Applying theory to designing and
evaluating behavioural interventions
Susan Michie
Professor of Health Psychology
Director of Centre for Behaviour Change
University College London
@SusanMichie
NIHR School for Public Health Research, 2014
Theory: MRC Guidance for developing and
evaluating complex interventions
Craig et al, 2009 BMJ
What is theory?
• How things relate to each other
– ‘things’ - behaviours, thoughts, emotions, environmental
and social variables
• In relation to interventions
– How they “work”
• mechanisms of action
• ‘mediators’
– Why they vary
• across population, setting, type of target
• ‘moderators’ or ‘modifying variables’
Why theory in developing interventions
1. Optimise their design
–
–
Identifies barriers and facilitators to change and what
needs to change
Identifies mechanisms of action
2. Shorten the time needed for development
3. Identify conditions/context necessary for their
success
4. Enhance learning from those efforts
Applying theory to intervention design and
evaluation
• Apply formal theory
– 83 theories of behaviour change identified
in cross-disciplinary review
• www.behaviourchangetheories.com
• Davis et al, 2014, Health Psychology Review
– Theory Coding Scheme
Michie & Prestwich, Health Psychology, 2010;
Prestwich et al, Health Psych, 2013
OR
• Use an integrative theoretical framework
– Behaviour Change Wheel
• www.behaviourchangewheel.com
• Michie et al, 2011, Implementation Science
Formal theories of
behaviour change
• 83 theories
– Summary of original
description
– List of constructs
– Network diagram of
source theories
– Searchable website
(in future)
Applying theory to intervention design and
evaluation
• Apply formal theory
– 83 theories of behaviour change
identified in cross-disciplinary review
– Theory Coding Scheme,
Michie & Prestwich, Health Psychology, 2010
OR
• Use an integrative theoretical framework
– Behaviour Change Wheel, Michie et al, 2011
• www.behaviourchangewheel.com
Developing interventions to change
behaviour
• Start with understanding the behaviour
you are trying to change
– in its context
– within a theoretical framework that points
to the types of intervention that are likely
to be effective
What is behaviour change?
• Adopting a new behaviour
– may require stopping or modifying an existing
behaviour
• Stopping a behaviour
– may require adopting or modifying an existing
behaviour
• Adopting a different behaviour pattern
– frequency, intensity and duration
Attempts and maintenance
• For behaviour change to improve population
health, goal is usually to translate attempts into
maintenance of new patterns of behaviour
– Routines
• Goal-driven sequence of behaviours that tend to be in the same
order, place and/or time of day/week.
– Habits
• Automatic behaviours triggered by the situation as a result of
repeated associations between situations and behaviour
Behavioural interactions
• Each behaviour is part of a larger system of behaviours
that facilitate and compete with each other
• Understanding the system of behaviours is necessary to
identify where best to intervene and how
Understand the behaviour in context
• Why are behaviours as they are?
• What needs to change for the desired behaviour/s
to occur?
• Answering this is helped by a model of behaviour
– COM-B
– Behaviour itself is a system
A thought experiment
For behaviour to change,
what three conditions
need to exist?
The COM-B system: Behaviour occurs as an
interaction between three necessary conditions
Psychological or physical ability
to enact the behaviour
Reflective and automatic mechanisms
that activate or inhibit behaviour
Physical and social environment
that enables the behaviour
Michie et al (2011) Implementation Science
Capability
• An individual’s ability to engage in a behaviour in
terms of:
– Knowing what to do, how to do it and why it is worth
doing
– Having the necessary information processing skills and
degree of self-control
– Having the necessary anatomical structures, physical
skills, strength and stamina
15
Opportunity: “behaviour in context”
• Access to necessary physical and social
resources for the behaviour to occur
• Physical resources consist of:
– time, finances, materials, prompts
• Social resources consist of:
– social structures, social support, role models,
linguistic/conceptual structures
Motivation
• Brain processes that energise and direct
behaviour, consisting of
– reflective motivation
• intentions, plans and evaluations
– ‘automatic’ motivation
• desires, impulses and inhibitions, emotions, habits
17
COM-B as a guide to intervening
For positive behaviour change …
Enhance:
educate, train, enable
Motivate:
persuade, incentivise,
coerce, role modelling
Facilitate:
restructure the social and
physical environment
A framework for behaviour change
•
Systematic literature review identified 19 frameworks
of behaviour change interventions
–
•
None met criteria of
–
•
•
related to health, environment, culture change, social
marketing etc.
