Advancing the Science of Behaviour Change

Susan Michie Professor of Health Psychology

University College LondonUK

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 article Description 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 consequences3. Information about approval4. Prompt intention formation 5. Specific goal setting 6. Graded tasks7. Barrier identification8. Behavioral contract9. Review goals10. Provide instruction11. Model/ demonstrate 12. Prompt practice13. Prompt monitoring 14. Provide feedback

15. General encouragement16. Contingent rewards17. Teach to use cues 18. Follow up prompts19. Social comparison20. Social support/ change21. Role model22. Prompt self talk23. Relapse prevention24. Stress management25. Motivational interviewing26. 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, 2010

• 137 identified by– consulting textbooks for training applied

psychologists in BC techniquesMichie et al, Applied Psychology: An International Review, 2008• 42 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, 1990-2007• 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, 690-701

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 0.29-0.54

• Very heterogeneous effects (I2=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

GOALCompare 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

GOALCompare 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 (I2 = 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, 11-24.

• 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, 25-39.

Intervention techniques

1. Give information2. Elicit questions3. Summarise message4. Set goals5. Self-monitor 6. Build motivation 7. Action plans

8. Use prompts 9. Use rewards 10. Build support 11. Review goals 12. Build habits13. Relapse prevention14. Generalise skills

Theories1. Theory of Planned Behaviour2. Relapse Prevention Theory3. Self-regulation Theory4. 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%

0

10

20

30

40

50

60

70%

Variation in implementation

0

10

20

30

40

50

60

70

session1

session2

session3

session4

fac 1 fac 2 fac 3 fac 4

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

Consensus of at least 3 of 4 raters for:

Techniques Theory

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

0

5

10

15

20

25

30

35

% protocol

delivered

Theory of P

lanned

Behaviour

Self-re

gulation

Theory

Operant L

earning

Theory Relapse

Preventio

n 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

Attitude Theory of Planned Behaviour

Parking car further away so has to walk further

Action plan Self-regulation Theory

Asking partner to remind him

Cue to action Operant Learning Theory

How was (a) professional (b) participant talk about behaviour distributed over the theories?

05

101520253035404550

% professionals

participants

Theory of P

lanned

Behaviour

Self-re

gulation

Theory

Operant L

earning

Theory Relapse

Preventio

n 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)

5.9

2.3

0

1

2

3

4

5

6

7

Number of BCTs

Protocol

Publisheddescription

Results: application of theory (n=92)

37

13

15

12

6

0

0 10 20 30 40

Is theory mentioned?

Are relevant theoretical constructstargeted?

Is theory used to select recipients ortailor interventions?

Are relevant theoretical constructsmeasured?

Is theory tested?

Is theory refined?

Number ofstudies

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

k Q 95% CI d+

Theory used to select recipients 3 2.84 0.15 to 0.52 0.33Group of intervention techniques linked to group of constructs

6 9.85 0.03 to 0.43 0.23

Theory used to select intervention techniques 37 191.40

0.13 to 0.29 0.21

Targeted construct mentioned as predictor of behaviour

18 60.07 0.11 to 0.31 0.21

Theory used to tailor intervention techniques to recipients

11 67.75 0.07 to 0.34 0.21

Theory or model of behaviour mentioned 30 161.33

0.11 to 0.28 0.19

At least one intervention technique is linked to theory

19 93.65 0.09 to 0.29 0.19

Intervention based on single theory 12 57.13 0.05 to 0.32 0.18All constructs are linked to intervention techniques 10 47.70 -0.02 to 0.37 0.18

At least one construct is linked to an intervention technique

18 70.63 0.07 to 0.27 0.17

All intervention techniques are linked to theory 2

Use of theory associated with effect size

-0.20

-0.10

0.00

0.10

0.20

0.30

0 1 2 3 4 5 6 7

Extent of use of theory: number of items

Effec

t siz

e (d

)

Effect size = -.07 + .03

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

Mo

tiva

tio

n

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

Per

suas

ion

Education

Coercion

Environmental

restructuringInce

ntiv

isat

ion

Enablement/ resources

Capability

Opportunity

Mo

tiva

tio

n

TrainingR

estriction

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 categoriesEducation Imparting knowledge e.g. on health

risks

Persuasion Using communication to induce belief or knowledge

Incentivisation Creating expectation of reward

Coercion Creating expectation of punishment or cost

Training Imparting skills

Restriction Reducing availability

Environmental restructuring

Changing the physical context

Modelling Providing an example for people to aspire to

Enablement/ resources

Increasing means/reducing barriers

The Behaviour Change Wheel

Behaviour source

Intervention categories

Policy categories

Regulation

Env

ironm

enta

l/so

cial

pla

nnin

g

Communication/

marketing

LegislationFiscal

Per

suas

ion

Education

Coercion

Environmental

restructuringInce

ntiv

isat

ion

Enablement/ resources

Capability

Opportunity

Mo

tiva

tio

n

TrainingR

estrictionService provision

Guidelines

Modelling

Physical

Psychol-ogical

Reflec-tive

Non reflect-ive

Physical

Social

Policy typesCommunication/ marketing Using print, electronic,

telephonic or broadcast media

Guidelines Creating documents that recommend or mandate practice

Fiscal Using the tax system

Regulation Establishing rules or principles of behaviour or practice

Legislation Making or changing laws

Environmental/ social planning

Designing and/or controlling the physical or social environment

Service provision Delivering 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 s.michie@ucl.ac.uk

“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, 1452-1519