1. 1 How to change behaviour: from education to enablement University College London 18 May 2011 Robert West Susan Michie

2. 2 Topics What are ‘behaviour change interventions’ and why is it important to study them? Understanding behaviour Developing a behaviour change strategy A worked example

3. 3 What is a behaviour change intervention (BCI)? In theory An action or activity that aims to get an individual or population to behave differently from how s/he or they would have acted without such an action 1.change the incidence/rate/duration of occurrence of a given type of behaviour from what it would otherwise have been 2.change the way that a given behaviour is performed In practice A coordinated set of behaviour change techniques (BCTs) applied to a group or population to change the prevalence or rate of a given behaviour pattern

4. 4 The ‘behavioural target’ A specification of what is intended E.g. –reduce smoking prevalence to 15% –increase the prevalence of people who eat 5+ portions of fruit and vegetables each day –reduce the prevalence of drivers who regularly exceed 30mph in a built up areas –increase the rate of condom use

5. 5 Importance of studying BCIs Maladaptive/anti-social behaviours are common –smoking –sedentary lifestyle –reckless driving –domestic violence –etc. Commonsense approaches are frequently ineffective or counter-productive Studying BCIs can produce better understanding of mechanisms and lead to more effective interventions

6. 6 Designing interventions 1.Describe the behavioural target (BT), the current situation and the prevailing context 2.Analyse what is needed for the BT to be attained 3.Choose an appropriate mix of broad intervention options based on that analysis, and policies needed to implement these 4.Construct specific behaviour change techniques (BCTs) that make up the interventions

7. 7 Common terms for methods for inducing behaviour change Educate Train Help Expose to Inform Discuss Suggest Encourage Incentivise Ask Order Plead Coerce Force Provide Prompt Constrain

8. 8 COM-B system for analysing behaviour in context 1.Capability, motivation and opportunity all need to be present for a behaviour to occur 2.They all interact as part of a system 3.Motivation must be stronger for the target behaviour than competing behaviours

9. 9 Common terms for methods for inducing behaviour change Capability Educate Train Help Motivation Expose to Inform Discuss Suggest Encourage Incentivise Ask Order Plead Coerce Force Opportunity Provide Prompt Constrain

10. 10 Understanding motivation Brain processes that energise and direct behaviour Not limited to choice and goal pursuit Needs to include –drive –habit –desire –instinct –self-regulation –etc.

11. 11 Motivation: reflective and automatic Beliefs about what is good and bad, conscious intentions, decisions and plans Emotional responses, desires and habits resulting from associative learning and physiological states Automatic Reflective Reflective-Impulsive Model, Strack & Deutsch, 2004 PRIME Theory of Motivation, West, 2006

12. 12 PRIME Theory: the structure of human motivation www.primetheory.com

13. 13 PRIME Theory: reflective and automatic processes www.primetheory.com

14. 14 PRIME Theory: Elementary change processes Automatic 1.Perception: acquiring information from the senses 2.Associative learning: operant and classical conditioning 3.Maturation: changes associated with growing older 4.Habituation: decrease in response with exposure 5.Sensitisation: increase in response with exposure 6.Imitation: direct copying 7.Identification: forming one’s own identity from perceptions of others 8.Consistency disposition: generation of motives, ideas from similar ones 9.Dissonance avoidance: negating or blocking uncomfortable beliefs 10.Objectification: generating evaluations from likes and dislikes 11.Chemical ‘insult’: pharmacological responses 12.Physical ‘insult’: brain lesions Reflective 1.Assimilation: acquiring information via communication 2.Inference: induction and deduction 3.Analysis: formal and informal calculation www.primetheory.com

15. 15 PRIME Theory: Self-control, identity and behaviour change We are self-aware and form mental representations of ourselves to which are attached emotions (identity) These include labels and rules Deliberate behaviour change involves adopting a new personal rule To the extent that this is based on evaluations it requires effortful self-control

16. 16 PRIME Theory: key propositions 1.At every moment we act in pursuit of what we most desire (want or need) at that moment. 2.Wants and needs involved imagined futures and feelings of anticipated pleasure/satisfaction (wants) or relief from mental or physical discomfort (needs) 3.Beliefs about what is good or bad can only influence our actions if they generate desires that are strong enough to overwhelm those arising from other sources (e.g. drives and emotional responses) or impulses arising automatically out of habit or instinct. They will do this to the extent that they generate clear imagery that can trigger necessary emotional associations. 4.Identity (our mental representations of ourselves and the emotions attached to these) is an important source of desires and provides a degree of stability to our behaviour by virtue of the labels we apply (e.g. non- smoker) and the rules that govern our behaviour (e.g. not smoking).

