Applying behaviour change principles to population health a

Applying behaviour change principles to population health: a comprehensive approach Robert West Susan Michie University College London 4 August 2011 1

Topics • What are ‘behaviour change interventions’ and why is it important to study them? • Understanding behaviour • Developing a behaviour change strategy • A worked example 2

What is a behaviour change intervention (BCI)? In theory • An action or activity that aims to get an individual or population to behave differently from how s/he or they would have acted without such an action 1. change the incidence/rate/duration of occurrence of a given type of behaviour from what it would otherwise have been 2. change the way that a given behaviour is performed In practice • A coordinated set of behaviour change techniques (BCTs) applied to a group or population to change the prevalence or rate of a given behaviour pattern 3

The ‘behavioural target’ • A specification of what is intended • E. g. – reduce smoking prevalence to 15% – increase the prevalence of people who eat 5+ portions of fruit and vegetables each day – reduce the prevalence of drivers who regularly exceed 30 mph in a built up areas – increase the rate of condom use 4

Importance of studying BCIs • Maladaptive/anti-social behaviours are common – – – smoking sedentary lifestyle reckless driving domestic violence etc. • Commonsense approaches are frequently ineffective or counter-productive • Studying BCIs can produce better understanding of mechanisms and lead to more effective interventions 5

Designing interventions 1. Describe the behavioural target (BT), the current situation and the prevailing context 2. Analyse what is needed for the BT to be attained 3. Choose an appropriate mix of broad intervention options based on that analysis, and policies needed to implement these 4. Construct specific behaviour change techniques (BCTs) that make up the interventions 6

Common terms for methods for inducing behaviour change Educate Train Help Expose to Inform Discuss Suggest Encourage Incentivise Ask Order Plead Coerce Force Offer Provide Prompt Constrain 7

COM-B system for analysing behaviour in context 1. Capability, motivation and opportunity all need to be present for a behaviour to occur 2. They all interact as part of a system 3. Motivation must be stronger for the target behaviour than competing behaviours 8

Common terms for methods for inducing behaviour change Capability Educate Train Help Motivation Expose to Inform Discuss Suggest Encourage Incentivise Ask Order Plead Coerce Force Opportunity Offer Provide Prompt Constrain 9

Understanding motivation • Brain processes that energise and direct behaviour • Not limited to choice and goal pursuit • Needs to include – – – drive habit desire instinct self-regulation etc. 10

Motivation: reflective and automatic Reflective Beliefs about what is good and bad, conscious intentions, decisions and plans Automatic Emotional responses, desires and habits resulting from associative learning and physiological states Reflective-Impulsive Model, Strack & Deutsch, 2004 PRIME Theory of Motivation, West, 2006 11

PRIME Theory: the structure of human motivation www. primetheory. com 12

PRIME Theory: reflective and automatic processes www. primetheory. com 13

PRIME Theory: Elementary change processes Automatic 1. Perception: acquiring information from the senses 2. Associative learning: operant and classical conditioning 3. Maturation: changes associated with growing older 4. Habituation: decrease in response with exposure 5. Sensitisation: increase in response with exposure 6. Imitation: direct copying 7. Identification: forming one’s own identity from perceptions of others 8. Consistency disposition: generation of motives, ideas from similar ones 9. Dissonance avoidance: negating or blocking uncomfortable beliefs 10. Objectification: generating evaluations from likes and dislikes 11. Chemical ‘insult’: pharmacological responses 12. Physical ‘insult’: brain lesions Reflective 1. Assimilation: acquiring information via communication 2. Inference: induction and deduction 3. Analysis: formal and informal calculation www. primetheory. com 14

PRIME Theory: Self-control, identity and behaviour change • We are self-aware and form mental representations of ourselves to which are attached emotions (identity) • These include labels and rules • Deliberate behaviour change involves adopting a new personal rule • To the extent that this is based on evaluations it requires effortful self-control 15

PRIME Theory: key propositions 1. At every moment we act in pursuit of what we most desire (want or need) at that moment. 2. Wants and needs involved imagined futures and feelings of anticipated pleasure/satisfaction (wants) or relief from mental or physical discomfort (needs) 3. Beliefs about what is good or bad can only influence our actions if they generate desires that are strong enough to overwhelm those arising from other sources (e. g. drives and emotional responses) or impulses arising automatically out of habit or instinct. They will do this to the extent that they generate clear imagery that can trigger necessary emotional associations. 4. Identity (our mental representations of ourselves and the emotions attached to these) is an important source of desires and provides a degree of stability to our behaviour by virtue of the labels we apply (e. g. nonsmoker) and the rules that govern our behaviour (e. g. not smoking). 16

PRIME Theory: key propositions 5. Identity change is the starting point for deliberate behaviour change (in terms of a new label and a new set of rules governing our behaviour) and can be regarded as an ‘act’ that occurs when the desire to make the change is momentarily greater than the desire not to. 6. Deliberate behaviour change is sustained when the desires arising from the new identity are stronger at each relevant moment than the desires arising from other sources to revert to the previous behaviour pattern, or are able to overwhelm habitual or instinctive impulses. 7. When identity change results from self-conscious beliefs about what is good and bad, maintaining behaviour change requires ‘self-control’: the effortful generation of desire to adhere to a rule that is sufficiently powerful to overcome desires arising from other sources. 8. Personal rules that have clear boundaries and a strong connection with components of identity that involve strong emotional attachments will generate more powerful desires when required and better suppress countervailing desires and so have a stronger lasting impact on behaviour. 17

