Designing and Implementing Evidence-Based
Behaviour Change Interventions
to Promote Weignt Loss
Charles Abraham
24th Finnish Conference on Sport and Exercise Medicine
10th November 2016
PSYCHOLOGY APPLIED TO HEALTH,
EXETER MEDICAL SCHOOL
Charles Abraham
Mark Tarrant
Sarah Dean
Mat White
Overview
• Intervention Mapping Protocols
• Information, Motivation, Behavioural Skills (IMB) Model
• What type of information?
• How can we change motivation?
• Dual Process Models – e.g., Reflective-Impulsive Model
• Techniques to alter impulsive mechanisms
• Conclusions
Intervention Mapping:
Design and Evaluation framework
Needs
Assessment
Logic Model
Program
Design
Program
Production
Implementation
Evaluation
Bartholomew, L.K., Markham, C. M.,
Ruiter, R., Fernández, M. E,, Kok, G.
& Parcel, G.S. (2016).Planning Health
Promotion Programmes An
Intervention mapping Approach.
Jossey-Bass, San Francisco.
The Intervention Mapping Process
Needs assessment and elicitation research
Define measurable change objectives determines outcome evaluation
Identification of change mechanisms (logic model)
determines process evaluation
Selection of evidence-based change techniques
capable to altering identified mechanisms
Identification of feasible, attractive and
sustainable delivery formats,
Co-creation of interventions with those who will deliver
and receive them
Planning marketing, adoption and implementation
Planning evaluation – before materials are created!
Identifying and Reporting Characteristics
Distinguishing Between Group-Based Interventions
Intervention Design
Participants
Intervention source/ development method
General setting
Venue characteristics
Total number of group sessions
Length of group sessions
Frequency of group sessions
Duration of the intervention
Group composition
Methods for group allocation
Continuity of participants’ group membership
Group size
Facilitators
Number of facilitators
Continuity of facilitators’ group assignment
Intervention Content
Facilitators’ professional background
Change mechanisms or theories of change Facilitators’ personal characteristics
Facilitators’ training in intervention delivery
Change techniques used
Facilitators’ training in group facilitation
Session content
Facilitators’ materials
Sequencing of sessions
Intended facilitation style
Participants’ materials
Activities during the sessions
Methods for checking fidelity of delivery
Borek, A., Abraham, C., Smith, J., Greaves, C., & Tarrant, M. (2015). A Checklist
to Improve Reporting of Group-Based Behavior-Change Interventions. BMC
Public Health. 15:963. doi: 10.1186/s12889-015-2300-6.
RCT of “Living Well, Taking Control”
(COMPOD Community-based Prevention of Diabetes)
Community-based programme delivered by voluntary sector to
prevent T2 diabetes, as planned for the UK National Diabetes
Prevention Programme.
Participants: 18-75 years
BMI ≥25 kg/m2 (or ≥23 for certain ethnic minority groups) and
<45 kg/m2 (for trial)
Weight loss is the primary outcome.
Will report soon!
Identifying Individual Mechanisms of Change
Information, Motivation, Behaviour Skills Model:
IMB: Fisher & Fisher (1992, Psychological Bulletin)
Information
Behavioural
Skills
Motivation
Behaviour
INFORMATION
DAILY ENERGY DEFICIT CALCULATIONS
1. How many calories should an adult eat a day?
2. How many calories are contained in a standard
(not jumbo) energy-dense chocolate bar?
3. How long would it take you to “burn” these calories
while walking?
WHAT OF TYPE INFORMATION
IS MOST USEFUL?
COLLABORATION WITH PASCAL SHEERAN UNC
Providing calorie information increases knowledge but
involves complex calculation: Can I eat X?
[intake so far today + likely intake later today + calories]
What if we transform calories into the time spent at brisk
walking that is needed to burn off those calories?
Calories Are Walking Times (CAWT)
10
ESTIMATE CALORIES AND WALKING TIMES IN EACH CASE
ESTIMATE CALORIES AND WALKING TIMES IN EACH CASE
3024 calories
37 calories
227 calories
9 hours, 42 mins
of brisk walking
7 mins
of brisk walking
2 hours, 40 mins
of brisk walking
DO PEOPLE BETTER ESTIMATE CALORIES USING CAWT?
