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Imagine you were tasked with developing a population level intervention to reduce/prevent obesity, discuss the approaches you might take, and their strengths and limitations.
Can fear appeals work to change health behaviours? Discuss with reference to Models of health behaviour: Putting theory into practice Learning objectives • To understand conceptual and methodological – limitations of common tests of health behaviour theories • To recognise the conceptual shortcomings of social cognitive theories of health behaviour • To appreciate the potential for theory to be used to inform behaviour change interventions • To be able to apply theory exhaustively to elements of design, reporting, and evaluation of behaviour change interventions Are theories adequately tested? How are theories tested? • Observational: – Tests whether ‘natural’ scores on theoretical constructs covary with variation in outcomes (intention or behaviour) – Primary data – HBM: Abraham et al (1999); TPB: Lavin & Groarke (2005) • Intervention: – Tests whether changing theoretical constructs changes hypothesised outcomes (intention or behaviour) – Primary data – PMT: Milne et al (2002), Rippetoe & Rogers (1987) • Meta-analysis: – Synthesises either observational or intervention studies – Secondary data – TPB: Armitage & Conner (2001) Are theories adequately tested? Common tests of health behaviour models • Designs: – Cross-sectional – Prospective • Correlational – Test whether variation in theory-derived variables is associated with variation in outcome (e.g. behaviour) • Subjective – Questionnaire-based – Often self-report Example: Theory of addiction Time TIME Motivational Level TIME Variation in variable measures • Other limitations of SC models – assume humans act in a rational way(!?) • PRIME theory, Robert West www.primetheory.com • Brings together what we know about motivation • “At every moment we act in pursuit of what we most want or need at that moment” • Why we do stupid things (like smoking) • Three central ideas: – Wants and needs at each moment drive our behaviour – Intentions and beliefs only influence actions if they create sufficiently strong wants and needs – Image of ourselves and how we feel about that potentially a very strong source of wants and needs – can overcome biological drives 9 Study design A typical cross-sectional TPB study Behaviour (Actual past bhvr, or typical bhvr) Intention (to do bhvr in future) Attitude (towards doing bhvr in future) Subjective norms (towards doing bhvr in future) PBC (over doing bhvr in future) ‘Baseline’ measures • All measures taken at single timepoint A cross-sectional TPB study of bingedrinking Behaviour (Actual: Binge drinking last week; Typical: Binge drinking in a typical week) Intention (to binge drink next week) Attitude (towards binge drinking next week) Subjective norms (towards binge drinking next week) PBC (over binge drinking next week) ‘Baseline’ measures Study design Problems with cross-sectional design: Correlation is not causation • Behaviour might predict cognitions (Reverse causation) – We may infer beliefs from behaviour – Via a self-perception process (Bem, 1972) TPB: “I like binge-drinking, therefore I binge-drink” Self-perception: “I binge-drink, therefore I must like binge-drinking” Attitude Behaviour Behaviour Attitude Problems with cross-sectional design Correlation is not causation • Behaviour enhances self-efficacy – Successful past performance increases confidence in our skills (Bandura, 1977) PMT: “I am confident that I can floss properly, therefore I floss” Alternative: “I have flossed for some time, and so am confident I can floss properly” Self-efficacy Behaviour Behaviour Self-efficacy Difficult to isolate true causal effects Intention Behaviour Observed effect (a) Actual effect (b) Actual effect (c) Observed intention-behaviour association (a) = Effect of intention on behaviour (b) + Effect of behaviour on intention (c) Further problems with cross-sectional design • Violation of ‘compatibility principle’ (Ajzen & Fishbein, 1980) – All variable measures must be identical re TACT: Target Action Context Time E.g. ‘Taking my dog for a walk in Regent’s Park on Tuesday at 5pm’ – Target = “My dog” – Action = “Taking … for a walk” – Context = “In Regent’s Park” – Time = “Tuesday at 5pm” • Cognition measures necessarily relate to a future timepoint – e.g. ‘I intend to do X [in the future]’ • Future behaviour is not measured in cross-sectional designs • So cognition and behaviour measures are not compatible re Time Study design Prospective design • Cognition measures taken at baseline, behaviour at follow-up • Tests whether baseline theoretical constructs predict later health behaviour • Allows for compatibility in cognition and behaviour measures • Usually taken to indicate causality Study design: A typical prospective TPB study Behaviour (between T1 and T2) Intention (to do bhvr between T1 & T2) Attitude (towards doing bhvr between T1 & T2) Subjective norms (towards doing bhvr between T1 & T2) PBC (over doing bhvr between T1 & T2) Baseline (Time 1) measures Follow-up (Time 2) Problems in using prospective