The Role of Goal Setting in Self- Management of Diabetes Susan Michie Professor of Health Psychology Director, Centre for Behaviour Change University College London, UK Diabetes in Primary Care Conference, Cork, Ireland,

Self-management Dictionary definition –the taking of responsibility for one's own behaviour and well-being “Taking of responsibility” –Requires Capability, Opportunity and Motivation

HealthDisease Disability and Death Behaviour To prevent ill health, manage illness, deliver effective health care When is behaviour important?

Health professional behaviours affect health Many do not follow evidence-based guidelines for good practice e.g. –making referrals –giving advice –prescribing drugs –keeping hands clean Research –Netherlands: 30-40% of patients did not receive ‘evidence-based’ health care Grol et al, 2001 –US: 20-25% received care that was unnecessary or even harmful Schuster et al, 2005 Every one of these requires multiple behaviours at multiple levels – individual, organisational, state/national Each behaviour differs in context, barriers and drivers

Behaviours occur do not occur in a vacuum

Every behaviour is part of a system of behaviours …. …that facilitate and compete with each other –Within and between individuals 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 is part of a system and itself is a system

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

Whose self-management? The person with diabetes Those living with that person? The practitioner offering support? The manager providing infrastructure? The commissioner deciding on the service?

Which behaviour to target in self-management Diet, physical activity, medication adherence, others? Questions to ask yourself –If I change this, what is the likely impact? –How easy is it to bring about change? –Spillover/generalisability to other behaviours and people? –Preference, acceptability, cost?

Where does goal setting fit in?

Effective principles of behaviour change Maximise to regulate own behaviour –Develop relevant skills (e.g. goal setting, monitoring, feedback) –Develop specific plans to change Maximise to support self-regulation –Elicit social support –Avoid social and other cues for current behaviour –Change routines and environment Increase to engage in the desired behaviour –Reward change –Develop appropriate beliefs E.g. benefits of changing, others’ approval, personal relevance, confidence to change –Develop positive feelings about changing Reduce to continue with the undesired behaviour NICE Guidance for Behaviour change (2007) NICE Guidance for Behaviour change (2014)

If improve goal setting, what else changes?

How does goal-setting fit in with other techniques to improve self- management?

Self-management is made up of many behaviour change techniques … “Active ingredients” within self- management support designed to change behaviour –Taxonomy of 93 behaviour change techniques Michie et al, Annals of Behavioral Medicine,

93 item BCT Taxonomy v1, Annals of Behavioral Medicine, 2013

BCT Taxonomy v1: 93 items in 16 groupings

Search for: BCTs Search for: BCTs* bcts.23.co.uk* * You’ll need an internet connection to use the app The BCTTv1 smartphone app Fully searchable version of BCTTv1 Search by BCT label, BCT grouping or alphabetically Increases familiarity with the taxonomy Increases speed and recall of BCT labels and definitions

How does goal-setting ‘work’ to change behaviour? Self-regulation Theory explains how goal-setting works synergistically with other behaviour change techniques Goal Theory explains the kind of goal-setting most likely to be effective

Self-regulation (control) Theory: Carver & Scheier, 82 GOAL Compare behaviour with standard Discrepancy noted Act to reduce discrepancy Environmental influences No discrepancy – goal reached Disengage from goal – give up SELF-MONITORING GOAL- SETTING ACTION-PLANNING

What techniques are effective in interventions to increase physical activity and healthy eating? Inclusion criteria –Interventions using behavioural &/or cognitive techniques –in adults –designs experimental or quasi-experimental –outcome measures objective or validated self-report 6 electronic databases, Intervention content analysed using –a reliable taxonomy of 26 BCTs (Michie & Abraham, 2009) –a theoretically-derived combination of BCTs Random effects meta-analysis and meta-regression Michie et al, Health Psychology, 2009

The interventions 84 interventions (n=28,838) Interventions ave. 6 techniques (range 1-14) –Many different combinations Effect d=0.37, 95% CI Very heterogeneous effects (I 2 =79%) –not explained by 10 moderators examined e.g. Setting, population, intervention characteristics, target behaviour

Results Only one technique, self-monitoring, had a significant effect for both behaviours across interventions –d=0.57, 14.6% variance Next step –Use theory to predict combinations of BCTs that might be more effective –Self-regulation Theory suggests how feedback may interact with other techniques to change behaviour Carver & Scheier, 1982

