriate Explicit and appropriate Not enough? Quantity Quality Over-used?

6 4 specific questions 1. Are theory based interventions more effective than non theory-based interventions? 2. Are behaviour change techniques used in published interventions linked to theory? 3. Do we need theories of behavior or theories of behaviour change? 4. Should theories be combined? If so, how and when?

7 1. Are theory-based interventions more effective? Many reviews claim that interventions based on theory are more effective than those not e.g. Albarracin et al (2005), Downing et al (2006), Fisher & Fisher (2000), Jemmott & Jemmott (2000), Gehrman & Hovell (2003), Kim et al (1997), Wingood & DiClemente (1996) However, this is stated rather than demonstrated Need a method of assessing the extent to which interventions are based on theory

8 Explicit use of theory: Theory Coding Scheme Reliable 19 item measure to assess: stated use of theory targeting relevant theoretical constructs using theory to select intervention recipients or tailor interventions measuring relevant theoretical constructs testing mediation effects refining theory Michie S, Prestwich A. (2010) Are interventions theory-based? Development of a Theory Coding Scheme. Health Psychology, 29,1-8.

9 Current review of 190 studies: 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 behavioiur change techniques, target participants What is the association between theoretical base and intervention content? Prestwich, Whittington, Sniehotta, Michie (in prep)

10 2. Are behaviour change techniques used in published interventions linked to theory? Theory / Mediators Modes of Delivery Content (Behaviour Change Techniques)

11 Linking content to theory In order to use theory to develop interventions need to understand how intervention content is linked to theory and its constructs This requires, as a minimum, a reliable method of specifying intervention content

12 Specifying intervention content 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

13 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)

14 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? 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

15 To specify content. Need a reliable method to identify active ingredients within interventions. distinct behaviour change techniques (BCTs) standardised and precise language BCTs observable, replicable and irreducible components of an intervention. Can be used alone or in combination with other BCTs.

16 Example: reliable taxonomy of BCTs to change physical activity and healthy eating behaviours 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 1. General information day/week), intensity 15. General (e.g., speed) encouragement or duration (e.g., for how long for). In addition, at least one of the following 2. Information on consequences 16. Contingent rewards contexts i.e., where, when, how or with whom must be specified. This 17. could Teach include identification to use cues of sub-goals or preparatory behaviours and/or specific contexts in which 18. Follow up prompts the behaviour will be performed. 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 Abraham & Michie (2008). Health Psychology; 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. Improved 40 item taxonomy Michie et al (in press) Psychology and Health

17 Further development Smoking cessation: 71 BCTs Michie et al, Annals Behavioral Medicine, 2010 Reducing excessive alcohol use: 42 BCTs Submitted General behaviour change:137 BCTs Michie et al, Applied Psychology: An International Review, 2008

18 BCTs allow us to link interventions to theory 35 BCTs from behaviour change literature Independently mapped by 4 researchers to theoretical domains Which behaviour change techniques would you use as part of an intervention to change each domain? 71% agreement A first attempt but further work needs to be done Michie, Johnston, Francis, Hardeman & Eccles (2008) Applied Psychology: an International Review.

19 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 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/ /2 Rehearsal of relevant skills

20 Michie Current study: Title: Strengthening evaluation and implementation by specifying components of behaviour change interventions Johnston Abraham Phases of work 1. Develop extensive, clearly defined, nonredundant list of BCT labels and definitions 2. Evaluate the BCTs by coding and writing interventions 3. Web-based users resource of final BCT taxonomy Francis Hardeman Expert coders needed! Website: Google BCT taxonomy Eccles

21 Conclusion Part 1 In order to ascertain whether behaviour change interventions are more effective Need to know whether our interventions are theorybased In order to say whether interventions are linked to theory need to have methods for specifying interventions linking BCTs to theoretical constructs

22 4 specific questions 1. Are theory based interventions more effective than non theory-based interventions? 2. Are behavior change techniques used in published interventions linked to theory? 3. Do we need theories of behavior or theories of behavior change? 4. Should theories be combined? If so, how and when?

23 Do we need theories of behavior or theories of behavior change?

24 Which behavioral theories to choose? Volitional Motivation: development of intention to change e.g.theory of planned behavior Action: changing behavior in line with intention or goals e.g.self-regulation theories Non-volitional : behavior change by associative processes e.g. Learning theory

25 Translating evidence into clinical practice Slow unreliable process Implementation interventions Some success Unpredictable Need for scientific rather than intuitive rationale behavioral theory Clinical practice as behavior Implementation as behavior change

26 Modelling process and outcomes: Predictive Studies General medical practitioners Requesting lumbar spine Xrays for low back pain Prescribing antibiotics for upper respiratory tract infections General dental practitioners Taking oral radiographs Placing fissure sealants on children s teeth Restoring teeth with caries Questionnaire measures to predict objective indices of evidence-based clinical behaviors