designs for repeated behaviours Weinstein (2007) • Prospective data cannot identify causality in behaviours that have been previously performed – e.g. food consumption, physical activity, tooth-brushing • Strong past-future behaviour relationship indicates stability over time – Behaviour performed in past continues to be performed in future Behaviour Past behaviour r = .90 What causes what in models of repeated behaviour? Intention Behaviour Attitude Subjective norms PBC Past behaviour What causes what in models of repeated behaviour? Intention Behaviour Attitude Subjective norms PBC • Prospective data cannot separate effects of behaviour on beliefs from effects of beliefs on behaviour Intention Behaviour Observed effect (a) Actual effect (b) Actual effect (c) Observed intention-behaviour association (a) = Effect of intention on behaviour (b) + Effect of behaviour on intention (c) Remains difficult to isolate true causal effects Example: Prospective TPB study of bingedrinking in undergraduates (Norman, 2011) Behaviour (Frequency of binge-drinking over previous month) Intention (to binge drink over the next month) Attitude (towards binge drinking over the next month) Subjective norms (towards binge drinking over the next month) PBC/Self- efficacy (over binge drinking over the next month) Baseline One month later R2 = .75 R2 = .37 Interpretation (Norman, 2011, p506) “…a number of practical implications can be drawn … Interventions should target the motivational determinants of binge-drinking among undergraduate students … interventions need to target attitudes and feelings of self-efficacy” Is this necessarily true? A possible alternative explanation University Week 1: Student begins university, has negative views towards binge-drinking (but drinks responsibly). If completing a questionnaire at this point: For me, binge-drinking next month… Attitude: Negative SN: Other people would disapprove PBC: Completely within my control Intention: Strongly intend not to A possible alternative explanation Week 2: Student goes for ‘quiet drink’ with friends. Unexpectedly turns into a binge drinking session. Student enjoys this and becomes more favourable towards binge drinking. Subjective norm Behaviour Attitude Week 3 onwards: Student regularly binge-drinks (behaviour) and remains favourable towards binge drinking (attitude, subjective norms, intentions). A possible alternative explanation Week 6: Student completes baseline TPB questionnaire. For me, binge-drinking next month would be: Attitude: Positive SN: Other people would approve PBC: Completely within my control Intention: Strongly intend to Week 10: Student completes follow-up behaviour measure. Did you have one or more binge-drinking sessions last month? Yes Error in causal inference • Inferring causality based on data from weeks 6 & 10 ignores performance history • Behaviour came first (at week 2) – despite unsupportive cognitions • Behaviour changed cognitions so that they became mo
re favourable • Practical implications: cognition change may not change behaviour Adequate study designs for testing theory Weinstein (2007) • Prospective – Only useful for completely novel behaviours • Where baseline cognitions necessarily precede behaviour • Experimental/quasi-experimental – Suitable for previously performed behaviours – Does changing theoretical constructs change intention or behaviour? – Experimental tests are rarely conducted – e.g. Armitage & Conner (2001) TPB review: • 185 datasets • 0 interventions! 29 Theory-based interventions significantly impact PA behaviour Which theory? Overlap How applied : <1/3 targeted all theory constructs Low variance explained – true effects or issues with self report? Is self-report valid? Example: Chaudhury & Esliger (2009) • Physical activity measured over 7 days • Self-report diary + accelerometer (objective measure) • Recommended activity level: – “At least 30mins activity per day on at least 5 days a week” • Of those self-reporting meeting recommended levels, accelerometer data suggested only 10% of men and 8% of women met recommendations – Self-presentation bias? – Difficulties in recalling own behaviour? 0 10 20 30 40 50 60 16-34 35-64 65+ % meeting recomendation Accelerometry Self report Physical activity levels in adults Data from 2008 Health Survey for England 0 10 20 30 40 50 60 16-34 35-64 65+ % meeting recomendation Accelerometry Self report Men Women • Questionnaire studies may change or create cognitions/behaviour (Ogden, 2003) – Focusing on a behaviour can change beliefs – People cannot hold cognitions towards unknown actions – Questioning is central to ‘motivational interviewing’ (a behaviour change strategy) • Questionnaire studies do not change cognitions / behaviour (Ajzen & Fishbein, 2004) – TPB questionnaire administered before vs. after behaviour – No difference in cognitions or behaviour according to when questionnaire administered (Ajzen et al, 2004) Questionnaire design Question-behaviour effects (aka ‘Mere measurement effects’) Godin et al (2008) • Registered blood donors, Canada • Experimental group – TPB questionnaire re cognitions towards blood donation (e.g. I intent to give blood in next 6 