Formal analysis of behaviour change interventions • • 1. Epicure taxonomy West (2006) Taxonomy of approaches designed to influence behaviour patterns 2. Culture capital framework Knott et al. (2008) Framework of knowledge about culture change, offering practical tools for policymaking 3. EPOC taxonomy of interventions Cochrane Effective Practice and Organisation of Care Review Group (EPOC) (2010) Checklist to guide systematic literature reviewers about the types of information to extract from primary studies 4. RURU: Intervention implementation taxonomy Walter et al. (2003) Taxonomy covering a wide range of policy, practice and organisational targets aimed at increasing impact of research 5. MINDSPACE Institute for Government and Cabinet Office (2010) Checklist for policy-makers aimed at changing or shaping behaviour 6. Taxonomy of behaviour change techniques Abraham et al. (2010) Taxonomy of behaviour change techniques grouped by change targets 7. Intervention mapping Bartholomew et al. (2011) Protocol for a systematic development of theory- and evidence-based interventions 18

Formal analysis of behaviour change interventions • • • 8. People and places framework Maibach et al. (2007) Framework that explains how communication and marketing can be used to advance public health 9. Public health: ethical issues Nuffield Council on Bioethics (2007) Ladder of interventions by government, industry, organisations and individuals to promote public health. 10. Injury control framework Geller et al. (1990) Heuristic framework for categorising and evaluating behaviour change strategies aimed at controlling injuries 11. Implement-ation taxonomy Leeman et al. (2007) Theory-based taxonomy of methods for implementing change in practice 12. Legal framework Perdue et al. (2005) Conceptual framework for identifying possible legal strategies used for preventing cardiovascular diseases 13. PETe. R White (in prep. ) Comprehensive and universally applicable model or taxonomy of health 19

Formal analysis of behaviour change interventions • • • 14. DEFRA’s 4 E model DEFRA (2008) Process model for policy makers aimed at promoting pro-environmental behaviours in accordance with social marketing principles 15. STD/ HIV framework Cohen and Scribner (2000) Taxonomy to expand the scope of interventions that can be used to prevent STD and HIV transmission 16. Framework on public policy in physical activity Dunton et al. (2010) Taxonomy aimed at understanding how and why policies successfully impact on behaviour change 17. Interven-tion framework for retail pharmacies Goel et al. (1996) Framework that presents factors that may affect retail pharmacy describing and strategies for behaviour change to improve appropriateness of prescribing 18. Environ-mental policy framework Vlek (2000) A taxonomy of major environmental problems, their different levels and global spheres of impact, and conceptual modelling of environmental problem- solving 19. Population Services International (PSI) framework PSI (2004) A conceptual framework to guide and help conduct research on social marketing interventions 20

A derived list of intervention functions • Education Increasing knowledge or understanding • Persuasion Using communication to induce positive or negative feelings or stimulate action • Incentivisation Creating expectation of reward • Coercion Creating expectation of punishment or cost • Training Imparting skills • Restriction Using rules to reduce the opportunity to engage in the target behaviour (or to increase the target behaviour by reducing the opportunity to engage in competing behaviours) • Environmental restructuring Changing the physical or social context • Modelling Providing an example for people to aspire to or imitate • Enablement Increasing means/reducing barriers to increase capability or opportunity 21

A derived list of policy categories • Communication/ marketing Using print, electronic, telephonic or broadcast media • Guidelines Creating documents that recommend or mandate practice. This includes all changes to service provision • Fiscal Using the tax system to reduce or increase the financial cost • 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 22

The Behaviour Change Wheel: hub 23

The behaviour Change Wheel: inner ring 24

Behaviour Change Wheel: complete 25

Where this leaves us • Still at the level of broad intervention functions • Construction of specific BCTs is still required • Michie et al have constructed a taxonomy of BCTs and this is being developed further • West, Michie et al have constructed specific BCTs used in behavioural support for smoking cessation 26

Worked example: getting GPs to deliver brief smoking cessation interventions • Behavioural target – increase the rate at which GPs offer cessation support to smokers from 25% to 50% • COM-B analysis – C: uncertainty about how to do it without embarrassment in the time available; ignorance of available options for support – O: limited time; lack of salient cues; limited access to high quality support – M: belief that it is a good thing but limited desire because not rewarded and often mildly punished 27

Worked example: getting GPs to deliver brief smoking cessation interventions • Intervention options – Education: on the best methods of brief advice and the benefits – Training: how to deliver advice quickly without embarrassment – Incentivisation: change QOF payments to link them with objective evidence of offer of support (e. g. referral to stopsmoking services) – Coercion: use professional and social disapproval for failure to achieve minimum intervention rate – Modelling: show examples that GPs can identify with – Environmental restructuring: provide salient prompts e. g. desktop post-it pads 28

Conclusions • Benefits of a comprehensive approach – prompts consideration of the full range of options – provides a basis for analysing behaviour in context to select an appropriate mix of options – takes account of environmental as well as intraindividual changes that may be needed • Only a first step The Behaviour Change Wheel: a new method for characterising and designing behaviour change interventions Susan Michie, Maartje M van Stralen, Robert West Implementation Science 2011, 6: 42 (23 April 2011) 29