1. University College London 4 August 2011
Applying behaviour change principles to population health: a comprehensive approach
Robert West
Susan Michie
University College London
4 August 2011

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. 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
change the incidence/rate/duration of occurrence of a given type of behaviour from what it would otherwise have been
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. 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. 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. Designing interventions
Describe the behavioural target (BT), the current situation and the prevailing context
Analyse what is needed for the BT to be attained
Choose an appropriate mix of broad intervention options based on that analysis, and policies needed to implement these
Construct specific behaviour change techniques (BCTs) that make up the interventions

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

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

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
Offer
Provide
Prompt
Constrain

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

12. PRIME Theory: the structure of human motivation

13. PRIME Theory: reflective and automatic processes

14. PRIME Theory: Elementary change processes
Automatic
Perception: acquiring information from the senses
Associative learning: operant and classical conditioning
Maturation: changes associated with growing older
Habituation: decrease in response with exposure
Sensitisation: increase in response with exposure
Imitation: direct copying
Identification: forming one’s own identity from perceptions of others
Consistency disposition: generation of motives, ideas from similar ones
Dissonance avoidance: negating or blocking uncomfortable beliefs
Objectification: generating evaluations from likes and dislikes
Chemical ‘insult’: pharmacological responses
Physical ‘insult’: brain lesions
Reflective
Assimilation: acquiring information via communication
Inference: induction and deduction
Analysis: formal and informal calculation
Long-term changes to the operation of the motivational system can come about through many elementary processes.
Many of these involve no reflective processes (e.g. maturation, perception).
Others involve reflective though: assimilation of communicated ideas, inference and analysis.

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. PRIME Theory: key propositions
At every moment we act in pursuit of what we most desire (want or need) at that moment.
Wants and needs involved imagined futures and feelings of anticipated pleasure/satisfaction (wants) or relief from mental or physical discomfort (needs)
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.
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. PRIME Theory: key propositions
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.
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.
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.
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. 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. 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. 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. 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. 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. The Behaviour Change Wheel: hub

24. The behaviour Change Wheel: inner ring

25. Behaviour Change Wheel: complete

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. 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. 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. Conclusions Benefits of a comprehensive approach Only a first step
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)