months’) • Control group – No questionnaire • 6 & 12 month follow-up – Registration at blood drive – Successful blood donation Question-behaviour effects (aka ‘Mere measurement effects’) Godin et al (2008) • Experimental group: – 8.6% more registrations at 6 months, 6.4% at 1 yr – 13.6% more blood donations at 6 months, 9.9% at 1 yr • BUT – Small effects – Not consistently replicated / more studies in HBs • Questionnaires may change cognitions and behaviour – Offers a low-cost behaviour change intervention strategy! Summary Are theories adequately tested? • Not by self-report questionnaire-based correlational designs for ongoing behaviours ØSelf-report may not be reliable ØCorrelational designs do not reveal causality • ‘Effects’ may be misleading ØQuestionnaires can change cognitions and behaviour 37 Are we making the most of theory? Newer theories • Self determination Theory http://selfdeterminationtheory.org/theory/ (sources of motivation) – external e.g. uni grades, internal – enjoyment • Autonomy (need to be in control) , competence (need to be effective in dealing with the environment), and relatedness (need to be connected) • Game theory – new technologies? 39 Models to be considered • COM-B model of behaviour in context – an overarching model of behaviour and what is needed to achieve behaviour change • The Behaviour Change Wheel – a system for developing theory- and evidence-based behaviour change interventions from COM-B • Taxonomy of Behaviour Change Techniques – A tool to indentify effective intervention content Why these models? Bring together core components of other theories into single coherent model aimed at changing behaviour COM-B: A simple model to understand behaviour… Psychological or physical ability to enact the behaviour Michie S, M van Stralen, West R (2011) The Behaviour Change Wheel: A new method for characterising and designing behaviour change interventions. Implementation Science, 6, 42. Physical and social environment that enables the behaviour Reflective and automatic mechanisms that activate or inhibit behaviour Reflective Automatic Evaluations, plans… Emotions, impulses… COM-B: A simple model to understand behaviour… Lack of knowledge of how to stop (psychological) Strong drive to smoke overpowering self-control (physical) Michie S, M van Stralen, West R (2011) The Behaviour Change Wheel: A new method for characterising and designing behaviour change interventions. Implementation Science, 6, 42. Ability to smoke anywhere (physical) Exposure to prompts to smoke (social) • Using this model, we can make the ‘behavioural diagnosis’ • This is the starting point for intervention design… Lack of concern about health effects (reflective) Liking being a smoker (automatic) Going beyond COM-B: The behaviour change wheel Michie et al (2011) Implementation Science, 6, 42 • Synthesis of 19 frameworks to classify interventions (health, environment, culture change and social marketing) Formal analysis of frameworks 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 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. Implementation 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. PETeR White (in prep.) Comprehensive and universally applicable model or taxonomy of health 14. DEFRA’s 4E 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. Intervention 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. Environmental policy framework Vlek (2000) A taxonomy of major environmental problems, their different levels and global spheres of impact, and conceptual modelling of environmental problem- solvi
ng 19. Population Services International (PSI) framework PSI (2004) A conceptual framework to guide and help conduct research on social marketing interventions Going beyond COM-B: The behaviour change wheel Michie et al (2011) Implementation Science, 6, 42 • Synthesis of 19 frameworks to classify interventions (health, environment, culture change and social marketing) • Centre: COM-B model Going beyond COM-B: The behaviour change wheel • Synthesis of 19 frameworks to classify interventions (health, environment, culture change and social marketing) • Centre: COM-B model • Inner ring: Nine intervention functions (what purpose(s) the intervention serves) Using rules that limit engagement in the target behaviour or competing or supporting behaviour Increasing knowledge or understanding Using communication to induce positive or negative feelings or stimulate action Creating an expectation of reward Creating an expectation of punishment or cost Imparting skills Increasing means or reducing barriers to increase capability or opportunity Provide an example for people to aspire to or emulate Changing the physical or social context Intervention functions Intervention functions Education Persuasion Incentivisation Coercion Training Restriction Environmental restructuring Modelling Enablement Physical capability Psychological capability Physical opportunity Social opportunity Automatic motivation Reflective motivation Selecting appropriate intervention functions • Synthesis of 19 frameworks to classify interventions (health, environment, culture change and social marketing) • Centre: COM-B model • Inner