University College London September 2013 The potential for smartphone applications to deliver behaviour change techniques Robert West Susan Michie University College London September 2013

Outline Principles of behaviour change Features of smartphone applications Judging how well smartphones can deliver behaviour change techniques

Principles of behaviour change To increase or decrease the incidence of a given behaviour it is necessary to alter one or more of: capability (physical or psychological) opportunity (physical or social) motivation (reflective or automatic) This can be done directly by targeting the behaviour or indirectly by targeting supporting or competing behaviours

The COM-B model of behaviour Michie S, M van Stratten, West R (2011) The Behaviour Change Wheel: A new method for characterising and designing behaviour change interventions. Implementation Science, 6, 42.

The COM-B model of behaviour Physical and psychological capability: knowledge, skill, strength, stamina

The COM-B model of behaviour Physical and social opportunity: time, resources, cues/prompts

The COM-B model of behaviour Reflective and automatic motivation: plans, evaluations, desires, impulses and responses West and Brown, 2013 Theory of Addiction: Oxford, Blackwell

Behaviour Change Wheel Michie S, M van Stratten, West R (2011) The Behaviour Change Wheel: A new method for characterising and designing behaviour change interventions. Implementation Science, 6, 42.

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 that limit engagement in the target behaviour or competing or supporting behaviour 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

Influencing capability Knowledge Educate about ways of enacting the desired behaviour or avoiding the undesired one Skill Train in cognitive, physical or social skills required for the desired behaviour or avoid the undesired one Strength Train or enable development of mental or physical strength required for the desired behaviour or to resist the undesired one Stamina Train or enable endurance required for desired behaviour or sustained resistance to undesired one

Influencing opportunity Train or restructure the environment to reduce time demand or competing time demands for desired behaviour (and additionally use restrictions to reduce undesired behaviour) Time Resources Restructure the environment to increase social support and cultural norms for desired behaviour (and additionally use restrictions to reduce undesired behaviour) Cues/prompts Restructure the environment to provide cues and prompts for desired behaviour (and converse for undesired behaviour)

Model desired behaviour to induce automatic imitation Influencing motivation Plans Educate, train or enable to form clearer personal rules/action plans, and train to remember and apply the rules when needed Evaluations Educate or persuade to create more positive beliefs about desired, and negative ones about undesired, behaviour Motives Educate, persuade, train, incentivise, coerce and model to feel positively about the desired behaviour and negatively about the undesired one Impulses/inhibition Train or enable to strengthen habitual engagement in the desired behaviour or weaken the undesired one Responses Model desired behaviour to induce automatic imitation

Smartphone features Feature + - Accessibility extremely low delivery cost, very easy to develop and deliver, almost always available not universally affordable Functionality can present text, present graphics, play audio, play video, vibrate, link to other apps, link to websites can record responses, third party information, information about other users, location, movement, date and time, video, audio, other data (e.g. expired air CO, GSR) through interfaces cannot directly empathise, exert physical power or locomote Flexibility can be programmed, learn and be upgraded … … up to a point!

Behaviour Change Technique Taxonomy (v1) Comprehensive, expert generated list of behaviour change techniques (BCTs) Able to be used reliably to characterise behaviour change interventions Grouped pragmatically into 16 categories: Michie et al (2013) Ann Behav Medicine, 46, 81-95.

App suitability judgements Rate smart phone apps using current technology for how effectively they can deliver or help deliver the following BCTs on a scale from 1-4: 1=not at all, 2=minimally, 3=moderately, 4=very well SM and RW independent ratings of each BCT Spearman r = 0.5, p<0.001 for the 93 BCTs Judgements for 16 BCT categories: High, Moderate, Low, Mixed SM and RW agreement on 11 out of 16 categories

Delivery of Behaviour Change Techniques BCT group App suitability Goals and planning (e.g. goal setting, problem solving) High Feedback and monitoring (e.g. self-monitoring of behaviour) Shaping knowledge (e.g. instruction on how to perform the behaviour) Natural consequences (e.g. salience of consequences) Antecedents (e.g. restructuring physical environment, distraction) Mixed Scheduled consequences (e.g. punishment, reward approximation) Comparison of behaviour (e.g. information about others’ approval) Associations (e.g. prompts/cues, exposure, satiation)

Delivery of Behaviour Change Techniques BCT group App suitability Social support (e.g. emotional support) Moderate Repetition and substitution (e.g. behavioural substitution) Comparison of outcomes (e.g. pros and cons, credible source) Self-belief (e.g. self-talk, focus on past success) Covert learning (e.g. imaginary punishment, vicarious consequences) Identity (e.g. valued self-identity, framing/re-framing) Reward and threat (e.g. material reward, social reward) Low Regulation (e.g. pharmacological support, conserving mental resources)

Conclusions An initial analysis of the features of smartphone applications suggests that they are likely to be: Good at delivering BCTs related to: goals and planning, feedback and monitoring, shaping knowledge, natural consequences Quite good at delivering BCTs related to: social support, repetition and substitution, comparison of outcomes, identity, self-belief, covert learning Not generally good at delivering BCTs related to: reward and threat, regulation Mixed at delivering BCTs related to: comparison of behaviour, associations, antecedents, scheduled consequences