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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

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

Susan Michie & Marie Johnston

Professors of Health PsychologyUniversity College London, UK Aberdeen University, UK

SBM Scientific Conference, Washington, 2011

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)

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

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

How has theory been used in developing behavioural interventions?

• Enough?– Implicit– Inappropriate– Explicit and appropriate

• Not enough?– Quantity– Quality

• Over-used?

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?

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

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.

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)

2. Are behaviour change techniques used in published interventions linked to theory?

Content (Behaviour Change Techniques)

Modes of Delivery

Theory / Mediators

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

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

Effects of internet behavioral counseling on weight loss in adults at risk for Type 2 diabetes

“feedback on self-monitoringrecord, 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)

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

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.

Example: reliable taxonomy of BCTsto change physical activity and healthy eating beha viours

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.

Abraham & Michie (2008). Health Psychology;

Improved 40 item taxonomy – Michie et al (in press) P sychology and Health

Further development

• Smoking cessation: 71 BCTs Michie et al, Annals Behavioral Medicine, 2010

• Reducing excessive alcohol use: 42 BCTsSubmitted

• General behaviour change:137 BCTsMichie et al, Applied Psychology: An International Review, 2008

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.

Technique for behaviour change

Social/ Professional role & identity

Knowledge Skills Beliefs about capabilities

Beliefs about consequences

Motivation and goals

Memory, attention, decision processes

Environmental context and resources

Social influences

Emotion

Action planning

Goal/target specified: behaviour or outcome

1 2 1 3 2 3 1 3 1 3 3 3 3 1 1 1 1 1 1 3 2 3 3

Monitoring 1 2 3 3 3 1 2 2 1 2 2 1 2 2 1 2 2 2 1 2 2 1 1 2

Self-monitoring 2 3 3 3 3 2 3 3 2 2 2 1 3 2 1 2 2 3 2 1 3

Contract 2 1 1 1 1 1 2 3 1 2 2 3 2 2 2 2

Rewards; incentives (inc Self-evaluation)

1 2 1 1 3 3 3 2 1 2 1 2 2 3 3 3 1 1 2 1 1 2 1 2 1 2 1 1

Graded task, starting with easy tasks

1 1 3 3 2 2 2 3 2 2 3 2 2 1 2 1 1 1 1 2 1*

Increasing skills: problem solving, decision making, goal setting

1 2 3 3 3 3

2 2 3 2 1 2 3 2 1 2 1 2 3 1

Stress management 1 1 2 1 1 1 1 1 2 1 1 2 1 1 3 3 2 1

1

Coping skills 1 2/3 3 1

2 2 2 1 1 1 1 1 1 3 2 2 1/2

Rehearsal of relevant skills

1 3 3 3 3

2 3 2 2 1 2 1 3 2 3 1 1

Current study: 2010-2013 Title: Strengthening evaluation and implementation by specifying components of behaviour change interventions

• Phases of work1. Develop extensive, clearly defined, nonredundant

list of BCT labels and definitions2. Evaluate the BCTs by coding and writing

interventions3. Web-based users’ resource of final BCT taxonomy

– Expert coders needed!

Johnston

Michie

Abraham

Francis

Hardeman

EcclesEmail: [email protected]: Google ‘BCT taxonomy

Conclusion Part 1

• In order to ascertain whether behaviour change interventions are more effective– Need to know whether our interventions are theory-

based

• In order to say whether interventions are linked to theory – need to have methods for

• specifying interventions• linking BCTs to theoretical constructs

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?

Do we need theories of behavior

or theories of behavior change ?

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 goalse.g.Self-regulation theories

• ‘Non-volitional’: behavior change by associative processese.g. Learning theory

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

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

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

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

Educationalone

financial reward alone

Education plus financial reward

neither

Results:

% children receiving fissure sealants

Significant effect of contingent financial reward

Education not significantInsufficient power to test interaction

0

10

20

30

40

50

contr ol

financial rewardeduca tion

both

%

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

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, 640-644.

Intervention was immediately

implemented by Chief Dental Officer

Should theories be combined ?

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

Combined behavioral (TPB) and Biomedical Model (ICF)

ImpairmentActivity

Limitation

Intention

Perceivedbehavioral

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, 191-200.

Modelling Process and OutcomeTesting 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 Modellingparticipants Before

surgeryBefore surgery

After surgery

community

ICF 28 35 52 n.s.

TPB 48 48 69 26

combined 57 59 82 55

Testing the Combined(TPB + ICF) Model: Results

Pain Impairment

Walking Limitation

R2 = 0.57

Intention

PBCR2=0.10

R2=0.68

0.54** (0.35)

-0.73** (-0.31)

-0.03 (-0.01)

0.97*** (0.82)

0.002 (0.004)

-0.38** (-0.58)

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 mobilitylimitations. Rehabilitation Psychology 53, 191-200.

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

-0.2

-0.1

0

0.1

0.2

control intervention

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

Recovery from activity limitationscompared with average

0

Behavior change intervention to reduce activity limitations following stroke by targeting perceived control

behavioral intervention: controlling for impairment

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

Questions for discussion1. 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, fundin g and publication, and training, education and policy

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

More information from [email protected] , [email protected]

“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