ring: Nine intervention functions (what purpose(s) the intervention serves) • Outer ring: Seven policy categories Going beyond COM-B: The behaviour change wheel Creating an expectation of punishment or cost Designing and/or controlling the physical or social environment Creating documents that recommend or mandate practice. This includes all changes to service provision Using the tax system to reduce or increase the financial cost Establishing rules or principles of behaviour or practice Delivering a service Using print, electronic, telephonic or broadcast media Policy categories Intervention functions Education Persuasion Incentivisation Coercion Training Restriction Environ. restructuring Modelling Enablement Communica tion/marketing Guidelines Fiscal measures Regulation Legislation Environ./ Social planning Service provision Selecting appropriate policy categories Interventions: theory-based, or theory-inspired? (cf Michie & Abraham, 2004) • Interventions typically draw on theory to identify constructs that – predict behaviour – should be targeted by interventions – should be measured as outcomes/mediators • Neglect of theory in determining intervention content – Guesswork involved re what will change cognitions and behaviour • Researchers often use theory to only inspire their intervention • The problem: – Variable terminology – Under-reporting of content – Therefore can’t understand mechanisms, replicate effective interventions or implement these • The solution – Agreed standard method for intervention description – Periodic Table’ or ‘Encyclopaedia’ of BCTs, each described using consistent terminology + clear labels à provides a common language – Criteria for operationalisation – Organised hierarchically Populating the content of interventions: Behaviour change techniques (BCTs) Theories are rarely linked with behaviour change techniques (BCTs) • Few theories or constructs are specified in conjunction with change techniques – How do we change e.g. attitudes or subjective norms? • Self-efficacy is an exception • Ways to boost self-efficacy include: – ‘Mastery experience’ – ‘Vicarious experience’ – ‘Verbal persuasion’ (Bandura, 1977) BCT labels and definitions • Definition: – Active ingredient of intervention aiming to change behaviour – Observable, replicable with measurable effect on behaviour – Smallest unit with potential to bring about behaviour change • Should be … – short enough to easily recall and recognise – as specific as possible to increase reliability – distinct from each other An early reliable taxonomy to change frequently used behaviour change techniques 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. Behavioural contract 9. Review goals 10. Provide instruction 11. Model/ demonstrate 12. Prompt practice 13. Prompt monitoring 14. Provide feedback 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 25. Motivational interviewing 26. Time management Abraham & Michie, 2008 12. 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 Further development • Smoking cessation: 53 BCTs Michie et al, Annals behavioural Medicine, 2010 • Physical activity & healthy eating: 40 BCTs Michie et al, Psychology & Health, 2011 • Reducing excessive alcohol use: 42 BCTs Michie et al, Addiction, 2012 • General behaviour change: 137 BCTs Michie et al, Applied Psychology: An International Review, 2008 • Health Behaviour Change Competency Framework: 98 BCTs Dixon & Johnston, NHS Health Scotland, 2010 • Sexual behavior: 47 BCTs Abraham et al, Psychology & Health, 2011 BCT Taxonomy v1 • Development work 2011-2012: – Synthesised 6 published BCT taxonomies – Delphi exercise: 14 experts – International Advisory Board input: 16 experts – Pilot coding and user testing: 6 experts – Grouping exercise: 18 experts – Total: 54 experts • 93 BCTs, 16 groupings • with labels, definitions and examples Michie et al. (2013) No. Label Definition Example 1 Material reward Arrange for the delivery of money, vouchers or other valued objects if and only if there has been effort and/or progress made towards performing the behaviour Note: if reward is unspecified, code 7, Non-specific reward Arrange for the person to receive money that would have been spent on cigarettes if and only if the smoker has not smoked for one month 2 Information about health consequences Provide information about health consequences of performing the behaviour Explain that not finishing a course of antibiotics can increase susceptibility to future infection Present the likelihood of contracting a sexually transmitted infection following unprotected sexual behaviour 5 Demonstration of the behaviour Provide an example of the successful performance of the behaviour for the person to aspire to or imitate (includes “Modelling”) During a training session, demonstrate to nurses how to raise the issue of excessive drinking with patients 6 Feedback on behaviour Provide feedback on performance of the behaviour (e.g. form, frequency, duration, intensity) Inform participants of how many steps they walked each day (as recorded on an accelerometer) or how many calories they ate each day (based on a food consumption questionnaire) Applying BCT Taxomies to identify + characterise BCTs in intervention descriptions: ‘The goal of the intervention is to adopt and maintain a healthier lifestyle, with regard to physical activity. In the intervention, participants will receive £5 for every kilo lost.’ BCT: Material Reward ‘Consultants watched a video demonstration showing how to resuscitate a child’ BCT: Demonstration of the Behaviour Linking BCW intervention functions to BCTs Intervention function Frequently used BCTs (as identified in Abraham et al. Testing the identification of behavior change techniques (BCTs) defined by the “BCT Taxonomy version 1” (BCTv1) in intervention descriptions. In preparation) Incentivisation Feedback on behaviour Feedback on outcome(s) of behaviour Monitoring of behaviour by others without evidence of feedback Monitoring out
come of behaviour by others without evidence of feedback Self-monitoring of behaviour Coercion Feedback on behaviour Feedback on outcome(s) of behaviour Monitoring of behaviour by others without evidence of feedback Monitoring outcome of behaviour by others without evidence of feedback Self-monitoring of behaviour Michie, Atkins and West, 2014 Putting it all together…. 1. What behaviour are you trying to change and in what way? Selecting and specifying a target behaviour 2. What will it take to bring about the desired change? COM-B model 3. What types of intervention are likely to bring about the desired change? Behaviour Change Wheel 4. What should be the specific intervention content? Behaviour Change Techniques Taxonomy (v1) Linking BCTs to existing theory Abraham & Michie (2008) (updated taxonomies in Michie et al, 2011, 2013) • Two coders agreed on which BCTs link to which theories • For example… • Techniques linked to TPB – Provide information on consequences – Provide information about others approval – Prompt intention formation • Designing new interventions – Using theory-matched techniques to change predictors of behaviour • Reviewing previous interventions – Identifying most effective techniques and inferring most valid theory from these (e.g. Michie et al, 2009) • Systematic review • 101 papers, reporting 122 intervention evaluations • Coded using 26-item BCT taxonomy • Meta-regression – Univariate (single IV): • Are interventions featuring a specific technique more effective than those without the technique? – Multivariate (multiple IVs): • Which techniques explain most variation in intervention effectiveness? Applying BCT taxonomy to diet and activity interventions Michie et al (2009) • ‘Self-monitoring’ most effective – i.e. explained most variation • ‘Self-monitoring’ plus at least one other Control Theory technique twice as effective as other interventions • Implies Control Theory offers best theoretical basis for behaviour change interventions in diet and PA Which BCTs are most effective – and what does this tell us about theory? Michie et al (2009) • Systematic review • 44 intervention evaluations • Coded using 26-item BCT taxonomy • Meta-regression Applying BCT taxonomy to diet and activity interventions in obese adults Dombrowski et al (2012) • No intervention used all techniques linked to a particular theory • Does using more theory-linked BCTs predict effectiveness? – E.g. Control Theory techniques • Prompt specific goal setting, Prompt review of behavioural goals, Prompt selfmonitoring of behaviour, Provide feedback on performance – Effects of more theory-linked BCTs only found for Control Theory (cf Michie et al, 2009) – Control Theory may offer best theoretical basis for diet and PA behaviour change interventions in this population Are theory-linked BCTs more effective? Dombrowski et al (2012) BCTs in cost-effective intervention (N=79) across different health behaviours? Shahab et al (2014) • Average intervention contained just 10 BCTs (range 2 to 39) • Smoking cessation interventions included the largest number of BCTs (mean=11.8, median=8, mode=7) • Depends on use and adequate reporting of theory-linked techniques – BCTs often poorly reported – If theory-linked techniques are not used (or not reported), they cannot be coded – Theory cannot then be adequately tested • Techniques more commonly used and reported can be examined more thoroughly – Are techniques linked to Control Theory simply better reported? • But use of taxonomy in new intervention studies will facilitate more informative future reviews Limitations of using the BCT taxonomy to test theory in past studies Conclusions • Traditional ‘tests’ of health behaviour theories are often weak – Typically based on self-report correlational data – Prospective designs remain problematic for previously performed behaviours – Rigorous tests of theory require experimental or quasi-experimental data • The potential usefulness of health behaviour theories is rarely realised – Few ‘theory-based’ interventions use theory exhaustively – BCT taxonomy links theory to change techniques • Allows for theory to be used to inform selection of techniques • Permits theory assessment – Reporting problems may preclude application to previous studies – Going forward comprehensive, over-arching model (BCW) may provide toolkit for constructing effective interventions