Theoretical combination of self-regulatory behaviour change techniques Self-monitoring PLUS One or more of: –setting goals –reviewing goals –feedback on performance –specifying action plans

Findings Interventions comprising self-monitoring with at least one other “self-regulatory” BCT (n=28) –compared with the other interventions (n=56) were twice as effective d=0.60 vs d=0.26 –Michie et al, 2009, Health Psychology Replicated for overweight populations with co-morbidities –Dombrowski et al, 2012, Health Psychology Review

Self-regulation (control) Theory: Carver & Scheier, 82 GOAL Compare behaviour with standard Discrepancy noted Act to reduce discrepancy Environmental influences No discrepancy – goal reached Disengage from goal – give up SELF-MONITORING GOAL- SETTING ACTION-PLANNING

To what extent are these techniques delivered in practice? How well are they delivered?

Translating evidence into practice Evidence/ theories of behaviour change Techniques in manual Delivery of techniques by professional Participant response to intervention e.g. physical activity Self- management

Intervention to increase physical activity of those at risk of Type 2 diabetes “ProActive”: 14 behaviour change techniques Delivered by trained professionals in 5 sessions over 12 months Specified in detailed protocols/manuals An RCT of 365 people, family history & sedentary –Increased activity by equivalent of 20 minutes walking per day –No difference between intervention and “control” groups Kinmonth et al, Lancet, 2008

Behaviour ChangeTechniques 1.Give information 2.Elicit questions 3.Summarise message 4.Set goals 5.Self-monitor 6.Build motivation 7.Action plans 8.Use prompts 9.Use rewards 10.Build support 11.Review goals 12.Build habits 13.Relapse prevention 14.Generalise skills Theories 1.Theory of Planned Behaviour 2.Relapse Prevention Theory 3.Self-regulation Theory 4.Operant Learning Theory

Question: What was delivered? 27 participants selected to study in depth Audio-recorded and transcribed sessions All discussion in sessions relevant to behaviour change was reliably coded into behaviour change techniques Hardeman et al, Psychology & Health, 2007; Michie et al, Psychology & Health, 2007

% BCTs in protocol delivered by providers: % 45%

Quality of techniques Behaviour change techniques can be delivered more or less well

S pecific M easurable A chievable R elevant T imely SMART Goal Setting A reliable measure of quality of goal-setting –developed in relation to behavioural support for smoking cessation Lorencatto et al (under review) Annals of Behavioral Medicine

0 Absence of goal setting +1Prompts goal setting (i.e. encourage client set quit date) +1Agrees clear quit date (dd/mm/yy) +1 Agreed quit date within appropriate time frame (1-2 weeks) +1Quit date allows appropriate time to obtain medication +1Advice why cutting down doesn’t work so well +1 Emphasise goal is to not smoke a single cigarette/puff +1Provide relevant normative information and examples -1Inappropriate goal setting (i.e. unclear date, incorrect time frame) -1Encourages or reinforces cutting down -1Undermines client commitment to quit date (i.e. imply flexibility)

Action Planning and If-Then rules… Action planning –Behaviour change is helped by a detailed action plan of how to change behaviour:  What are they going to do?  Where are they going to do it?  When are they going to do it?  With whom are they going to do it? ‘If-then’ rules –Specific type of action plan –Good evidence of effectiveness

Action planning: ‘If-then’ rules “If situation X arises then I will perform behaviour Y” The situation becomes a trigger, or reminder, to perform the behaviour For example, “If it is a weekday morning, then I will prepare a healthy lunch to take to work.”

Maintaining behaviour change Changing behaviour is hard –Maintaining that change is harder Effective strategies –Use the environment to support making behaviour automatic building routines environmental support and prompts feedback rewards and incentives

Summary Effective self-management requires capability, opportunity and motivation Goal-setting is an important behaviour change technique –for everyone … patients, family, professionals Goal-setting works best within the context of other techniques Goal-setting can be delivered and used more or less well

Acknowledgements Health Psychology Research Group Key funders

For more information Susan Michie Books – – UCL Centre for Behaviour Change – All proceeds from CBC teaching, training, books and products go to further development