27 Results: predictive variables Intention Perceived behavioral control Self-efficacy Action Planning Anticipated consequences Habit very few motivational variables Walker, A., Grimshaw, J.M., Johnston, M., Pitts, N., Steen, N. and Eccles, M.P. (2003) PRIME; PRocess modelling in ImpleMEntation research: selecting a theoretical basis for interventions to change clinical practice. BMC Health Services Research 2003, 3:22

28 Intervention to increase dentists use of fissure sealants Clinicians preferred model Education to increase understanding of evidence-based practice Theory and evidence-based model no need to enhance motivation plan: change consequences to enhance habit Research Design 2 x 2 factorial Education Financial reward Education alone Education plus financial reward financial reward alone neither

29 Results: 50 % children receiving fissure sealants % control financial reward education both Significant effect of contingent financial reward Education not significant Insufficient power to test interaction

30 Choosing theory Intervention based on implicit educational model did not alter behavior Theories of behavior were predictive Intervention based on explicit behavior change model increased number of fissure sealants Intervention was immediately implemented by Chief Dental Officer Clarkson JE, Turner S, Grimshaw JM, Ramsay CR, Johnston M, Scott A, Bonetti B, Tilley CJ, Maclennan G, Ibbetson R, MacPherson LMD and Pitts NB (2008) Changing clinicians' behavior: a randomized controlled trial of fees and education. J Dent Res, 87,

31 Should theories be combined?

32 Interventions to reduce disability Theory: Biomedical: (International classification of functioning and disability: ICF ) Diagnosed health condition Impairments of body structure and function e.g. pain behavioral : (Theory of Planned behavior: TPB) Intention Perceived behavioral control combined

33 Combined behavioral (TPB) and Biomedical Model (ICF) Intention Impairment Activity Limitation Perceived behavioral Control Dixon, D., Johnston, M., Rowley, D., & Pollard, B. (2008) Using the ICF and psychological models of behavior to predict mobility limitations. Rehabilitation Psychology 53,

34 Modelling Process and Outcome Testing the Combined (TPB + ICF) Model Participants: patients with osteoarthritis a) before b) after joint surgery random sample of community residents Biomedical: Pain Impairment: (ICF: International Classification of Functioning and Disability) Behavioral: (TPB: Theory of Planned Behavior) Perceived behavioral control Intention Variance Explained Structural Equation Modelling participants Before surgery Before surgery After surgery ICF n.s. TPB combined community

35 Testing the Combined(TPB + ICF) Model: Results (-0.01) Intention R 2 = (0.004) Pain Impairment 0.97*** (0.82) Walking Limitation R 2 = ** (-0.31) PBC R 2 = ** (-0.58) 0.54** (0.35) FIT INDICES: χ2 (59) = 97.7, p 0.001; NNFI = 0.95; CFI = 0.96; RMSEA (90% CI) = 0.06 (0.03, 0.08) Dixon, D., Johnston, M., Rowley, D., & Pollard, B. (2008) Using the ICF and psychological models of behavior to predict mobility limitations. Rehabilitation Psychology 53,

36 Behavior Change Intervention to enhance perceived control: Stroke Workbook Intervention behavior change techniques information tailored persuasive message social support goal setting planning self-monitoring feedback coping training stress management

37 Behavior change intervention to reduce activity limitations following stroke by targeting perceived control 0.2 Recovery from 0.1 activity 0 limitations compared with -0.1 average -0.2 control intervention behavioral intervention: controlling for impairment Johnston M, Bonetti D, Joice S, Pollard B, Morrison V, Francis JJ, MacWalter R. (2007). Recovery from disability after stroke as a target for a behavioral intervention: Results of a randomised controlled trial. Disability & Rehabilitation, 2007; 1-11

38 Combining theories - opportunities Explains more Explicit rather than implicit and therefore testable Draws on more evidence Suggests more interventions e.g. when biomedical did not suggest opportunities for intervention

39 Questions for discussion 1. Are theory based interventions more effective than non theory-based interventions? 2. Are behavior change techniques used in published interventions linked to theory? 3. Do we need theories of behavior or theories of behavior change? 4. Should theories be combined? If so, how and when? 5. Are there differences in the use of theory in behavioral medicine and translational behavioral medicine? 6. When and how do we modify and adapt theories for new situations or in the light of new evidence? 7. Future implications for research strategy, funding and publication, and training, education and policy

40 Cross-cutting commentaries Russ Glasgow (5 mins) Deputy director of dissemination and implementation science, National Cancer Institute, US Bonnie Spring (5 mins) Prof of Preventive Medicine. Northwestern University, US Editor, Translational Behavioral Medicine

41 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, More information from s.michie@ucl.ac.uk, m.johnston@abdn.ac.uk