17. 17 PRIME Theory: key propositions 5.Identity change is the starting point for deliberate behaviour change (in terms of a new label and a new set of rules governing our behaviour) and can be regarded as an ‘act’ that occurs when the desire to make the change is momentarily greater than the desire not to. 6.Deliberate behaviour change is sustained when the desires arising from the new identity are stronger at each relevant moment than the desires arising from other sources to revert to the previous behaviour pattern, or are able to overwhelm habitual or instinctive impulses. 7.When identity change results from self-conscious beliefs about what is good and bad, maintaining behaviour change requires ‘self-control’: the effortful generation of desire to adhere to a rule that is sufficiently powerful to overcome desires arising from other sources. 8.Personal rules that have clear boundaries and a strong connection with components of identity that involve strong emotional attachments will generate more powerful desires when required and better suppress countervailing desires and so have a stronger lasting impact on behaviour.

18. 18 Formal analysis 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

19. 19 Formal analysis of behaviour change 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. Implement-ation 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

20. 20 Formal analysis of behaviour change interventions 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. Interven-tion 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. Environ-mental policy framework Vlek (2000) A taxonomy of major environmental problems, their different levels and global spheres of impact, and conceptual modelling of environmental problem- solving 19. Population Services International (PSI) framework PSI (2004) A conceptual framework to guide and help conduct research on social marketing interventions

21. 21 A derived list of 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 to reduce the opportunity to engage in the target behaviour (or to increase the target behaviour by reducing the opportunity to engage in competing behaviours) 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

22. 22 A derived list of policy categories Communication/ marketing Using print, electronic, telephonic or broadcast media Guidelines Creating documents that recommend or mandate practice. This includes all changes to service provision Fiscal Using the tax system to reduce or increase the financial cost Regulation Establishing rules or principles of behaviour or practice Legislation Making or changing laws Environmental/ social planning Designing and/or controlling the physical or social environment Service provision Delivering a service

23. 23 The Behaviour Change Wheel: hub

24. 24 The behaviour Change Wheel: inner ring

25. 25 Behaviour Change Wheel: complete

26. 26 Where this leaves us Still at the level of broad intervention functions Construction of specific BCTs is still required Michie et al have constructed a taxonomy of BCTs and this is being developed further West, Michie et al have constructed specific BCTs used in behavioural support for smoking cessation

27. 27 Worked example: getting GPs to deliver brief smoking cessation interventions Behavioural target –increase the rate at which GPs offer cessation support to smokers from 25% to 50% COM-B analysis –C: uncertainty about how to do it without embarrassment in the time available; ignorance of available options for support –O: limited time; lack of salient cues; limited access to high quality support –M: belief that it is a good thing but limited desire because not rewarded and often mildly punished

28. 28 Worked example: getting GPs to deliver brief smoking cessation interventions Intervention options –Education: on the best methods of brief advice and the benefits –Training: how to deliver advice quickly without embarrassment –Incentivisation: change QOF payments to link them with objective evidence of offer of support (e.g. referral to stop- smoking services) –Coercion: use professional and social disapproval for failure to achieve minimum intervention rate –Modelling: show examples that GPs can identify with –Environmental restructuring: provide salient prompts e.g. desktop post-it pads

29. 29 Conclusions Benefits of a comprehensive approach –prompts consideration of the full range of options –provides a basis for analysing behaviour in context to select an appropriate mix of options –takes account of environmental as well as intra- individual changes that may be needed Only a first step The Behaviour Change Wheel: a new method for characterising and designing behaviour change interventions Susan Michie, Maartje M van Stralen, Robert West Implementation Science 2011, 6:42 (23 April 2011)