Comprehensive, coherent, linked to a model of behaviour
Degree of overlap
So …. Developed a synthesis of the 19 frameworks
Michie et al (2011) The Behaviour Change
Wheel: a new method for characterising and
designing behaviour change interventions,
Implementation Science
Behaviour at the hub …. COM-B
Behaviour at the hub …. COM-B
Interventions
Interventions:
activities
designed to
change
behaviours
Policies
Intervention functions
Policies:
decisions
made by
authorities
concerning
interventions
Michie et al (2011) The Behaviour Change Wheel: a new method for characterising and
designing behaviour change interventions Implementation Science
Use the Behaviour Change Wheel to …
1. Design interventions and policies
– COM-B links to intervention functions link to BCTs
2. “Retrofit” – identify what is in current
interventions and policies
3. Provide a framework for evaluation
– How are interventions working?
4. Structure systematic reviews
For more information
• Susan Michie
– [email protected]
• Books
– www.behaviourchangewheel.com
– www.behaviourchangetheories.com
• UCL Centre for Behaviour Change
– www.ucl.ac.uk/behaviour-change
ADDITIONAL SLIDES
What is theory?
“A set of concepts and/or statements which
specify how phenomena relate to each other.
Theory provides an organising description of a
system that accounts for what is known, and
explains and predicts phenomena.”
Using rules to reduce the
opportunity to engage in the
behaviour (or to increase
behaviour by reducing
opportunity to engage
in competing
behaviours)
Increasing knowledge
or understanding
Using communication to induce
positive or negative feelings to
stimulate action
Changing the physical or
social context
Creating an expectation of
reward
Provide an example for
people to aspire to or
emulate
Increasing means
or reducing barriers to
increase capability (beyond
education or training) or opportunity
(beyond environmental restructuring)
Creating an expectation of
punishment or cost
Imparting skills
Creating documents that
recommend or mandate
practice. This includes all
changes to service provision
Designing and/or controlling the
physical or social environment
Using print, electronic,
telephonic or broadcast
media
Using the tax system to reduce
or increase the financial cost
Establishing rules or principles
of behaviour or practice
Creating an expectation of
punishment or cost
Delivering a service
Example …. hand hygiene in hospital staff
• Nurses and doctors
– Cleaning hands in identified situations
• Infection control nurses
– Conducting audits and feeding back
results
• Staff responsible for distributing
alcohol handrub
– Ensuring that dispensers contain
alcohol handrub
2004-2011
led by Sheldon Stone
• Opportunity
– Alcohol hand rub beside every bed
• Motivation
– Persuasive posters
– Encouraging patients to ask
• Capability
– No intervention
Capability
• Nurses have the capability to clean their hands
– But not to
• pay attention to this behaviour over other competing behaviours
• develop routines for noticing when the behaviour does not
occur, and plans for acting in future
• Train staff to set goals, observe their behaviour,
develop action plans on the basis of feedback
• Developed at UCL, based on behavioural theory
Findings: 60 wards in 16 hospitals in England
• Use of soap and alcohol hand rub tripled
from 21.8 to 59.8 ml per patient bed day
• Rates of MRSA bacteraemia and
C difficile infection decreased
– Stone, Fuller, Savage, Cookson et al, BMJ, 2012
• Giving 1-1 feedback led to staff being
13-18% more likely to clean their hands
– Fuller, Michie, Savage, McAteer et al, PLoS One, 2012
An example…
Target behaviour: Increasing participation in cycle to work scheme
Target population: Employees
Behavioural diagnosis:
“Employees unlikely to take up scheme
because they don’t have a bike to use”:
Physical opportunity
Summer School
2014
An example…
Target behaviour: Increasing participation in cycle to work scheme
Target population: Employees
Behavioural diagnosis
“Employees unlikely to take up scheme
because they don’t have a bike to use”:
Physical opportunity
Select intervention functions
Physical opportunity maps onto:
Environmental restructuring
Select BCTs
Environmental restructuring can include the
BCTs…
• Adding objects to the environment
• Restructuring the physical environment
E.g. “Employees were given bikes to use
and cycle racks were installed in the office
car park”
Summer School
2014