Participants (N = 155) were randomized to estimate either
calories or walking times for 30 food images
10 images for ‘low’, ‘medium’, and ‘high’ foods
CAWT for item = kcal / (MET * weight [kg])
where MET = 3.8 (3.5mph walk) and weight = 82.03kg
Analysis
1. Magnitude of under- or over-estimation using d-values
2. Accuracy (actual minus estimated calories): To this
end, CAWT estimates were back-transformed to
calories
13
ACCURACY BY CONDITION AND CALORIE CONTENT
Estimate Calories
Estimate Walking Times
All participants overestimated
calories for low- and medium-calorie
food, and underestimated calories for
high-calorie foods
Less under-estimation for highcalorie foods in CAWT condition
213
Accuracy
Greater over-estimation for low- and
medium-calorie foods in CAWT
condition
400
68
133
43
0
-400
-539
-800
-777
Low
Calorie
Medium
Calorie
High
Calorie
Identifying Individual Mechanisms of Change
Information, Motivation, Behaviour Skills Model:
IMB: Fisher & Fisher (1992, Psychological Bulletin)
Information
Behavioural
Skills
Motivation
Behaviour
Modifiable Determinants of Motivation
Fishbein et al (2001 in Baum et al. Handbook of Health Psychology )
More likely to intend if you...
 believe advantages (e.g., benefits) outweigh the
disadvantages (e.g., costs) of behaviour – attitude,
 anticipate a positive emotional reaction to the behaviour,
 see more social (normative) pressure,
 perceive behaviour to be consistent with self-image,
 and believe you are capable of performing the behaviour
in a range of circumstances i.e., high self-efficacy.
Does changing attitudes norms and self-efficacy
change health-related motivation and behaviour?
Yes… if the cognition change is effective then small to medium effect sizes are
found for motivation and behaviour change.
0.48
Attitude
0.38
0.49
Social norms
Intention
0.36
Behavior
0.51
Self-efficacy
0.47
0
0.2
0.4
0.6
Sheeran P, Maki A, Montanaro E, Avishai-Yitshak A, Bryan A, Klein WM, Miles E, Rothman AJ. (2016). The
impact of chaning attitudes, norms and self-efficacy on health-related intentions and behaviour: A meta
analysis. Health Psychology, 35(11):1178-1188.
Identifying Individual Mechanisms of Change
Information, Motivation, Behaviour Skills Model:
IMB: Fisher & Fisher (1992, Psychological Bulletin)
Information
Behavioural
Skills
Motivation
Behaviour
Behavioural Skills
When motivation is established… check behaviourspecific skills
Motor skills
Instruction, demonstration, practice and feedback are
often used in interventions to develop such skills.
Social skills
Demonstration, practice and feedback – e.g., role play
are often used in interventions to develop such skills.
Self-regulatory skills
Goal setting, planning and rehearsal, self monitoring,
provision of feedback and goal review are often used in
interventions to develop such skills.
Two Systems Regulate Behaviour:
Dual Process Models
Strack & Deutsch (2004, Personality & Social Psych Review)
Reflective and Impulsive model (RIM)
Borland (2014) Context Executive and Operational System (CEOS) model
Reflective:
Top-down. Mindful. Conscious awareness and monitoring, including
awareness of impulsive system “urges”. Language-based, goal-directed,
capable of evaluation and one-time learning – long-term memory and self
representation important. Can override impulsive regulation.
Impulsive:
Bottom up. Mindless. Default system functioning in response to eternal
cues without reflective initiation. Thought to be largely associative with
growing neural activation resulting in priority of action through initiation of
well-learnt (potentially complex) motor routines.
HELPING MOTIVATED,
OVERWEIGHT AND OBESE WOMAN TO LOSE WEIGHT
Research Question
Does action and if-then planning help motivated
people lose weight?
Sample
Randomised Controlled Trial of 45 women attending
Weight Watchers classes.
Intervention
Single session add-on “planning” session
(including if-then planning).
Enhanced planning was the expected mechanism of action.
Primary Outcome.
Weight loss two months later.
Luszczynska, A., Sobczyk, A, & Abraham, C. (2007) Planning to lose weight: RCT of an
implementation intention prompt to enhance weight reduction among overweight and
obese women. Health Psychology, 26, 507-512.
Luszczynska, Sobczyk & Abraham, 2007
Outcome Evaluation – 2 Months Later
Control 2.1kg Lost
Intervention
Lost
Clinically significant reduction of weight (5%):
54.2% of Intervention participants
8.3% of Control participants
4.2 Kg
Simple Process Evaluation
Reported Use of Planning Changed - and
Mediated the Intervention Effect
Reported change
in planning
.39**
.56**
Intervention
Effect
.30 ns
Body Weight Change
Sobel’s Z = 2.27, p < .05
Techniques to Modify Impulsive Processes
Evidence of effectiveness - for eating?
Van Beurden et al (2016)
Systematic Review of 93 studies identified 17 categories of techniques classified into 3 groups.
Evidence categorised as: 1) insufficient, 2) mixed, or 3) promising
Techniques that target impulse strength
1. Priming
2. Cue-exposure
3. Attentional Bias Training
4. Approach/Avoidance training
5. Inhibition Training
6. Physical Activity
Techniques with unclear mechanisms
1. Episodic Future Thinking
2. Manipulating Regulatory Fit
Techniques that target reflective control
over impulse.
1. Mindfulness-based strategies
2. Visuospatial Loading
3. Cognitive Loading
4. Implementation Intentions
5. Thought Suppression
6. Cognitive Restructuring
7. Emotional Freedom Technique
8. I don’t refusal framing
9. Autonomous learning conditions
van Beurden, S. B., Greaves, C. J., Smith, J. R., & Abraham, C. (2016). Techniques for modifying
impulsive processes associated with unhealthy eating: A systematic review. Health Psychology, 35(8),
793–806. https://doi.org/10.1037/hea0000337
Self-directed interventions
to promote weight loss I
Meta analyses of 25 evaluations. Those using self-directed
interventions lost significantly more weight than those receiving
minimal/ no treatment intervention (MD = −1.56 kg, CI −2.25,
−0.86), range 0.6 to 5.3 kg.
Jason C. H. Tang, Charles Abraham, Colin J. Greaves & Vasilis Nikolaou (2016): Self-directed
interventions to promote weight loss: a systematic review and metaanalysis, Health Psychology
Review, DOI: 10.1080/17437199.2016.1172979
Self-directed interventions
to promote weight loss II
The majority of interventions were internet based (N=18).
These were effective at 3 months (MD = −1.74 kg, CI
−2.65, −0.82 ranging from 0.6 to 4.8 kg) and
at 6 months follow-up (MD = −2.71 kg, CI −4.03, −1.39
ranging from 2.2 to 5.3 kg).
However self-directed interventions may not be effective in
helping people sustain weight loss at 12 months plus..
Jason C. H. Tang, Charles Abraham, Colin J. Greaves & Vasilis Nikolaou (2016): Self-directed
interventions to promote weight loss: a systematic review and metaanalysis, Health Psychology
Review, DOI: 10.1080/17437199.2016.1172979
Managing “Food Rehab”:
Kessler’s Recommendations: The “Treatment” I
1. Awareness of the cue-brain response
Recognise and avoid high risk (cue-laden) environments.
2. Learn competing behaviours
Learn, cognitively rehearse and practice new substitute behaviour
Set absolute rules – change anticipation… “rules of disengagement”
3. Learn competing thoughts
Learn and rehearse immediate alternative responses – including self
instruction - rejecting automatic psychological responses.
Over time, reconceptualise the meaning of the cue – change attitudes
beliefs and norms – may take time – requires cognitive rehearsal.
Managing “Food Rehab”:
Kessler’s Recommendations: The “Treatment” II
4. Social support
Sharing with others and making commitments can be very helpful –
others can also undermine “rehab”.
5. Emotional learning
We invest behavioural responses with anticipated affect –
“it will be soo nice (even if naughty)”.. “it will feel fantastic”... etc.
Such associations strengthen the impulsive impact of cues.
Unlearning affective associations is important - the things we want/
crave are not so special and often leave us unsatisfied.
Replacing advertising messages with automatic negative evaluations.
“Once I thought a big plate of food was what I wanted and needed to feel
better. Now I see it for what it is… fat of fat on sugar on fat that will never
provide lasting satisfaction and only keeps me coming back for more…”
Useful Checklist
IMB + Automaticity Development
Information
(I know about X)
Motivation
(I want to do X)
Behavioural Skills
(I am able to do X)
Breaking unwanted habits and making new ones.
(I do X without thinking)
Results in maintenance.
Key Points
Adopt an Intervention mapping approach.
Identify underlying mechanisms of action e.g.,
information,
motivation
self regulatory skills
habits/ automaticity of action.
.
Develop a logic model, identifying mechanisms of action and techniques
that initiation change.
Develop materials and practices that can be used in everyday work/
leisure environments and are sustainable over time….
Evaluate!
Thank You!
Questions?
Summary Chapter
Denford, S., Abraham, C., Smith, J., Lloyd, J. J., White, M., Tarrant, M.,
Wyatt, K., Greaves, C., & Dean, S. (2015). Designing and evaluating
behavior change interventions to promote health.
In K.J. Reynolds & N.R. Branscombe (Eds.), The Psychology of Change:
Life Contexts, Experiences, and Identities. New York: Psychology Press.